choices daily regarding their personal and individual decisions including choice of clothes, activity and meals. Activities included bingo, card playing and reading the local or national newspaper. Residents were seen using the outdoor facilities and taking the opportunity to sit in the sun. The centre operated a flexible visiting policy and facilities were available for residents to meet visitors in private. Inspectors observed relatives and visitors freely coming and going. Residents spoken with were generally complimentary of the service provided.
and the centre’s policy was implemented as appropriate. Staff monitored the food and fluid intake of all new residents and any residents at risk nutritionally. The inspector found that this was comprehensively completed. A jug of water was provided in each resident’s bedroom and in the sitting and dining rooms. Staff were observed to assist residents with fluid intake. Guidelines were in place to guide staff in the monitoring of residents weights. Residents' weights were recorded monthly or more often if indicated. There was clear, documented system of communication between nursing and catering staff regarding residents’ nutritional needs and preferences. The inspector spoke to the chef who was knowledgeable about the service delivered and the special diets .There was a menu plan in place and the menu had been audited by the dietician in order to ensure that it was nutritionally balanced. The menu was on display in the dining room. If weight loss was identified the GP was informed and a referral made to the dietician. Care plans reviewed with regard to nutritional care were found to be comprehensive and guided the staff in safe person centred care. Staff had received training in the area of nutrition; this included the nutrition, Dysphasia, hydration training, MUST (malnutrition, universal, screening, tool) and primary food hygiene training.
Each residents wellbeing and welfare is maintained by a high standard of evidence- based nursing care and appropriate medical and allied health care. Each resident has opportunities to participate in meaningful activities, appropriate to his or her interests and preferences. The arrangements to meet each residents assessed needs are set out in an individual care plan, that reflect his/her needs, interests and capacities, are drawn up with the involvement of the resident and reflect his/her changing needs and
The inspector found that each resident’s wellbeing and welfare was promoted by a high standard of nursing care and that appropriate access to medical and allied healthcare services was available when required. There were suitable arrangements in place to meet the health and nursing needs of residents with dementia. Pre-admission assessments were undertaken to ensure that the service could meet the needs of individual residents. Prospective residents and their families were invited to visit the centre prior to deciding to live there and some residents had been admitted for periods of respite care and were familiar with the environment which families said was of benefit when it came to exploring long term care options. There were social opportunities
Care plans provided a good overview of residents’ care and how care was delivered. On admission, a comprehensive nursing assessment and additional risk assessments were complied for all residents. This assessment was based on a range of evidence based practice tools. For example, a nutritional assessment tool was completed to identify risk of nutritional deficits, a falls risk assessment to determine vulnerability to falls and a tissue viability assessment to assess pressure area risk. The inspector noted that the assessments were used to inform care plans and that care was delivered in accordance with established criteria to ensure well being and prevent deterioration. They were updated at the required intervals or in a timely manner in response to a change in a resident’s health condition. Residents had access to GP services and records showed that GP’s visited the centre to review medications and to respond to changes in health care. Access to allied health professionals such as speech and language therapists, dieticians, occupational therapists and community mental health nurses was available. There was evidence that residents and relatives were involved in care plans and their views were recorded and incorporated into daily care practice.
The inspector found that the numbers and skill mix of staff was appropriate to the assessed needs of residents and the size and layout of the centre on the day of inspection. The inspector reviewed the staff rota and found the staff number and skill mix reflected the information described. Residents and staff the inspector talked to said that staffing levels were sufficient and residents said that staff are busy but able to respond to requests for help without delay. Staff were observed to answer call bells promptly and residents were supervised at all times. There were two nurses on duty daily and this included the person in charge Monday to Friday. There were seven carers on duty and this number included a senior healthcare assistant who allocated workloads and provided guidance to the care staff team. An additional carer was on duty during the evening and early night from 18.00 to 22.00 hours to support the night duty complement of one nurse and two carers. In addition there was catering, household, administration, activity, maintenance and laundry staff on duty. The occupational therapist and physiotherapist from the B-Fit team were available two days a week to support the care and nursing staff in the delivery of specific care programmes. A staff training programme was available and training was planned in advance. The schedule for 2016 indicated that training had been provided on the mandatory topics of fire safety, moving and handling and elder abuse. Other training had been provided on a range of topics that included infection control, palliative care, falls and continence management. All staff had up to date mandatory training in fire safety, safeguarding of vulnerable adults and manual handling.
A residents advocacy committee established and met every two months and the person in charge explained that she reviewed the minutes of these meetings and acted upon any requests. Residents' had access to an independent advocate and a second advocate had just come on board acting specifically on behalf of residents' with dementia. The management also undertook a satisfaction survey annually to obtain feedback from residents' and their families. The findings were included in the centre's annual review. Residents were seen partaking in some activities during the inspection. Five activity coordinators were employed to provide opportunities for meaningful engagement to all residents. Records were maintained on residents' interests and participation in activities each day. A programme of events was displayed and included religious ceremonies, Sonas (a therapeutic programme specifically for residents with dementia), music, movies, quizzes, flower arranging and many more. Residents' told inspectors that they went out to different events in the local community which were organised by the activity coordinators. They had regular outings for coffee, lunch and shopping. Access to the centres own private bus meant these trips occurred on almost a daily basis. The feedback on residents' questionnaires about the availability of activities inside and outside the centre was extremely positive.
the resident. Decisions to use restrictions were made in consultation with the resident or representative, nursing staff and general practitioner (GP). Decisions were also reflected in the resident's care plan and subject to review. Alternative equipment such as, low beds, sensory alarms and floor mats were available and tried prior to the use of bedrails. As part of living with dementia some residents displayed behavioural and psychological symptoms of dementia (BPSD). Inspectors observed that staff were working well with residents to support them to follow their chosen routines, and to manage any anxiety or stress. Staff spoken with were familiar with the centre’s policy and procedures to be implemented including the referral process to relevant professionals to inform the care- plan process. They confirmed their training had covered this topic. Care plans provided clear and person centred guidance for staff, and they were seen to be following it in practice.
Residents' care records are maintained on a computer programme. A sample was reviewed. Care plans were detailed and included a care plan for end of life care. The inspector saw instances where staff had captured very personal views and wishes of residents in relation to how they wished their end of life care to be managed. For example a resident had clearly stated how he wished his death and burial to be organised including not being buried in a conventional and these details were fully recorded so that the instructions could be followed by family members. Some residents had outlined their wishes to die in the centre and not to have active interventions in the event of their health deteriorating and this was recorded in end of life care plans and in medical records. There were some advanced care directives in place and there was ongoing training being provided for staff on this topic. If residents expressed a wish to return home this was recorded. In practice this had not happened so far but the person in charge said that family members would be supported to achieve this where it was practical to plan for this outcome. Care plans described spiritual care including prayers, sacraments and clergy that residents indicated they would like to have at the time of death. Their wishes to have relatives informed and who they wished to have with them were also outlined. In instances where residents had memory problems or dementia they continued to be consulted in accordance with their cognitive ability and where family members made contributions to end of life care plans these were clearly described.
Communication with residents with dementia was enhanced by careful signage around the building, that would help them find their way, However there was no signage in use to mark individual bedroom doors. Posters displaying the activity programme were small and not easily identified by residents with dementia and while there were clocks around the building and signs informing the residents what nursing staff were on duty, there was no large orientation board or boards in key locations that could prompt residents to know the day of the week, the date or the weather conditions outside.
Quality of care seemed to be dependent on whether the nursinghome could adapt and form uniqueness in the organization that closed the gap between the services offered and the needs and expectations of the residents. For instance, in Shelter many of the residents had fewer medical needs but had moved to the nursinghome be- cause they could not stay at home due to lack of home health services. This nursinghome had organized small groups of residents led by certified nursing assistants (CNAs) who had worked there a long time and knew the residents well. Likewise, one resident with extensive medical needs living in Hospital felt that ‘the service was as good as it could be’ (quote from in-depth interview with the resident), even though his feeling of ‘at-home- ness’ was not present. Village had organized the care with primary nurses or contact persons (CNAs) who were responsible for each resident’s total care-physical, psychological, social and spiritual. The primary nurse de- veloped care plans and normally cared for his or her resident almost like a family member. It seemed to be a good system for individually adjusted care. However, new care staff who were still not aware of the norms in the culture threatened the understanding of what was important for quality of care from the staff’s point of view and as experienced by residents.
The inspectors reviewed the accident and incident records and cross referenced these with medical and nursing documentation to assess care and review practice in relation to falls incidents. There was satisfactory information in three of the records examined and in the provider response that explained how the injuries had occurred, however in two cases there was inadequate information provided to demonstrate that these unexplained injuries had been adequately investigated. In both cases residents were being assisted by staff at the time an incident occurred however the records available did not indicate the extent of the falls, how residents were subsequently moved, if equipment such as the use of a bed rail could have caused entrapment, if medical conditions, staffing levels or activity levels in the centre at the time could have been a contributory factor. It is a requirement of this report that these two incidents are reviewed in more detail and that possible causes are explored to inform staff learning and to prevent recurrences.
Inspectors reviewed the care files of residents that had fallen and fractured limbs.There was evidence that some residents were at a high risk of falling due to their medical condition and had a high-fall risk rating. Nursing staff had completed an initial falls risk assessments on these residents and these residents were regularly reviewed by the physiotherapist. However, in a number of cases, there was no evidence that their fall prevention care plans reflected their current care needs. For example, one resident had received two fractures from falls in the past three months, and there had been no changes made to the residents care plan since October 2013. In addition to this, the physiotherapist had recommended that the resident be supervised when walking but the resident had fallen while mobilising independently post this advice.
The person in charge had conducted a recent nutritional audit of the body mass index (BMI) of 46 residents, it showed that 33 residents or 72% of residents had a normal (BMI) 11 residents had above average BMI and only 4 % had a BMI of less than 20. A validated nutritional assessment tool was used to identify residents at potential risk of malnutrition or dehydration on admission and were regularly reviewed. Records of resident's food intake and fluid balance were accurately completed. Residents' were offered therapeutic or modified consistency diets, if recommended by a speech and language therapist or a dietician. This was evidenced in the residents care records. Records also showed that eight residents had their nutritional status checked by the dietician in the past month, including one resident with Percutaneous endoscopic gastrostomy (PEG) feed, and the dietician recommendations were recorded in the resident files, which were accessible to all nursing and care staff.
registered provider also fulfils the role of the person in charge. The provider is knowledgeable of the physical and psychosocial care needs of residents. He was observed to engage well with all residents. Residents were familiar with the provider. The person in charge is supported in his role by a senior nurse. However, the role is not consistently full time. The inspectors found the senior management team requires additional resources to ensure robust governance. The provider is rostered to spend the majority of his time in the delivery of clinical nursing care. There was not sufficient time allocated to oversee the operational management and administration of the centre. There was some evidence of quality improvement strategies and monitoring of the services. However, the audit program requires review to ensure a defined set of criteria are reviewed regularly and systemically. The last audit of accidents or falls by residents was at the end of the March 2016. Similarly an audit of nutrition which was completed to a high standard during 2015 was not undertaken during 2016.
Residents' were encouraged to personalise their bedrooms and inspector saw that most residents had photographs and personal items on display. The communal areas were decorated in a comfortable home like way where residents could relax. Seats were provided at the end of corridors and provided quiet pace for some residents to sit by themselves for short periods. These areas were also used by residents when meeting visitors. The main dining room was noted to have features such as a wooden dresser with crockery on display and wall light fittings in place. The floor covering was being replaced at the time of inspection with the majority of the work complete. Residents spoken with were interested in the decorating.
A revised risk management and infection control policy is now in place. Infection control training was given to staff on the 26-01-2015 for the first group and second group on the 30-01-2015.Nurse manager and Director of nursing is supervising and guiding staff in relation to infection control practice. A BIO safe biohazard clean up pack for safe removal of body spillages is available in the centre. For cleaning and disinfecting the centre we are using Diversey infection prevention solutions to reduce and prevent the risk.
There was adequate private and communal accommodation. The size and layout of bedrooms were suitable to meet the needs of residents with a sufficient number of residents toilets, bathrooms and showers. There were wash-hand basins in each bedroom. Each bedroom is furnished with; a bed, bedside locker, wardrobe, a chair. Shared rooms provided screening to ensure privacy for personal care, free movement of residents and staff. There was suitable storage for residents’ belongings. There was a functioning call bell system in place.