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Report of an inspection of a Designated Centre for Older People. Issued by the Chief Inspector Name of designated centre:

Kilcoole Lodge Nursing Home

Name of provider: Mowlam Healthcare Services Unlimited Company

Address of centre: Kilcoole Lodge Nursing Home, Ballydonarea, Kilcoole, Wicklow

Type of inspection: Unannounced

Date of inspection:

07 July 2020

Centre ID: OSV-0007714

Fieldwork ID: MON-0029967

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About the designated centre

The following information has been submitted by the registered provider and describes the service they provide. Kilcoole Lodge Nursing Home is situated in the village of Kilcoole and is in walking distance of the sea. It is a purpose-built facility which can accommodate a maximum of 89 residents over two floors in 81 single en-suite rooms and 4 twin en-suite rooms. It is a mixed gender facility catering for dependent persons aged 18 years and over, providing long-term residential care, respite, convalescence, dementia and palliative care. Care for persons with learning, physical and psychological needs can also be met within the unit. Care is provided for people with a range of needs: low, medium, high and maximum dependency. The registered provider is Mowlam Healthcare Services Unlimited. The person in charge of the centre works full time and is support by a senior management team and a team of healthcare professionals and care and support staff. The following information outlines some additional data on this centre.

Number of residents on the

date of inspection:

25

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How we inspect

This inspection was carried out to assess compliance with the Health Act 2007 (as amended), the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013 (as amended), and the Health Act 2007 (Registration of Designated Centres for Older People) Regulations 2015 (as amended). To prepare for this inspection the inspector of social services (hereafter referred to as 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.

A full list of all regulations and the dimension they are reported under can be seen in

Appendix 1.

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This inspection was carried out during the following times:

Date Times of

Inspection

Inspector Role

Tuesday 7 July 2020

10:25hrs to 17:45hrs

Liz Foley Lead

Tuesday 7 July 2020

10:25hrs to 17:45hrs

Caroline Connelly Support

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What residents told us and what inspectors observed

The inspectors met and spoke with the majority of the residents present during the inspection.They also saw a small number of relatives coming in to visit residents but unfortunately did not have an opportunity to talk with them.

One of the residents who spoke with the inspectors said that he is happy in the centre but would rather be at home. He says he gets out in the garden and enjoys a bit of gardening in the fine weather. He told the inspectors that there was sometimes music and a singer in the garden which he enjoyed and this was confirmed by the activity staff member. The resident also told the inspectors that the staff were great and the nurses look after all his needs. He went on to explain that he had been seen and examined by the GP this morning and felt his health care needs were well met.

One lady said ''I miss not seeing my son'' and while she had been able to see him recently with the easing of visiting restrictions, she still felt lonely, as the visits were short and not the same as before. This resident said staff were kind to her and attentive to her needs but she missed normal conversation and felt staff were too busy at times to chat with her.

Residents were complimentary about the food and said they were offered choice via a menu system. Inspectors observed residents having their lunch and tea in the centre. The dining rooms were observed to be bright and spacious and the staff had ensured social distancing by having one resident at most tables and upstairs there was a maximum of two residents per table. Tables were appropriately set and the food presented to residents looked both appetising and in appropriate portions for the active residents who appeared to enjoy it and clear their plates. Residents confirmed that they had fully enjoyed their lunch. However in the upstairs dining room the inspectors observed that boxes of PPE were piled up in the room in close proximity to the residents dining and this inappropriate placement of PPE took from the ambiance of the dining experience.

Inspectors observed some lively activities taking place during the inspection, including football and ball throwing. The activity co-ordinator was also observed doing some one to one activities with residents including taking residents for walks. All staff were observed interacting positively with residents throughout the inspection. It was evident that staff knew residents well and described person-centred care interventions for individual residents.

Residents told inspectors they attended residents meetings with the person in charge and staff. The meetings described a project by a local craft group which started out in hospitals and then extended to nursing homes. The residents all received a hand knitted heart along with a special message in a gift bag. The heart was a symbol of love and remembrance for residents who may be feeling isolated from family and friends during COVID-19. The residents their families and staff

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reported to be delighted with this lovely gesture.

Capacity and capability

Prior to the recent COVID-19 pandemic, Kilcoole Lodge Nursing Home, operated by Mowlam Healthcare Services Unlimited Company, had a good level of regulatory compliance. The centre had opened in January 2020 and had complied with it's admission schedule and had safe staffing levels in line with the needs of it's new residents. An inspection in March 2020 found minor non-compliances and the provider took the necessary steps to achieve compliance and to ensure that residents were safe and well cared for.

The centre is one of a large group of nursing homes and the management structure consisted of the registered provider, an unlimited company which has two directors with responsibility for running the group. The provider had put in place a central office which provided the centre with human resources, finance and learning supports; this was operated remotely to the centre. The management structure included a director of care services and a healthcare manager who supported the centre remotely and came on site as required.

A person in charge, responsible for the day-to-day operations of the designated centre, was supported by an assistant director of nursing and other staff members including nurses, carers, an activities coordinator, housekeeping, catering, maintenance and administration staff. In addition staff were redeployed from another centre in the group on a temporary basis, this included an experienced senior nurse manager, who was also involved in the daily operation of the centre.

The centre had managed an outbreak of COVID-19 which was declared over in May 2020. Two residents and one staff member tested positive and the centre recorded one death related to COVID-19. This inspection was triggered by unsolicited information raising concerns about infection control, staffing and resources. Inspectors found evidence to support some of the concerns raised.

There were 25 residents in the centre with mainly high to maximum dependency needs. One resident was in hospital on the day of the inspection. None of the centre's current residents had tested positive for COVID-19.

On the day of inspection the inspectors found that the management structure in place, which had provided a good service prior to COVID-19 outbreak, was not effectively monitoring the safety of the service in the following areas;

the public health and infection control advice and guidance from the HSE outbreak control team in relation to PPE and cohorting staff to residents was not being implemented.

the service was under resourced. The compliment of household staff was inadequate to effectively clean the centre

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unsafe allocation of staffing to meet the needs of residents with responsive behaviours and to ensure staff were safe.

inappropriate supervision of new staff, who did not have sufficient experience in older persons care.

ineffective management systems to monitor the delivery of safe care. notifications had not been submitted to the chief inspector outlining serious

incidents or adverse events which occured in the centre.

An urgent action plan was issued following the inspection. The registered provider submitted a comprehensive response which included:

Mandatory wearing of face masks in the centre and updated protocols for PPE use; the provider also ensured that the the most up to date national guidance was available to staff.

Staffing was reviewed; and specific staff were allocated to only look after residents who were being isolated. Two staff were specifically allocated to care for the residents on the first floor, some of whom had responsive behaviours.

Rostering of staff revised to ensure newer and less experienced care staff are more appropriately mentored and supervised by experienced and senior staff.

Ongoing review of housekeeping resources to ensure the centre is appropriately clean.

Ongoing recruitment of experienced staff to ensure sufficient staff resources.

Regulation 15: Staffing

Staffing levels required review as there was an inadequate allocation of staff for housekeeping. The current allocation to housekeeping was falling short of routine cleaning and the staff member allocated to this department also had responsibility for the residents' laundry.

There was a minimum of one registered nurse on duty 24hrs per day. However the skill mix of staff required ongoing review. New care staff had been recruited as a staff contingency for a COVID-19 outbreak and had received a condensed learning programme. Further learning and mentoring was planned to enable these staff to complete a validated learning programme in caring. Ongoing review was required to ensure suitable rostering and allocation of new staff to ensure safe and effective care was provided to residents.

Allocation of staff also required review to ensure that residents who were isolated were cared for by a dedicated team to reduce the potential spread of infection and maintain the safety of all other residents and staff.

Nine staff had left the service since March 2020 and current staffing levels would not be sufficient to cover staff sick leave should a second outbreak occur in the centre. The service was actively recruiting new staff. The centre was already feeling the

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impact of staff resignations particularly in the housekeeping department.

All staff were participating in the weekly staff screening for COVID-19.

Judgment: Substantially compliant

Regulation 16: Training and staff development

Inspectors reviewed training records in the centre. The majority of staff had received training in infection prevention and control. All staff had watched a training video in relation to donning and doffing (putting on and taking off) personal protective equipment (PPE).

Inspectors observed that staff were not using PPE in line with the national guidelines. For example, staff were not wearing face masks when attending to residents in communal areas and staff told inspectors they did not always wear a mask when attending to residents personal care. Persons responsible for monitoring compliance with infection control guidelines were not ensuring correct use of PPE in line with national guidelines therefore were not appropriately supervising its use.

Supervision of new staff required review to ensure correct procedures were adhered to and to ensure safe and effective care was provided to residents.

Judgment: Not compliant

Regulation 21: Records

All records as requested during the inspection were made readily available to the inspectors. Records were generally maintained in a neat and orderly manner and stored securely.

A sample of four staff files viewed by the inspectors were found to contain Garda vetting and the person in charge assured the inspectors that vetting was completed for all staff prior to commencement in the centre. However inspectors found that recruitment process in the attainment of references were not sufficiently robust. One staff file had only one written reference when the requirement is two, another two files had ''to whom it may concern'' references and there was no evidence that these had been verified by the management in the centre. Another file had a verification of employment and there was no evidence of follow up in relation to the staffs performance in the previous centre and their suitability for the role they were undertaking. The inspectors also noted unexplained gaps in one CV. Although there was evidence of completed inductions there was no evidence of ongoing probationary meetings or any supervision records in staff files of staff recruited to the centre. The staff files did not meet the requirements of schedule 2 and lack of

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robust recruitment could put vulnerable residents at risk.

Judgment: Substantially compliant

Regulation 23: Governance and management

Management systems required review to ensure that the service provided was safe, appropriate, consistent and effectively monitored. Some clinical aspects of care were being monitored and audited for example, nutrition and wound care and actions were take to address any identified needs. However inspectors found many areas of care that were not effectively monitored and posed an immediate risk to residents and staff, for example;

Systems for monitoring infection prevention and control practices and compliance were ineffective. Practices were not in line with the Interim Public Health, Infection Prevention & Control Guidelines on the Prevention and Management of COVID-19 Cases and Outbreaks in Residential Care Facilities V5.2 19/06/2020. Staff were observed working in close proximity with each other without wearing face masks. Staff were observed without face masks engaging in the following; hugging residents and holding hands with them on many occasions, assisting an isolated resident, assisting with meals and working in close proximity with each other for long periods of time. This posed an immediate risk of cross contamination to residents, staff and visitors in the centre.

Recent staff resignations had impacted particularly on the housekeeping department and while the provider was actively recruiting to fill vacancies the current allocation of staff to housekeeping was not in line with the centre's COVID-19 prevention and contingency plan. One housekeeping staff was allocated to clean the entire centre and to do the residents laundry. It was not possible for one staff member to complete basic cleaning in the time allotted and bedrooms were only being cleaned at minimum every three days. These arrangements were inadequate to ensure effective decontamination and appropriate cleanliness and infection control standards in the designated centre.

Residents with known responsive behaviours were being cared for on the first floor of the centre and one staff member was allocated to supervise and care for them. The allocation of one staff member was unsafe as two of these residents had recent history of physical aggression towards staff. This required urgent review to ensure the safety of staff and the wellbeing of the residents on the first floor.

Recently recruited staff who were undergoing an accelerated learning programme to become competent care staff were not consistently mentored or rostered to work with senior staff. This potentially impacted on the quality and safety of care and on the learning experience of the new staff members.

An immediate action plan was issued to the provider following the inspection. Other

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areas were found that also required improvement, for example, the person in charge had not notified the Chief Inspector of serious incidents that had occurred in the centre. Improvements were also required in the centre's recruitment procedures to ensure new staff were suitable for the role they were recruited for.

Judgment: Not compliant

Regulation 31: Notification of incidents

Inspectors identified that notifications had not been submitted to the Chief Inspector within the required time lines in accordance with Schedule 4 of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013. For example, notification of an unexpected death had not been submitted to the Chief Inspector.

Judgment: Not compliant

Regulation 34: Complaints procedure

There was an effective complaints procedure in the centre, this was displayed in the reception area. There was a nominated person who dealt with complaints. The complaints log was viewed by inspectors and included information about the nature of the compliant, investigation of the complaint and action plans to address the complaint. The level of satisfaction of the complainant were documented.

Judgment: Compliant

Quality and safety

Overall, residents were supported and encouraged to have a good quality of life which was generally respectful of their wishes and choices. There was evidence of good consultation with residents and their needs were being met through good access to healthcare services and opportunities for social engagement. However, Inspectors found that the quality and safety of resident care during the COVID-19 pandemic was compromised by inadequate management of infection control, inadequate staffing skill mix and management of risk.

Inspectors saw that residents appeared to be very well cared for and residents gave positive feedback regarding care in the centre. Staff supported residents to maintain their independence where possible and residents' healthcare needs were met.

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Residents had comprehensive access to general practitioner (GP) services, to a range of allied health professionals including physiotherapy and occupational therapy in house. Residents in the centre also had access to psychiatry of older life and attendance at outpatient services was facilitated. The dietician was in regular contact with the centre and reviewed residents routinely. There was evidence that residents had access to other allied healthcare professionals including, speech and language therapy, dental, chiropody and ophthalmology services. A number of these consultations took place over the phone or via video link in the current COVID-19 pandemic. The resident assessment process was seen to involve the use of a variety of validated tools and care plans were found to be person centred and sufficiently detailed to direct care.

There was a full-time activity coordinator in the role of meeting residents' social care needs. There was a comprehensive programme of activities available to residents. Other staff were also seen to be involved in providing social stimulation to residents such as playing ball games and providing exercise groups. The activity staff provided residents with opportunities to communicate with their families via video links. She was found by inspectors to be very knowledgeable about residents likes, past hobbies and interests so that she could provide social stimulation that met their needs and interests.

The design of the premises enabled residents to spend time in private and communal areas of the centre maintaining social distancing. There was access to the enclosed gardens from the dining room and café and there were walkways and seating areas with raised flower beds to be enjoyed by residents. Overall, there appeared to be a warm and friendly atmosphere between residents and staff. Staff were seen to also be supportive, positive and respectful in their interactions with residents.

The centre normally operates an open visiting policy but due to the COVID-19 pandemic and outbreak the centre had generally closed to visitors except in exceptional and compassionate circumstances for end of life and some window visits had been facilitated. The centre has recently reopened to visitors following public health guidelines and the inspectors saw that the centre was endevouring to follow these guidelines. Visits were pre booked on the centres website and, visitors undertook a screening process where health checks were undertaken. The visiting area was set out with a long table maintaining a minimum of two meters distance between the resident and the visitor. On the day of the inspection the inspectors saw that a visitor was not fully abiding by the controls in place. They were not wearing a face mask, therefore inspectors were not assured that sufficient monitoring of visitors compliance with national guidance was in place to maintain the safety of residents.

Inspectors saw that the centre had an isolation area for residents who tested positive for COVID-19. The purpose of this area is to target outbreak control measures to specific areas of the centre in the event of an outbreak. This area was not in use during the inspection as they did not have any resident who was COVID-19 positive. However they did have two residents who were in two weeks isolation following return from the acute sector. These residents were in rooms in the main

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centre. Inspectors found staff moved between all areas of the centre and there was no staff specifically allocated to the residents in isolation. While the layout of the centre supported the cohorting of residents based on their infection status, this was not being done on the day of the inspection. Additionally, there was inadequate segregation of staff caring for the various categories of resident which could lead to spread of infection. Improvements were also required in relation to the appropriate use of PPE. Overall, infection control practice and protocols observed during the inspection were not in line with the Health Protection Surveillance Centre (HPSC) Interim Public Health and Infection Prevention Control Guidelines on the Prevention and Management of COVID-19 Cases and Outbreaks in Residential Care Facilities V5.2 19/06/2020.

There were systems in place to safeguard residents from abuse and training for new staff was ongoing. All staff had a valid Garda vetting disclosure in place prior to their commencement. The centre was not acting as a pension agent for any resident.

Regulation 11: Visits

A policy of restricted visiting was in place to protect residents, staff and visitors from risk of contracting COVID-19 infection. Staff were committed to ensuring residents and their families remained in contact by means of planned visiting in line with the national guidance. Visitors could book an appointment via the centers website and a schedule of arranged visits was in place Monday to Friday during the day. Inspectors queried if there was flexibility for people who worked during the day to visit outside these times and they were assured that facilities would be made available in the evenings and weekends where possible. Visiting controls included symptom checking and a visitor health risk assessment before the visit, hand hygiene, maintaining social distancing, cleaning of the room following every visit. However as identified and actioned under infection control more robust monitoring and supervision of visits to ensure compliance with the controls in place was required.

Judgment: Compliant

Regulation 26: Risk management

The centre had a risk management policy in place and regularly completed environmental and individual risk assessments. Residents had been assessed for their risk of contracting COVID-19 infection and controls were in place to mitigate the risk.

Arrangements were in place for the identification, recording, investigation and learning from serious incidents. Records of incidents in the centre were comprehensive and included learning and measures to prevent

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recurrence. However, risks around infection-control, training and supervision of staff and allocation of staff had not been identified. These are discussed specifically under each of these regulations.

Judgment: Substantially compliant

Regulation 27: Infection control

Infection control practice and protocols observed during the inspection were not in line with the Health Protection Surveillance Centre (HPSC) Interim Public Health and Infection Prevention Control Guidelines on the Prevention and Management of COVID-19 Cases and Outbreaks in Residential Care Facilities V5.2 19/06/2020.

The infection control procedures require immediate review to ensure that they are implemented in line with National Standards for infection prevention and control in community services published by the Health Information and Quality Authority and the Health Protection Surveillance Centre Guidelines.

There was no housekeeping staff on duty when inspectors arrived at the centre, this was due to sick leave and although another staff member attended on their day off to assist there was limited numbers of housekeeping staff available to provide cover. This posed a risk to all residents and staff in the centre.

PPE was available to staff in the centre but was not being used in line with the national guidance cited above; this posed an immediate risk of cross contamination to all residents and staff.

Visiting had recommenced in the centre, however inspectors were not assured that sufficient monitoring of visitors compliance with national guidance was in place to maintain the safety of residents.

The centre were using an outdated version of the national guidance cited above.

Two residents were isolated in the centre as a precaution, however, staff were not cohorted to care for these residents. This meant that all staff on duty would potentially be in contact with these residents. This was not in line with best practice as it would contribute to the spread of infection in the event of a positive COVID-19 diagnosis, particularly as staff were not using PPE in line with the guidance.

A urinal was stored on the toilet in a communal bathroom and two mattresses were stored on the floor in another communal bathroom. These posed a risk of cross contamination to residents.

A yellow risk waste bag was tied to a clean trolley that was storing PPE outside an isolation room. The waste bag was open at the top, this posed a risk of cross contamination to staff, residents and there was no assurances that the clean PPE stored on the trolley had not been contaminated by the waste.

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Judgment: Not compliant

Regulation 5: Individual assessment and care plan

Residents assessments were undertaken using a variety of validated tools and care plans were developed following these assessments. Four care plans which were viewed in detail by the inspectors were found to be comprehensive, extremely personalised and very person-centered. They were regularly reviewed and updated following assessments and recommendations by allied health professionals. Care plans were sufficiently detailed to guide staff in the provision of person-centred care and had been updated to reflect changes required in relation to COVID-19 guidelines.

Care plans in end of life care had been updated based on resident's expressed wishes and there were clear pathways in place for treatment escalation.

Judgment: Compliant

Regulation 6: Health care

The inspectors were satisfied that the health care needs of residents were well met. There was evidence of good access to medical staff with regular medical reviews in residents files. During the COVID-19 pandemic GP's visiting routinely twice per week and more frequently if required. One of the residents confirmed that he was examined by his GP the morning of the inspection.

In relation to COVID-19, there was evidence of liaison with the public health officer and with the HSE locally regarding supplies of oxygen, PPE, funding and management of same. Minutes of meetings were maintained including liaison in relation to the COVID-19 outbreak.

Access to allied health care services was evidenced by regular reviews by the physiotherapist who attends the centre weekly and the occupational therapist who visits monthly. There was evidence of dietician, speech and language and tissue viability reviews as required. During the pandemic they were provided remotely but prescriptions and advice were followed through to the pharmacist and GP. Psychiatry of old age were also regular visitors to the centre to review specific residents on their caseloads.

Judgment: Compliant

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Regulation 7: Managing behaviour that is challenging

Staff had received training in dementia and in responding to responsive behaviours (how people with dementia or other conditions may communicate or express their physical discomfort, or discomfort with their social or physical environment). Overall there was a person-centred approach to managing responsive behaviours. Since the previous inspection improvements were seen in the documentation of behavioural assessments and triggers in care plans which support staff to work therapeutically with residents and to manage the behaviours effectively. However as identified and actioned under Regulation 23: Governance and Management the skill mix and number of staff allocated to care for residents with responsive behaviours required review.

There were 3 residents using bedrails as a form of restraint at the time of the inspection. There was evidence that when restraint was used there was an assessment to ensure it was used for the minimal time and as a least restrictive method. Other alternatives to restraint such as low low beds were seen to be in use.

Judgment: Compliant

Regulation 8: Protection

Staff in the centre had all undertaken training on safeguarding vulnerable adults and were clearly able to articulate the actions they would take if there was an allegation of abuse. This was in line with the centers policy and procedure on safeguarding. Residents who spoke with inspectors reported they felt safe and at home in the centre and that staff were very kind. Inspectors observed that staff interaction with residents were positive and person-centred throughout the inspection.

There was locked storage available in residents bedrooms to store their valuables and the person in charge confirmed that the centre was not acting as a pension agent for any resident.

Judgment: Compliant

Regulation 9: Residents' rights

Following the previous inspection a full time activity co-ordinator was employed by the centre. The inspectors met and spoke with her during the inspection. She was currently undertaking specialist activity training. A social assessment ‘Key to Me’ had been completed for residents which gave an insight into each resident's history, hobbies and preferences to inform individual activation plans for residents. The

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inspectors reviewed a sample of these activation plans; they were found to contain person-centred information to direct staff when developing and planning the centres activity plan. Activities included gardening, bingo, arts and crafts, floor games, ball games including football in the garden, exercises and reminiscence.

Overall, residents’ right to privacy and dignity were respected and positive respectful interactions were seen between staff and residents.The residents had access to copies of local newspapers, radios, telephones and television. Internet access was available and the activity staff member was seen to use portable technology with residents to enable them to keep in touch with their families.

Residents were consulted about and participated in the organisation of the centre through regularly held residents meetings. Inspectors reviewed records of the last two resident meetings held in March and May 2020; while these contained details of meaningful discussion between residents and staff there was no specific information about COVID-19 detailed. Residents however told inspectors that they were informed about COVID-19 in the centre and of their results where appropriate. There was evidence of action plans created following the meetings and follow through on actions required.

Judgment: Compliant

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Appendix 1 - Full list of regulations considered under each dimension This inspection was carried out to assess compliance with the Health Act 2007 (as amended), the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013 (as amended), and the Health Act 2007 (Registration of Designated Centres for Older People) Regulations 2015 (as amended) and the regulations considered on this inspection were:

Regulation Title Judgment

Capacity and capability

Regulation 15: Staffing Substantially compliant

Regulation 16: Training and staff development Not compliant

Regulation 21: Records Substantially compliant

Regulation 23: Governance and management Not compliant

Regulation 31: Notification of incidents Not compliant

Regulation 34: Complaints procedure Compliant

Quality and safety

Regulation 11: Visits Compliant

Regulation 26: Risk management Substantially compliant

Regulation 27: Infection control Not compliant

Regulation 5: Individual assessment and care plan Compliant

Regulation 6: Health care Compliant

Regulation 7: Managing behaviour that is challenging Compliant

Regulation 8: Protection Compliant

Regulation 9: Residents' rights Compliant

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Compliance Plan for Kilcoole Lodge Nursing Home OSV-0007714 Inspection ID: MON-0029967

Date of inspection: 07/07/2020 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 in charge has not complied with a regulation and considerable action is required to come into compliance. Continued non-compliance or where the non-compliance poses a significant risk to the safety, health and welfare of residents using the service will be risk rated red (high risk) and the inspector have identified the date by which the provider must comply. Where the non-compliance does not pose a risk to the safety, health and welfare of residents using the service it is risk rated orange (moderate risk) and the provider must take action within a reasonable timeframe to come into compliance.

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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 15: Staffing

Substantially Compliant

Outline how you are going to come into compliance with Regulation 15: Staffing: We will increase the number of Housekeeping staff on duty to ensure that a high standard of cleanliness can be maintained in accordance with infection prevention and control guidelines. The laundry service is mainly outsourced, but there is a laundry service for residents’ personal clothing, and we will ensure that this service has a designated staff member to deal with residents’ clothing efficiently. We appointed Healthcare Assistants as a staff contingency during the Covid-19 crisis, and these staff had received a condensed training programme. We will enhance their training in Care of Older Persons by providing additional QQI Level 5 certified training in September 2020, which will be delivered by a certified QQI trainer. We will ensure that the skill mix of staff on duty at any time will include sufficient experienced staff to provide guidance and supervision to the less experienced team members. Recruitment is actively ongoing to appoint experienced Healthcare Assistants, which will enhance the available skill mix. Interviews are scheduled to take place. We will ensure that the Assistant Director of Nursing and the staff nurses provide close supervision and direction to the Healthcare Assistants in the home and we will develop and monitor their practice to enhance the safety and effectiveness of care. We will ensure that the care staff ratio is sufficient to meet the assessed care needs of all residents at all times Staff are now being allocated appropriately to ensure that residents who are isolated as a precautionary measure (following admission from hospital, for example) are cared for by a dedicated team to reduce the potential spread of infection and to maintain the safety of all other residents and staff.

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Regulation 16: Training and staff development

Not Compliant

Outline how you are going to come into compliance with Regulation 16: Training and staff development: All staff have now completed additional online HSE Infection Prevention & Control (IPC) training and assessment on HSELand to further enhance their knowledge and awareness and to help them to maintain vigilant IPC procedures. Additional on-site IPC control training has taken place on 16/07/20 and further training is scheduled for September. Staff are required to physically practice donning and doffing full PPE in accordance with best practice guidelines and there is a regular Covid-19 practice drill to ensure a constant state of alertness about the appropriate actions to take in the event of a staff member or resident testing positive for Covid-19. This has enhanced staff awareness and vigilance. In addition to mandatory training staff have also received training in responsive behaviours All staff are required to wear a face mask when on duty at all times and to practice social distancing. The Person in Charge (PIC) and Assistant Director of Nursing (ADON) are providing close supervision and direction to all staff in the home to ensure compliance with appropriate PPE wearing. We will ensure that all new staff are supported through their induction phase and that they are supervised appropriately; we will develop and monitor their practice to enhance the safety and effectiveness of care.

Regulation 21: Records

Substantially Compliant

Outline how you are going to come into compliance with Regulation 21: Records: A review of all staff files was completed following the inspection. All staff files are now in full compliance with Schedule 2 of the Health Act and are available for inspection by the Authority. All staff have two references on file. The references have been verified by the management and by Human Resources.

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All unexplained gaps in CVs have been addressed and satisfactorily explained. All new staff will have records of induction and regular performance/probationary meetings to document the level of support and assessment of performance of each individual staff member.

Regulation 23: Governance and management

Not Compliant

Outline how you are going to come into compliance with Regulation 23: Governance and management: The Interim Public Health, Infection Prevention and Control (IPC) guidelines on the Prevention and Management of COVID 19 Cases and Outbreaks in Residential Care Facilities V5.2 19/06/2020 is now available for staff. These guidelines have been discussed with all staff members. Updated versions of these guidelines will be made available for staff as they are published. Internal guidelines were circulated on 10/07/20 regarding the mandatory requirement for all staff to wear a face mask when on duty. Social distancing is also implemented in the workplace as far as practicable for staff and residents. There are occasions when staff are required to maintain close contact with resident when delivering care, but they are adhering to hand washing and sanitising procedures as well as appropriate wearing of PPE. The PIC and ADON are supervising staff to ensure full compliance with these protective measures. We will ensure that there are sufficient Housekeeping staff on duty each day to maintain the high standards of hygiene in the nursing home. Staff laundry will be managed by a designated member of the Housekeeping team. The PIC and ADON will monitor the standards of hygiene of all rooms in the home and they will ensure that the Housekeeping staff roster is managed appropriately to meet the needs of the nursing home. Recruitment is actively ongoing to appoint experienced Healthcare Assistants, which will enhance the available skill mix. Interviews are scheduled to take place. Also, recruitment has commenced for the positions of Clinical Nurse Manager. We will ensure that the Assistant Director of Nursing and the staff nurses provide close supervision and direction to the Healthcare Assistants in the home and we will develop and monitor their practice to enhance the safety and effectiveness of care. There are two staff members allocated to the first floor of the home and the PIC will ensure that the roster always reflects the appropriate number and skill mix of staff to meet the assessed care needs of all residents based on the dependency levels of the residents as well as the geographical layout of the home.

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The PIC will ensure that new or less experienced staff members are supervised by more experienced, senior members of the team and that they are supported and guided in the provision of safe care to all residents. We will ensure that our recruitment procedures will facilitate the selection of staff who are suitable to undertake the role they have been employed for and the PIC and ADON will undertake appropriate competency assessments to ensure that staff are proficient in their individual roles. The PIC will notify the Authority of all serious incidents in a timely and comprehensive manner as required.

Regulation 31: Notification of incidents

Not Compliant

Outline how you are going to come into compliance with Regulation 31: Notification of incidents: All incidents will be notified to the Chief Inspector within the appropriate timeframes and ensuring that a comprehensive report of the incident, response and outcome is provided, in accordance with regulation 31. The PIC will ensure that any unexpected death is notified to the Authority within 3 working days as per the legislative requirement.

Regulation 26: Risk management

Substantially Compliant

Outline how you are going to come into compliance with Regulation 26: Risk management: We will ensure all risks are identified and managed in accordance with regulation 26. All adverse incidents will be recorded, reported, investigated and there will be learning outcomes documented and implemented as a result of adverse incidents in the nursing home. Records of IPC training and Covid-19 preparedness and contingency planning are now recorded and will be regularly reviewed and updated. We will ensure that all risks related to infection control are identified, recorded and that there are appropriate policies and guidelines to mitigate the risk and to guide staff practice in order to maintain a safe, hygienic environment in the nursing home.

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We will ensure that there are appropriate levels of staff supervision in place, including recruitment of suitable staff for their roles, providing new staff with sufficient support and induction to ensure that they are safe practitioners, and providing sufficient numbers and skill mix of suitably trained staff to safely and effectively meet all the assessed care needs of the residents.

Regulation 27: Infection control

Not Compliant

Outline how you are going to come into compliance with Regulation 27: Infection control: There is a revised policy in place that requires all staff to wear surgical face masks at all times while on duty. The importance of infection control and prevention in the nursing home is discussed daily at each handover with staff, including housekeeping staff. All staff have now completed additional HSE infection control training and assessment on HSELand to further enhance their knowledge and awareness and to help them to maintain vigilant IPC procedures. Additional infection control training on site has taken place on 16/07/20 and further training is scheduled for September 2020. The PIC will oversee increased clinical supervision of staff and regular auditing of IPC and housekeeping practices. The Interim Public Health, Infection Prevention and Control Guidelines on the Prevention and Management of COVID 19 Cases and Outbreaks in Residential Care Facilities V5.2 19/06/2020 is now available for staff and there is regular discussion about these guidelines at every staff handover meeting to enhance staff awareness and ensure their understanding. We will allocate specific staff to care for residents who are being nursed in isolation, including the residents in isolation as a precautionary measure following an admission to hospital, for example. Every effort will be made to encourage and support residents in maintaining an appropriate 2 metres social distance from each other. We acknowledge that a small number of residents lack the capacity to comprehend the need for social distancing and they may be unable to comply with isolation protocol, but their risk of exposure to infection is reduced by staff wearing masks while on duty. We will ensure that the cleaning schedule and the provision of housekeeping staff are consistent with the requirements and layout of the nursing home. We now have a designated Laundry Assistant who will be responsible for laundering residents’ personal items and returning them to the residents’ rooms in a clean and neat condition.

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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 15(1) The registered provider shall ensure that the number and skill mix of staff is appropriate having regard to the needs of the residents, assessed in accordance with Regulation 5, and the size and layout of the designated centre concerned.

Substantially Compliant

Yellow

30/09/2020

Regulation 16(1)(b)

The person in charge shall ensure that staff are appropriately supervised.

Not Compliant Orange

31/08/2020

Regulation 21(1) The registered provider shall ensure that the records set out in Schedules 2, 3 and 4 are kept in a designated centre and are available for inspection by the Chief Inspector.

Substantially Compliant

Yellow

31/08/2020

Regulation 23(a) The registered provider shall

Not Compliant Red

18/08/2020

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ensure that the designated centre has sufficient resources to ensure the effective delivery of care in accordance with the statement of purpose.

Regulation 23(b) The registered provider shall ensure that there is a clearly defined management structure that identifies the lines of authority and accountability, specifies roles, and details responsibilities for all areas of care provision.

Substantially Compliant

Yellow

31/08/2020

Regulation 23(c) The registered provider shall ensure that management systems are in place to ensure that the service provided is safe, appropriate, consistent and effectively monitored.

Not Compliant Red

18/08/2020

Regulation 26(1)(a)

The registered provider shall ensure that the risk management policy set out in Schedule 5 includes hazard identification and assessment of risks throughout the designated centre.

Substantially Compliant

Yellow

31/08/2020

Regulation The registered Substantially Yellow 31/08/2020

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26(1)(b) provider shall ensure that the risk management policy set out in Schedule 5 includes the measures and actions in place to control the risks identified.

Compliant

Regulation 27 The registered provider shall ensure that procedures, consistent with the standards for the prevention and control of healthcare associated infections published by the Authority are implemented by staff.

Not Compliant Red

18/08/2020

Regulation 31(1) Where an incident set out in paragraphs 7 (1) (a) to (j) of Schedule 4 occurs, the person in charge shall give the Chief Inspector notice in writing of the incident within 3 working days of its occurrence.

Not Compliant Yellow

18/08/2020