Padre Pio Nursing Home is a two-storey facility situated in a rural setting within close proximity to the village of Holy Cross, Co. Tipperary. The centre is registered to accommodate 49 residents. Bedrooms comprise single and twin rooms, some with en-suite shower and toilet facilities; all bedrooms have hand-wash basins. There is chair lift access to the upstairs accommodation. There are two dining rooms, two day rooms, a sun room and a large quieter seating area in the Poppy wing which also accommodates the oratory and hairdressers salon. Residents have access to the secure well maintained garden via several points around the centre. Padre Pio Nursing Home provides 24-hour nursing care to both male and female residents. It can accommodate older people (over 65), people requiring long-term care,
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activities. Residents were facilitated to personalise their bedrooms with photographs and furniture from home. Residents' routines were documented clearly in their care plans and staff were seen to respect these. For example, some residents enjoyed an early breakfast or a soft night light. Residents were observed to be offered a choice of activities and communal area. At mealtimes, residents were offered a clothes protector and were asked if they would appreciate assistance with their meal. The inspector observed that residents with dementia were given the freedom and space to stroll around the centre safely and to access their bedrooms and personal possessions throughout the day.
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reviewed regularly to ensure comfort and symptom management. Documents indicated that in the last two years nine of the ten deaths which had occurred had taken place in the centre without resource to acute care services. Nursing staff have had training in the management of subcutaneous fluids which helped to prevent unnecessary admissions. Mass was held in the centre on the first Friday of each month and a commemorative mass was held annually at Christmas. Items including religious symbols, candles and the Hospice care symbols were available.
The inspector reviewed a sample of residents’ medicine prescription records and they were maintained in a tidy and organised manner, they were clearly labelled, they had photographic identification of each resident and they were legible. There was evidence that residents’ medicine prescriptions were reviewed regularly by a medical practitioner as well as a pharmacist. Where medicines were to be administered in a modified form such as crushing, this was prescribed on the top of medication prescription and in one case on an old prescription sheet. This was not individually prescribed by the prescriber on the prescription chart. This could lead to errors as not all medications can be crushed and nursing staff could be administering them as such. The maximum dose for 'as
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The systems in place to make sure healthcare plans reflected the care delivered and were amended in response to changes in residents’ health were implemented by the nursing team. Most care plans were found to be detailed enough to guide staff on the appropriate use of interventions to manage the identified need and most reviews considered the effectiveness of the interventions to manage and /or treat the need. Some comprehensive risk assessments on which to base care plans were found and there were efforts to plan and deliver care in a person-centred manner. However, there were areas that needed to be improved.
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The centre was clean, warm, well ventilated and well maintained in areas occupied and used by residents, visitors and staff. Entry and exit was via the main entrance centre which was monitored and controlled by staff. A private nursing office was located at the back of the main reception area. The provider also had designated private office space. Catering facilities were adequate, a new cleaning room, had been identified and was in place since the last inspection. A level access secure garden was available for residents and visitors to access outdoors from the main day room. The garden had graas and pathways in place and suitable outdoor furniture. Plans were in place to complete a raised planting area for gardening activity. Other communal areas included a furnished seating area at reception and on the first floor.
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confirmed that the custom in the centre was to wake up a number of residents and give them breakfast and medications from 06.00am. This practice is institutional as it does not offer choice to residents and does not fit in with person-centred care practices. Inspectors could see that fresh vegetables were used to prepare meals. The provider explained that the nursing home received a delivery of fresh vegetables, meat and fish each week. Recent changes to the food storage and menu rotation system meant that meat was no longer frozen in bulk but cooked fresh. The fridge was adequately stocked and brown bread had been baked to serve with breakfasts.
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procedures for safe ordering, prescribing, storing and administration of medicines and handling and disposal of unused or out-of-date medicines. On the previous inspection this did not adequately address the procedure around as required PRN medications. On this inspection the policy was updated and this was seen to be included. Nursing staff with whom the inspector spoke demonstrated best practice regarding administration of medicines. Photographic identification was in place for all residents as part of their prescription/drug administration record chart. Controlled drugs were maintained in line with best practice professional guidelines and the count undertaken by inspectors was found to tally with records in the centre. The medication trolley was securely maintained and a nurses’ signature sheet was in place as described in professional guidelines.
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reported insufficient communication about medication, medication education for caregivers (concerning dosage, indication, administration with other medications, rec- ognition of side effects and therapeutic outcomes) would be helpful. This has also been suggested by Campbell and colleagues . Regular drug reviews with the par- ticipation of the (in-)formal caregivers and the persons with dementia might be even more necessary for people with dementia than for the general population. This is also demanded by existing guidelines  and viewed as an indicator of the quality of care . The interviewed (in-)formal caregiver took over responsibility for the health and medical care of people with dementia. Other studies also state (in-)formal caregivers serve as surro- gates for medical decision making among patients with dementia , act as care coordinators, and as informa- tion sources and front-line communicators . In triads composed of practitioners, people with dementia and in- formal caregivers interaction shifts over time. Communi- cation with the caregiver increases while communication with the patient decreases . This was also true in our study. The person with dementia is often marginalized in communication and no longer takes part in his/her own care decisions , e.g. in our study, the perceived necessity of a hospitalization was never reported to be discussed with the person with dementia. Nevertheless many informal caregivers do not know enough about available help/services  and do not get sufficient symptom management advice . This increased need for information is a long known fact [16, 31, 32]. Creat- ing possibilities for the reimbursement of conversations between GPs, informal caregivers and people with dementia (about medications, side-effect-monitoring and health care strategies) could potentially diminish this problem. In addition, a regular exchange between ambu- latory care providers and GPs, as well as, between nurs- ing home caregivers and GPs should be fostered, as suggested by our interviewees and van den Bussche and colleagues . This need for the interconnectedness of medical, nursing and further treatment and support is accepted on paper, but not yet realized in actual care in Germany .
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Despite the use of increasing numbers of antihypertensive agents in care home residents, there has been no improvement in the control of their blood pressure. These vulnerable people are therefore being exposed to an increased risk of side effects without the intended bene ﬁ t. This increase in the number of agents may well re ﬂ ect the growing problem of polypharmacy, which has been extensively documented and discussed over the past few years. 30 These ﬁ ndings justify further study of the treatment of hypertension in care homes in countries outside the United States. They also justify reexamination of whether the bene ﬁ t of treatment exceeds the harm in some diagnostic groups resident in care homes, such as those with dementia in whom the risk of side effects may be particularly high. The ﬁ ndings also remind clinicians to take particular care to weigh potential bene ﬁ ts and harms in prescribing for hypertension in care home residents, given that increasing treatment does not necessarily lead to better blood pressure control.
When nurses multitask, manipulate timers, work through breaks, avoid logging overtime, or rush/skip tasks, it creates an appearance that the allocated decision-time is sufficient, and the challenges remain hidden . Through nurses ’ and patients ’ compensatory actions, the unfortunate conse- quences of NPM-organization are concealed, and NPM appears more successful than it really is. Policy makers and leaders may assume that nurses will continue to provide comprehensive care, despite understaffing and increased workload . Studies indicate that understaffing is a way of forcing nurses to make rationing choices at the bedside, as well as high prevalence of missed care responsibilities like preventative care, disadvantaged groups, administration etc. [6, 75]. A worrying finding in this study is nurses’ feelings of wanting to give up and surrender to the system. This may indicate that NPM’ s prioritization of goals and values may over time wear down nurses’ compensatory actions. The problem is: how long nurses can retain their profes- sional identity if the core content is counteracted by organizational boundaries? Thus, we might not yet have seen the full negative effects of NPM in home care.
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Quality of care seemed to be dependent on whether the nursing home 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 nursing home be- cause they could not stay at home due to lack of home health services. This nursing home 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.
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The centre was a well established nursing home operating under the private management of Inishan Nursing Homes Ltd. A company director represented the provider entity and was available throughout the inspection to provide information as necessary. Care was directed through the person in charge who was in attendance at the centre on a full-time basis. The assistant director of nursing was also available throughout the inspection. The inspector discussed all aspects of service provision with the management team, including resources, staffing and the quality review of clinical care. Governance was directed through a clearly defined management structure, as set out in the statement of purpose. The provider representative was an active member of management who routinely attended the centre meeting with staff, residents and visitors on a regular basis. Management systems to monitor the safety and consistency of service provision included a process of supervision through senior staff and regular clinical governance meetings. Management implemented a schedule of audits on areas of both clinical and non-clinical care. For example infection control and medication management, as well as resident and staff satisfaction surveys. The results of these audits were used to identify areas for focus in the quality improvement plan.
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unnecessary or unsuitable hospital admissions. There was evidence of on-going discussions and planning for the end stage of life. Residents at risk of developing pressure ulcers had pressure relieving mattresses and cushions to prevent ulcers developing. The inspector reviewed the care of one resident who had a wound and found that detailed scientific assessments were completed and photographic evidence was used to assess changes in the wound. Care given was seen to be in accordance with evidenced based practice and nursing staff advised the inspector that they had access to support from the tissue viability nurse if required.
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In the sample of care plans reviewed there was evidence that the care plans were updated at the required intervals or in a timely manner in response to a change in a resident’s health condition. The assessment, development and review of care plans were carried out by nursing staff in consultation with residents or their representatives. Each resident’s care plan was subject to a formal review; within four monthly intervals. There was evidence that timely access to health care services was facilitated for all residents. Five general practitioners (GP's) were attending to the needs of the residents and an ''out of hours'' GP service was available if required. The records confirmed that residents were assisted to achieve and maintain the best possible health through medicine reviews, blood profiling and annual administration of the influenza vaccine. Residents were referred as necessary to the acute hospital services and there was evidence of the exchange of comprehensive information on admission and discharge from hospital. In line with their needs, residents had ongoing access to allied healthcare professionals including dietetics, speech and language therapy, out-patient clinics, chiropody and physiotherapy. The inspector also saw that residents had easy access to other community care based services such as dentists and opticians. The inspector saw that there was good input from the palliative care services and community mental health services also. Residents and relatives told the inspector that they were satisfied with the nursing and medical care provided in the centre.
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The inspector reviewed the staff rota and noted that there had been a reduction of the numbers of nursing staff available. However, this was mitigated by the fact the provider is a qualified nurse and has been undertaking regular nursing duties. The person in charge has also undertaken duty as the nurse where this was required. In this way the current shortage had not impacted on the residents care. The person in charge
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The inspector reviewed the staff rota and was satisfied that the staff numbers and skill mix were appropriate to meet the needs of the residents having consideration for the size and layout of the centre. All staff were appropriately trained in mandatory areas such as elder abuse, manual handling and fire procedures and prevention. The system of supervision was directed through the person in charge. The qualifications of senior nursing staff and their levels of staffing also ensured appropriate supervision at all times. The inspector reviewed training records and procedures and spoke with staff and management about training issues. Staff were competent to deliver care in keeping with current evidence based practice and were also enabled in relation to further training and development with an evident commitment by management to continuous professional development.
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consistencies and how to implement instructions on thickening fluids for example. The dining area of the centre was bright and open plan with tables laid attractively for use by individuals or small groups according to preferences. Residents who required full assistance with their meals were seen to be supported appropriately with assistance provided in a discreet and person-centred manner. Menus were regularly rotated and offered good choice and appropriate nutritional balance. Meals were seen to be freshly prepared and home baking was also provided. Meals were thoughtfully presented including those for residents who required the consistency of their food to be modified. Snacks and refreshments were seen to be appropriately provided on a regular basis throughout the duration of the inspection.
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procedures for safe ordering, storing and administration of medicines and handling and disposal of unused or out-of-date medicines, however, it did not detail prescribing. While transcription was defined, it did not state whether transcription occurred in the centre. The deputy person in charge stated that transcription did not occur. Nursing staff with whom the inspector spoke demonstrated best practice regarding administration of medicines. Photographic identification was in place for all residents as part of their prescription/drug administration record chart. Controlled drugs were maintained in line with best practice professional guidelines. The controlled drug register was discussed with nursing staff and the inspector suggested that this book be re-evaluated upon completion as it was more suited to the acute-care setting rather than a designated centre. Medication trolleys were securely maintained within the locked clinical room in the nurses’ office. A nurses’ signature sheet was in place as described in professional guidelines.
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