In records reviewed it conveyed that residents and relatives were consulted and where they wished to express a view about how their end of life care should be managed this was recorded. There were issues of capacity to make decisions that nursing staff had to consider as some residents were highly dependent, had dementia or a combination of complex conditions. The nursing staff who spoke with the inspector recognised that decisions made in relation to end of life care were determined by the clinical
The inspector was told that a recruitment drive had been on-going and that a number of staff including nursing staff had been employed recently. At the time of this inspection there were new members of nursing staff recently recruited on duty that confirmed this. The inspector found from an examination of the staff roster, communication with staff on duty and residents that the levels and skill mix of staff at the time of inspection were sufficient to meet the needs of residents. However, the inspector was not assured that the supervision of staff, staffing levels and skill mix at all times, including night time, was suitable and sufficient to meet the needs of all residents. While there was the minimum of one registered nurse on duty at all times, all staff working in the centre had not completed appropriate training and or certification relevant to their role and
The provider's self-assessment and overall self assessment of compliance identified compliance with Outcome 14 and Standard 16 of the National Quality Standards for Residential Care Settings for Older People in Ireland. The inspector reviewed the centre's policy on end-of-life care and noted that the policy was up to date, robust and comprehensive. It provided good guidance on the management of the period prior to death and the care of the body. It outlined procedures for end of life care and provided guidance for staff on care planning for end of life, consent, assessment of capacity, symptom control and how to provide support to relatives. Staff who spoke with the inspector were familiar with the policy. Training records indicated that the policy was also presented to all staff by a member of the nursing staff.
The inspector was satisfied that there were suitable arrangements in place to meet the health and nursing needs of residents with dementia. Residents were satisfied with the service provided. Residents had access to general practitioner (GP) services and out-of- hours medical cover was provided. A full range of other services was available on referral including speech and language therapy (SALT) and occupational therapy (OT) services. Physiotherapy services were available on site. Chiropody, dental and optical services were also provided. The inspector reviewed residents’ records and found that some residents had been referred to these services and results of appointments were written up in the residents’ notes.
The centre was managed by a suitably qualified and experienced nurse who was accountable and responsible for providing a high standard of care to residents. The health needs of residents were met to a high standard. Residents had access to general practitioner (GP) services, to a range of other health services and evidence- based nursing care was provided.
The inspector confirmed that up to date registration numbers were in place for nursing staff. The inspector reviewed the roster which reflected the staff on duty. Resident dependency was assessed using a recognised dependency scale and the staffing rotas were adjusted accordingly. The inspector was satisfied that there was sufficient staff on duty to adequately provide care to the residents. Residents spoken with confirmed this. The person in charge promoted professional development for staff. Training was tailored to meet residents’ needs. Staff told the inspector they had received a broad range of training which included caring for the person with dementia, end-of-life care, responsive behaviour and hand hygiene. Detailed records were maintained of attendance and course content.
Nursing staff had not completed the wound assessment records consistently or completely. Records were not maintained sufficiently to give a clinical picture of the condition or of previous treatment of residents by nursing and medical staff. There were gaps of up to 6 weeks where the only entry with regard to the provision of care was by way of cross referencing care plans with letters and no supporting narrative note with regard to the medical/nursing care provided to residents.
Residents had a comprehensive nursing assessment on admission. The assessment process involved the use of validated tools to assess each resident’s dependency level, risk of malnutrition, falls, and their skin integrity. A care plan was developed within 48 hours of admission based on the residents assessed needs. Care plans contained the required information to guide the care of residents, and were updated routinely on a four monthly basis or to reflect the residents' changing care needs. The ‘key to me’ was used to support residents and relatives, where appropriate to inform their assessments and the care plans. However not all the files reviewed held a completed ‘Key to me’ document. There was no documentary evidence that residents and family where appropriate participated formally in care plan review meetings.
The provider and person in charge were aware of their responsibility to notify the Chief Inspector of the proposed absence of the person in charge from the designated centre and the arrangements in place for the management of the designated centre during her absence. The fitness of the deputising person in charge - Sarah Murphy was determined by interview during this inspection. She was found competent. She had qualified as a registered nurse in 2009 and was appointed to the post of Clinical Nurse Manager 2013. She worked full-time in the centre and had maintained her professional development. She recently completed a course on CHEWS, medication management, foot screening and associated education of patients with diabetes, hip replacement and total knee replacement, dementia care, Alzheimer’s care, special purpose award in care of the older person and had a certificate in respiratory nursing. Her mandatory training in adult protection, manual handling and fire safety and her registration was up-to-date with an An Bord Altranais.
The inspector found that there was an adequate complement of consistent nursing and care staff on duty each day and night. There were two nurses on duty with the person in charge daily. Care staff numbers were varied throughout the day to meet the needs of residents and there were usually 3 or 4 carers on duty. The care team was supported by the provider representative who had responsibility for general business matters, maintenance and fire safety and who worked daily in the centre. Cleaning, laundry and catering staff were also on duty each day. At night there was one nurse and two carers until 23.30 when the staff complement reduced to one nurse and one carer. Staff were noted to be deployed effectively and were available in adequate numbers during the early morning and evening when residents were getting up and going to bed.
There were systems in place to meet the health and nursing needs of residents with dementia. There was evidence of on-going work including staff training and auditing to ensure assessment and documentation of residents' needs was maintained to a good standard. The person in charge demonstrated recent improvements she and the staff team had made to ensure residents' needs were addressed. The majority of residents' needs were documented in care plans that were person-centred and informative. Inspectors found that one resident with BPSD and one resident with responsive behaviours did not have a behavioural support care plan in place. The behavioural support care plans that were in place required some improvement to ensure they clearly informed the behaviour experienced by the resident, triggers to the behaviour where identified and the effective intervention strategies staff should use to de-escalate any BPSD. The interventions to direct care actions in activation care plans required some improvement to clearly inform the scope of residents' individual interests and capabilities especially residents with levels of dementia that impacted on their ability to participate and benefit from group activities.
The inspector reviewed the care files of the two residents accommodated for short term care. A comprehensive suite of risk assessments to identify all their care needs was not completed. A moving and handling risk assessment was not completed for one resident. Another did not have a care plan to outline the post surgery guidance issued by the hospital. There was evidence in the nursing notes of one resident of contact with the public health nurse to plan for a home discharge, However, each resident did not have a discharge care plan completed to guide staff in their rehabilitive goals and ensure a safe discharge.
Recent changes had occurred to the organisational structure. A new person in charge had taken up post. The clinical nurse manager (CNM) was promoted to assistant director of nursing (ADON) and a new group manager was also in post. The group manager also had responsibilities for two other centres. The organisational structure was defined in the statement of purpose.
The inspector observed the activity co-ordinator preparing to facilitate a scheduled activity while background music was playing. While twenty six of the fifty one residents residing in the centre were in the sitting room at this time, not all participated. Residents spoken with by the inspector said they preferred to listen rather than participate in some activities. One resident told the inspector that while she attended the activity and didn't participate, she planned to participate in the scheduled afternoon activity as it was her favourite. The weekly activity programme was displayed. Another resident with reduced mobility function told the inspector that she wasn't able to engage in the activities she used to do to relax at home due to her medical condition. Staff were knowledgeable regarding her past interests and hobbies. However, the inspector found that inadequate records were available evaluating whether participation in scheduled activities resulted in positive outcomes for individual residents. Although the inspector was told that the activity co-ordinator attended residents who remained in bed or in their bedrooms, an activity/recreation care plan was not present in one resident's documentation reviewed. Judgment:
The inspector found that arrangements were in place to avoid unnecessary transfer to hospital, including nursing staff trained in the administration of medication via a syringe driver and subcutaneous injection. In this way, residents who were no longer able to take oral medication for pain relief could have their pain managed via other routes. Where a resident refused care, this was respected and clearly documented.