Report of an inspection of a Designated Centre for Older People. … 2020. 11. 11. · Sheila...

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Report of an inspection of a Designated Centre for Older People. Issued by the Chief Inspector Name of designated centre:

Larissa Lodge Nursing Home

Name of provider: Mountain Lodge Nursing Home Limited

Address of centre: Carnamuggagh, Letterkenny, Donegal

Type of inspection: Unannounced

Date of inspection:

13 August 2020

Centre ID: OSV-0005791

Fieldwork ID: MON-0030172

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About the designated centre

The following information has been submitted by the registered provider and describes the service they provide. The provider provides care to 40 residents over the age of 18 years, male and female who require long-term and short-term care (assessment, rehabilitation, convalescence and respite). The building is single storey. Communal facilities and residents’ bedroom accommodation consists of a mixture of 32 single and four twin bedrooms all with full en-suite facilities. The building is laid out around central communal facilities that include a spacious lounge with multiple areas with views outside and a variety of seating options, an internal dining room with a large skylight, an oratory/prayer room and a visitors room near reception. A variety of outdoor courtyards are accessible from many parts of the building. The philosophy of care is to provide person centred, compassionate care and services with a commitment to excellence through adherence to high standards, disciplined leadership and respect for all. The following information outlines some additional data on this centre.

Number of residents on the

date of inspection:

33

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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

Thursday 13 August 2020

11:30hrs to 17:30hrs

Sheila McKevitt Lead

Friday 14 August 2020


Sheila McKevitt Lead

Thursday 13 August 2020


Ann Wallace Support

Friday 14 August 2020


Ann Wallace Support

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What residents told us and what inspectors observed

Residents were seen mobilising around the centre and sat chatting with each other or with staff in the foyer. Some residents chose to spend time in their rooms. These residents told the inspectors they preferred their quite space but that staff popped in to see them and invite them to activities that were on offer. Residents told the inspectors that staff were very good but that recent staff changes and a shortage of staff had impacted negatively on their daily lives in the designated centre.

Residents told inspectors that it was a wonderful place to live, if you could help yourself. They said that staff were lovely, kind and gentle but that there was not enough of staff to meet their needs. This was verified on the inspection when inspectors saw that call bells were not being answered in a timely manner and that there were not sufficient staff available to assist residents at meal times. Residents told inspectors that staff did not always come to answer their call bell when they rang it. One resident recalled how this had resulted in them having to walk to the toilet on their own even though they knew they needed the assistance of staff. Another resident described a recent incident in which they had been assisted to the toilet by a member of staff who had not ensured that the call bell was in reach to alert staff when they had finished on the toilet. As a result the resident waited for a long time and when the member of staff did not return they eventually got up and walked back to their chair by themselves. The resident told the inspectors that they were very nervous about mobilising without the help of a member of staff and that they had felt unsafe.

A number of residents reported that they did not feel safe at night-time. They described how two residents wandered at night-time and often wandered into their bedroom. They said these residents were not being supervised and they had to shout at them to get out as there were no staff in the area. One resident described how they had started to lock their bedroom door at night-time to keep other residents out. Another resident told the inspectors they would be too afraid to lock their bedroom door but that they could not sleep when they knew other residents might come into their room.

Residents told inspectors that a high number of staff had left in recent weeks which had resulted in staff shortages and poor moral amongst those staff who remained to care for them. Residents said that they felt the need to reassure the remaining staff and encourage them to stay on as part of the care team. Residents were genuinely concerned about the turnover of staff in the designated centre.

The inspectors spoke with the person in charge and reviewed the current staffing situation. Inspectors issued an immediate action plan to the provider to increase the staffing levels in the designated centre. This was acted on and an additional carer was rostered onto each day and night shift to commence that night. On the second morning of the inspection rosters confirmed that an additional carer had been on duty the previous night. Residents told the inspectors they had slept well and that

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they had not been disturbed through the night.

Residents were very satisfied with their meals. They told the inspectors that there was a good variety of choices available at meal times and that they had plenty of snacks and drinks throughout the day. Residents particularly enjoyed the home baking and smoothies that were on offer. However residents did report that they sometimes had to wait for the meals if there were not enough staff on duty. This was verified by the inspectors who on the first day of the inspection observed that during lunch those staff who were supervising residents with their meals in the dining room were frequently interrupted whilst they went to attend to other residents who required supervision. In addition inspectors saw that there was no staff available to assist two residents who had been served their meals in their bedrooms. As a result the meals had gone cold and had not been touched by either resident.

Residents said that there was enough for them to do. They explained that the activities staff had recently changed and that the member of staff who was now doing activities with them was very good. They said they could choose whether to take part or not and that they were enjoying the activities on offer. However inspectors observed that those residents who stayed in their bedrooms spent long periods of time with out social interaction.

Residents told the inspectors that they were not informed about the need for the recent increase in visiting restrictions in the centre. Whilst residents understood the need for visiting restrictions they said these changes were not discussed or communicated to them in a timely manner. One resident described how she and her relative were only informed of the recent change when their relative came to the centre to take them out for a pre-arranged outing. Understandably this resident felt that the situation was not fair or respectful to them or to their family member.

Residents knew the person in charge, who was new in post, and said that she was approachable. Residents said that they could talk to staff if they had any concerns.

Capacity and capability

This unannounced risk inspection had been triggered in response to the number of concerns that had been received by the Chief Inspector during and following the COVID-19 outbreak in the centre in April 2020 during which period 4 residents had died.

The provider submitted a notification of an outbreak of COVID-19 in the centre to the Chief Inspector on 02 April 2020. During the course of the outbreak, the provider had access to a sufficient supply of personal protective equipment (PPE) and access to COVID-19 testing for staff and residents via the community services Crisis Management Team. The provider and the person in charge worked with nursing and care staff in order to maintain staffing levels in the centre

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throughout the outbreak.

There had been significant changes in the designated centre following the outbreak which included a high level of staff turn over and a change of person in charge. On this inspection the inspectors found that the provider did not have adequate oversight of the service and as a result a number of regulations were found to be non-compliant. The arrangements for monitoring the quality and safety of care being delivered to residents were not robust and did not provide assurances that care and services were delivered in line with the centre's statement of purpose. This was reflected in the fact that inspectors issued three immediate and one urgent action plan during the course of this two day inspection. The three immediate action plans were implemented prior to the end of the inspection and the improvements were monitored by the inspectors following the inspection in order to ensure that staffing levels were maintained.

There was a newly appointed management team in place. The provider representative had not changed, however a general manager and new person in charge had commenced at the end of June 2020. The person in charge (PIC) had not received a handover from the outgoing PIC or from the provider and she had not had any form of induction into her role. As a result the PIC did not have adequate knowledge about the management systems that were in place in the centre and her regulatory role and responsibilities.This had resulted in a failure to ensure that there was robust oversight of the care and services delivered to residents and that staff were adequately supervised.

Inspectors found that staffing levels were not adequate to meet the needs of residents in a safe manner. Following the issuing of an immediate action plan, the provider put an additional staff member on duty over a 24 hour period.

Staff working with residents had not received an induction and had not completed mandatory training prior to commencing work in the centre. This included permanent and agency staff. This posed a potential risk to residents as staff did not have clear information about the policies and procedures to follow relevant to their role, including, fire safety and infection control. It was also evidenced by the poor medication management practices observed and the high level of medication errors that were found on this inspection.

Risk management and infection control practices were not well managed and inspectors found several areas for improvement. It was of particular concern that their was no contingency plan in place for a COVID-19 outbreak and no infection control committee established although they were recovered from the outbreak since mid June 2020. This lack of preparedness put residents at an increased risk of contracting COVID-19 in the event of a future outbreak.

The provider had voluntarily closed to admissions on the 12 August 2020 due to staffing issues. Following this inspection the provider submitted written assurances to the Chief Inspector that the centre would remain closed to admissions until regulatory compliance was achieved. The provider was asked to submit fortnightly monitoring reports to the Chief Inspector, the first one of which was due and

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received on 31 August 2020.

Regulation 14: Persons in charge

The newly appointed person in charge (PIC) worked full time in the designated centre. She was a registered general nurse with over three years experience working in a managerial role caring for older persons. She was in the final stages of completing a post registration certificate management course in healthcare management.

Inspectors found that she had not been provided with a comprehensive induction prior to commencing in her role as PIC. The provider had not provided adequate support since she had started in her post and at the time of the inspection she was not sufficiently informed about the management systems that were in place in the centre and she did not have a clear understanding of her roles and responsibilities as outlined in the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older Persons) Regulations 2013.

Judgment: Compliant

Regulation 15: Staffing

The staffing levels and skill mix were not appropriate to meet the needs of residents taking into account the layout of the designated centre. This was evidenced by inspectors observation of call bells not being answered in a timely manner and the lack of staff available to support residents at lunch time. This was verified by the residents who told the inspectors that they did not always feel safe in the centre with current staffing levels and the number of new staff working in the centre.

Judgment: Not compliant

Regulation 16: Training and staff development

Not all staff working in the designated centre had the appropriate knowledge and skill to provide safe and appropriate care for the residents. For example inspectors found that a number of staff did not have the required mandatory training in place (safeguarding and fire safety) and in addition staff had not completed the required training in infection control as outlined in section in the current guidance (Health Protection Surveillance Centre Interim Public Health, Infection Prevention and Control Guidelines on the Prevention and Management of COVID-19 Cases and

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Outbreaks in Residential Care Facilities guidance).

Records showed that a number of staff had not received training on safeguarding vulnerable residents, manual handling practices or fire training. Staff who spoke with the inspectors did not have adequate knowledge on these topics and this is evidenced by the findings of the inspectors throughout this report.

Nursing staff had not received appropriate training and assessments of their competencies in medication management and administration. These findings resulted in an urgent action plan being issued to the provider. The urgent action plan referred to the need for all qualified staff to complete the recommended training on medication management and be assessed as competent in their medication practices, prior to them being allowed to administer medications to residents.

Member of the senior management team did not have adequate knowledge of the up to date infection prevention and control guidance, (Health Protection Surveillance Centre Interim Public Health, Infection Prevention and Control Guidelines on the Prevention and Management of COVID-19 Cases and Outbreaks in Residential Care Facilities guidance). As a result staff were not adequately trained in infection prevention and control practices relevant to their roles.

Inspectors found that the supervision of staff was not adequate. For example a permanent employed health care assistant was paired to work with an agency employed health care assistant, to ensure some continuity of care for residents. However the allocation was changed by the care assistants without consulting with nursing staff and inspectors found that two agency care assistants were working together and the two permanent health care assistants were working together and not providing support and supervision of the agency staff who did not know the residents or their routines. This resulted in a lack of continuity of care for the residents from carers who did not know them and their preferences for care and support. In addition the agency staff did not have an induction and were not familiar with the fire or emergency procedures in the designated centre.

There was no induction for newly employed permanent or agency staff. Those staff spoken with confirmed they had not had an induction into the centre. This posed a potential risk to residents as some staff did not know where the fire panel was located and were not clear on what to do when the fire alarm sounded. An immediate action plan was issued in relation to this non-compliance which required the provider to commence an action plan to immediately address the deficit.


Regulation 23: Governance and management

The governance and management of this centre was not robust and did not ensure that the care and services provided for the residents was safe and appropriate and

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in line with the centre's statement of purpose. There was one ongoing non-compliance from the last inspection in relation to resident's rights that had not been completed by the provider. This is addressed under Regulation 9.

Although the management structure in place reflected that outlined in the statement of purpose, members of the management team were not clear about their roles and responsibilities and it was not clear to the inspectors or to staff and residents who was responsible for what areas of care provision. This resulted in the high levels of regulatory non-compliance found on the inspection and reflected in this report.

There was no evidence that recommendations made from internal audits and reviews were implemented in practice. For example recommendation arising from the internal audits conducted in March 2020 had not yet been been implemented. Although incidents such as falls were recorded and trended there was no evidence that the required improvement actions were identified and communicated to the relevant staff.

An annual review had not been conducted for 2019.


Regulation 24: Contract for the provision of services

A sample of residents’ contracts of care were reviewed. They were signed by the resident or their representative and included details of the services to be provided, the weekly fee and any additional fees charged. They also stated if there were other occupants in the bedroom, however they did not include the room number occupied by the resident.

Judgment: Substantially compliant

Regulation 3: Statement of purpose

The statement of purpose had been reviewed and was on display in the centre. The contents met the regulatory requirements and reflected the number and makeup of the beds in the centre. A copy of the revised statement of purpose had been submitted to the Chief Inspector but it did not reflect the staffing numbers in the centre and did not identify the person who would take over in the absence of the person in charge (PIC).


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Regulation 31: Notification of incidents

Inspectors noted an accident which resulted in a resident receiving an injury and requiring treatment in hospital that had not been notified to the Chief Inspector as required within three working days.


Regulation 34: Complaints procedure

Inspectors were informed that the centre had received a number of complaints in 2020, four of which remained open.

The complaints procedure was displayed where it was clearly visible to residents, relatives and staff. However, this did not contain the correct information since the complaints policy had been reviewed in 2020. Both documents contained conflicting information regarding the person responsible for overseeing the complaints. In addition inspectors found that neither the outcome of the complaint nor the complainant's level of satisfaction with that outcome were recorded for all closed complaints.

The oversight of complaints was not robust as evidenced in minutes of the senior management team meeting which took place on 29 July 2020.


Regulation 4: Written policies and procedures

The schedule 5 policies were available for review. Inspectors observed that the policies had not been updated to include the up to date infections prevention and control guidance. (Health Protection Surveillance Centre Interim Public Health, Infection Prevention and Control Guidelines on the Prevention and Management of COVID-19 Cases and Outbreaks in Residential Care Facilities guidance). This included;

the end of life policy the visiting policy the admission, transfer and discharge policy medication management

In addition staff did not receive appropriate training and updates relevant to their roles. As a result staff did not implement the policies and procedures and there

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were inconsistencies in their practices in key areas such as infection prevention and control, care planning and medications.


Regulation 21: Records

The record of the one fire drill on file was comprehensive. This action plan from the previous inspection in March 2019 had been addressed to a satisfactory level.

Judgment: Compliant

Quality and safety

Residents were not receiving a high standard of safe and appropriate care in order to meet their needs. Some residents told the inspectors that they felt vulnerable and worried about their safety at times due to the current staffing situation and because of residents who displayed responsive behaviours, (Residents who are living with dementia or other conditions may communicate or express their physical discomfort, or discomfort with their social or physical environment), were not adequately supervised and supported especially at night.

Inspectors found that risk was not well managed in the centre. The risk register was not kept up to date. The failure to identify and mitigate risks in a timely manner had resulted in residents being exposed to potential risks for a prolonged period of time.

Infection control practices did not meet the current best practice guidance. There was a lack of oversight of infection control practices and this lack of oversight resulted in poor practices going unnoticed by the management team. As a result residents were not adequately protected against infections.

Residents were not having their health and social care needs met in a holistic person centred way. There was no clear process in place for contacting a residents general practitioner (GP) and inspectors found that there were inconsistencies in how residents were able to access their GP and other medical services.

Poor medication management practices over a period of weeks had gone undetected by the management team. This had resulted in a number of medication errors not being identified. Inspectors identified this issue and issued an immediate action plan to the provider to mitigate this risk without delay and to ensure that residents were administered their medications safely.

Some staff who spoke with the inspectors were not able to clearly articulate what

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they would do in the event of the fire alarm sounding. As a result inspectors were not assured that these staff would know what actions to take to keep the residents in their care safe in the event of a fire emergency.

The nursing documents were not clear, concise or reflective of the residents needs and required plan of care. Inspectors also found that care staff were not sufficiently informed about the care needs of the residents they were allocated to look after. This had led to some residents not receiving the appropriate care and support that they needed.

The visitor restrictions that were in place at the time of the inspection were not in line with the current guidance for the locality and infringed the rights of residents with no clear rationale for the decision to stop all visiting in the designated centre. Residents and their families had not been afforded the platform to communicate their views and therefore their voice was not being heard.

In addition residents who spent time in their bedrooms were further exposed to becoming socially isolated due to the lack of person centred activities that were available to them.

Regulation 11: Visits

The provider had identified a visitors room in the centre which was easily accessible from the garden and did not necessitate visitors walking through resident areas. Precautionary measures were in place for visitors who attended the centre. All visitors had their temperature checked and completed a declaration that they did not have signs and symptoms of COVID-19 and had not travelled outside of the country in the last two weeks.

However the provider had recently stopped visits in the centre due to the increased risk in three other counties in the country. There was no clear rationale for the complete cessation of visits in the centre and the restrictions were not in line with the public health guidance at the time. In addition the changes to the visiting arrangements had not been communicated to all families and during the inspection one visitor arrived for a pre-arranged visit and was turned away by staff.


Regulation 17: Premises

The centre was spacious, well lit with natural daylight and was clean.

The large spacious lounge area was furnished with high back chairs arranged in small groups around the room. This gave the room an institutional appearance and

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was not homely and inviting. As a result the residents chose to sit on the comfortable couch and chairs in the foyer and the main lounge remained empty for most of the day.

The dining room provided adequate space for residents to sit at the tables and to take their meals whilst maintaining social distance. Tables were nicely set out with condiments and table settings.

Overall bedrooms were spacious and had sufficient storage for residents to store their belongings. Maintenance staff were available to put up additional shelving and storage at the resident's request. Most bedrooms were single en-suite. There were four twin bedrooms and inspectors found that the screening between the beds did not ensure that residents had adequate privacy when they were in bed. This non-compliance is addressed under Regulation 9 in this report.

The inspectors observed that there was a lack of storage space for equipment such as walking aids, hoists and personal protective equipment (PPE). For example

1. hoists and trolleys were stored on corridors and were seen blocking the handrails that residents used to mobilise safely.

2. three walking frames were stored in a communal bathroom on Swilley unit. 3. PPE was being stored in two un-occupied bedrooms.


Regulation 18: Food and nutrition

Residents had access to a range of hot drinks, juices and snacks throughout the day. Fresh drinking water was available and water jugs were regularly refreshed by the catering staff.

Residents were offered a choice of meals at meal times. All meals were freshly prepared on the premises and were nicely presented and served hot. Residents told the inspectors that they enjoyed their meals and that they could always ask for an alternative if they did not like what was on the menu.

Inspectors found that there were not sufficient staff available at lunch time to assist residents who needed support. For example one resident who displayed responsive behaviours (how residents who are living with dementia or other conditions may communicate or express their physical discomfort, or discomfort with their social or physical environment) left his place at the table three times during the meal time and a member of staff who was assisting another resident had to repeatedly leave the resident she was assisting to attend to the gentleman. Inspectors also observed that there were no staff available to assist three residents who were served their meals in their rooms. As a result their meals had gone cold and two residents had fallen asleep with their uneaten cold dinners in front of them.

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Residents had their weights monitored and had access to dietitian and speech and language therapy for specialist advice. Textured and specialist diets were available in line with the recommendations of the specialist practitioners. However the inspectors were not assured that the oversight of residents' nutritional needs was adequate. For example;

Fluid and dietary records were not kept up to date by care staff Nursing staff did not take appropriate actions when fluid and food

intake records indicated that the residents' dietary needs had not been met. There was no suitable diabetic juice available until a resident identified to

staff that what they were being served contained sugar.


Regulation 26: Risk management

There was an up to date risk management policy in place which had been updated to include risks associated with the COVID-19 pandemic. The policy met the requirements of the regulation. However the inspectors were not assured that the risk management policy was implemented in practice. For example;

A resident who was assessed as being at risk of self harm did not have a care plan in place to mitigate this risk.

A resident who was at high risk of falls did not have a clear care plan in place to address this risk.

A fire compartment door on Errigal unit did not close correctly and would not adequately protect residents and staff from smoke. The provider was aware of the fault but had not arranged for the fault to be repaired promptly.

There was a risk register in place but a number of the risks identified by the inspectors were not included in the register.

There was an emergency plan in place for responding to major incidents likely to cause death, injury or serious disruption to the service. In addition the centre had a COVID-19 contingency plan to manage and contain any future outbreaks in the centre. Inspectors found that the plan that was in place did not give clear information for managers and staff in line with the current infection prevention and control guidance.(Health Protection Surveillance Centre Interim Public Health, Infection Prevention and Control Guidelines on the Prevention and Management of COVID-19 Cases and Outbreaks in Residential Care Facilities guidance).

Arrangements that were in place for the reporting, investigating and learning from incidents such as falls, medication errors and near misses were not robust and inspectors found that a number of incidents had not been recorded and investigated in line with centre's own policies.

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Regulation 27: Infection control

The centre was clean and tidy and the housekeeping team worked hard to ensure that the cleaning schedules were completed to the required standard. However the infection prevention and control processes in the centre required significant improvement to ensure that residents were adequately protected.

Managers and staff were not familiar with the current guidance in relation to the prevention and control of COVID-19 infections in long term care facilities.(Health Protection Surveillance Centre Interim Public Health, Infection Prevention and Control Guidelines on the Prevention and Management of COVID-19 Cases and Outbreaks in Residential Care Facilities guidance). As a result the guidance was not being used to inform policy and practices in the centre.

The staff changing area was cluttered with no storage available for items such as outdoor coats, bags and shoes. These items were stored on the floor, on the backs of doors and in the toilet and shower rooms. As a result the staff changing area could not be thoroughly cleaned and the floor and other areas were dusty.

Staff practices did not follow good infection control standards; residents' wash basins were stored on the floor in their en-suite facilities, clean towels were stored on the grab rails beside the residents' toilets as there was no towel rails available, clean PPE equipment was stored next to the clinical waste bin along the corridor on Swilly unit. This meant that clean equipment was touching the top of the waste bin.

Residents who required a hoist to meet their moving and handling needs did not have their own slings and there was not a clear process in place to launder the slings between resident use and to clearly label the clean slings as ready for re-use.

Cleaning schedules were in place but these had not been revised in line with the HSPC guidance.

There was only one mop bucket available and this was used by the housekeeping teams in all areas including the isolation unit.

Staff on the Swilley Unit were not clear about who was responsible for emptying the black bags when they became full. As a result the inspectors found that bags were overfilled and on one occasion a full bag was left in the residents' communal bathroom.

inspectors observed that some nursing and care staff did not wear their face masks correctly.

Agency staff were not made aware of the precautions that were required for those residents who were self-isolating following their recent admission to the designated centre.

There was no clear signage for hand hygiene stations and the bedrooms of

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those residents for whom full droplet precautions were required.


Regulation 28: Fire precautions

Staff spoken with did not know what to do if the fire alarm sounded, one staff member did not know where the fire panel was located in the designated centre.

Inspectors noted that although the fire drill records were comprehensive there had only been one fire drill practiced with staff since March 2019. The provider gave an under taking to complete a fire drill with night staff within the next two weeks.

In addition the weekly fire door checks had not identified that a fire door on Errigal unit was not closing correctly.


Regulation 29: Medicines and pharmaceutical services

Medication management was not safe. There had been a change of pharmacy and the process of dispensing medications had changed. The medication management policy had not been updated to reflect this change and staff had not received any training on the new system implemented. All qualified nursing staff dispensing medications had not completed the appropriate medication management training and had not been deemed competent to administer medications to residents.

All of the above had resulted in a several medication errors occurring on a daily basis. These medication errors were identified by inspectors. Inspectors raised concerns that although the errors were clearly obvious they had not been identified or reported by qualified staff administering medications to residents.

These findings resulted in an immediate action plan being issued to the provider in relation to medication management. The immediate action plan requested that only those staff that had completed HSELand training on medication management and been competency assessed to administer medications would do so.

Inspectors noted that all medications prescribed were not individually signed by the prescriber.


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Regulation 5: Individual assessment and care plan

There were policies and procedures in place for assessment and care planning however these were not implemented in practice. In addition the pre admission and assessment tools did not ensure that each resident had a comprehensive assessment of their needs using evidence based assessment tools.

Inspectors reviewed a sample of resident's records and found that significant improvements were required;

One resident who had been recently admitted did not have a comprehensive assessment and care plan in place.

The catering team had not been informed about the nutritional care plans for two residents who had recently been admitted.

The sample of care plans reviewed did not provide sufficient, up to date information in order to guide staff to provide safe and appropriate care for the residents.

The records of daily care given were not well maintained and did not give a clear record of residents' fluid and dietary intake, repositioning and responsive behaviours.

A number of care plans had not been reviewed four monthly as required by the regulation.

There was no clear evidence that residents and where appropriate their families were involved in the care planning processes.


Regulation 6: Health care

Significant improvements were required to ensure that residents had access to health and social care services to meet their needs including a high standard of evidence based nursing care.

Residents had access to a general practitioner (GP) of their choice. GPs visited the centre regularly however inspectors found that there were inconsistencies in how residents were referred to their GP by nursing staff. For example one resident who had had a recent fall and whose condition had deteriorated had not been referred to their GP for review. The change in the resident's condition had not prompted nursing staff to refer the resident to their GP prior to the inspector raising the issue with the clinical nurse manager on duty. In addition there was no evidence that the resident's family had been informed about the fall or about the resident's change in condition.

There was evidence that residents had access to dietitian, speech and language therapy and physiotherapy services. Specialist tissue viability advice and palliative

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care services were also available. However there was no clear evidence that care prescribed by specialist practitioners was consistently implemented by nursing and care staff in the designated centre.


Regulation 7: Managing behaviour that is challenging

There had been a significant turnover of staff in the centre in recent months and not all staff were up to date with the knowledge and skills to respond to and manage behaviour that was challenging (Residents who are living with dementia or other conditions may communicate or express their physical discomfort, or discomfort with their social or physical environment).

Not all residents who displayed responsive behaviours had an up to date care plan in place which gave clear details about the potential triggers for their behaviours and the appropriate distraction techniques to support the resident when they became agitated or distressed. Records showed that residents' responsive behaviours were not being monitored in line with the centre's own policies and procedures. As a result some resident's with high levels of responsive behaviours were not being referred for medical and specialist review when required. In addition the responsive behaviours of two residents had had a significant impact on the quality of lives of other residents living around them and this had not been adequately addressed.

There was a low level of restraints in use in the centre and the person in charge was committed to working towards a restraint free environment. However the policy for use of restraints and restrictive practices did not reflect best practice guidance in that it required an annual review of restraints which did not provide appropriate monitoring of the use of restraints in the centre. In addition the restraints register did not include all usage of as required psychotropic medications.


Regulation 8: Protection

Significant improvements were required in the measures that were in place for the protection of residents in the designated centre;

Staff were not up to date in Safeguarding vulnerable adults training. Appropriate Garda vetting was not in place for one member of staff working

in the designated centre. An allegation of verbal abuse by a member of staff had not been investigated

and followed up in line with the centre's own policies and procedures.

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Two residents told the inspectors that they did not feel safe at night because of the responsive behaviours of other residents.


Regulation 9: Residents' rights

Overall resident and staff interactions were positive and respectful. Staff who had worked in the centre for a period of time knew the residents well and were aware of their past lives and personal history prior to their admission to long term care.

However inspectors found that resident's rights were not upheld in a number of areas;

Although there was a full time activities coordinator in post this was not sufficient to ensure that all residents had the opportunity to participate in some form of meaningful activity. This was particularly relevant to those residents who spent their day in their bedrooms, whether this be their choice or because they were required to self-isolate. The inspectors observed that a number of residents spent long periods of the day in their rooms without social interaction.

The way that care was organised did not promote a person centred approach and a number of task orientated practices were observed; there was no named nurse or key worker system in place to ensure continuity of care for residents; staff were using a communal hairdryer and rollers to dry and set residents' hair. Communal equipment used for the personal care of residents was stored on a trolley on the corridor on Errigal Unit. Resident's did not have their own continence wear stored in their bedrooms.

At the time of the inspection the twin bedrooms were occupied by one resident however if a second resident was occupying the room the layout of these bedrooms did not ensure that the privacy and dignity of both residents could be upheld at all times. This was an outstanding action from the previous inspection in March 2019 which the provider had been required to address by the end of July 2019.

Residents meetings were not held regularly in line with the centre's statement of purpose and where residents had made suggestions in the meetings there was no evidence that this had been followed up.

Residents did have access to radio, television and local newspapers and staff were observed discussing local news and issues with residents each day.

Independent advocacy services were made available to residents when required.


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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

Regulation 14: Persons in charge Compliant

Regulation 15: Staffing Not compliant

Regulation 16: Training and staff development Not compliant

Regulation 23: Governance and management Not compliant

Regulation 24: Contract for the provision of services Substantially compliant

Regulation 3: Statement of purpose Substantially compliant

Regulation 31: Notification of incidents Not compliant

Regulation 34: Complaints procedure Substantially compliant

Regulation 4: Written policies and procedures Not compliant

Regulation 21: Records Compliant

Quality and safety

Regulation 11: Visits Not compliant

Regulation 17: Premises Substantially compliant

Regulation 18: Food and nutrition Not compliant

Regulation 26: Risk management Not compliant

Regulation 27: Infection control Not compliant

Regulation 28: Fire precautions Substantially compliant

Regulation 29: Medicines and pharmaceutical services Not compliant

Regulation 5: Individual assessment and care plan Not compliant

Regulation 6: Health care Not compliant

Regulation 7: Managing behaviour that is challenging Not compliant

Regulation 8: Protection Not compliant

Regulation 9: Residents' rights Not compliant

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Compliance Plan for Larissa Lodge Nursing Home OSV-0005791 Inspection ID: MON-0030172

Date of inspection: 14/08/2020 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 15: Staffing

Not Compliant

Outline how you are going to come into compliance with Regulation 15: Staffing: • 27 new staff member recruited since inspection - Complete • Staffing levels increased to 1 nurse and 3 HCA on night duty - Complete • Staffing levels increased on day duty to 2 nurses and 6 HCA plus Activity Coordinator - Complete • No requirement for Agency Staff on Roster as of 1st October. - Complete

Regulation 16: Training and staff development

Not Compliant

Outline how you are going to come into compliance with Regulation 16: Training and staff development: Training Matrix Compliance as of 1/10/20 • Fire management 92.7% • Infection control 98% • Med management 100% • Safeguarding 96% • Manual handling 92.7% • Dementia 41.03% (Training Scheduled for 2nd October – after which 90% of staff will have received training). This compliance includes new staff who are on the roster as of 2nd October 2020.

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- New staff will have mandatory training prior to commencing - Ongoing

Regulation 23: Governance and management

Not Compliant

Outline how you are going to come into compliance with Regulation 23: Governance and management: 1. Statement of Purpose reviewed/updated and in line with Regulations 2. PIC in place until 26/10/20 3. PIC / DON commences on 26/10/20 with planned 3 week orientation/induction to Eliza Care Governance Systems and Philosophy of care with scope for prolonged orientation as indicated 4. CNM commences on 5/10/20 5. Competency frameworks reviewed as part of orientation/induction for CNM and New nursing Staff – lines of accountability reinforced - Ongoing 6. Induction competency checklist for all new HCA staff in place - Ongoing 7. Governance and Management meetings have been scheduled on a weekly basis for September, October and November. These meetings will be scheduled on a fortnightly basis / monthly basis thereafter - Ongoing 8. Governance & Management reporting template reflects HIQA regulations. 9. Governance and Management Reports will inform yearly Quality Review in terms of KPI and QIP - Ongoing 10. Template for Quality Review will be in place by 30th October 2020.

Regulation 24: Contract for the provision of services

Substantially Compliant

Outline how you are going to come into compliance with Regulation 24: Contract for the provision of services: • Going forward residents’ room number will be included in Contract Of Care Complete

Regulation 3: Statement of purpose Substantially Compliant

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Outline how you are going to come into compliance with Regulation 3: Statement of purpose: • Statement of Purpose has been updated to reflect all Leads and their deputies. Complete

Regulation 31: Notification of incidents

Not Compliant

Outline how you are going to come into compliance with Regulation 31: Notification of incidents: • HIQA NFO Forms have and will be returned as appropriate - Ongoing • NFO’s are reported as an integral part of the Governance and Management Meetings - Ongoing

Regulation 34: Complaints procedure


Outline how you are going to come into compliance with Regulation 34: Complaints procedure: • Complaints Policy and Procedure updated to reflect new Complaints Officer - Complete • Complaints Audit tool in place - Ongoing • Complaints Audit Aug scored 80% compliance and will be reaudited in Nov 2020 • All families with recurring complaints have been met by Group General Manager and complaints resolved with positive outcomes - Complete • Emerging themes from Complaints; communication has been addressed by appointing a full-time receptionist and a bi monthly newsletter updating families on visiting information and activities – “News from the Lodge” – Complete and Ongoing

Regulation 4: Written policies and procedures

Not Compliant

Outline how you are going to come into compliance with Regulation 4: Written policies and procedures: • Admission Policy updated to reflect current Pandemic - Complete

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• Pre admission assessment is within VCare – it is reflective of single assessment framework - Ongoing • Medication Policy updated to include management of medication errors and Microbial stewardship within context of current Pandemic - Complete • Complaints Policy updated as above - Complete • Risk Management Policy being reviewed to reflect Xyea (Management system addressing risk/Audit/Training Matrix) live from 22/9/20 • Infection Control Policy updated to take account of COVID 19 outbreak - Complete • COVID 19 Preparedness Plan in place updated onto NHI template - Complete

Regulation 11: Visits

Not Compliant

Outline how you are going to come into compliance with Regulation 11: Visits: • Visiting is in line with current guidance from Public Health – currently Level 3 • Residents updated daily and video calls facilitated • Families kept informed though “News from the Lodge” via email and those who prefer message by phone or post are facilitated - Complete and Ongoing

Regulation 17: Premises


Outline how you are going to come into compliance with Regulation 17: Premises: • All fire doors have been adjusted as required and are compliant with fire regulations Complete

Regulation 18: Food and nutrition

Not Compliant

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Outline how you are going to come into compliance with Regulation 18: Food and nutrition: • Staffing levels are sufficient to ensure assistance is available to residents – this is checked on the floor on a daily basis - Ongoing • Fluid intake documentation reinforced and total fluid intake is recorded in progress notes as indicated – ongoing audits will monitor compliance. Ongoing • Audit to be carried out 14/10/20

Regulation 26: Risk management

Not Compliant

Outline how you are going to come into compliance with Regulation 26: Risk management: • Risk Management Policy being reviewed to include risk of COVID 19 – Complete • The COVID 19 Risk assessment remain in place and updated in line with current Infection Control/HSPC guidance as it emerges - Ongoing • The risk register and controls are being transferred to Xyea Software System – (Management system for Risk/Audit/Training Matrix/Events/Complaints) –Expected Completion Date 30/10/20 • Outstanding risk that remain amber will be reviewed 3 monthly - Ongoing • Outstanding risk that remains red will remain on Governance and Management Agenda and reassessed as required – maximum reassessment period will be on a monthly basis - Ongoing • New risk assessments include; Loss of PIC/High volume of New staff - Complete

Regulation 27: Infection control

Not Compliant

Outline how you are going to come into compliance with Regulation 27: Infection control: • There was a Policy in place underpinned by latest HSPC guidelines – in light of HIQA comments – the Preparedness Plan has been revised to reflect NHI template and includes links to HPSC guidance/Nursing Matters/HSE land - Complete • The Plan is available for all nurses on the Nurses station desktop - Complete • All policies and information going forward will contain a Statement of Understanding to be signed by all staff as indicated - Ongoing • Infection Control Policy reviewed to include COVID 19 outbreak management - Complete • An infection Control Lead has been appointed in house - Complete • Recent Infection Control Audits have scored 82% compliance on 19/9/20 with an action plan on correct use of Bins in place

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• All staff have undergone HSE land training on Infection Control 98% compliance across all staff sectors - Ongoing • Lockers and Shoe racks in place in changing room - Complete • Towel rails in place – staff informed not to use grabrails for hanging towels – checked on a daily basis - Ongoing • More slings have been ordered and are available - Complete • All SOP for housekeeping in place and have been reinforced and crosschecked to ensure reflective of current guidance - Complete • One MOP bucket confirmed with HSE Infection Control Manager as best practice as using colour coded flat mop, single dip system which has requirement for 1 bucket. Remains in place with confirmation from Infection Control NW Nurse Manager CHO area 1. In addition, we have an automated iMop Scrubber Dryer which is used in conjunction with flat mopping system throughout the nursing home - Ongoing • Senior carer on duty each day is responsible for ensuring all bins are emptied post assistance - Ongoing • Designated Mask Compliance Officer in place on a daily basis - Ongoing • Residents on isolation is clearly identified on both HCA and Nursing handover reports - Ongoing

Regulation 28: Fire precautions


Outline how you are going to come into compliance with Regulation 28: Fire precautions: • Fire doors have been adjusted and are compliant with Fire Regulations - Complete • Fire drills 4.5 minutes and 1.54 minutes – simulated evacuations ongoing with Audit in place - Ongoing • 97% compliance with Fire Management training – 3 members of staff will receive training in coming week - Ongoing

Regulation 29: Medicines and pharmaceutical services

Not Compliant

Outline how you are going to come into compliance with Regulation 29: Medicines and pharmaceutical services: • This has been a priority in terms of compliance; • Medication Management Policy includes management of medication errors and the Pharmacist has included a three-page supplement on how to order/receive and store medications - Complete • The system of administration has not changed – only the receipt and ordering component of medication management which should not have impacted on the Nurse

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ability to dispense medications safely - Complete • 100% nurses have undertaken HSE Land Medication Management and In house Medication Competency Assessment – Complete and Ongoing • Recent Medication Audits demonstrate continuous improvement and compliance. • Policy changes and Audit action plans shared with nursing staff with a Statement of Understanding - Ongoing • Planned Standard Operational Procedures for Medication Management will be in place by – Expected Completion Date 1/12/20

Regulation 5: Individual assessment and care plan

Not Compliant

Outline how you are going to come into compliance with Regulation 5: Individual assessment and care plan: • A schedule of assessments and care plans on admission is available at nurses’ station - Ongoing • All care plans are currently being reviewed and nurses individually mentored by PIC over coming 4 weeks – Complete by 30/10/20 • A system in place for sharing MUST and Dietary needs is in place - Complete • Care plans that are person centered and reflect accurately the residents needs is a practice development priority – full overview and review by 30/11/20

Regulation 6: Health care

Not Compliant

Outline how you are going to come into compliance with Regulation 6: Health care: • Going forward all multidisciplinary referrals will be recorded in progress notes and intervention notes on Vcare - Ongoing • PIC/CNM will oversee nursing handover and cross check that all referrals and reviews have been appropriately identified and actioned - Ongoing

Regulation 7: Managing behaviour that is challenging

Not Compliant

Outline how you are going to come into compliance with Regulation 7: Managing

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behaviour that is challenging: • All Behaviour and Mood care plans are being reviewed to ensure they identify triggers – Compete by 9/10/20 • A Restraint Log is in place which identifies unintentional restraint or restrictive practice – this will be reviewed annually - Ongoing • The restraint Log includes Psychotropic PRN medication - Ongoing • The restraint/restrictive Practice log will include risk assessment on use of profiling beds as low beds with crash mats – Complete by 20/10/20 • One resident with responsive behaviors that were unpredictable has been transferred for a full Psychiatric review • Managing Responsive Behaviour tips are shared daily on HCA handover reports - Ongoing

Regulation 8: Protection

Not Compliant

Outline how you are going to come into compliance with Regulation 8: Protection: • All staff have Garda vetting in place prior to coming onto roster – Complete and Ongoing • Safeguarding Training compliance is 96% across the staff sectors - Ongoing • Residents feeling unsafe – their concerns have been addressed individually in cooperation with their NOK/Families to their satisfaction – Complete and Ongoing • All allegations of safeguarding will be investigated as per Policy and Guidelines – Ongoing

Regulation 9: Residents' rights

Not Compliant

Outline how you are going to come into compliance with Regulation 9: Residents' rights: • We will continue to use twin rooms as single rooms pending a full curtain fit – expected date of - completion 30/10/20 • Residents will have Continence wear stored appropriately in their wardrobe – full list of continence wear updated – Complete and Ongoing • Residents have individual hair dressing equipment (rollers). Additional hair dryers have been provided - Complete • Residents forum held on 25/8/202 – residents expressed satisfaction with level of care and noted high number of new starters – all new starters to be introduced individually to residents - Ongoing • Residents are encouraged to attend dayroom for televised mass at 10 am followed by activities - Ongoing • A full 7-day activity plan is in place with documented levels of engagement on Vcare -

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Ongoing • All activity care plans will be fully updated by 10/10/20

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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 11(1) The registered provider shall make arrangements for a resident to receive visitors.

Not Compliant Orange

14/08/2020

Regulation 11(2)(a)(i)

The person in charge shall ensure that in so far as is reasonably practicable, visits to a resident are not restricted, unless such a visit would, in the opinion of the person in charge, pose a risk to the resident concerned or to another resident.


14/08/2020

Regulation 15(1) The registered provider shall ensure that the number and skill mix of staff is appropriate having regard to the needs of the residents, assessed in accordance with Regulation 5, and

Not Compliant Red

13/08/2020

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the size and layout of the designated centre concerned.

Regulation 16(1)(a)

The person in charge shall ensure that staff have access to appropriate training.


02/10/2020

Regulation 16(1)(b)

The person in charge shall ensure that staff are appropriately supervised.


28/08/2020

Regulation 16(1)(c)

The person in charge shall ensure that staff are informed of the Act and any regulations made under it.


02/10/2020

Regulation 16(2)(c)

The person in charge shall ensure that copies of relevant guidance published from time to time by Government or statutory agencies in relation to designated centres for older people are available to staff.


17/08/2020

Regulation 17(1) The registered provider shall ensure that the premises of a designated centre are appropriate to the number and needs of the residents of that centre and in accordance with the statement of purpose prepared under Regulation 3.


Yellow

30/10/2020

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Regulation 17(2) 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.


Yellow

14/09/2020

Regulation 18(1)(c)(iii)

The person in charge shall ensure that each resident is provided with adequate quantities of food and drink which meet the dietary needs of a resident as prescribed by health care or dietetic staff, based on nutritional assessment in accordance with the individual care plan of the resident concerned.


14/08/2020

Regulation 18(3) A person in charge shall ensure that an adequate number of staff are available to assist residents at meals and when other refreshments are served.


13/08/2020

Regulation 23(a) The registered provider shall ensure that the designated centre has sufficient resources to ensure the effective delivery


17/08/2020

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of care in accordance with the statement of purpose.

Regulation 23(b) The registered provider shall ensure that there is a clearly defined management structure that identifies the lines of authority and accountability, specifies roles, and details responsibilities for all areas of care provision.


28/08/2020

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.


28/08/2020

Regulation 23(d) The registered provider shall ensure that there is an annual review of the quality and safety of care delivered to residents in the designated centre to ensure that such care is in accordance with relevant standards set by the Authority under section 8 of the Act and approved by the Minister under section 10 of


30/10/2020

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the Act.

Regulation 23(e) The registered provider shall ensure that the review referred to in subparagraph (d) is prepared in consultation with residents and their families.


30/10/2020

Regulation 23(f) The registered provider shall ensure that a copy of the review referred to in subparagraph (d) is made available to residents and, if requested, to the Chief Inspector.


30/10/2020

Regulation 24(1) The registered provider shall agree in writing with each resident, on the admission of that resident to the designated centre concerned, the terms, including terms relating to the bedroom to be provided to the resident and the number of other occupants (if any) of that bedroom, on which that resident shall reside in that centre.


Yellow

14/08/2020

Regulation 26(1)(a)

The registered provider shall ensure that the risk management policy set out in Schedule 5 includes hazard identification and


28/08/2020

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assessment of risks throughout the designated centre.

Regulation 26(1)(b)

The registered provider shall ensure that the risk management policy set out in Schedule 5 includes the measures and actions in place to control the risks identified.


11/09/2020

Regulation 26(1)(d)

The registered provider shall ensure that the risk management policy set out in Schedule 5 includes arrangements for the identification, recording, investigation and learning from serious incidents or adverse events involving residents.


11/09/2020

Regulation 27 The registered provider shall ensure that procedures, consistent with the standards for the prevention and control of healthcare associated infections published by the Authority are implemented by staff.


18/09/2020

Regulation 28(1)(d)

The registered provider shall make arrangements for


25/09/2020

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staff of the designated centre to receive suitable training in fire prevention and emergency procedures, including evacuation procedures, building layout and escape routes, location of fire alarm call points, first aid, fire fighting equipment, fire control techniques and the procedures to be followed should the clothes of a resident catch fire.

Regulation 28(1)(e)

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.


26/08/2020

Regulation 28(2)(i) The registered provider shall make adequate arrangements for detecting, containing and extinguishing fires.


Yellow

18/09/2020

Regulation 29(5) The person in Not Compliant 14/08/2020

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charge shall ensure that all medicinal products are administered in accordance with the directions of the prescriber of the resident concerned and in accordance with any advice provided by that resident’s pharmacist regarding the appropriate use of the product.

Orange

Regulation 03(1) The registered provider shall prepare in writing a statement of purpose relating to the designated centre concerned and containing the information set out in Schedule 1.


Yellow

21/08/2020

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.


14/08/2020

Regulation 34(1)(f)

The registered provider shall provide an accessible and effective complaints procedure which includes an appeals procedure, and shall ensure


Yellow

26/08/2020

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that the nominated person maintains a record of all complaints including details of any investigation into the complaint, the outcome of the complaint and whether or not the resident was satisfied.

Regulation 34(3)(a)

The registered provider shall nominate a person, other than the person nominated in paragraph (1)(c), to be available in a designated centre to ensure that all complaints are appropriately responded to.


Yellow

26/08/2020

Regulation 34(3)(b)

The registered provider shall nominate a person, other than the person nominated in paragraph (1)(c), to be available in a designated centre to ensure that the person nominated under paragraph (1)(c) maintains the records specified under in paragraph (1)(f).


Yellow

26/08/2020

Regulation 04(1) The registered provider shall prepare in writing, adopt and implement policies and procedures on the matters set out in Schedule 5.


30/09/2020

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Regulation 04(3) The registered provider shall review the policies and procedures referred to in paragraph (1) as often as the Chief Inspector may require but in any event at intervals not exceeding 3 years and, where necessary, review and update them in accordance with best practice.


30/09/2020

Regulation 5(2) The person in charge shall arrange a comprehensive assessment, by an appropriate health care professional of the health, personal and social care needs of a resident or a person who intends to be a resident immediately before or on the person’s admission to a designated centre.


28/08/2020

Regulation 5(3) The person in charge shall prepare a care plan, based on the assessment referred to in paragraph (2), for a resident no later than 48 hours after that resident’s admission to the designated centre concerned.


28/08/2020

Regulation 5(4) The person in charge shall


30/10/2020

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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.

Regulation 5(5) A care plan, or a revised care plan, prepared under this Regulation shall be available to the resident concerned and may, with the consent of that resident or where the person-in-charge considers it appropriate, be made available to his or her family.


30/10/2020

Regulation 6(1) The registered provider shall, having regard to the care plan prepared under Regulation 5, provide appropriate medical and health care, including a high standard of evidence based nursing care in accordance with professional guidelines issued by An Bord Altranais agus Cnáimhseachais


30/10/2020

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from time to time, for a resident.

Regulation 6(2)(c) 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.


Yellow

28/08/2020

Regulation 7(1) The person in charge shall ensure that staff have up to date knowledge and skills, appropriate to their role, to respond to and manage behaviour that is challenging.


09/10/2020

Regulation 7(2) Where a resident behaves in a manner that is challenging or poses a risk to the resident concerned or to other persons, the person in charge shall manage and respond to that behaviour, in so far as possible, in a manner that is not restrictive.


09/10/2020

Regulation 7(3) The registered provider shall ensure that, where restraint is used in a designated centre, it is only used in accordance with national policy


Yellow

28/08/2020

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as published on the website of the Department of Health from time to time.

Regulation 8(1) The registered provider shall take all reasonable measures to protect residents from abuse.


25/09/2020

Regulation 8(2) The measures referred to in paragraph (1) shall include staff training in relation to the detection and prevention of and responses to abuse.


25/09/2020

Regulation 8(3) The person in charge shall investigate any incident or allegation of abuse.


14/08/2020

Regulation 9(2)(b) The registered provider shall provide for residents opportunities to participate in activities in accordance with their interests and capacities.


28/08/2020

Regulation 9(3)(a) A registered provider shall, in so far as is reasonably practical, ensure that a resident may exercise choice in so far as such exercise does not interfere with the rights of other residents.


28/08/2020

Regulation 9(3)(b) A registered Not Compliant Orange 17/08/2020

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provider shall, in so far as is reasonably practical, ensure that a resident may undertake personal activities in private.

Regulation 9(3)(d) A registered provider shall, in so far as is reasonably practical, ensure that a resident may be consulted about and participate in the organisation of the designated centre concerned.


25/08/2020

Report of an inspection of a Designated Centre for Older People. … 2020. 11. 11. · Sheila...

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