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

Sonas Nursing Home Cloverhill

Name of provider: Sonas Asset Holdings Limited

Address of centre: Lisagallan, Cloverhill, Roscommon

Type of inspection: Announced

Date of inspection:

04 November 2019

Centre ID: OSV-0000384

Fieldwork ID: MON-0022806

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About the designated centre

The following information has been submitted by the registered provider and describes the service they provide. Sonas Cloverhill is a 53 bed purpose-built facility combining care and a home environment for those no longer able to live alone. A full spectrum of individualised care is available for residents. Residents can avail of gardens, sitting rooms, TV lounge and activity room. It is situated in a rural area approximately two miles from Roscommon town. The centre’s statement of purpose, states that Sonas Nursing Home offers long term care for residents with chronic illness, mental health illness including Dementia type illness and End of Life Care in conjunction with the local Palliative Care Team. The centre comprises three different care areas each with its own sitting and dining areas. The reception area has tea and coffee making facilities for people visiting the centre. There are enclosed accessible gardens available and ample parking is available. The following information outlines some additional data on this centre.

Number of residents on the

date of inspection:

44

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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

04 November 2019 09:00hrs to 17:00hrs

Catherine Sweeney Lead

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What residents told us and what inspectors observed

The feedback from the residents spoken with during this inspection was complementary of the staff and the overall running of the centre. Inspectors spoke with seven residents throughout the day and spent time observing staff and resident engagement. Residents spoken with identified that they were happy with the service provided, and that they felt safe in the centre. Residents voiced how they enjoyed exercise sessions, attending mass, and watching the live stream of mass from the Knock Basilica. Other activities enjoyed by residents included decorating the centre for the various celebrations, and completing crosswords. Residents told the inspectors that they especially enjoyed regular visits from the physiotherapist.

Residents were observed by the inspectors to be comfortable and relaxed in the company of staff. Inspectors observed that staff were patient, respectful and kind when communicating with residents.

Residents informed the inspectors that they felt their views were respected in the centre. Residents meeting were held monthly and records show a high level of attendance and participation.

Capacity and capability

The centre had sufficient resources to ensure the effective delivery of care. There was a clearly defined management structure in place in the centre. The person in charge was supported by two clinical nurse managers, senior staff nurses, staff nurses, health care assistants and support staff.

Inspectors reviewed the staffing levels in the centre. Unsolicited information had been received by the Chief Inspector in relation to staffing levels. Inspectors were satisfied that there was adequate staff in place to meet the assessed needs of the residents. The current staffing levels were appropriate for the size and layout of the building. Fire drill records reviewed by the inspector provided assurance that staffing levels at night were adequate to safely evacuate the largest compartment within the centre. Staffing levels were kept under review by the person in charge. A review of the roster found that the staffing compliment did not reflect what was stated in the centres statement of purpose. This issue required review.

Inspectors noted improvements in the staff training record since the last inspection. Records reviewed evidenced that staff had received training in safeguarding, manual handling, infection control, fire safety and person-centred care, which included dementia care and training in responsive behaviours.

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The provider and the person in charge had systems in place to ensure oversight of the quality of care received by residents. Residents were regularly consulted for feedback and management and staff meeting notes were detailed and robust. However, some of the completed audits lacked the detail required to ensure quality improvements. Key trends were not clearly identified and analysed from the data, and action plans did not reflect the quality improvement issues.

There was an annual review for 2018 that demonstrated good oversight of the clinical and quality of life of the residents.

Inspectors reviewed the complaints log. The centre had a designated informal complaints log. This log was used to record verbal complaints and the interventions used to address issues. The management team explained that formal complaints, when they arise, are documented in a separate complaint recording system that had not been made available for review on the day of inspection. The management team told the inspectors that no formal complaints had been received. This procedure was not in line with the centres policy and procedures for the management of complaints.

Regulation 14: Persons in charge

The designated centre had a suitably qualified and experienced person in charge. Inspectors reviewed the staff file of the person in charge and found that it contained all documents required under Schedule 2 of the Regulations.

Judgment: Compliant

Regulation 15: Staffing

Staffing levels were adequate to meet the needs of the residents and for the size and layout of the building. However, the statement of purpose identifies that there is a full-time laundry worker as part of the staffing compliment in the centre. There was no laundry worker named on the rosters reviewed. The person in charge explained that the laundry duties were completed by a member of the care team. This member of the care team worked as a carer from 8am to 11am and then commenced laundry duty. This staffing arrangement does not reflect the information set out in the centre's statement of purpose.

Judgment: Substantially compliant

Regulation 16: Training and staff development

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Staff spoken with told inspectors that they attended regular training and were well supervised. The centre had a robust system of orientation and induction for new staff and on-going appraisals were on file for each member of staff.

Judgment: Compliant

Regulation 19: Directory of residents

The directory of residents in place did not record all the requirements set out in Schedule 3 of the regulations. The cause of death was not consistently recorded for residents who had deceased.

Judgment: Substantially compliant

Regulation 23: Governance and management

The centre had appropriate management systems in place, however, some improvements were required to ensure that care delivery was effectively monitored.

Judgment: Substantially compliant

Regulation 3: Statement of purpose

The designated centre had a Statement of Purpose and Function in place which had been revised within the current year. A review of the statement of purpose was required to ensure that it contained all the information required under Schedule 1 of the Regulations.

Judgment: Substantially compliant

Regulation 34: Complaints procedure

The centre had a robust complaints policy and procedure in place. However, improvements were required to ensure that all complaints were logged appropriately.

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Judgment: Substantially compliant

Regulation 4: Written policies and procedures

The required policies and procedures as set out under Schedule 5 of the regulations were available for review. Policies had been reviewed and updated in accordance with best practice guidelines and regulatory requirements.

Judgment: Compliant

Quality and safety

Overall, the inspectors were satisfied that care was delivered to residents in a person-centred and evidence-based manner.

The documentation of residents care plans had improved significantly since the last inspection. A review of the assessment and care plans found that each resident had an up-to-date and person-centred care plan in place that was based on the individuals assessed needs and preferences. The centre used an electronic documentation system to record the residents care plans. All care staff had access to the residents care plans through touch-screens located throughout the centre.

Residents whose symptoms included agitation and aggression had the triggers to these behaviours identified and managed in a sensitive and person-centred way. Nursing care was documented in a respectful and caring manner and included the documenting of the psycho-social and emotional well-being of the resident on a daily basis.

A review of the medication systems within the centre found that the ordering, storage, and disposal of medicines were in line with best practice. The medicine administration system in the centre used digital technology to document the administration of medication. The nursing team explained that this system was managed in partnership with the local pharmacy. The doctors' signed prescription was externally uploaded to a software system. This meant that nurses were required to check both the doctors prescription and the digital record prior to administration of medication.

The centre had good access to a general practitioner (GP) service and appropriate access to allied health care professionals when needed. The centre had access to out-of-hours GP service. Residents had access to a dietitian, physiotherapist, occupational therapy, palliative care support and psychiatry of later life support.

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The centre was purpose-built and was generally well maintained.

The centre comprised of three units, the Emlagh, Camms, and the Ard Kieran units. Each area had an accommodation area, and communal living and dining areas. The Emlagh living area was a quieter communal space which was used as a multi-sensory room was available for residents to use at their leisure. Residents rooms were observed to be decorated in a person-centred and individual manner. The premises was generally in a good state of repair, however, a number of maintenance issues noted on inspection were communicated to the provider. The communal areas, bedrooms and bathrooms were observed to be clean. The signage in the centre was appropriate and well positioned.

The layout and design of the Emlagh unit required review as the provision of showers and bathrooms did not meet the assessed needs of the residents in this part of the centre. The unit consists of nine rooms, accommodating ten residents.The residents on this unit shared one shower room.

The centre had a residents guide, available in large print. Notice-boards and seasonal orientation boards were in place around the centre detailing the daily and weekly activity schedule, local community information and resident information such as access to personal services such as hairdressing and chiropody. Information relating to advocacy support services was also available.

Records reviewed found that the fire safety systems and all fire fighting equipment had been listed, serviced and maintained. Inspectors found a number of inconsistencies in the guidance maps associated with the fire panel. This issue was addressed by the provider on the day following the inspection.

All staff in the centre had completed fire evacuation drills. The drills were well documented with timings and learning identified. However, the fire drills did not provide assurance that the largest compartment in the centre could be evacuated safely with night time staffing levels. A fire drill was submitted to the Office of the Chief inspector three days after the inspection which provided assurances that a full evacuation drill had been completed in a safe and timely manner.

Regulation 17: Premises

A number of maintenance issue were identified during the inspection. These included the quality of the flooring in the assisted bathroom in the Emlagh, fittings on the residents bath, linen trolleys and grab rails were in a poor state of repair. The provider informed the inspectors that there was a plan in place to address these issues. Inspectors were shown newly acquired equipment and furniture in storage and were satisfied that the outstanding issues would be addressed in a timely manner.

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A review of the availability of toilets and showers was required to ensure that residents had access to facilities appropriate to their care needs.

Judgment: Not compliant

Regulation 20: Information for residents

There was a residents guide available for review. It contained all the requirements under the regulation.

Judgment: Compliant

Regulation 26: Risk management

The centre has a risk management policy in place. Site-specific hazards were identified and appropriate controls and actions had been documented.

Judgment: Compliant

Regulation 28: Fire precautions

A floor map attached to the panel was in place to guide staff to the location of a fire. However, a review of the floor plans identified a number of issues of concern.

a door numbers for one bedroom was incorrectly documented. For example, room 23 was documented as room 32.

some rooms were incorrectly identified. For example, the floor plan identifies the assigned clinical room as bedroom 5.

compartments were not clearly identified

A second, large fire safety map was available within the fire safety folder. This map clearly outlined the fire compartments. The conflicting information on the two maps posed a risk of causing confusion in the case of an emergency situation and required review. The provider submitted an updated map to the Office of the Chief Inspector following the inspection.

A review of fire drills conducted did not provide adequate assurance that residents could be safely evacuated in the case of emergencies.

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Judgment: Substantially compliant

Regulation 29: Medicines and pharmaceutical services

A review of the medication administration system was required to ensure that the administration of medications was in line with professional guidelines.

Judgment: Substantially compliant

Regulation 5: Individual assessment and care plan

A comprehensive, person-centred assessment was completed for each resident which identified their physical, social, psychological and emotional needs. This assessment informed the development of the residents care plan which addressed the assessed needs of the resident with particular focus on individual preferences. There was strong evidence that care plans were developed with the residents and their representatives.

Judgment: Compliant

Regulation 6: Health care

A review of the records found that treatment prescribed by allied health care professionals was integrated into the residents care plans and communicated clearly to all staff. This action had been addressed since the last inspection.

Judgment: Compliant

Regulation 7: Managing behaviour that is challenging

Inspectors reviewed the management of residents with behavioural and psychological symptoms associated with their diagnosed conditions. A review of the care plans found that responsive behaviours were management in line with best practice guidelines. Behaviour triggers had been identified and appropriate care interventions had been developed in all care plans reviewed. The use of restrictive practice was minimal and used only as a last resort. This action had been addressed since the last inspection.

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Judgment: Compliant

Regulation 8: Protection

All staff had received training in safeguarding of vulnerable persons. All staff and service providers to the centre had suitable Garda Síochána (police) vetting in place.

The centre did not act as a pension agent for any residents. There was a robust system in place to manage residents finances. Residents had access to their pocket money at all times. There was adequate storage for residents to store their clothing and other personal possessions.

Judgment: Compliant

Regulation 9: Residents' rights

Residents were facilitated to vote within the centre. Local and national newspapers were available to all residents.

Resident bedrooms were located in close proximity to communal living rooms and residents were not restricted to any one communal room. Staff were observed coming and going from individual residents’ bedrooms. Inspectors observed that all staff knocked on resident bedrooms and waited for a reply prior to entering the room.

Residents had access to advocacy services.

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 14: Persons in charge Compliant

Regulation 15: Staffing Substantially compliant

Regulation 16: Training and staff development Compliant

Regulation 19: Directory of residents Substantially compliant

Regulation 23: Governance and management Substantially compliant

Regulation 3: Statement of purpose Substantially compliant

Regulation 34: Complaints procedure Substantially compliant

Regulation 4: Written policies and procedures Compliant

Quality and safety

Regulation 17: Premises Not compliant

Regulation 20: Information for residents Compliant

Regulation 26: Risk management Compliant

Regulation 28: Fire precautions Substantially compliant

Regulation 29: Medicines and pharmaceutical services Substantially 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 Sonas Nursing Home Cloverhill OSV-0000384 Inspection ID: MON-0022806

Date of inspection: 04/11/2019 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: The laundry shifts have now been separated from the HCA roster so that they are clearly identifiable. 18/11/2019

Regulation 19: Directory of residents

Substantially Compliant

Outline how you are going to come into compliance with Regulation 19: Directory of residents: All causes of deaths have been entered into the residents register and will be completed going forward as soon as this information becomes available. 11/11/2019

Regulation 23: Governance and management

Substantially Compliant

Outline how you are going to come into compliance with Regulation 23: Governance and management: The recent falls audit which required further analysis has now been complete

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18/11/2019

Regulation 3: Statement of purpose

Substantially Compliant

Outline how you are going to come into compliance with Regulation 3: Statement of purpose: The laundry shifts have now been separated from the HCA roster so that they are clearly identifiable and hence reflect the staffing compliment in the statement of purpose. 18/11/2019

Regulation 34: Complaints procedure

Substantially Compliant

Outline how you are going to come into compliance with Regulation 34: Complaints procedure: We have recently moved to a computerised documentation system and will now be logging complaints, concerns and compliments on this system where they can be analysed, tracked and trended. 21/11/2019

Regulation 17: Premises

Not Compliant

Outline how you are going to come into compliance with Regulation 17: Premises: We have the required number of toilets and showers in the home but based on the recommendations re. the locations of these we plan to reconfigure the use of some of our rooms – plans will be submitted to the inspector. 30/06/2019

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Regulation 28: Fire precautions

Substantially Compliant

Outline how you are going to come into compliance with Regulation 28: Fire precautions: Both maps now outline correct room numbers and compartments. An additional fire drill was subsequently submitted that provided the inspector with assurance that a full evacuation had been completed in a safe and timely manner. 11/11/2019

Regulation 29: Medicines and pharmaceutical services

Substantially Compliant

Outline how you are going to come into compliance with Regulation 29: Medicines and pharmaceutical services: Risk assessment for the electronic medication administration records has now been completed. 08/11/2019

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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

18/11/2019

Regulation 17(2) The registered provider shall, having regard to the needs of the residents of a particular designated centre, provide premises which conform to the matters set out in Schedule 6.

Not Compliant Orange

30/06/2019

Regulation 19(3) The directory shall include the information specified in paragraph (3) of Schedule 3.

Substantially Compliant

Yellow

11/11/2019

Regulation 23(c) The registered Substantially Yellow 18/11/2019

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provider shall ensure that management systems are in place to ensure that the service provided is safe, appropriate, consistent and effectively monitored.

Compliant

Regulation 28(1)(d)

The registered provider shall make arrangements for staff of the designated centre to receive suitable training in fire prevention and emergency procedures, including evacuation procedures, building layout and escape routes, location of fire alarm call points, first aid, fire fighting equipment, fire control techniques and the procedures to be followed should the clothes of a resident catch fire.

Substantially Compliant

Yellow

11/11/2019

Regulation 29(5) The person in charge shall ensure that all medicinal products are administered in accordance with the directions of the prescriber of the resident concerned and in accordance with

Substantially Compliant

Yellow

08/11/2019

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any advice provided by that resident’s pharmacist regarding the appropriate use of the product.

Regulation 03(1) The registered provider shall prepare in writing a statement of purpose relating to the designated centre concerned and containing the information set out in Schedule 1.

Substantially Compliant

Yellow

18/11/2019

Regulation 34(2) The registered provider shall ensure that all complaints and the results of any investigations into the matters complained of and any actions taken on foot of a complaint are fully and properly recorded and that such records shall be in addition to and distinct from a resident’s individual care plan.

Substantially Compliant

Yellow

21/11/2019