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: St Augustine's Community Nursing Unit Health Service Executive Cathedral Road, Ballina, Mayo Type of inspection: Announced Date of inspection: 05 April 2018 Centre ID: OSV-0000649 Fieldwork ID: MON-0021147 Page 1 of 19

About the designated centre The following information has been submitted by the registered provider and describes the service they provide. St Augustine s Community Nursing Unit is a 33 bedded community nursing unit which is under the management of the Health Service Executive (HSE). It is situated in the town of Ballina close to St. Muradech s Cathedral. Nursing care is provided to long stay and respite residents who have increasing physical frailty, some living with dementia and others requiring assistance with mental health or palliative care needs. The environment is stimulating and friendly. The philosophy of care is to embrace positive ageing and place the older person at the centre of all decisions in relation to their care and support. The service promotes independence, health and wellbeing. The voice of the resident is paramount in all decision making, while recognising the importance of involving family and friends. Accommodation includes single and twin rooms. A safe accessible courtyard garden and a further garden to the front of the building was available. A day care service is provided 5 days per week. Communal space is shared by day and residential residents. A maximum of nine people attend daily. The amalgamation of day care clients with residents is a source of stimulation as residents frequently meet up with neighbours and friends and enjoy catching up on the local news. One resident told the inspector we hear the local gossip. The following information outlines some additional data on this centre. Current registration end date: Number of residents on the date of inspection: 18/06/2018 32 Page 2 of 19

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 19

This inspection was carried out during the following times: Date Times of Inspection Inspector Role 05 April 2018 11:00hrs to 20:00hrs Mary McCann Lead Page 4 of 19

Views of people who use the service The inspector spoke with 15 residents, who were unanimous in their views that they were treated well by staff. They told the inspector they were well cared for, the staff were very good to them and staff were polite, courteous and friendly. They confirmed that they felt safe in the centre and if they had a worry or a concern they would speak to one of the staff. They were complimentary of how they were helped to maintain good health, how staff respected their wishes, how they had choice as to how could spend their day, the food and the laundry service. Residents were complimentary of the premises, the gardens and the garden furniture and ornaments to include the ornamental donkey and cart and the bird bath. Visitors spoken with stated they were given a warm welcome and offered refreshments. Throughout the inspection, residents were seen to be treated with dignity and respect, choices were being respected, and staff was working to ensure residents needs were met. The activity programme was seen to engage a range of the residents with beauty therapy, bingo, card games, reminiscence sessions, reading the local newspaper and music forming part of the activity schedule. Residents described to the inspector how well they got on together and how they enjoyed their time. Capacity and capability The provider is the Health Service Executive (HSE), represented by the general manager for the Mayo / Roscommon area. A robust management structure was in place which provided a good oversight of the service and ensures the delivery of a safe quality service.the provider representative has changed since the last inspection and was described by the person in charge as interested in the provision of and committed to ensuring a person centred service was provided with positive outcomes for residents. This included a management structure, good communication, clear assignment of defined roles and responsibilities and clear accountability arrangements.the registered provider representative held monthly meetings with the person in charge. Minutes were available of these which showed that areas that required review were discussed and action plans developed to address any deficits identified. A senior nurse was on duty in the absence of the person in charge which ensured good management systems that supported accountability and appropriate support and supervision within the service. Notifications in line with the regulations of serious incidents were submitted to HIQA. Where a serious incident occurred, effective governance arrangements ensured that when something went wrong, staff and the registered provider representative were able to assure HIQA that they could maintain the Page 5 of 19

safety and welfare of residents. Quality and safety meetings took place every two months to review incident and accidents and risk management procedures. All accident and incident records were reviewed by the person in charge and reported to the registered provider representative. Any deficits identified were addressed to try and prevent re-occurrence and decrease the risk of injury to residents. Previous inspections of the centre demonstrated a good level of compliance and a good standard of care. The last inspection which took place in November 2016 was a dementia thematic inspection, where dementia care was found to be of a good standard. The provider and person in charge had ensured that seven of the ten actions from the previous inspection were addressed and the actions in regard to the premises, provision of occupational therapy services and more comprehensive recording of fire drills were in the process of being addressed. A comprehensive annual review for 2017 of the quality and safety of care delivered to residents which outlined the service provided, audits undertaken, their results and feedback from residents' and relatives surveys was completed. It outlined the improvements made in 2017; however, it required a more robust quality improvement plan where any deficits or improvements planned were documented with a time line and details of personnel responsible for their enactment had been completed. The policy for the management of complaints provided a clear procedure and named the person in the centre responsible for managing complaints, and the oversight arrangements. The procedure was on display in a prominent place in the centre and residents who gave feedback to the inspector and in residents' and relatives' questionnaires confirmed they understood the process and felt any issues raised would be addressed. There were good recruitment practices for staff. The registered provider representative had ensured that there were adequate staff to ensure the effective delivery of care in accordance with the statement of purpose. This was supported by a review of the rosters which showed that the staffing levels during the inspection were the usual staffing levels. No relative or residents spoken with or in the completed pre registration questionnaires raised any issue with regard to staffing levels. The person in charge confirmed that if residents needs required an extra staff for example at end of life care or responsive behaviour (how people with dementia or other conditions may communicate or express their physical discomfort, or discomfort with their social or physical environment) this would be facilitated. Opportunities to complete training courses to ensure staff had the relevant skills to meet the needs of residents were available. Many staff had completed training in the delivery of care to residents with dementia and in other areas for example hand hygiene, advocacy for the older person and end-of-life care. A training plan for 2018 was in place and included training in auditing, infection control, care planning, assessing capacity, delivering bad news well and nutritional care. Page 6 of 19

Registration Regulation 4: Application for registration or renewal of registration The registered provider representative has changed since the last inspection. A signed and dated application for renewal of registration of this centre which contained all of the information set out in schedule 1 of the registration of designated centre for older people regulations 2015 was submitted by the registered provider representative on behalf of the registered provider. This application was to register 33 beds. The fee for the application to renew registration together with the statement of purpose and floor plans of the centre were also submitted. Judgment: Registration Regulation 6: Changes to information supplied for registration purposes There has been a change of provider representative since the last registration of this centre and this is reflected in the application form Judgment: Regulation 14: Persons in charge The person in charge is a registered nurse who has the appropriate experience in working in older persons services. She works full-time and is engaged in the management and administration of the designated centre. Judgment: Regulation 15: Staffing An actual and planned roster was available with any changes clearly indicated. The number and skill mix of staff met the assessed needs of residents. Staff displayed a good knowledge of residents' preferences and were observed to spent time chatting with residents in a pleasant respectful manner. Judgment: Page 7 of 19

Regulation 16: Training and staff development Staff had access to appropriate training, were appropriately supervised and training had been delivered on the Health Act and associated regulations. Copies of the Health Act and the current regulations made under the Act were available in the centre Judgment: Regulation 19: Directory of residents The directory of residents contained all of the information required by schedule 3 of the regulations and was maintained up to date. Judgment: Regulation 21: Records Records listed in Schedules 2, 3 and 4 of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People Regulations 2013 (as amended) were available and were stored and maintained securely. The person in charge confirmed that all staff had been vetted by An Garda Síochána (police). Judgment: Regulation 22: Insurance An up-to-date contract of insurance was in place which provided cover for residents against injury and loss or damage to their property. Judgment: Page 8 of 19

Regulation 23: Governance and management A quality management system was in place. This included audits with regard to nutritional care, infection control, care documentation, health and safety and hygiene audits. While the inspector could see that deficits identified had been addressed, there was no formal quality improvement plan enacted following audits which showed the timescale from when the deficit was identified to when it was addressed, or dates for re-auditing to ensure sustainable improvement. Judgment: Substantially compliant Regulation 24: Contract for the provision of services Contracts were signed and dated and detailed all services and fees payable. The contracts of care detailed the room to be occupied by the resident but did not detail whether the room was a single or shared as required by the 2016 regulations. Judgment: Substantially compliant Regulation 3: Statement of purpose The statement of purpose outlined the ethos and aims of the centre. While it contained all the matters as per Schedule 1 of the regulations, it failed to provide adequate detail in some areas for example, a description of each room in the centre, its capacity and function. A revised statement of purpose has been submitted since the inspection. Judgment: Regulation 31: Notification of incidents Incidents and quarterly returns had been notified to the Chief Inspector. However, a report had not been provided to the Chief Inspector at the end of each six month period in the event of no three day notifiable incident occurring in the centre. Page 9 of 19

Judgment: Substantially compliant Regulation 34: Complaints procedure An effective and accessible complaints procedure, which included an appeals procedure was available to residents. This was displayed in a prominent position in the centre and a summary was contained in the residents guide which was available to all residents. Complaints made were recorded and investigated, and records showed that a resolution was reached and the complainant was satisfied with the outcome of their complaint. A suggestion box was available in the reception area. Judgment: Regulation 4: Written policies and procedures The provider had ensured that all policies listed in schedule 5 were available in the centre. Further policies and procedures to inform practice were available in the centre. Judgment: Quality and safety As the registered provider and person in charge had good governance structures in place which included a quality management system and adequate resources to ensure appropriate staffing levels, this ensured a safe quality service was delivered to residents. The centre had an ethos of providing a person centred care service where the residents were encouraged to voice their views, these were listened to, and acted upon ensured that residents had a good quality of life living in the centre. The administrator in conjunction with a local shop ran a service for residents where residents chose what they required and had an account with the administrator. This ensured that residents had control over the purchase of their toiletries and personal items of choice for example their favourite treats especially those who had few visitors. A comprehensive overview document entitled My support plan at a glance was in place for all residents. This detailed a very good person centred view of the resident way of life, their likes dislikes and how they wished to live their life with the resident as the driving force supported by staff and services provided. For example, How you can help me to do the things I can still do and support me with the things Page 10 of 19

I find difficult. How dementia has affected my thinking and doing.pre admission assessment was completed to ensure the centre could meet residents needs. Many residents had been in respite or day-care prior to admission and knew the staff and the type of service provided. All residents had a comprehensive assessment completed on admission which focused on their abilities and current care and support needs. Care plans were enacted as required and reviewed at four monthly intervals and in most instances contained enough detail to ensure the delivery of safe quality care. Where residents were seen by a specialist service their advice was incorporated into the care plan to ensure a comprehensive care package was delivered to residents. A review of residents medical notes showed that residents had access to regular review by the general practitioner. A narrative record was recorded daily and this gave an overall clinical picture of the resident. There was evidence of resident/relative involvement in the care planning process. Access to a wide range of allied health was available. Systems were in place to prevent unnecessary hospital admissions. Staff had been trained in sub-cutaneous fluid administration and the centre had good links with the palliative care team. Good processes were in place in regard to transfers and discharge of residents and hospital admissions with evidence available of communication between the centre and acute care services when a resident was being transferred for care. Comprehensive information was provided in relation to medication when residents were admitted to the centre. Safe management systems were in place with regard to medication management. These included a comprehensive policy, safe storage and training for staff. A pharmacist was available for consultation with residents if required. A recording system to monitor and review any medication errors was in place. The nutritional needs of residents were well met. Fresh meat, vegetables, fish and fruit was available. Homemade scones, cakes and deserts were available. Likes and dislikes were recorded and residents told the inspector that these were respected. Residents on a modified diet could choose from the same menu as regular diets. All food was cooked fresh daily. Weights were recorded monthly and more regularly according to clinical need. There was adequate staff on duty to support residents at meal times. Those with any identified nutritional care needs had a nutritional care plan in place. The centre had acquired two ABLE (ability tables) These tables assisted residents to be more independent at meal times as residents in assisted chairs could sit into the tables comfortably and theses tables were adjustable. They also provided for staff to sit discreetly beside a resident. End of life care was delivered according to a person centred care plan where there was evidence of discussion with residents about their wishes and there was also evidence where appropriate of input from families and significant others. The centre was supported by community palliative care services. The oratory is available to residents and their families for private prayer and if residents or relative choose to repose the body of their loved one. Staff had undertaken training in end of life care. Page 11 of 19

Residents had the opportunity to participate in activities that were meaningful and purposeful to their individual needs and interests. An assessment of all residents preferred activities had been completed. Care staff supported an activity programme and a varied activity schedule which included music sessions, art, exercise groups and reminiscence was in place. The inspector observed staff providing assistance to residents where required and noted that the manner and attitude of staff was pleasant with a good rapport between staff and residents. Most staff had undertaken training in dementia care and management of responsive behaviour. A priest attended the centre on a weekly basis to celebrate Mass. Other pastoral services could also be made available if required. A remembrance mass was held each November. Staff described informal individual consultation with residents which occurred on a daily basis. A residents advocacy group which includes residents and family members, meets every two months. Minutes were available of these meetings. An independent advocacy service is available to residents. Contact details for this service were displayed in the centre. Residents are facilitated to exercise their civil, political, rights, some residents were registered to vote and residents had access to a radio and television. National and local newspapers were also available. There were no restrictions on visitors attending the centre. The health and safety of residents, staff and visitors was promoted and protected. A detailed emergency plan was in place to guide staff in responding to an emergency. Good falls prevention measures were in place including low entry beds, crash mats and alarm sensor mats. A procedure for the safe evacuation of residents and staff, in the event of fire, was prominently displayed. All staff had received training in fire safety and evacuation procedures and knew what to do in the event of a fire and a personal emergency evacuation plan completed which considered the mobility and aids required to evacuate was available for each resident. Fire evacuation plans showing the building layout and nearest evacuation route were displayed. A fire assembly point was identified. Fire fighting equipment and emergency lighting was serviced annually and the fire alarm was serviced quarterly. Regulation 10: Communication difficulties A communication assessment formed part of the initial comprehensive assessment. Care plans were in place detailing the communication needs of residents. A nonverbal menu guide was available. Judgment: Regulation 11: Visits Page 12 of 19

Unrestricted visiting was in place with the exception of mealtimes. A visitors record was in place to ensure the safety and security of residents. A visitor s room was available so that residents could receive visitors in private. Judgment: Regulation 12: Personal possessions An individual wardrobe and locker with a locked drawer was available to each resident. Clothing was laundered regularly on site. An inventory and labelling system was in place. Transparent arrangements were in place with regard to managing residents finances with two staff signatures available for all transactions. where the resident was deemed to have capacity they also signed. The registered provider acted as an agent for two residents. Statements were received on a fortnightly basis from the finance department. Comfort monies were given to the resident on a weekly basis. Judgment: Regulation 13: End of life Where a resident was approaching the end of their life the resident had a care plan in place which was based on their assessed care needs. On review of a recent endof-life care file, the inspector was satisfied that appropriate end-of-life care was given to residents. A single room was offered to residents for end-of-life care and a relatives' room with access to an adjoining toilet was available. Where decisions had been made with regard to advance care these were recorded. Support and advice was available from the local palliative care team. Staff were provided with training in end-of-life care. Judgment: Regulation 17: Premises A bathroom and two accessible shower rooms are available for 31residents. This does not comply with current national standards. A further 5 additional toilets are available. Aspects of the premises require review, this includes The dining room door is narrow and it is difficult to manoeuvre residents into the Page 13 of 19

dining room.this was an action at the time of the last inspection and while some discussion has taken place with regard to remedying this, it has not been completed. The decor in the dining room is dull and dated. A stainless steel style storage unit which is not domestic in nature is in the dining room. The hand rail into the courtyard garden requires painting Judgment: Not compliant Regulation 18: Food and nutrition The dietary needs of residents were met. A supply of fresh drinking water was available to resident s. on the day of inspection there was a choice of food available to residents at meal times and residents told the inspector that this was a daily occurrence and their food preferences were honoured. The inspector observed that food served was wholesome and nutritious. Judgment: Regulation 20: Information for residents A residents guide which included a summary of the services and facilities offered to residents was available. This guide also provided information on the terms and conditions of residing in the centre, the complaints procedure and arrangements for visits. Judgment: Regulation 25: Temporary absence or discharge of residents Processes were in place to ensure that when residents were admitted, transferred to hospital or other establishments, or discharged to and from the centre, relevant and appropriate information about their care and treatment was available, and shared between services. Judgment: Page 14 of 19

Regulation 26: Risk management Missing persons profiles were available for all residents. Missing person drills were not being completed. Judgment: Substantially compliant Regulation 27: Infection control Commodes were stored in the bathroom this does not comply with good infection control practice. Judgment: Not compliant Regulation 28: Fire precautions Improvements were required in relation to the recording and completion of fire drills. The records indicated the duration of the drills and the staff that took part, however they did not identify if there were any impediments to swift evacuation and describe what actually occurred, was there a full or part evacuation. Additionally no drill had been undertaken with night staffing levels and in the area where the greatest number of residents would require evacuation. Judgment: Substantially compliant Regulation 29: Medicines and pharmaceutical services Prescription and administration records contained appropriate identifying information, including residents photographs, and were clear and legible. Where medication was being crushed, this was prescribed as safe to use in this format. Medicines were stored securely in accordance with best practice guidelines. Judgment: Regulation 5: Individual assessment and care plan Page 15 of 19

Comprehensive assessment of all activities of daily living and a range of assessment were completed on admission. Care plans were developed to address problems or if a potential risk was identified. Care plans were kept under formal review on a fourmonthly basis or as required by the residents' changing needs in consultation with residents or their representatives Judgment: Regulation 6: Health care A general practitioner (GP) of the residents choice was available to residents. Current residents had been seen by an occupational therapist for seating assessments but this service was not available at the time of this inspection. Judgment: Substantially compliant Regulation 7: Managing behaviour that is challenging ABC charts (assessment forms) were being completed in order to assess if there was a pattern of behaviour and if there was any antecedent to the behaviour. Behaviour management plans were in place to guide staff when working with residents who had responsive behaviours (how people with dementia or other conditions may communicate or express their physical discomfort, or discomfort with their social or physical environment); however, not all contained a personalised strategy for the management of the behaviour. Judgment: Regulation 8: Protection A review of incidents since the previous inspection showed that no allegations of abuse had been reported. where a notification of an allegation of abuse had been submitted in the past this was appropriately managed. All staff had undertaken training in safeguarding vulnerable adults at risk of abuse. Staff were aware of the role and reporting arrangements to the local safeguarding team. Staff confirmed that they would report any suspected allegation of abuse.. Page 16 of 19

Judgment: Regulation 9: Residents' rights One resident is unable to access the dining room as the dining room door is too narrow to accommodate her specialist chair. Judgment: Not compliant Page 17 of 19

Appendix 1 - Full list of regulations considered under each dimension Regulation Title Capacity and capability Registration Regulation 4: Application for registration or renewal of registration Registration Regulation 6: Changes to information supplied for registration purposes Regulation 14: Persons in charge Regulation 15: Staffing Regulation 16: Training and staff development Regulation 19: Directory of residents 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 10: Communication difficulties Regulation 11: Visits Regulation 12: Personal possessions Regulation 13: End of life Regulation 17: Premises Regulation 18: Food and nutrition Regulation 20: Information for residents Regulation 25: Temporary absence or discharge of residents 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 Substantially compliant Substantially compliant Substantially compliant Not compliant Substantially compliant Not compliant Substantially compliant Substantially compliant Not compliant Page 18 of 19

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Compliance Plan for St Augustine's Community Nursing Unit OSV-0000649 Inspection ID: MON-0021147 Date of inspection: 05/04/2018 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 8

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 Substantially Outline how you are going to come into compliance with Regulation 23: Governance and management: A quality improvement plan has been introduced to reflect the persons responsible and due date for actions required to address deficits following audit. The audit schedule has been amended to ensure areas are re-audited ensuring continuous improvement. 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: All existing service user contracts have been amended to reflect the number of people occupying the room. This will be done on admission, ongoing. Regulation 31: Notification of incidents Substantially Outline how you are going to come into compliance with Regulation 31: Notification of incidents: In future the Chief Inspector will be notified at the end of each six month period in the Page 2 of 8

event there are no three day notifiable events. Regulation 17: Premises Not Outline how you are going to come into compliance with Regulation 17: Premises: Narrow Doorway This area has significant design, Structural as well as fire safety issues that prohibit a prompt resolution and in this regard has been referred to HSE Estates for a design that resolves the issue. Decorate dining room A request will be made for minor capital to obtain funding for same. Stainless Steel Cupboard This will be removed when the new cupboard, which is on order, arrives. 1 assisted bathroom needed this unit was refurbished commencing in 2015 in line with the then National Quality Standards for Residential Care Settings for Older People at a ratio of 1 assisted bathroom/shower to 11 residents. We note the change in 2016 standards of 1 to 8 residents. At present we feel we are conforming with Regulation 17(2) schedule 6 in regards to providing a sufficient number of assisted bathrooms/showers to meet the needs of our current residents. We are satisfied that our SOP on bathing ensures that the operational plan for bathing can satisfactorily achieve the bathing of all residents as required within an acceptable time frame. There have been no complaints or incidents around the bathing/showering of clients. We will continue to review this situation as new residents are admitted. Hand rail to courtyard this has been reported to our maintenance department who will Paint same. Regulation 26: Risk management Substantially Outline how you are going to come into compliance with Regulation 26: Risk management: Missing persons drills to be commenced 5 th June 2018, and will continue on a regular planned basis thereafter Page 3 of 8

Regulation 27: Infection control Not Outline how you are going to come into compliance with Regulation 27: Infection control: Commode storage: We are going to establish an area within the designated centre to store commodes in by the 30 th September 2018 Regulation 28: Fire precautions Substantially Outline how you are going to come into compliance with Regulation 28: Fire precautions: Fire drills will continue to be conducted regularly but will reflect the number of staff on duty and number of residents to be evacuated from the particular zone, time taken and any problems encountered. Drills will be conducted with night staffing numbers in the area with the highest number of residents. Regulation 6: Health care Substantially Outline how you are going to come into compliance with Regulation 6: Health care: We had previously an arrangement with an Agency Occupational Therapist who serviced Ballina but the OT is now unable to cover this area. We are liaising with several agencies to get cover for the designated centre. Regulation 9: Residents' rights Not Outline how you are going to come into compliance with Regulation 9: Residents' rights: Narrow Doorway This area has significant design, Structural as well as fire safety issues that need to be considered and in this regard has been referred to HSE Estates for advice on how to proceed Page 4 of 8

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Section 2: Regulations to be complied with The provider or person in charge must consider the details and risk rating of the following regulations when completing the compliance plan in section 1. Where a regulation has been risk rated red (high risk) the inspector has set out the date by which the provider or person in charge must comply. Where a regulation has been risk rated yellow (low risk) or orange (moderate risk) the provider must include a date (DD Month YY) of when they will be compliant. The registered provider or person in charge has failed to comply with the following regulation(s). Regulation Regulation 17(2) Regulation 23(c) Regulatory requirement The registered provider shall, having regard to the needs of the residents of a particular designated centre, provide premises which conform to the matters set out in Schedule 6. The registered provider shall ensure that management systems are in place to ensure that the service provided is safe, appropriate, consistent and effectively monitored. Judgment Risk Date to be rating complied with Not Orange 31/12/2018 Substantially Yellow 31/5/2018 Regulation 26(1)(c)(ii) The registered provider shall ensure that the risk management policy set out in Schedule 5 Substantially Yellow 5/6/2018 Page 6 of 8

includes the measures and actions in place to control the unexplained absence of any resident. Regulation 28(1)(e) Regulation 31(4) Regulation 6(2)(c) The registered provider shall ensure, by means of fire safety management and fire drills at suitable intervals, that the persons working at the designated centre and, in so far as is reasonably practicable, residents, are aware of the procedure to be followed in the case of fire. Where no report is required under paragraphs (1) or (3), the registered provider concerned shall report that to the Chief Inspector at the end of each 6 month period. The person in charge shall, in so far as is reasonably practical, make available to a resident where the care referred to in paragraph (1) or other health care service requires additional professional expertise, access to such treatment. Substantially Substantially Substantially Yellow 30/6/2018 Yellow 30/6/2018 Yellow 31/08/2018 Page 7 of 8

Regulation 9(2)(b) The registered provider shall provide for residents opportunities to participate in activities in accordance with their interests and capacities. Not Orange 31/12/2018 Page 8 of 8