Health and Social Care Needs Theme:

Effective care and support

The Registered Provider is failing to comply with a regulatory requirement in the following respect:

The full care needs of all residents were not being met and suitable safe and sufficient care was not being provided.

9. Action Required:

Under Regulation 05(1) you are required to: Arrange to meet the needs of each resident when these have been assessed in accordance with Regulation 5(2).

Please state the actions you have taken or are planning to take:

•To improve operational management systems, the roles and responsibilities of senior Director of Cares who support the Provider Nominee/Person In-Charge are under review to include Practice Development, Care Planning, Documentation, Continuous Training and Education, Policy Development and Operational Management.

•A full review of all Care Plans has commenced prioritizing those with nutritional, behavioural and wound management care needs. A new individualised person centred plan of care is being put in place for every resident to ensure that they receive the best quality of care and enhanced quality of life by having their needs appropriately

assessed, planned and delivered in accordance with the residents needs and wishes. •Implementation of “Key Worker” system for both nursing and care staff, ensuring there is clarity in relation to responsibility for resident care.

•Following a Comprehensive Assessment of Needs, timely referral and review will be conducted by the appropriate AHP and resident’s plan of care will be revised to incorporate all recommendations.

•The care plans will be formally reviewed and evaluated in consultation with the resident and/or representative as indicated by the residents changing needs and/or

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circumstances, and no less frequently than at four-monthly intervals.

•In addition to the Clinical Nurse Managers, the Provider Nominee/Person In-Charge will maintain on-going oversight to provide guidance and support.

•The Provider Nominee/Person In-Charge will keep under review and monitor the quality of care and quality of life of residents in the centre on a weekly basis to ensure appropriate supports are in place.

•A Clinical Audit Programme for 2016 outlining the Clinical Audits and the frequency with which they will be conducted is currently being devised. Findings from these Audits will be used to improve Standards of Care.

•Following staff training, competency assessments of knowledge and skills will be conducted to ensure staff are adequately equipped to deliver quality care in accordance with resident’s assessed needs and plan of care.

Proposed Timescale: 16/02/2016

Theme:

Effective care and support

The Person in Charge (PIC) is failing to comply with a regulatory requirement in the following respect:

Residents did not have comprehensive nursing assessments to identify their personal, health and social care needs as detailed in the report.

10. Action Required:

Under Regulation 05(2) you are required to: 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 the designated centre.

Please state the actions you have taken or are planning to take:

A full review of all Care Plans using a comprehensive assessment tool has commenced prioritising those with nutritional, behavioural and wound management care needs. A new individualised person centred plan of care is being put in place for every resident to ensure that they receive the best quality of care and enhanced quality of life by having their needs appropriately assessed, planned and delivered in accordance with the residents needs and wishes.

Proposed Timescale: 16/02/2016

Theme:

Effective care and support

The Person in Charge (PIC) is failing to comply with a regulatory requirement in the following respect:

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consistent care.

Residents did not have care plans for existing medical conditions Care plans were not amended in light of residents changing needs

Care plans for behaviours that challenge did not identify triggers in order to prevent escalation of behaviours.

11. Action Required:

Under Regulation 05(3) you are required to: Prepare a care plan, based on the assessment referred to in Regulation 5(2), for a resident no later than 48 hours after that resident’s admission to the designated centre.

Please state the actions you have taken or are planning to take:

•A full review of all Care Plans has commenced prioritising those with nutritional, behavioural and wound management care needs. A new individualised person centred plan of care is being put in place for every resident to ensure that they receive the best quality of care and enhanced quality of life by having their needs appropriately

assessed, planned and delivered in accordance with the residents needs and wishes. •All residents who by their assessed need require a Positive Behavioural Support Care Plan, will have their needs assessed and a care plan developed which clearly outline triggers in order to prevent escalation of behaviours.

•Implementation of “Key Worker” system for nursing staff ensuring there is clarity in relation to responsibility for resident care.

Proposed Timescale: 16/02/2016

Theme:

Effective care and support

The Person in Charge (PIC) is failing to comply with a regulatory requirement in the following respect:

There was no documentary evidence that the quarterly review of care plans included an evaluation to determine the effectiveness of the interventions in the plan.

12. Action Required:

Under Regulation 05(4) you are required to: Formally review, at intervals not exceeding 4 months, the care plan prepared under Regulation 5 (3) and, where necessary, revise it, after consultation with the resident concerned and where appropriate that resident’s family.

Please state the actions you have taken or are planning to take:

•Following a full review of all Care Plans and transfer to the new care planning documentation, all care plans will be evaluated to determine the effectiveness of the interventions in the plan as indicated by the residents changing needs and

circumstances. Reviews will take place no less frequently than at four monthly intervals in consultation with the resident concerned and where appropriate the resident’s family. •A recognised Computerised Care Planning Systems is being implemented with

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mandatory training for staff commencing week being 11/1/2016.

•Implementation of “Key Worker” system for nursing staff ensuring there is clarity in relation to responsibility for resident care reviews.

Proposed Timescale: 16/02/2016