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Report of an inspection of a
Designated Centre for Older People
Name of designated
centre:
The Cottage Nursing Home
Name of provider:
Tipperary Healthcare Limited
Address of centre:
70 Irishtown, Clonmel,
Tipperary
Type of inspection:
Unannounced
Date of inspection:
08 May 2018
Centre ID:
OSV-0004587
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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 Cottage Nursing Home is located within the urban setting of the town of Clonmel, Co. Tipperary. The original building, historically, was the Cottage hospital and this has undergone significant refurbishment. It is a two-storey facility with a lift and stairs access to the upstairs. The centre is registered to accommodate 25
residents. Residents' accommodation comprises single and double occupancy bedrooms with hand-wash facilities; assisted shower en-suite bathrooms are available throughout the centre; day room and dining areas are located on both floors. The Cottage Nursing Home provides 24 hour nursing care to male and female residents whose dependency needs range from low to maximum with varying care needs including care of people with a diagnosis of dementia.
The following information outlines some additional data on this centre.
Current registration end
date:
11/08/2018
Number of residents on the
date of inspection:
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How we inspect
To prepare for this inspection the inspector or inspectors reviewed all information about this centre. This included any previous inspection findings, registration information, information submitted by the provider or person in charge and other unsolicited information since the last inspection.
As part of our inspection, where possible, we:
speak with residents and the people who visit them to find out their experience of the service,
talk with staff and management to find out how they plan, deliver and monitor
the care and support services that are provided to people who live in the centre,
observe practice and daily life to see if it reflects what people tell us,
review documents to see if appropriate records are kept and that they reflect practice and what people tell us.
In order to summarise our inspection findings and to describe how well a service is doing, we group and report on the regulations under two dimensions of:
1. Capacity and capability of the service:
This section describes the leadership and management of the centre and how effective it is in ensuring that a good quality and safe service is being provided. It outlines how people who work in the centre are recruited and trained and whether there are appropriate systems and processes in place to underpin the safe delivery and oversight of the service.
2. Quality and safety of the service:
This section describes the care and support people receive and if it was of a good quality and ensured people were safe. It includes information about the care and supports available for people and the environment in which they live.
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This inspection was carried out during the following times:
Date
Times of
Inspection
Inspector
Role
08 May 2018 09:30hrs to
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Views of people who use the service
The inspector spoke with four residents in their bedrooms and joined residents at lunchtime in the dining room. Residents gave positive feedback regarding the care and life in the centre. They were thrilled with the refurbishment work that has been going on in the centre, their newly redecorated bedrooms and the paintings
decorating the walls throughout. Residents spoke of the kindness and
encouragement they received from staff and the choices they have in their daily lives.
Capacity and capability
Overall, the inspector found a good standard of care. There were clear lines of accountability and responsibility demonstrated. There was evidence of effective governance arrangements to enable positive outcomes for residents whereby the provider engaged with the service on a weekly basis to ensure oversight. The inspector observed care and support given to residents was relaxed, unhurried and appropriate to the needs of residents. Feedback from residents was positive and they said that they had access to lots of activities in accordance with their
preferences, that enhanced their quality of life.
Residents were familiar with the person in charge and staff, and good banter between residents and staff was observed which created a friendly atmosphere. Residents gave positive feedback regarding care, attention and encouragement to improve their independence and quality of life. The inspector observed that staff had a holistic knowledge of residents in their care. Residents spoke openly and freely with staff, discussing a variety of topics, all of which demonstrated a culture of trust and respect.
The person in charge demonstrated the continuous quality improvement strategy which comprised both clinical and social care. Audits were completed and these informed practice. The assistant director of nursing was involved with the person in charge in the audit programme. The audit schedule in place was based on the requirements set out in Regulation 23(d); the person in charge had oversight and responsibility of these and the results of these informed residents' meetings, staff meetings, training and staff appraisals.
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included when the need was identified.
Records to be maintained such as medications, controlled drugs and
healthcare were reviewed. Healthcare records were comprehensive and showed timely assessments, interventions, reviews of care and the resident’s response to treatments. Records showed that care was discussed and agreed with residents and the inspector observed this throughout the inspection. Medication management records and controlled drug records required attention to ensure compliance with best practice professional guidelines.
Regulation 14: Persons in charge
The person in charge had the necessary qualifications, experience and clinical knowledge as required in the regulations. She demonstrated responsibility and accountability for the role and was engaged in the governance, operational management and administration of the centre.
Judgment: Compliant
Regulation 16: Training and staff development
The training matrix reviewed demonstrated that all staff training was up to date and this was facilitated by in-house training, external trainers and on-line courses. The staff appraisal system was utilised to follow-up on training and inform the training needs analysis to ensure staff have the required skills and knowledge. Practice observed demonstrated that care policies were implemented whereby interactions and assistance given to residents were in line with best practice; staff were
supervised to ensure the rights, dignity and safety of residents.
Judgment: Compliant
Regulation 24: Contract for the provision of services
Contracts of care were in place for each resident and contained the requirements set out in the regulations. They were signed and dated and updated when there was a change to the contract details.
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Judgment: Compliant
Regulation 31: Notification of incidents
Notifications were reviewed and they were submitted in accordance with the regulations. The person in charge was aware of the responsibility associated with submission of notifications.
Judgment: Compliant
Regulation 4: Written policies and procedures
Policies and procedures were updated by the person in charge in 2018. Generally, procedures observed demonstrated that best practice was implemented. To ensure best practice and minimise the risk of medication errors or near misses, a review of the medication management policy implementation was required, in areas for example, recording in the drug kardex when a resident self-medicated; two
signatures were not always evident in the twice-daily controlled drug count in line with professional guidelines.
Judgment: Substantially compliant
Quality and safety
The inspector observed that the person in charge was known to residents. Care and support given to residents was relaxed, unhurried and appropriate to the needs of residents. There were two activities staff to facilitate group stimulation as well as one-to-one therapy in residents' bedrooms and interactive therapy was observed on inspection. Appropriate assistance and encouragement was given to residents when needed; staff demonstrated good communication strategies with each resident including people with complex communication needs.
There were several quality initiatives to support residents and relatives, for example, 'Why We Do What We Do'. This was a series of pictorial displays on one wall
explaining topics such as exercises, hand massage, meditation and other activities and the benefit to residents. The 'Word Wall' contained large displays of words and what they meant to different residents, for example singing, dancing and family.
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and residents gave positive feedback about these improvements. The programme of works also included moving the laundry and relocating the main door and reception and considerable work was in progress for those. Nonetheless, other areas required consideration to improve the quality of life of residents, such as the very limited outdoor space available.
The quarterly newsletter welcomed new residents and staffs, bid farewell to other staff and remember friends who had passed away, RIP. It contained lots of
photographs of events and parties held in the centre and detailed upcoming activities for residents' enjoyment.
Catering manager works full-time between two services. Good oversight of menus, nutrition and hydration need, specialist diets was described by the catering
manager. Residents had access to speech and language therapy and dietician services to enhance care and support. Menu choice and meals were a standing item on the residents' meeting agenda and the inspector observed that meals were presented in a pleasing manner to enhance their dining experience.
Regulation 10: Communication difficulties
Information was provided for residents in an accessible format, appropriate to their needs. The inspector observed that staff actively engaged with residents which empowered residents to exercise their rights to make choices. Information such as the Resident's Guide, Statement of Purpose and inspection reports were available to residents and their families. The residents' meetings were held every three months and these were dynamic and positively influenced the quality of life in the centre.
Judgment: Compliant
Regulation 11: Visits
The inspector observed unrestricted visiting. Visitors were welcomed and staff
actively engaged with them. There was adequate space for residents to receive their visitors in private in the sitting room upstairs if they wished.
Judgment: Compliant
Regulation 12: Personal possessions
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possessions. There was a laundry on site and laundry was segregated at source to minimise cross infection. The laundry staff had recently completed training in infection prevention and control to enhance their practice.
Judgment: Compliant
Regulation 17: Premises
A schedule of works was in place to refurbish the centre and this was in progress and on target. The centre was homely, accessible and provided adequate physical space to meet the assessed needs of residents. Assisted toilets and shower facilities were available throughout the centre both upstairs and downstairs as none of the bedrooms had en-suite facilities. Bedrooms has hand-wash facilities and all had been refurbished at the time of inspection. Other redecorating work completed at the time of inspection included the communal rooms, flooring, hallways and corridors, which gave the appearance of light and airiness and residents relayed their happiness at the upgrading of their home.
Additional areas that required upgrading to enhance the refurbishment works included the outdoor space for residents. At the time of inspection the outdoor space for residents was not fit for purpose and views form most windows were uninspiring.
The storage linen press downstairs required upgrading to ensure health, safety and infection control best practice.
Judgment: Not compliant
Regulation 18: Food and nutrition
The inspector observed meal and snack times during the inspection. Mealtime was a sociable occasion where choice was offered and meals were presented in an
appetising and pleasing manner. Specialist consistency meals were attractive and appealing in their presentation. There were adequate staff to support residents during mealtimes. Daily menus were displayed in pictorial format as well as narrative and residents were assisted to make choices regarding menu choice. Residents gave positive feedback regarding meals, mealtimes and the quality of food.
Choice was available for all meals. The catering manager outlined that she received feedback following residents' meetings which informed the menu. Residents had access to speech and language therapy and dietician services to inform dietary requirement to promote positive outcomes for residents.
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Judgment: Compliant
Regulation 27: Infection control
Staff training was up to date regarding infection prevention and control, hand hygiene, cleaning, laundry and food hygiene safety. The person in charge discussed infection control and outlined that this topic was highlighted and discussed regularly at staff handovers as well as at staff meetings. Refresher information
sessions regarding infection control were ongoing to ensure best practice was adhered to. Sluice rooms were in the process of being refurbished and additional storage racks for urinals and commode inserts were awaited at the time of inspection. New laminated risk management waste disposal charts were also awaited at the time of inspection.
Judgment: Compliant
Regulation 6: Health care
Residents had timely access to medical services as well as specialist services, both within the centre and externally, for example, psychiatry of old age, ophthalmic and audiology services. Included in the residents' notes was a synopsis of the life of the individual, their interests, likes and dislikes all of which was in a booklet called 'This is Me'. This helped staff get to know the person in order to proved appropriate person-centred care and support.
Judgment: Compliant
Regulation 7: Managing behaviour that is challenging
Staff training was up to date and the inspector observed that staff had the appropriate skills to respond to and manage responsive behaviours to enable positive outcomes for residents.
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Appendix 1 - Full list of regulations considered under each dimension
Regulation Title
Judgment
Capacity and capability
Regulation 14: Persons in charge Compliant Regulation 16: Training and staff development Compliant Regulation 24: Contract for the provision of services Compliant Regulation 31: Notification of incidents Compliant Regulation 4: Written policies and procedures Substantially
compliant
Quality and safety
Regulation 10: Communication difficulties Compliant
Regulation 11: Visits Compliant
Regulation 12: Personal possessions Compliant
Regulation 17: Premises Not compliant
Regulation 18: Food and nutrition Compliant Regulation 27: Infection control Compliant
Regulation 6: Health care Compliant
Regulation 7: Managing behaviour that is challenging Compliant
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Compliance Plan for The Cottage Nursing Home
OSV-0004587
Inspection ID: MON-0022391
Date of inspection: 08/05/2018
Introduction and instruction
This document sets out the regulations where it has been assessed that the provider or person in charge are not compliant with the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013, Health Act 2007 (Registration of Designated Centres for Older People) Regulations 2015 and the National Standards for Residential Care Settings for Older People in Ireland.
This document is divided into two sections:
Section 1 is the compliance plan. It outlines which regulations the provider or person in charge must take action on to comply. In this section the provider or person in charge must consider the overall regulation when responding and not just the individual non compliances as listed section 2.
Section 2 is the list of all regulations where it has been assessed the provider or person in charge is not compliant. Each regulation is risk assessed as to the impact of the non-compliance on the safety, health and welfare of residents using the service.
A finding of:
Substantially compliant - A judgment of substantially compliant means that
the provider or person in charge has generally met the requirements of the regulation but some action is required to be fully compliant. This finding will have a risk rating of yellow which is low risk.
Not compliant - A judgment of not compliant means the provider or person
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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 4: Written policies and
procedures Substantially Compliant
Outline how you are going to come into compliance with Regulation 4: Written policies and procedures:
We will update our Kardex drug charts to include a section for self administration of medication.
We have had a meeting with all nursing staff to ensure that the policy of medication management especially in regard to controlled medications are strictly adhered to.
Regulation 17: Premises Not Compliant
Outline how you are going to come into compliance with Regulation 17: Premises: The linen press will be refurbished to meet the correct standards.
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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 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.
Not Compliant Yellow 30/6/18
Regulation 04(1) The registered provider shall prepare in writing, adopt and
implement policies and procedures on the matters set out in Schedule 5.
Substantially
