Health Information and Quality Authority Social Services Inspectorate Inspection report Designated centres for older people Centre name: St Colmcille s Nursing Home Centre ID: 0165 Centre address: Oldcastle Road Kells County Meath Telephone number: 046-9249733 Fax number: 046-9247018 Email address: stcolmcillesnh@eircom.net Type of centre: Private Voluntary Public Registered provider: Person in charge: St Colmcille s Nursing Home Ltd Ms. Caroline Day Date of inspection: 17 February 2011 Time inspection took place: Start: 14:40 hrs Completion: 18:20 hrs Lead inspector: Support inspector(s): Purpose of this inspection visit Florence Farrelly N/A Application to vary registration conditions Notification of a significant incident or event Notification of a change in circumstance Information received in relation to a complaint or concern Follow-up inspection Page 1 of 17
About the inspection The purpose of inspection is to gather evidence on which to make judgments about the fitness of the registered provider and to report on the quality of the service. This is to ensure that providers are complying with the requirements and conditions of their registration and meet the Standards, that they have systems in place to both safeguard the welfare of service users and to provide information and evidence of good and poor practice. In assessing the overall quality of the service provided, inspectors examine how well the provider has met the requirements of the Health Act 2007, the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) and the National Quality Standards for Residential Care Settings for Older People in Ireland. Additional inspections take place under the following circumstances: to follow-up matters arising from a previous inspection to ensure that actions required of the provider have been taken following a notification to the Health Information and Quality Authority s Social Services Inspectorate of a change in circumstance for example, that a provider has appointed a new person in charge arising from a number of events including information received in relation to a concern/complaint or notification to the SSI of a significant event affecting the safety or well-being of residents to randomly spot check the service All inspections can be announced or unannounced, depending on the reason for the inspection and may take place at any time of day or night. All inspection reports produced by the Health Information and Quality Authority will be published. However, in cases where legal or enforcement activity may arise from the findings of an inspection, the publication of a report will be delayed until that activity is resolved. The reason for this is that the publication of a report may prejudice any proceedings by putting evidence into the public domain. Page 2 of 17
About the centre Description of services and premises St Colmcille s is a single-storey, purpose-built facility, with capacity for 42 people. The centre provides continuing care, respite and dementia care services for 42 residents, and also accommodates residents with physical and / or intellectual disabilities. Accommodation includes 21 single and eight twin bedrooms, as well as five single bedrooms with en suite shower. There are eight assisted toilets for residents and four assisted showers/baths. Other facilities include: foyer/reception area, dining room, sitting room, visitors room, oratory, nurses office, clinical room a sluice room and two store rooms. Additionally there are staff changing and toilet facilities, staff canteen, kitchen and laundry. There is a landscaped garden at the front and a central courtyard area which residents can access, both are well maintained with shrubberies and seating areas and there is car parking for staff and visitors to the front of the building. Location St Colmcille's is located in a rural setting close to the town of Kells, County Meath. It is on a busy main road with access to all local amenities. Date centre was first established: 1999 Number of residents on the date of inspection 40 + 1 in hospital Number of vacancies on the date of inspection 10 Dependency level of Max High Medium Low current residents Number of residents 14 14 13 0 Management structure Caroline Day is the Person in Charge, she reports to the Registered Provider, Tom Ryan on behalf of St Colmcille's Nursing Home Ltd. She is responsible for the day-to-day management of the service. The person in charge, Aoife Brady, from the other centre owned by St Colmcille's Nursing Home Ltd deputises in her absence. Page 3 of 17
The person in charge is supported in her role by a senior staff nurse. All nursing, care and ancillary staff are directly supervised by the person in charge and report to her and the provider. Staff designation Number of staff on duty on day of inspection Person in Charge Nurses Care staff Catering staff 0 2 6 1 chef and 1 assistant Cleaning and laundry staff Admin staff Other staff 4 2 2* * One activities coordinator and the person in charge from the other centre owned by St Colmcille's Nursing Home Ltd was present in the centre during the inspection Page 4 of 17
Background St Colmcille's Nursing Home was first inspected by the Health Information and Quality Authority s (the Authority) Social Services Inspectorate on 2 and 3 June 2010. This was a registration inspection and the inspectors found that overall care delivered in the centre was of a good standard. Staffing levels and skill mix were appropriate to meet the needs of the current residents profile. Inspectors were satisfied that the medical and other healthcare needs of residents were catered for. The report following this inspection identified where some improvements were necessary to comply with the requirements of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) and the National Quality Standards for Residential Care Settings for Older People in Ireland. The provider was required to complete an action plan to address areas where significant improvements, some improvements and minor issues were required. The inspection report 0165 can be found at www.hiqa.ie. This additional inspection report outlines the findings of a follow-up inspection that took place on 17 February 2011. The inspection was unannounced and focused on the action plan where significant improvements and some improvements required outlined as points one to 10 in this report and minor issues to be addressed as outlined in the recommendations. Summary of findings from this inspection The follow-up inspection was facilitated in a helpful and welcoming way by the nurse in charge and other staff on duty. The person in charge was not in the centre during the inspection, nursing and other staff on duty could identify who the acting person in charge was on the day. The inspector arrived unannounced at 14:40 hrs and found the centre was warm and clean. There were a number of activities going on and a number of residents were going out for an afternoon trip. The inspector spoke to a number of residents and all were complimentary about the staff, facilities and the care they were receiving. The progress of the actions agreed with the provider to address the issues outlined in the report of 2 and 3 June 2010 was reviewed. The inspector found that eight out of the 10 actions outlined in the Action Plan had been fully addressed and two had not been fully completed however, one of the incomplete actions remained within the agreed timeframe of 30 March 2011. The provider and person in charge have put in place actions to address the issue raised in best practice recommendation in line with the National Quality Standards for Residential Care Settings for Older People in Ireland. Overall the staff have made substantial improvements and addressed the actions in their action plan. Documents such as the statement of purpose, the emergency plan and the Page 5 of 17
residents guide requested on the previous inspection had been submitted in a timely fashion and meet legislative requirements. Residents were being reviewed regarding their moving and handling requirements, complaints, residents financial accounts and residents laundry issues identified on the previous inspection had been addressed satisfactorily. Page 6 of 17
Actions reviewed on inspection: 1. Action required from previous inspection: Amend the statement to incorporate all matters as listed in Schedule1of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended). Ensure the statement of purpose accurately describes the service provided, specific categories of care and the level of need which can be safely and appropriately met. This action had been addressed in full. Prior to the inspection an updated statement of purpose had been submitted to the Authority. Having read the document the inspector was satisfied that it incorporated all matters as listed in Schedule 1. The service to be provided was clearly outlined and the level of need the centre could appropriately care for was included. 2. Action required from previous inspection: The registered provider shall ensure that there is an emergency plan in place for responding to emergencies. The plan to include an outline of the resources available, specific contact details and arrangements to evacuate residents if required. This action had been addressed in full. Prior to the inspection an updated emergency plan was submitted to the Authority. The inspector reviewed the document and was satisfied that resources available, specific contact details and arrangements to evacuate residents if required were clearly documented. Staff spoken with during the inspection were knowledgeable regarding the procedure to be followed in the event of an emergency. 3. Action required from previous inspection: Compile a residents guide which accurately reflects the statement of purpose and contains all of the information as required in the legislation. This action had been addressed in full. Prior to the inspection an updated residents guide was submitted to the Authority. The inspector reviewed the document and was satisfied that the residents guide accurately reflected the statement of purpose. The inspector noted during inspection that copies were available to residents in their bedrooms Page 7 of 17
4. Action required from previous inspection: Establish best practice procedures in the moving and handling of residents, to include assessment of residents, individual moving and handling plans, staff training and monitoring of practice. This action had been addressed in full. During the inspection the inspector reviewed a sample of residents files and noted that all residents had a recent moving and handling assessment which outlined the procedure to be used by staff, the equipment required to transfer residents for example, wheelchair or hoist and if the resident used alternative devices such as a walking frame. The inspector observed staff moving residents around the centre during the inspection and found that best practice principle were being adopted. The inspector also saw staff transporting residents around the centre using wheelchairs, all appropriate safety precautions were in place. The inspector spoke to the person in charge from the other centre owned by St Colmcille's Nursing Home Ltd. She informed the inspector that she was a manual handling instructor for the two centers and since the last inspection all staff had been trained, prior to certificates being issued they had a manual handling assessment. The inspector reviewed staff training documentation and confirmed this to be the case. 5. Action required from previous inspection: Review the management and recording of complaints so that all complaints are documented in a timely and complete manner. Record all investigations, actions, outcomes and learning on each individual complaint and ensure that this record meets the requirements of the legislation Record notification of the complainant of the outcome of the complaint and his/her satisfaction or otherwise of the outcome and any other follow up action taken. Put in place a written policy and procedure which meets the requirements of the legislation including an independent appeals process. This action had been addressed in full. The inspector reviewed the complaints folder and noted that three complaints had been recorded since 18 January 2011. Two were from residents and the other was from a family member. All were documented as per policy and responded to in a timely fashion by the person in charge; satisfaction of the complainant was recorded and follow up action documented. The inspector reviewed the complaints policy and was satisfied that all legislative requirements including the appeals process were in place. Page 8 of 17
6. Action required from previous inspection: Establish a forum for consultation with employees on all aspects of health and safety as required by legislation. Provide for the election by democratic process of a health and safety representative for staff as provided for in the legislation. Review on a regular and at least annual basis, all health and safety statements and establish and maintain a system to address all risks identified and transfer of learning from the outcome of these reviews. Ensure all staff are aware of their responsibilities in relation to health and safety legislation. This action had been partially addressed however; the outstanding action remained within the agreed timeframe of 30 March 2011. The inspector spoke with the nurse in charge regarding safety representatives and was informed that two staff members had been elected. The nursing in charge was one of the persons elected and he was able to discuss the principles of health and safety and informed the inspector that monthly meeting with all staff were in train. The inspector saw a notice posted in the staff room announcing a health and safety meeting which was to be held 25 February 2011. The inspector spoke with the person in charge from the other nursing home regarding the Health and Safety statement which was to be compiled by an external consultancy firm. A copy of the statement for her nursing home was available however; a statement for St. Colmcille s was not available for review. 7. Action required from previous inspection: Action required: Amend the current financial management system to include the process of providing residents with a regular statement on their financial status. This action had been addressed in full. The inspector viewed records maintained by the administrator regarding residents personal monies and checked one residents account. Receipts were kept for all transactions and the amount of money in safe keeping corresponded with the balance sheet recorded. The centre currently manage the financial account of one resident, the person n charge is the nominated agent, a copy of the agreement was retained in the centre and the resident was provided with a copy for her records. The inspector viewed monthly statements which were provided to the resident. Page 9 of 17
8. Action required from previous inspection: Review arrangements to ensure that systems in place to minimise the loss of residents clothing are robust. Establish appropriate systems and processes which ensures residents clothing is carefully maintained and neatly stored. Put in place regular audit and review of systems and processes established. Ensure that audits are recorded and that all actions and outcomes arising are addressed and/or implemented as appropriate This action had been addressed. The inspector visited the rooms of some residents and noted that their wardrobes were neat and tidy. Clothing belonging to the occupant was clearly marked and appropriately stored. All residents looked well presented with appropriate apparel in place. 9. Action required from previous inspection: A complete review of the design and layout of the premises and the provision of suitable and sufficient equipment required to meet the needs of all residents is required. Review laundry facilities and put in place such facilities as is required to meet the current legislative requirements and the National Quality Standards for Residential Care Settings for Older People in Ireland. Provide suitable and sufficient equipment as required to meet the needs of residents and the requirements of the legislation specifically, separate cleaning facilities with safe lockable storage for chemicals, sluicing sink, external mechanical ventilation and adequate and appropriate hand washing facilities for catering and non catering staff. Provide separate toilet and shower facilities for catering and non catering staff. Provide a wash-hand basin hairdressing sink and external mechanical ventilation in the hairdressing room. Provide lockable storage space and provision for access to private telephone in each resident s bedroom. Secure the outer perimeter of the centre on all sides. Replace or repair the flooring in the staff canteen. Page 10 of 17
This action had been partially addressed. The inspector viewed the premises and found that the following issues had been addressed: the inspector spoke with the laundry assistant who demonstrated good knowledge of infection control procedures. She informed the inspector of the new system in place regarding the segregation of clean and soiled laundry. The inspector went to the laundry and noted that the doors to the laundry were double doors which could be opened on both sides; these doors were clearly marked to denote soiled laundry would be taken in on the left side and clean laundry would exit on the right. The floor had been marked with zones outlining segregation. A hand washing sink had been installed, additional worktop space had been provided and the ironing board was positioned within the clean area. each resident had a secure lockable space in their bedroom separate toilet and shower facilities were available for catering and non catering staff the outer perimeter of the centre was secured with fencing on all sides the flooring in the staff canteen had been replacement chemical were securely locked in the sluice room The following issues had not been addressed: a hairdressing sink had been installed in the hairdressing room however, there was no hand washing sink or mechanical ventilation in place there was no sluicing sink available in the sluice room there was no mechanical ventilation in the cleaning room 10. Action required from previous inspection: Review or replace the directory of residents to ensure it includes all of the information specified in schedule 3 of the (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended). This action had been addressed in full. The inspector reviewed the directory of residents and confirmed that all the items as specified in schedule 3 of the (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) were included. Page 11 of 17
Recommendations These recommendations are taken from the best practice described in the National Quality Standards for Residential Care Settings for Older People in Ireland and the registered provider should consider them as a way of improving the service. Standard Standard 11: The Resident s Care Plan Best practice recommendations Review care plans to ensure each assessed need is reflected in an individual care plan that is resident specific. Provider s response: There is now a greater emphasis and more strategic approach in relation to the above. When the staff nurses are handing over to each other, it is done via care plans. This approach ensures that all identified needs are reflected via use of a specific care plan. Inspectors findings: The inspector reviewed a number of residents care plans and noted that needs were assessed and reflected in individualised care plans. However, the inspector noted that in one residents notes the front page of her mobility care plan stated that she used a tripod for mobility with the assistance of 1 staff member. Her care plan was reviewed on the evaluation sheet at the back of the plan and stated that she is chair bound following a recent hospitalisation and she is only up out of bed for short periods. This discrepancy in information has the potential to lead to inappropriate care being delivered and the resident s needs not being met. Page 12 of 17
Report compiled by: Florence Farrelly Inspector of Social Services Social Services Inspectorate Health Information and Quality Authority 29 March 2011 Chronology of previous HIQA inspections Date of previous inspection Type of inspection: 2 and 3 June 2010 Registration Scheduled Follow up inspection Announced Unannounced Page 13 of 17
Health Information and Quality Authority Social Services Inspectorate Action Plan Provider s response to additional inspection report * Centre: St Colmcille s Nursing Home Centre ID: 0165 Date of inspection: 17 February 2011 Date of response: 05 April 2011 Requirements These requirements set out what the registered provider must do to meet the Health Act 2007, the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) and the National Quality Standards for Residential Care Settings for Older People in Ireland. 1. The provider has failed to comply with a regulatory requirement in the following respect: A health and safety statement for every identified risk was not in place. Action required: Put in place a health and safety statement that identifies all risks within the centre Action required: Review on a regular and at least annual basis, all health and safety statements and establish and maintain a system to address all risks identified and transfer of learning from the outcome of these reviews. * The Authority reserves the right to edit responses received for reasons including: clarity; completeness; and, compliance with legal norms. Page 14 of 17
Reference: Health Act, 2007 Regulation 30: Health and Safety Standard 26: Health and Safety Please state the actions you have taken or are planning to take with timescales: Timescale: Provider s response: Health and Safety statement is now completed and it has identified all risks in St.Colmcilles nursing home. Completed 24 February 2011 2. The provider has failed to comply with a regulatory requirement in the following respect: The physical design and layout of the centre and the level of equipment provided does not fully meet the needs of the residents. Action required: Provide a wash-hand basin hairdressing sink and external mechanical ventilation in the hairdressing room. Action required: Provide a sluicing sink and external mechanical ventilation in the cleaning room Reference: Health Act, 2007 Regulation 19: Premises Standard 25:Physcial Environment Please state the actions you have taken or are planning to take with timescales: Timescale: Provider s response: Wash hand basin in the hairdressing room will be inserted in the hairdressing room. Mechanical ventilation is now completed in the hairdressing and cleaning room. Sluicing sink will be available in the cleaning room as soon as possible, as it will involve alterations to the room. 31 July 2011 19 February 2011 31 July 2011 Page 15 of 17
Recommendations These recommendations are taken from the best practice described in the National Quality Standards for Residential Care Settings for Older People in Ireland and the registered provider should consider them as a way of improving the service. Standard Standard 11: The Resident s Care Plan Best practice recommendations Consider reviewing the method currently in place for reviewing residents care plans to ensure up to date care needs are reflected in the actual care plan. Page 16 of 17
Any comments the provider may wish to make: Provider s response: The current system for reviewing care plans is currently being researched so as to establish best practice and suitability for St. Colmcille s Nursing Home Provider s name: Tom Ryan Date: 05 April 2011 Page 17 of 17