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Report of an inspection of a Designated Centre for Older People Issued by the Chief Inspector Name of designated centre:
Heatherlee Nursing Home
Name of provider: Mary O'Brien
Address of centre: Lawlor's Cross, Tralee Road, Killarney, Kerry
Type of inspection: Announced
Date of inspection:
04 March 2020
Centre ID: OSV-0000237
Fieldwork ID: MON-0025208
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About the designated centre
The following information has been submitted by the registered provider and describes the service they provide. Healtherlee Nursing Home is situated five miles outside Killarney town, at Lawlors Cross. The centre is owned and operated since the late 1990s by Mary O Brien who is a Registered Nurse and the named person in charge. The centre aims to promote quality of life and maintain a level of independence through a professional and friendly services. It focuses on the delivery of person centred care, support and treatment in a secure and professional environment. The overall aim is to support dependent people who can no longer live at home independently, in a caring environment with the highest professional standards of nursing care. The accommodation at Healtherlee Nursing Home is suitable for a maximum of 22 residents. It is a single story facility with a frontal courtyard availing of natural light. It comprises of six single and eight twin bedrooms. There are designated seating areas available for residents. The centre has a spacious sitting room, dining rooms and visitors rooms for residents. There is also a secure backyard garden and ample parking for visitors and staff. Healtherlee Nursing Home is intended to care for individuals requiring long or short term nursing or personal care. The residents are predominantly over the age of 50 and have varying dependencies. The centre offers long term care, respite and convalescence care. The following information outlines some additional data on this centre.
Number of residents on the
date of inspection:
19
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How we inspect
This inspection was carried out to assess compliance with the Health Act 2007 (as amended), the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013 (as amended), and the Health Act 2007 (Registration of Designated Centres for Older People) Regulations 2015 (as amended). To prepare for this inspection the inspector of social services (hereafter referred to as 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.
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This inspection was carried out during the following times:
Date Times of
Inspection
Inspector Role
Wednesday 4 March 2020
10:00hrs to 16:30hrs
Ella Ferriter Lead
Thursday 5 March 2020
08:45hrs to 15:00hrs
Ella Ferriter Lead
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What residents told us and what inspectors observed
Feedback was received from residents, both verbally, over the two days of inspection, and through seven residents' questionnaires. Feedback was overwhelmingly positive, in relation to the residents' relationship with the staff in the centre. They described staff as nice, extremely capable, and kind. Residents told the inspector that they felt safe, comfortable and very well looked after. Residents appeared to be relaxed in the company of staff. One resident stated that she loved particularly that it was a small place, and that it was very personal, like a home.
Residents stated that they would always speak to the person in charge if they had any issues or problems. They reported that issues were always dealt with in a timely and satisfactory manner. The residents who the inspector spoke with reported satisfaction with the food, and said choices were available at meal times. Residents spoke of their privacy being protected and having choice about when they get up in the morning, retire at night and where to eat their meals. The inspector observed residents getting up for breakfast at different times of the morning.
The inspector observed that staff knew residents well and took time in care delivery. Many staff spoken to had worked in the centre for more than ten years. They stated they enjoyed their work, and were observed taking time with residents and treating them with dignity and respect. Staff encouraged residents to treat Healtherlee as their home.
Capacity and capability
This inspection was undertaken as part of an application by the registered provider to re-register the centre in accordance with the requirements set out in the Health Act 2007 (Registration of Designated Centres for Older People) Regulations 2015. The prescribed documentation was submitted and application fees paid in compliance with the registration regulations.
The accommodation at Healtherlee Nursing home is suitable for a maximum of 22 residents. The centre is a single-storey bungalow situated five miles outside Killarney town. There was evidence of a ''home from home'' environment with an ethos of respect and dignity for residents. Although the centre did not have a dementia specific unit, at the time of inspection there was a significant proportion of the 19 residents living in Healtherlee Nursing Home with a diagnosis of dementia. The inspector found the staff were very committed in providing personalised high quality care to each of these residents. They had an in depth understanding of their individual needs and functional ability. Residents spoken with were familiar with individual staff members, and also recognised the person in charge. The culture of
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care at the centre was community oriented with many residents and members of staff from the local area.
The person in charge was also the Registered Provider of the centre, and and was on site most days. She held sole responsibility for the delivery of the service since commencement of the centre in the late 1990's. She demonstrated a commitment to continuous quality improvement and had taken effective action to address improvements required following the previous inspection of July 2019. She demonstrated thorough knowledge of her role and responsibilities. She is a Registered Nurse and was actively involved in the provision of nursing care to residents on a daily basis, thus giving her good oversight of each residents individual needs. The person in charge was supported in her role by an assistant person in charge, an administrator, senior nurses, care staff, kitchen and domestic staff. The administrator supported the services regarding non clinical matters, such as assisting with recruitment and monitoring staff training. The team of staff were proactive in response to issues as they arose. Some improvements were noted on this inspection in relation to submission of notifications, infection control practices, policies, staff recruitment and resident consultation.
The service was appropriately resourced, with staffing levels in line with that described in the statement of purpose. A sample of rosters were reviewed, and staff and residents confirmed that there were adequate staff on duty at all times. Staff reported it to be a very good place to work. Staff meetings and shift handovers ensured information on residents’ changing needs was communicated effectively. There was evidence that staff received training appropriate to their roles, and all staff had attended mandatory training. There were clear lines of accountability and responsibility. Staff were well supervised and supported in their roles, and there was evidence of an induction and appraisals system in place. Some improvements were required in ensuring two references from previous employers were obtained for all staff.
The statement of purpose was updated on inspection to ensure compliance with the regulations. Copies of the standards and regulations were available and accessible by staff. Written policies and procedures as listed in Schedule 5 were in place, however, some required review to ensure they described centre-specific practice. Good systems of information governance were in place and the records required by the regulations were maintained effectively. A synopsis of the complaints procedure was displayed in the centre, and records demonstrated thorough investigations of formal complaints. All residents had a contract of care in accordance with the regulations. An incident and accident log was maintained in the centre. Based on a review of documentation and from discussion with the person in charge, however, the inspector was not satisfied that all notifications had been submitted as required by the regulations.
The inspector saw evidence that the quality and safety of care provided to residents was being monitored. This was through audits on areas such as falls, medication management, infections and health and safety. However, it was acknowledged that this information was required to be collected more frequently and could be utilised more appropriately, to improve quality and inform the annual review. There was
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evidence of consultation with residents and relatives through satisfaction surveys. The person in charge and her team demonstrated a commitment to on-going improvement and quality assurance, with a focus on the quality of life and quality of care for the residents.
Registration Regulation 4: Application for registration or renewal of registration
All prescribed documentation was submitted and fees were paid in accordance with the registration regulations.
Judgment: Compliant
Regulation 14: Persons in charge
The person in charge is a suitably qualified nurse with extensive experience in the care of older persons. She had a strong presence in the centre and was well known to the residents and families. The inspector was told by residents and family members that there was a culture of open communication in the centre and that they had a positive relationship with the person in charge.
Judgment: Compliant
Regulation 15: Staffing
A review of the staff roster, and the observations of the inspector indicated that there were adequate numbers and skill mix of staff on duty on the days of the inspection to meet the needs of residents. Staff were seen to be kind and caring, and all interactions by staff with residents were conducted in a respectful manner.
Judgment: Compliant
Regulation 16: Training and staff development
There was a comprehensive programme of training and based on records made available to inspectors, all staff had attended up-to-date training in mandatory areas such as safeguarding residents from abuse, manual and people handling, fire safety and responsive behaviour. The human resource policy was centre-specific and included details for the recruitment, selection and vetting of staff. There was an
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induction process for new staff and annual appraisals being preformed.
Judgment: Compliant
Regulation 19: Directory of residents
The directory of residents was reviewed and found to contain all the information required in Schedule 3 of the Regulations.
Judgment: Compliant
Regulation 21: Records
Records in accordance with Schedule 2, 3 and 4 were maintained on the premises. The inspector reviewed a sample of staff files and found that records were very well maintained and easily retrievable. A review of personnel records indicated that most of the requirements of Schedule 2 were met, however, a second employment reference was not available for one registered nurse. Documentation was seen which indicated that staff appraisals were carried out annually. The person in charge stated that all staff were required to have updated Garda (police) vetting clearance in place, for the centre, prior to taking up employment at the centre.
Judgment: Substantially compliant
Regulation 22: Insurance
A certificate of insurance was available confirming that the centre had a contact of insurance in place.
Judgment: Compliant
Regulation 23: Governance and management
Governance was implemented directly through the person in charge with the support of a nominated Assistant Director of Nursing, who also participated in the management of the centre. Management arrangements were set out in the statement of purpose. Care was directed through the person in charge who was in attendance at the centre on a full-time basis. The centre was appropriately
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resourced to ensure effective delivery of care, that was in keeping with the assessed needs of residents.
The quality and safety of the centre was monitored through a programme of audits that included audits of health and safety, infection control, medication management, complaints, restraints, falls and nutrition. While there was a process for collecting data, the inspector noted the system could be enhanced by analysing these areas more frequently and determining trends, as an opportunity for quality improvement. An annual review of the quality and safety of care took place and a copy of the report on this review was available for reference as required by the regulations. However, it did not incorporate an quality improvement action plan for implementation.
Judgment: Substantially compliant
Regulation 24: Contract for the provision of services
All residents had a contract of care, which identified fees including possible additional fees to be charged, and details of the services to be provided.
Judgment: Compliant
Regulation 3: Statement of purpose
There was a written statement of purpose that accurately described the services provided in the centre. It contained all of the information required by Schedule 1 of the regulations.
Judgment: Compliant
Regulation 30: Volunteers
There were no volunteers to the service at the time of inspection. Nonetheless, the person in charge articulated the regulatory requirements should there be volunteers in the centre.
Judgment: Compliant
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Regulation 31: Notification of incidents
The Inspectors reviewed the accident and incident log and found that adequate action was taken in response to individual accidents and incidents such as falls. However, from discussion with the person in charge and from review of documents it was evident that some incidents that occurred in the centre had not been reported to the chief inspector as per the regulations. The inspector acknowledged that these incidents had been investigated and appropriately managed.
Judgment: Not compliant
Regulation 34: Complaints procedure
The complaints procedure was on prominent display in the centre, and it identified the person responsible for addressing complaints and the appeals process. On review of the complaints log there was evidence that complaints were documented, investigated and outcomes recorded. Complainants were notified of the outcome of their complaint and records evidenced whether or not they were satisfied.
Judgment: Compliant
Regulation 4: Written policies and procedures
Current written policies and procedures on matters set out in Schedule 5 were available to staff, and were reviewed and updated in accordance with best practice. Nonetheless, policies required review to ensure they were centre-specific and could guide care delivery.
Judgment: Substantially compliant
Quality and safety
Overall, residents were supported and encouraged to have a good quality of life in Healtherlee Nursing Home, which was respectful of their wishes and choices. The inspector saw that residents appeared to be very well cared for, and residents gave very positive feedback regarding all aspects of life and care in the centre. Care and support given to residents was calm and unhurried. Appropriate assistance was given when needed, and staff demonstrated good communication strategies for
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people with complex communication needs.
The centre was clean, homely, warm, had a good standard of decor and was well maintained. Residents had adequate space to maintain their belongings. Bedrooms were spacious and had adequate space to accommodate furniture and seating, and were decorated in accordance with people's preferences. There was an open visiting policy and visitors were complimentary about the care being delivered and the kindness of staff.
The inspector was satisfied that the healthcare needs of residents were well met. There were a number of local general practitioners (GPs) providing medical services to the centre, and there was evidence of regular reviews of residents. Specialist medical services were also available when required, such as access to psychiatry of older life. The dietitian and speech and language therapist (SALT) visited the centre and reviewed residents. There was evidence that residents had access to other allied healthcare professionals including physiotherapy, dental, chiropody and occupational therapy services. There were written operational policies and procedures relating to the ordering, prescribing, storing and administration of medicines to residents. Residents were facilitated with choice of pharmacy, and pharmacists were supported to fulfil their obligations to residents.
Residents were comprehensively assessed on admission by the person in charge and at regular intervals thereafter using recognised evidence-based assessment tools for issues such as risk of malnutrition, risk of falling, risk of developing pressure sores and dependency level. Care plans were developed based on these assessments. Each resident had an individual assessment and care plan documented. However, improvements were required in care planning documentation. Some care plans reviewed by the inspector did not reflect the quality of person-centred care that was observed to be delivered to the residents, and did not guide and support care delivery. The inspector was satisfied that caring for a resident at end of life was regarded as an integral part of the care service provided. End of life care plans for residents were person centred and the majority of residents had advance care directives in place.
There were adequate measures in place to promote a positive approach to residents that presented with responsive behaviours (how people with dementia or other conditions may communicate or express their physical discomfort, or discomfort with their social or physical environment). Training records indicated that all staff had attended training in responsive behaviour. Detailed care plans were in place identifying possible triggers and appropriate interventions that may meet the needs of residents, and prevent escalation of the behaviour and distress to residents. The inspector observed that all interactions between staff and residents were conducted in a caring and respectful manner. The inspector found that there were measures in place to protect residents from suffering harm or abuse. There was a low use of bedrails. Records indicated the exploration of alternatives to bed rails, such as low low beds, alarm mats and crash mats. Psychotropic medication was kept under review and used infrequently.
The provider had put systems in place to manage risks and ensure that the health
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and safety of all people using the service was promoted. The health and safety statement was reviewed regularly, and appropriate fire safety practices were followed. The fire alarm and emergency lighting were serviced quarterly. All staff had attended up-to-date training in fire safety. Fire drills were held frequently, and detailed records were maintained of the time it took to simulate evacuation and also of any learning from the drills. Staff members spoken with were knowledgeable of what to do in the event of a fire, including horizontal evacuation. Appropriate infection control procedures were in place and staff were observed to abide by best practice in infection control and good hand hygiene. The inspector found there were some areas for improvement in infection control, to meet the requirement of good infection control standards and best practice guidance.
There were opportunities for residents to participate in activities which suited their needs, interests and capacities. There was a full time activities coordinator working in the centre who engaged with activities such as bingo, arts & crafts, music, card playing and sonas. The inspector noted that issues raised by residents and families were brought to the attention of the person in charge and there was documentary evidence of consultation with residents and their relatives on a daily basis, However, there were not regular consultation with residents and their representatives via meetings. Positive interactions between staff and residents were observed during the inspection, and staff availed of opportunities to socially engage with residents, for example, chatting, singing. Advocacy services were available via an external advocate and their was evidence that this service had been utilised appropriately. There was an emphasis on promoting health and general well being of residents in Healtherlee Nursing Home. The centre ensured that the rights and diversity of residents were respected and promoted.
Regulation 10: Communication difficulties
Staff demonstrated good communication strategies for people with complex communication needs. Positive interactions between staff and residents were observed during the inspection. Residents with dementia received care in a dignified way that respected their privacy. The communication policy included strategies for effective communication with residents who had dementia and care plans in individual resident's files supported effective communication.
Judgment: Compliant
Regulation 11: Visits
There was open visiting and visitors were seen to come and go throughout the two days of the inspection. Visitors met with conveyed their satisfaction with the care and the kindness of staff. There was also a small reading room with seating where
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residents could receive visitors in private.
Judgment: Compliant
Regulation 12: Personal possessions
Adequate space was provided for each resident to store and retain control over their personal property. Residents were encouraged to personalise their rooms and many had photographs and other personal belongings in their bedrooms. There were adequate laundry facilities, and there were adequate procedures in place for the segregation of residents laundry.
Judgment: Compliant
Regulation 13: End of life
A policy for end-of-life care was in place. Staff were knowledgeable about the procedures in relation to end-of-life care. Staff spoken described how residents and families are supported in a person-centred and respectful manner. A number of end-of-life care plans were in place and others were being developed with support from relatives. Staff had received training in advance care directives and the majority of the 19 residents had advanced care directives in place. The centre is supported in the delivery of end of life and palliative care by the local palliative care team who visit the centre as required.
Judgment: Compliant
Regulation 17: Premises
The location, design and layout of the centre was suitable for its stated purpose and met residents’ individual and collective needs in a comfortable and homely way. The inspector found it to be well maintained and nicely decorated. It was warm, clean and odour free throughout. The communal areas had a variety of comfortable furnishings and were domestic in nature. Residents had access to an enclosed garden which was easily accessible. Signage had been improved since the previous inspection.
Judgment: Compliant
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Regulation 18: Food and nutrition
Residents nutritional status was kept under review. There was access to SALT and dietetics services. Food appeared to be nutritious and staff paid particular attention to ensuring that modified consistency food was attractively presented and appetising in appearance. Residents had a choice of food at mealtimes and there was access to drinks and snacks between meals. The chef was knowledgeable about the individual needs of each resident. There was also good communication between catering and healthcare staff about the needs and preferences of residents.
Judgment: Compliant
Regulation 20: Information for residents
Residents had access to a residents guide which contained all the information required under Regulation 20.
Judgment: Compliant
Regulation 25: Temporary absence or discharge of residents
There were processes in place to ensure that when residents were admitted, transferred or discharged to and from the centre, relevant and appropriate information about their care and treatment was available. This included where residents were attending appointment at local clinics or with consultants.
Judgment: Compliant
Regulation 26: Risk management
There was an up-to-date safety statement that was signed and dated. There was a risk management policy that addressed the risks specified in the regulations. There was a risk register that identified clinical and non-clinical risks and this had controls in place for the risks identified. There was an emergency plan in place which included clear guidance for staff in the event of a wide range of emergencies including the arrangements for alternative accommodation should it be necessary to evacuate the building.
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Judgment: Compliant
Regulation 27: Infection control
There was a comprehensive infection control policy in place. Hand sanitising dispensing units were located at the front entrance and throughout the building. The inspector observed that the building was maintained in a clean condition throughout. All staff had received training on infection control procedures. Some improvements were required in relation to compliance with the centres own policy, on the wearing of protective clothing by all members of staff entering the kitchen, and the storage of equipment in communal bathrooms.
Judgment: Substantially compliant
Regulation 28: Fire precautions
Personal Emergency Evacuation Plans (PEEPS) were in place for all residents. All staff had received fire training and there was evidence of regular fire drills being completed. Evacuations were timed and audited, and learning from drills informed improvements in practice. Appropriate documentation was maintained for daily, weekly and monthly fire equipment checks. Staff were knowledgeable and confident in relation to evacuation procedures. A recent upgrade to the fire system in the centre had improved fire safety measures. The fire detection and alarm system now met the required L1 standard, in line with current guidance for nursing homes.
Judgment: Compliant
Regulation 29: Medicines and pharmaceutical services
The inspector found evidence of good medicines management practices and sufficient policies and procedures to support and guide practice. Medicines requiring strict controls were appropriately stored and managed. Secure refrigerated storage was provided for medicines that required specific temperature control. Medication management systems were audited and learning communicated. Improvements identified during the previous inspection in relation to maximum dose and crushing of medications had been implemented. Residents had access to pharmacy services and the pharmacist was facilitated to fulfil their obligations under the relevant legislation and guidance issued by the Pharmaceutical Society of Ireland.
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Judgment: Compliant
Regulation 5: Individual assessment and care plan
There was evidence of regular nursing assessments using validated tools, for issues such as falls risk assessment, dependency levels, moving and handling, nutritional assessment and risk of pressure ulcer formation. Care plans were developed based on the assessments, and these were predominantly personalised. However, the inspector noted that while care plans were in place for all residents, in some cases care plans did not guide the care delivered of the resident. Staff spoken with were knowledgeable regarding the specific needs of each residents, however, this was not always reflected in the care plans.
Judgment: Substantially compliant
Regulation 6: Health care
The inspector was confident that the healthcare needs of residents were well met. Residents had timely access to medical services. Records demonstrated residents were regularly reviewed by their GP. Residents had access to allied health professionals such as speech and language therapy and dietetics following referral. Nursing care was to a high standard and there was a low incidence of pressure ulcers. Clinical care was delivered in accordance with evidence based best practice. Nursing staff and health care assistants spoken with were familiar with and very knowledgeable regarding residents up to date needs.
Judgment: Compliant
Regulation 7: Managing behaviour that is challenging
There was a policy on responsive behaviour, and staff were provided with training in the centre on behaviours that challenge, along with dementia specific training which was confirmed by staff and training records. There was evidence that residents who presented with responsive behaviour were reviewed by their GP and referred to psychiatry of old age or other professionals for full review and follow up as required. The inspector found that evidenced-based tools were utilised to monitor behaviours where required. Individualised care plans on behaviour issues were in place in a sample of residents' records reviewed by the inspector. The inspector found that staff appeared to be patient and understanding when any resident began to communicate restlessness or anxiety.
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Judgment: Compliant
Regulation 8: Protection
Inspectors found that measures were in place to protect residents from harm and abuse. Training records confirmed that staff had received training in this aspect of care. Residents spoken with said that they felt safe in the centre, and that staff were supportive and kind. The centre was not a pension agent for any residents and they did not maintain day to day expenses for residents. All additional charges for hairdressing and chiropody was via a robust invoice system. There was an up-to-date policy on restraint and there was evidence that the use of restraint was in line with the national policy and best practice guidelines. There was a low use of bedrails and psychotropic medication administration. Where these were used, appropriate assessments were in place to ensure the practice was safe and that it was the least restrictive method.
Judgment: Compliant
Regulation 9: Residents' rights
The rights of residents were protected and supported. Residents had control over their daily routine, such as when and where to have their meals, what time to get up in the morning and when to go to bed. Residents were treated with dignity and respect, and all interactions observed between staff with residents were conducted in a respectful manner. The inspector observed a number of activity sessions, and saw that residents' well being was enhanced by the various social moments and personal interactions. The programme of activities in the centre was varied and included Sonas, exercises, bingo, singing, and arts & crafts. One staff member worked five days a week in the centre to co-ordinate and lead the activity programme, however, all staff saw social stimulation of residents as a critical part of their role and responsibility.
The person in charge was in daily attendance and met regularly with residents to ensure their needs were met. There was evidence of consultation with residents and relatives through satisfaction surveys. However, improvements were required in consultation with residents and their representatives through regular residents meetings, as it was noted that there was only one meeting in 2019. Residents had access to an advocacy service and contact details were on display. The centre aimed to maintain strong links with the community, and were visited by the local national school and Kerry Comhaltas music group. Residents were facilitated to exercise their civil, political and religious rights. Residents had access to the daily and weekly Kerry newspapers and residents were observed enjoying these papers.
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Judgment: Substantially compliant
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Appendix 1 - Full list of regulations considered under each dimension This inspection was carried out to assess compliance with the Health Act 2007 (as amended), the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013 (as amended), and the Health Act 2007 (Registration of Designated Centres for Older People) Regulations 2015 (as amended) and the regulations considered on this inspection were:
Regulation Title Judgment
Capacity and capability
Registration Regulation 4: Application for registration or renewal of registration
Compliant
Regulation 14: Persons in charge Compliant
Regulation 15: Staffing Compliant
Regulation 16: Training and staff development Compliant
Regulation 19: Directory of residents Compliant
Regulation 21: Records Substantially compliant
Regulation 22: Insurance Compliant
Regulation 23: Governance and management Substantially compliant
Regulation 24: Contract for the provision of services Compliant
Regulation 3: Statement of purpose Compliant
Regulation 30: Volunteers Compliant
Regulation 31: Notification of incidents Not compliant
Regulation 34: Complaints procedure Compliant
Regulation 4: Written policies and procedures Substantially compliant
Quality and safety
Regulation 10: Communication difficulties Compliant
Regulation 11: Visits Compliant
Regulation 12: Personal possessions Compliant
Regulation 13: End of life Compliant
Regulation 17: Premises Compliant
Regulation 18: Food and nutrition Compliant
Regulation 20: Information for residents Compliant
Regulation 25: Temporary absence or discharge of residents Compliant
Regulation 26: Risk management Compliant
Regulation 27: Infection control Substantially compliant
Regulation 28: Fire precautions Compliant
Regulation 29: Medicines and pharmaceutical services Compliant
Regulation 5: Individual assessment and care plan Substantially compliant
Regulation 6: Health care Compliant
Regulation 7: Managing behaviour that is challenging Compliant
Regulation 8: Protection Compliant
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Regulation 9: Residents' rights Substantially compliant
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Compliance Plan for Heatherlee Nursing Home OSV-0000237 Inspection ID: MON-0025208
Date of inspection: 05/03/2020 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 non-compliance 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.
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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 Judgment
Regulation 21: Records
Substantially Compliant
Outline how you are going to come into compliance with Regulation 21: Records: Posted a circulatory memo on 19/03/20 for staff awareness regarding obtaining references. Regulations now require two work references coming from previous employer. Informed the registered nurse in question to comply. She has contacted previous employer in the HSE but at the moment its slow in processing because of the ongoing covid 19 crisis.
Regulation 23: Governance and management
Substantially Compliant
Outline how you are going to come into compliance with Regulation 23: Governance and management: We are in the process of revising the annual review report to in co-operate quality improvement action plan. Our target completion date is 26/08/2020.
Regulation 31: Notification of incidents
Not Compliant
Outline how you are going to come into compliance with Regulation 31: Notification of incidents: Incident notified to HIQA on 01/04/2020 and entered into the incident report book.
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Plan of action in place for future safety risk issues.
Regulation 4: Written policies and procedures
Substantially Compliant
Outline how you are going to come into compliance with Regulation 4: Written policies and procedures: Schedule 5 policies will be updated and reviewed to ensure they are centre specific in care delivery. Expected completion will be 26/08/2020
Regulation 27: Infection control
Substantially Compliant
Outline how you are going to come into compliance with Regulation 27: Infection control: New policy in place whereby members of staff are no longer allowed to enter kitchen premises. Food and wares coming back and forth from kitchen is placed on a designated trolley where it can be wheeled into the dining room by staff. A designated area in the store room is now allocated for the storage of equipment found in the communal bathrooms at time of inspection.
Regulation 5: Individual assessment and care plan
Substantially Compliant
Outline how you are going to come into compliance with Regulation 5: Individual assessment and care plan: .Individual care plans are now being revised by nursing staff. Nursing Assessments are carried out on same manner but individual care plans are assessed according to their needs. A specific care plan is only initiated when problem is identified and are appropriate to each residents’ needs. A 3 monthly formal review is ongoing.
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Regulation 9: Residents' rights
Substantially Compliant
Outline how you are going to come into compliance with Regulation 9: Residents' rights: More regular residents’ meetings organised.
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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 Regulatory requirement
Judgment Risk rating
Date to be complied with
Regulation 21(1) The registered provider shall ensure that the records set out in Schedules 2, 3 and 4 are kept in a designated centre and are available for inspection by the Chief Inspector.
Substantially Compliant
Yellow
30/04/2020
Regulation 23(c) The registered provider shall ensure that management systems are in place to ensure that the service provided is safe, appropriate, consistent and effectively monitored.
Substantially Compliant
Yellow
26/08/2020
Regulation 27 The registered provider shall ensure that procedures, consistent with the standards for the prevention and control of healthcare
Substantially Compliant
Yellow
08/04/2020
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associated infections published by the Authority are implemented by staff.
Regulation 31(1) Where an incident set out in paragraphs 7 (1) (a) to (j) of Schedule 4 occurs, the person in charge shall give the Chief Inspector notice in writing of the incident within 3 working days of its occurrence.
Not Compliant Yellow
01/04/2020
Regulation 04(1) The registered provider shall prepare in writing, adopt and implement policies and procedures on the matters set out in Schedule 5.
Substantially Compliant
Yellow
26/08/2020
Regulation 5(4) The person in charge shall formally review, at intervals not exceeding 4 months, the care plan prepared under paragraph (3) and, where necessary, revise it, after consultation with the resident concerned and where appropriate that resident’s family.
Substantially Compliant
Yellow
10/03/2020
Regulation 9(3)(d) A registered provider shall, in so far as is reasonably practical, ensure that a resident
Substantially Compliant
Yellow
13/03/2020
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may be consulted about and participate in the organisation of the designated centre concerned.
