St. Doolagh's Park Care and Rehabilitation Centre. Malahide Road. Balgriffin. Dublin 17.

Transcription

1 Health Information and Quality Authority Social Services Inspectorate Inspection report Designated centres for older people Centre name: St. Doolagh's Park Care and Rehabilitation Centre Centre ID: 0173 Centre address: Malahide Road Balgriffin Dublin 17 Telephone number: Fax number: address: Type of centre: Private Voluntary Public Registered providers: Person in charge: Guardian Healthcare Company Ciara Hopper Date of inspection: 20 January 2012 Time inspection took place: Start: 09:00 hrs Completion: 17:30 hrs Lead inspector: Support inspector: Nuala Rafferty Ann Delaney Type of inspection: Announced Unannounced Application to vary registration conditions Notification of a significant incident or event Purpose of this inspection visit: Notification of a change in circumstance Information received in relation to a complaint or concern Follow-up inspection Page 1 of 19

2 About the inspection The purpose of inspection is to gather evidence on which to make judgments about the fitness of the registered provider and to report on the quality of the service. This is to ensure that providers are complying with the requirements and conditions of their registration and meet the Standards, that they have systems in place to both safeguard the welfare of service users and to provide information and evidence of good and poor practice. In assessing the overall quality of the service provided, inspectors examine how well the provider has met the requirements of the Health Act 2007, the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) and the National Quality Standards for Residential Care Settings for Older People in Ireland. Additional inspections take place under the following circumstances: to follow up matters arising from a previous inspection to ensure that actions required of the provider have been taken following a notification to the Health Information and Quality Authority s Social Services Inspectorate of a change in circumstance for example, that a provider has appointed a new person in charge arising from a number of events including information received in relation to a concern/complaint or notification to the SSI of a significant event affecting the safety or wellbeing of residents to randomly spot check the service. All inspections can be announced or unannounced, depending on the reason for the inspection and may take place at any time of day or night. All inspection reports produced by the Health Information and Quality Authority will be published. However, in cases where legal or enforcement activity may arise from the findings of an inspection, the publication of a report will be delayed until that activity is resolved. The reason for this is that the publication of a report may prejudice any proceedings by putting evidence into the public domain. Page 2 of 19

3 About the centre Description of services and premises St. Doolagh s Care and Rehabilitation Centre is a purpose-built, two-storey building which can accommodate up to 72 residents. Categories of care provided include care of the older person, dementia care, young chronic sick with complex needs and acquired brain injury. The centre provides continuing respite and rehabilitative care to persons over 18 years of age. The unit on the ground floor is a specific acquired brain injury unit which provides step down rehabilitation or long-term care services. The first floor provides long-term care to people who are young chronic sick and older persons. All bedrooms are single with en suite bathrooms and there are a variety of communal areas which residents can access for leisure and relaxation purposes such as games rooms and TV rooms. The ground floor also consists of a reception area with a comfortable seating area and administration offices, staff changing and toilet facilities, physiotherapy, games room, dining room, sitting room, store rooms, visitors toilet, a nurses station, drugs store, one sluice, one cleaners store, three assisted toilets, three assisted showers/ bathrooms, laundry and main kitchen with separate change facilities for catering staff. In addition a small self-contained area is provided as a transitionary living unit containing separate dining and sitting room, kitchenette, toilet and assisted shower/ bathroom. The first floor includes a dining room with adjoining multi purpose room, psychologist s office, nurses station, two alcoves with comfortable seating and televisions for residents use, sluice room, store room, cleaners store, linen room, four assisted toilets, and two assisted shower/bathrooms. Outdoors there is an enclosed landscaped courtyard and a sports area which can be used for football, volley ball or basket ball. The centre is set on a large enclosed parkland area with ample walkways for residents to enjoy. It is secured with high walls and electronic gates. Parking is available for staff and visitors. Location The centre is located in a parkland area set back off the main Malahide road. A long winding driveway brings you from the entrance gates to the front door. It is close to both Malahide and Swords Village. A regular bus service to Malahide village is available at the entrance gates. Page 3 of 19

4 Date centre was first established: 2003 Number of residents on the date of inspection: 64 with 2 residents on home leave and 2 in hospital Number of vacancies on the date of inspection: 4 Dependency level of current residents Max High Medium Low Number of residents* * includes 2 residents on home leave and 2 in hospital Management structure Ciara Hopper is the Person in Charge and she reports to the Provider, Keith Robinson who is the Chief Executive Officer of the Guardian Healthcare Company. The Person in Charge is supported by an Assistant Director of Nursing. All nursing staff report to the assistant director of nursing and to the person in charge. Each team of care assistants are supervised by a head care assistant. All care assistants also report to the nursing staff. All other household and catering staff report to the person in charge. An interdisciplinary team consisting of a full-time clinical psychologist and assistant psychologist, physiotherapy, psychiatry and full time activities coordinator are overseen by the Person in Charge Staff designation Number of staff on duty on day of inspection Person in Charge Nurses Care staff Catering staff Cleaning and laundry staff Admin staff * Other staff *1 assistant director of nursing, 1 clinical nurse manager, 2 allied health professionals, 1 maintenance person, 1 household supervisor, 1 activities coordinator Page 4 of 19

5 Background St. Doolagh's Park Care and Rehabilitation Centre was previously inspected by the Health Information and Quality Authority s (the Authority) Social Services Inspectorate on 6 October 2009, 18 February 2010, 5 and 6 May 2010 and 5 and 6 August The inspection in August 2010 was a registration inspection and inspectors found the overall care delivered in the centre was of a good standard. Staffing levels and skillmix were appropriate to meet the needs of the current residents profile. Ongoing efforts to improve person centered care practices were evident. A number of improvements were required to comply with the Health Act 2007 (Care and Welfare of Residents in Designated Centre s for Older People) Regulations 2009 (as amended) and the National Standards for Residential Care Settings for Older people in Ireland. The provider was required to complete an Action Plan to address these areas. An Action Plan identifying sixteen non compliances was developed by the inspection team based on their findings where some or significant improvement was required by the provider to comply with the legislation. A follow up inspection took place on 18 February and 2 March The inspection was unannounced and focused on the implementation of the action plan issued to the provider and also covered issues related to information received by the Authority. Of the 16 non compliances identified from the registration inspection, the provider had complied with nine, partially complied with six and not complied with one as required by the Authority. This additional inspection report outlines the findings of a further follow up inspection that took place on 20 January2012. A further action plan with six failings was developed requiring the provider to continue improvements in line with the Regulations and the Standards. All inspection reports for St. Doolagh's Park Care and Rehabilitation Centre, centre ID173 can be found at Page 5 of 19

6 Summary of findings from this inspection The follow up inspection was facilitated in a helpful manner by the person in charge, assistant director of nursing and all staff on duty. On arrival the inspector found the centre was warm, clean and well maintained. Care was delivered within a calm respectful atmosphere. Of the six non compliances identified from the February 2011 follow up inspection, the provider had complied with four, partially complied with one and not complied with one as required by the Authority. Improvements relating to premises, equipment, communication policies and processes and a review of all policies and procedures were identifed. Issues in relation to care plans and risk management were partially addressed although further issues in terms of risk management were identified on inspection. A further action plan has been developed requiring the provider to improve these areas in line with the Regulations and the Standards. Page 6 of 19

7 Issues covered on inspection The primary focus of the inspection was to review and assess the progress of the agreed action plan from the registration and subsequent follow up inspections of 5 and 6 August 2010 and 18 February It also involved a review of the required notifications received by the authority in respect of incidents in the centre. These notifications must be received in a timely and complete manner by the Chief Inspector. Documentation and Risk Management Information in the form of notifications were received by the Authority in Two notifications of deaths under 70 were reviewed. The centre s resident profile is comparatively young. One death was related to the residents diagnosis and comorbidities and was expected. In relation to the second, a coroner s inquest is pending. Other notifications related to a number of incidences such as unexplained absences and suspected abuse. Provider Led Investigations were requested and carried out by the provider into these incidences. Detailed reports outlining the investigations into the incidences and their outcomes were notified to the Authority in a complete and timely manner. All aspects of the details of the investigation, communication supports and learning outcomes provided were reviewed during the inspection process. Inspectors found that some risk management measures were implemented in a timely and appropriate manner. A review of the documentation of the interventions undertaken and supports established during the investigations identified gaps that resulted in a lack of clarity in the decision making process. The documentation of reviews and examinations carried out as part of the investigation process by members of the clinical and medical personnel was limited and in some instances absent. Inspectors also found gaps in the risk management policies and procedures which require to be addressed in order to comprehensively manage the risks and limit the potential for recurrent incidences. A review of the investigation and management processes to promote safety and transfer of learning for all staff was not implemented. Staff Training On review of records inspectors found that a comprehensive level of staff training was planned and delivered throughout An equally high level of clinical training linked to performance appraisal and the current residents profile is planned for It was noted that although the training was planned and delivered, not all staff attended the mandatory training on fire safety, moving and handling or other training such as prevention and detection of elder abuse and food safety. Page 7 of 19

8 Actions reviewed on inspection: 1. Action required from previous inspection: The person in charge shall ensure each resident s needs are set out in an individual care plan developed and agreed with each resident. The interventions required to meet the changing needs of residents to be continuously assessed, monitored and evaluated on an as required basis and no less frequently than every three months. Care plans to reflect interventions recommendations or referrals made by all allied health professionals and the general practitioner (GP) in a timely consistent manner. Review of care plans should be linked to ongoing nursing assessment and evaluation of the effectiveness of interventions and therapies provided. This action was partially addressed. A sample number of care plans were checked and an overall improvement was found. Care plans were noted to be reviewed on a three-monthly basis as required by the Regulations. However, healthcare assessments required to be improved to ensure better outcomes for residents, were not comprehensive or appropriate. In the case of one resident, it was found that although there were recent indicators of potential deterioration or change in condition a referral for review by a specialist consultant was not made. Furthermore, goals identified at multi-disciplinary team meetings were not linked to care plans to identify timelines for updates and assessment of effectiveness of interventions made. It was also noted that where restraints were in place, the documentation of the duration of restraints were not always included. 2. Action required from previous inspection: Ensure all staff are aware of the policies and procedures in place to manage risks in the centre. Ensure staff are aware of their roles and responsibilities in relation to risk management and the safety and protection of residents at all times. Provide additional training or information sessions or other support systems where necessary to update and support staff in relation to risk management their roles and responsibilities. Page 8 of 19

9 This action was addressed. However, other issues in relation to risk management further to information in respect of notifications were found and are reflected under issues found on inspection above. Procedures in place to manage risks associated with escorted and unescorted leave from the centre were found to be consistently implemented by staff. Further training was provided to staff on risk management and risk assessment on a variety of dates and a total of 36 staff attended the training. A member of the senior management team has since upskilled in risk management in order to provide in house support to staff on risk management issues. 3. Action required from previous inspection: Carry out an immediate review of all written policies and procedures and ensure they are reviewed regularly to meet best practice and the Regulations as required and at least every three years. Ensure that all policies and procedures meet the requirements of the Regulations. Ensure staff are aware of the policies and procedures and knowledgeable in relation to their responsibilities towards their implementation. Establish a system which audits and reviews implementation of policies and procedures and disseminates learning to all staff. This action was addressed. The person in charge reviewed all policies and procedures in the centre. Where changes were made, a circular was issued to advise staff to read the policy. A sign off sheet attached to the policies indicated where staff had read and understood the policies in place. An audit of policies and practice was undertaken in July 2011 to assess the level of staff understanding and competence in terms of implementing policies into practice. A sample number of twenty staff were involved in the audit. 4. Action required from previous inspection: Put in place written policies and procedures on all communication processes operational in the centre. Page 9 of 19

10 This action was addressed. A review of the communication processes to include protocols for documentation and outcomes of meetings within and between teams was undertaken and a staff communications policy devised. The policy outlines the various formal means used in the centre to ensure a flow of information. The policy references the use of verbal and written methods and identifies where and when communication meetings are held and where records of the meetings can be accessed. 5. Action required from previous inspection: Ensure that staff records contain all the requirements listed in Schedule 2 of the Regulations. This action was not addressed. A sample number of staff personnel records were reviewed and all information as required by Schedule 4 of the Regulations was not available such as, evidence of physical/mental fitness or self declaration, full employment history or Garda vetting. In addition, evidence that the personnel files of staff employed by a private company working in the centre meet the regulations and fulfil the contract signed with the provider was not found. 6. Action required from previous inspection: Review sluicing facilities and put in place sluicing facilities which meet best practice in relation to infection prevention and control in relation to racking drainage facilities. Provide adequate ventilation in all areas of the centre and specifically in the laundry and cleaners rooms. Maintain regular documented checks on the temperatures in all areas of the centre to ensure they are within recommended guidelines. Identify the specific designated function of each room in the centre. This action was addressed. Both sluice rooms on the ground and first floor were reviewed and racking was in place for storage and drainage of equipment. Mechanical extraction ventilation was in place and operational in the cleaners and laundry room. A record of temperature checks within the centre was in place and noted to be within recommended ranges. A sample of temperature checks were taken on inspection and also found to be within recommended range. Signs identifying the designated function of all rooms were in place. Page 10 of 19

11 Report compiled by: Nuala Rafferty Inspector of Social Services Social Services Inspectorate Health Information and Quality Authority 1 February 2012 Chronology of previous HIQA inspections Date of previous inspection Type of inspection: 20 January 2012 Registration Scheduled Follow up inspection Announced Unannounced 18 February and 2 March 2011 Registration Scheduled Follow up inspection Announced Unannounced 5 and 6 August 2010 Registration Scheduled Follow up inspection Announced Unannounced 5 and 6 May 2010 Registration Scheduled Follow up inspection Announced Unannounced 18 February 2010 Registration Scheduled Follow up inspection Announced Unannounced 6 October 2009 Registration Scheduled Follow up inspection Announced Unannounced Page 11 of 19

12 Health Information and Quality Authority Social Services Inspectorate Action Plan Provider s response to inspection report Centre: St. Doolagh's Park Care and Rehabilitation Centre Centre ID: 0173 Date of inspection: 20 January 2012 Date of response: 8 March 2012 Requirements These requirements set out what the registered provider must do to meet the Health Act, 2007, the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 (as amended) and the National Quality Standards for Residential Care Settings for Older People in Ireland. 1. The provider is failing to comply with a regulatory requirement in the following respect: Risk management policy and processes in place were not sufficiently robust or specific to ensure the health and safety of both residents and staff were promoted and protected at all times. The policy was also limited in that it did not identify or assess all of the risks associated with protocols in place specifically the policy for unescorted and escorted leave for residents, near miss incidents and safety of staff when escorting residents outside of the centre. Put in place a comprehensive written centre-specific risk management policy and implement this throughout the designated centre. The Authority reserves the right to edit responses received for reasons including: clarity; completeness; and, compliance with legal norms. Page 12 of 19

13 Ensure that the risk management policy covers, but is not limited to, the identification and assessment of risks throughout the designated centre and the precautions in place to control the risks identified. Ensure that the risk management policy covers the arrangements for the identification, recording, investigation and learning from serious or untoward incidents or adverse events involving residents. Ensure that the risk management policy covers the precautions in place to control the following specified risks: the unexplained absence of a resident; assault; accidental injury to residents or staff; aggression and violence; and self-harm. Take all reasonable measures to prevent accidents to any person in the designated centre in the grounds of the designated centre and when outside of the centre with staff knowledge. Reference: Health Act, 2007 Regulation 31: Risk Management Procedures Standard 26: Health and Safety Standard 29: Management Systems Please state the actions you have taken or are planning to take with timescales: Timescale: Provider s response: We have a comprehensive risk management policy in place. We will review this policy to ensure it meets all the requirements of legislation and current best practice. All staff will be made aware that the policy has been reviewed and of the changes made to the policy. The risk management policy includes a risk assessment which includes the assessment of risks and the controls which are required to minimise risk. Risk management training will be delivered in March/April 2012 to ensure all staff are aware of the changes to policy and have had a refresher in the use of the risk assessment tool. Page 13 of 19

14 The risk management policy will detail procedures to be followed relating to untoward incidents or adverse incidents. A risk management committee will review risk on a bi-monthly basis. They will meet and review incidents for period and meetings will be minuted with an action plan to address issues which may arise. In relation to serious or untoward incidents or adverse events our procedures and protocols will be strengthened as follows: 1. a full investigation of each event will take place which will include 2. a multi-disciplinary team meeting, this will be minuted and available for all staff on each floor 3. a follow-up meeting with the multi-disciplinary team will be held within seven days 4. changes will be made to policies and procedures, if they require amendment, as a result of the learning process 5. communication with other stakeholders will be carried out as per policy 6. notification to the appropriate bodies will be conducted 7. an evidence file of documentation relating to the above will be held and available for review. We have external Health and Safety Consultants who review our Safety Statement on an annual basis. In addition, we have monthly Health and Safety meetings which are minuted and have actions based on Health and Safety issues as they arise. We will continue to take all reasonable measures to prevent accidents to any person in the designated centre, in the grounds of the designated centre and when outside of the designated centre with staff knowledge. 30/03/ /03/ The provider is failing to comply with a regulatory requirement in the following respect: Effective management systems in place to review the quality and safety of care were not sufficiently robust or comprehensive to support and promote the delivery of quality care services or implement improvements to ensure a culture of learning, quality assurance and continuous improvement. The information from quality improvement initiatives were not formulated into a report in accordance with Regulation 35. Establish and maintain a system for improving the quality of care provided at, and the quality of life of residents in, the designated centre. Page 14 of 19

15 Consult with residents and their representatives in relation to the system for reviewing and improving the quality and safety of care, and the quality of life of residents. Make a report in respect of any review conducted by the registered provider for the purposes of Regulation 35, and make a copy available to the Chief Inspector. Reference: Health Act, 2007 Regulation 35: Review of Quality and Safety of Care and Quality of Life Standard 30: Quality Assurance and Continuous Improvement Please state the actions you have taken or are planning to take with timescales: Timescale: Provider s response: Currently in St. Doolagh's Park Care and Rehabilitation Centre we have the following Quality Improvement Initiatives in place. Quality of care reviews which are called "periodic service reviews", and which take place three-monthly. The resident and his/her representative are invited to attend and members of the multidisciplinary team who are involved in the resident's care attend. Documentation will be amended to include evidence of the resident's or his/her representatives input, where possible. Monthly Family Support Group meetings are facilitated by our Psychology Department to address issues pertinent to the families of our residents, these include Quality of Life issues of our residents. Notes of these meetings are kept in the Senior Psychologist's office in line with Psychological Society of Ireland s ethical guidelines. Our multi-disciplinary meetings take place weekly to review residents' care needs and these include Quality of Life issues. Residents' council meetings take place monthly and minutes of these meetings are available. Annual relatives' satisfaction surveys take place, which are then collated to develop an action plan to address any issues which may arise. Page 15 of 19

16 We have a Home Audit tool which looks at all aspects of the service and which is undertaken bi-monthly by the director of nursing or the assistant director of nursing. There is a section of this tool which outlines actions required and the members of the team responsible for same. Our residents' receive advocacy services through the National Advocacy Service and we have an independent advocate through this service for our residents. We have comments cards and a suggestions box available in the reception area and our director of nursing has an open door policy to discuss any issues which the residents' may wish to raise with her. We will develop a Quality Improvement policy as a result of feedback from this inspection and this will be disseminated to all staff by 20 April Following the feedback received at this inspection we will formalise and summarise all these Quality Improvement Initiatives into a report which will be forwarded to the Authority by 20 April /04/ /04/ The person in charge has failed to comply with a regulatory requirement in the following respect: Continuous assessment, monitoring and review of resident s changing needs were not consistently reflected in the care plans. Care plans did not reflect interventions recommendations or referrals made by all allied health professionals and the general practitioner in a timely consistent manner. Review of care plans were not consistently linked to ongoing nursing assessment and evaluation of the effectiveness of interventions and therapies provided. Keep each resident s care plan under formal view as required by the resident s changing needs or circumstances and no less frequent than at three-monthly intervals. Revise each resident s care plan, after consultation with him/her. Notify each resident of any review of his/her care plan. Page 16 of 19

17 Reference: Health Act, 2007 Regulation 8: Assessment and Care Plan Standard 11: The Resident s Care Plan Please state the actions you have taken or are planning to take with timescales: Timescale: Provider s response: Care plans have always been reviewed no less frequently than at three-monthly. Audits of care plans are undertaken by the person in charge or her representative bi-monthly and feedback is disseminated to nurses in relation to changes required. Residents and their representatives are invited to the quality of care reviews which we refer to as "periodic service reviews". We will strengthen our policies and procedures on care planning and documentation to ensure that each resident s care plan is revised after consultation with allied health professionals. Care planning and documentation training will take place in April to ensure that nurses and members of the MDT are familiar with the requirements of our strengthened policies and procedures. 23/03/ /04/2012 Revised Summaries of Daily Care or "Daily Routines" will be signed off by each Resident, where possible, or the next of kin. 4. The person in charge has failed to comply with a regulatory requirement in the following respect: The personnel records of some staff did not contain all of the required documentation as required in Schedule 2 of the Regulations. Ensure that staff records contain all the requirements listed in Schedule 2 of the Regulations. Reference: Health Act, 2007 Regulation 24: Staffing Records Standard 22: Recruitment Page 17 of 19

18 Please state the actions you have taken or are planning to take with timescales: Timescale: Provider s response: The four staff members in question now have the required documentation in place. Although they had completed a self medical declaration form we were awaiting evidence from their general practitioners. We are still awaiting the return of a Garda Vetting form for one of these staff members from An Garda Síochána and have re-applied for this person (please note this staff member has signed a self declaration form in this respect). We have amended our human resource policy to ensure there is follow up where Garda Vetting forms are not returned by An Garda Síochána within twelve weeks. Complete Complete Our external catering contractor staff members will have all required documentation in place by 31 March The person in charge has failed to comply with a regulatory requirement in the following respect: Although access to education and training was provided, all Staff did not attend up-todate mandatory training as required by legislation to meet the needs of residents. Provide staff members with access to education and training to enable them to provide care in accordance with contemporary evidence based practice. Supervise all staff members on an appropriate basis pertinent to their role. Make staff members aware, commensurate with their role, of the provisions of the Health Act 2007, the Regulations, the statement of purpose and any policies and procedures dealing with the general welfare and protection of residents. Reference: Health Act, 2007 Regulation 24: Staffing Records Standard 22: Recruitment Page 18 of 19

19 Please state the actions you have taken or are planning to take with timescales: Timescale: Provider s response: As noted by the Authority there is a comprehensive training plan in place. Our training records form has been amended to include our Induction Training Programme which includes all mandatory training, with the exception of safe moving and handling. Complete and ongoing We will ensure all staff attend mandatory training going forward. Any comments the provider may wish to make: Provider s response: We wish to thank the inspectors for the courtesy shown to the residents throughout the inspection and to thank them for their positive comments at the feedback meeting. The acknowledgement of the considerable work done and the "keep up the good work" comment at the conclusion of the meeting was invaluable feedback for the team at St Doolagh's Park Care and Rehabilitation Centre. Provider s name: Guardian Healthcare/Keith Robinson, CEO. Date: 8 March 12 Page 19 of 19