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

TLC Carton

Name of provider: TLC Carton

Address of centre: Tonlegee Road, Raheny, Dublin 5

Type of inspection: Unannounced

Date of inspection:

08 October 2019

Centre ID: OSV-0005800

Fieldwork ID: MON-0027841

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About the designated centre

The following information has been submitted by the registered provider and describes the service they provide. TLC Carton is a purpose-built nursing home designed to meet the individual needs of the older person, whilst facilitating freedom and independence for the more active. TLC Carton is located off the Malahide Road and close to Beaumont Hospital, and can accommodate male and female residents (over 18years of age) up to a maximum of 163 residents. The building has three floors consisting of 135 single bedrooms and 14 of double/twin bedrooms. Each bedroom has a full en-suite and furniture which includes a television, call bells and a phone. Each floor is serviced by stairwells and passenger lifts and access to outdoors spaces are available on the ground and first floor. TLC Carton provides long term, respite care and stepdown care to meet the health and social needs of people with low, medium, high and maximum dependencies. The centre provides 24 hour nursing care. The provider's aim is to ensure freedom of choice, promote dignity and respect within a safe, friendly and homely environment that respects the individuality of each resident who chooses to reside in TLC Carton. A commitment to promoting the independence of residents, personally, medically, psychologically, socially, spiritually, active and fulfilling a life is set out as the objectives within the centre's statement of purpose. Residents and families will be encouraged and supported at all times to participate in decision making regarding care, where appropriate, and residents will be supported to develop new friendships and participate in activities appropriate to their needs. The following information outlines some additional data on this centre.

Number of residents on the

date of inspection:

99

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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

08 October 2019 09:30hrs to 18:30hrs

Sheila McKevitt Lead

08 October 2019 09:30hrs to 18:30hrs

Leanne Crowe Support

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What residents told us and what inspectors observed

Residents said they felt safe in the centre. Their families and friends were made welcome and they had access to a number of quiet areas to meet their visitors in private.

Residents said the staff were ''lovely and really kind'' to them however there was not always enough staff on duty. Some said that at times staff appeared very busy and they had to wait a ''long while'' for their call bells to be answered. One said when staff numbers were low they were ''run off their feet''.

They said the beds were comfortable however, the duvets were a little heavy and the sheets were rough. One said that the bed linen was not routinely changed by staff and they had to ask for this to be done.

Residents enjoyed the variety of activities which took place daily. All those spoken with said there were plenty of meaningful activities to choose from.

Capacity and capability

This risk inspection was carried out to follow-up on the non compliant regulations identified on the unannounced inspection which took place on 27 March 2019 and to review the issues identified in six unsolicited pieces of information received by the Chief Inspector since that inspection. Three pieces of information had been received in April and a further three in September 2019. Despite seeking written assurances from the provider representative that issues identified had been addressed, the continued receipt of information prompted an inspection. The issues highlighted by complainants included poor staffing levels which were having a negative impact on residents, poor medication management, poor infection control practices and unclear end-of-life planning. A number of these concerns have been substantiated, as reflected in this report.

This centre was not well-governed. The governance and management arrangements were weak and had contributed to the high level of non-compliance with the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013 (as amended) identified on this inspection. It had also lead to inconsistencies in the standard of care being delivered to residents.

The management team comprised of the provider representative, director of clinical services for the group, the person in charge, two assistant directors of nursing, five clinical nurse managers and a team of staff. There had been one change to the management team since the centre opened on 3 December 2019; an assistant

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director of nursing had left and was replaced within two months. The provider representative and person in charge met at regular face to face meetings and at the TLC group monthly management meetings. Despite this inspectors found that an adequate level of support was not being provided to the person in charge, given the following:

The centre was a newly registered 163 bedded nursing home that was admitting new residents.

It was the person in charge's first role in a designated centre for older persons.

Systems and processes to support the operation of the centre were being established.

A large number of newly recruited staff were required to become familiar with these systems.

The system in place to monitor the quality of care was ineffective. Inspectors were informed that key performance indicators were gathered and reported monthly to the provider representative and monthly audits were conducted on some areas of practice. Inspectors found some audits had been completed. However, a review of these showed it was not clear who received the feedback or who was responsible for implementing the required actions and within what timeframe. Therefore, inspectors were not assured that the completion of these audits was having a positive impact on the quality of care being delivered to residents. Some areas of practice were not being audited such as, staff files and the directory of residents and this had lead to a poor level of compliance with the Health Act 2007.

The staffing numbers and skill mix on the day of this inspection were adequate to meet the needs of the 99 residents. Residents and staff confirmed this but some informed inspectors that this was not always the case. Inspectors reviewed the rosters and found the master copy of the actual roster held at reception had not been updated to reflect the staff who were on unplanned leave on the day of inspection. This had the potential to put residents, staff and members of the emergency service at risk in the event of an emergency as the actual roster did not reflect the staff in the building.

Inspectors reviewed previous weeks rosters which showed there was a high incidence of unplanned leave among health care assistants. For example, three health care assistants were on unplanned leave on the day of inspection. This had been identified as an issue at a management meeting in July 2019 however it was not clear if a plan had been put in place to address the issue.

Staff files reviewed contained all the required documents outlined in Schedule 2 of the regulations. However, inspectors noted that the recruitment policy was not robust enough and did not reflect practices described to inspectors. All staff had a Garda vetting disclosure in place and their roles and responsibilities were clearly outlined. However, inspectors noted that one staff member had commenced her contract two weeks before a Garda vetting disclosure had been received by TLC Spectum Limited for the employee.

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Although the person in charge, two assistant directors of nursing and clinical nurse managers were supernumerary when on duty Monday to Friday, inspectors found the supervision of staff was not adequate. On the day of inspection the person in charge, assistant director of nursing and a clinical nurse manager were on duty however, none of these staff were allocated solely to the ground floor, where inspectors observed the administration of medications was not reflective of best practice.

Staff explained that following recruitment, they underwent a 10 month probationary period. Of the staff spoken with, two health care assistants who had been employed for over ten months had not had their three or six month probation interviews conducted. They had received no feedback on their performance to date, at a time when the high turnover of staff had been identified as an issue at management meetings.

The directory of residents did not include all the information required. The statement of purpose and all Schedule 5 policies and procedures were available for review. The medication management and recruitment policy were not reflected in practice.

Regulation 14: Persons in charge

There was a full-time person in charge employed in the centre. She was person in charge since the centre opened on 3 December 2018, was a registered nurse and had a post registration management qualification.

Judgment: Compliant

Regulation 15: Staffing

The staffing levels and skill-mix were adequate to meet the needs of the 99 residents. Staffing levels had been increased recently with the employment of additional staff nurses. These newly employed staff nurses were covering vacant health care assistants posts and any unplanned leave. Inspectors were informed that the vacant health care assistants posts had been advertised, and a recruitment day was being held on the week of the inspection.

Judgment: Compliant

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Regulation 16: Training and staff development

The supervision of staff required improvement. Staff on the ground floor were not being supervised on the day of inspection.

Staff were subject to a ten month probation period, however some staff had not completed their three and six month probation interviews despite working in the centre for a ten month period.

All staff had mandatory training in place and had good clear knowledge of what to do in the event of the fire alarm sounding and how to safeguard residents. However, inspectors found that staff were not well informed of the Act and the regulations made under it.

Judgment: Not compliant

Regulation 19: Directory of residents

A directory of residents was established but not well maintained in the designated centre. It did not contain all of the information specified in paragraph (3) of schedule 3 required by the regulations. For example the following was not included;

the name, address or telephone number of each residents general practitioner.

the cause of death for one resident who had died.

Judgment: Not compliant

Regulation 21: Records

The actual roster given to inspectors did not reflect the staff on duty. A number of staff were on unplanned leave on the day of inspection, this was not reflected on the master copy of the actual roster. Codes were used on the rosters, it was not clear what hours of work these codes referred to, and therefore it was not clear what hours staff were working.

Judgment: Substantially compliant

Regulation 23: Governance and management

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The level of support provided to the person in charge from senior management was not adequate. Giving that this was a newly established 163 bedded centre the role for the person in charge was a challenge and additional supports needed to be put in place.

Audits in different areas of practice had been conducted on an ad-hoc basis by members of the nursing management team. Audits completed to date were reviewed. Data had been collected but had not been adequately analysed. It was not clear what was being done with the findings, whether any actions had been taken, by whom and within what time-frame. A meeting had taken place to discuss audits and their relevance, however the person in charge was not in attendance. The members of the nursing management team who were carrying out the audits had not been provided with any audit training.

An annual review was due to be completed in the coming months, as the centre was only ten months in operation at the time of the inspection.

Judgment: Not compliant

Regulation 3: Statement of purpose

The statement of purpose had been reviewed in September 2019 and was on display. The contents met the regulatory requirements and reflected the services and facilities provided to residents.

Judgment: Compliant

Regulation 31: Notification of incidents

All notifiable incidents had been reported into the Chief Inspector in a timely manner.

Judgment: Compliant

Regulation 4: Written policies and procedures

The policies and procedures outlined in schedule 5 of the regulations were available for review. They had been signed by the provider representative and the person in charge. However, some such as the medication management and recruitment policies were not implemented in practice. The recruitment policy did not clearly

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reflect the legislative requirement of the employer having a Garda vetting disclosure in place for each employee prior to commencing their contract of employment.

Judgment: Substantially compliant

Quality and safety

The centre was newly built and well laid out. It was clean, tidy, bright and furnished in a homely manner. Bedroom accommodation was spacious and comfortable, and there was a variety of communal rooms available on all floors. Residents had access to a well maintained secure ground floor courtyard and first floor balcony. The corridors were wide with hand-rails on either side which enabled residents to walk independently or with the assistance of others.

Visitors were welcome in the centre and there were arrangements in places for residents to receive visitors in private. Residents were observed meeting with visitors throughout the day of the inspection.

Residents had timely access to general practitioners (GPs) who visited the centre as necessary. There were arrangements in place for prompt access to allied health professionals, pharmacy services, dietitians, speech and language therapy, tissue viability, psychiatry of old age and chiropody. There were arrangements in place for the assessment, care planning and review of residents' needs, but inspectors found that some care plans did not contain adequate or appropriate information to guide residents' care. Decision-making processes in relation to end of life care required review to ensure residents' wishes were consistently incorporated, where possible. The administration, storage or disposal of medicines was not being carried out in line with the centre's policy or national legislation.

There were systems in place to cater for residents' nutritional and hydration needs. Residents were screened for nutritional risk on admission and reviewed regularly thereafter. Where risks had been identified, residents were referred to appropriate services such as speech and language or dietitian services. Mealtimes were observed to be a very social occasion and residents were seen to receive assistance with eating and drinking if required.

The provider promoted a restraint-free environment and there was low use of restrictive practices in the centre. Residents were encouraged and supported to optimise their independence where possible.

There were systems in place to maintain the cleanliness of the centre and prevention the spread of infection. However, deep-cleaning practices and the storage of inappropriate items in a sluice room required review.

Risk management was informed by the procedures and policies in place to assess and manage risks identified. While the risk register contained centre-specific risks

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and the required controls to mitigate risk, one identified risk in relation to staffing had not been entered into the register.

There were systems in place to safeguard residents.

Regulation 11: Visits

Arrangements were in place for residents to receive visitors in private. There were no restrictions on residents receiving visitors but visitors were asked to respect mealtimes. There was a visitors sign in book at the front door.

Judgment: Compliant

Regulation 13: End of life

Staff provided end-of-life care to residents with the support of their GP and community palliative care services as necessary. Residents had end-of-life care plans developed. However, they did not consistently describe residents' preferences and wishes regarding their end-of-life physical, psychological and spiritual care.

In a small number of cases, decisions regarding end of life care were being made by relatives rather than the resident or clinical staff. The decision making process required review.

Judgment: Substantially compliant

Regulation 17: Premises

The premises was appropriate to the number and needs of the residents. The centre was spacious, warm, bright and welcoming. It provided spacious bedroom accommodation for residents, as well as a number of communal rooms including an activities room, an oratory and a number of dining rooms. Sitting rooms of various sizes were also located throughout the centre, which provided residents with the opportunity to socialise with others, receive visitors or reflect in a quiet space. A spacious garden was located at the rear of the building. This contained suitable seating, shading and a variety of plants and shrubbery. Residents had unrestricted access to this area, as well as a large balcony on the first floor.

Judgment: Compliant

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Regulation 18: Food and nutrition

The nutrition and hydration needs of residents were assessed and monitored. Residents' weights were checked routinely on a monthly basis and more frequently if they experienced unintentional weight loss or gain.

Nutritional assessments and care plans were in place that outlined the recommendations of the dietitian and speech and language therapists where appropriate. There were arrangements in place for communication between nursing and catering staff to support residents with special dietary requirements. The centre's chefs and catering staff took care to prepare fresh ingredients and serve food in line with residents' preferences. Residents receiving modified consistency meals were presented in an appetising manner; items such as pureed vegetables were piped onto plates in the shape of the original vegetables. Residents were provided with discreet assistance with eating, where necessary. Snacks and drinks were available throughout the day.

Judgment: Compliant

Regulation 26: Risk management

The centre had policies and procedures in place relating to health and safety. A risk management policy was in place and a risk register which reflected some risks but not all those identified within the centre. For example, inspectors noted that while unplanned leave was noted as an issue in a recent governance meeting, this had not been documented in the risk register.

Judgment: Substantially compliant

Regulation 27: Infection control

There were infection prevention and control procedures in place in the centre. Staff were knowledgeable of these. However, inspectors found that the records relating to cleaning schedules required review. It was not clear if rooms designated for deep-cleaning on the day of the inspection had been cleaned. Additionally, it was not clear whether aspects of cleaning, such as changing of bed linen, had been completed.

The centre was maintained to a high standard and while most areas were visibly clean, improvement was required in relation to the centre's clinical room. Additionally, inspectors found that a large number of crates and some laundry

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trolleys were being stored in the ground floor sluice room. These trolleys restricted access to the room's hand wash sink. This was not in line with national infection prevention and control standards.

Judgment: Substantially compliant

Regulation 29: Medicines and pharmaceutical services

Medicinal products :

were not administered in accordance with the directions of the prescriber were not stored securely that were out-of-date were not segregated from other medicinal products or

disposed of in accordance with national legislation.

Judgment: Not compliant

Regulation 5: Individual assessment and care plan

Assessments of residents needs were completed within 48 hours of being admitted to the centre. Validated tools were used to assess risk of malnutrition, falls and skin integrity among others. While residents' care plans were informed by this process, in some care plans reviewed there was insufficient or conflicting detail provided to guide staff regarding residents' individual care preferences and wishes. For example, a continence care plan for one resident with an indwelling catheter referred incorrectly to the use of incontinence pads and a resident requiring specific moving and handling methods had a number of care plans that contained conflicting information in relation to moving and handling procedures. Details regarding a resident's communication needs were documented in their nutritional care plan, but not in their communication care plan.

Judgment: Substantially compliant

Regulation 6: Health care

Residents were provided with timely access to health care services from local general practitioners (GPs), emergency out-of-hours medical care and allied health care professionals as necessary.

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Judgment: Compliant

Regulation 7: Managing behaviour that is challenging

The centre had a low use of restrictive practices and maintained a comprehensive register of any practice that was or may be restrictive. All restrictive practices had been risk assessed and the use of restraint was regularly reviewed. Where a resident required a restrictive practice for their safety or wellbeing, the least restrictive option was used. Doors to the secure garden and balcony were open and residents were observed accessing these areas freely.

A restrictive practice meeting had taken place in August and had outlined measures to minimise restraint use in the centre, including staff training.

Judgment: Compliant

Regulation 8: Protection

All reasonable measures were implemented to protect residents from abuse.

There was a safeguarding policy in place and staff spoken with had a good clear knowledge of what to do in the event of witnessing any form of abuse.

The process in place to manage pensions on behalf of a small number of residents were safe.

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 Compliant

Regulation 16: Training and staff development Not compliant

Regulation 19: Directory of residents Not compliant

Regulation 21: Records Substantially compliant

Regulation 23: Governance and management Not compliant

Regulation 3: Statement of purpose Compliant

Regulation 31: Notification of incidents Compliant

Regulation 4: Written policies and procedures Substantially compliant

Quality and safety

Regulation 11: Visits Compliant

Regulation 13: End of life Substantially compliant

Regulation 17: Premises Compliant

Regulation 18: Food and nutrition Compliant

Regulation 26: Risk management Substantially compliant

Regulation 27: Infection control Substantially compliant

Regulation 29: Medicines and pharmaceutical services Not compliant

Regulation 5: Individual assessment and care plan Substantially compliant

Regulation 6: Health care Compliant

Regulation 7: Managing behaviour that is challenging Compliant

Regulation 8: Protection Compliant

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Compliance Plan for TLC Carton OSV-0005800 Inspection ID: MON-0027841

Date of inspection: 08/10/2019 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 16: Training and staff development

Not Compliant

Outline how you are going to come into compliance with Regulation 16: Training and staff development: 1. By end of October 31st 2019, each CNM will be clearly allocated their areas of responsibility to include being a visible presence on the floors and this will be clearly indicated on the daily allocation sheet. 2. By 15th November 2019, a review of the nursing management resource and function in the building will be undertaken particularly in the context of ongoing pre-admission assessments as the numbers of residents grows in the centre. 3. By 15th November, a full report of the current status of staff probation and appraisal meetings will be completed and reviewed at the monthly governance management meeting. This will be reviewed and discussed monthly on an ongoing basis and any outstanding meetings will be prioritized to ensure full compliance monthly. 4. By 6th November 2019, all CNMs will have received training in conducting staff appraisals.

Regulation 19: Directory of residents

Not Compliant

Outline how you are going to come into compliance with Regulation 19: Directory of residents: 1. By 31st October 2019, all residents’ GP details and cause of death where appropriate will be recorded in the EPIC system which constitutes the Directory of Residents. 2. By 15th November 2019, the first audit of the Directory of Residents will be completed and these will be conducted quarterly thereafter.

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Regulation 21: Records

Substantially Compliant

Outline how you are going to come into compliance with Regulation 21: Records: 1. By 31st October 2019, the Timepoint system will be updated daily to reflect actual roster worked in the previous 24 hours. A master (as worked) roster will also be maintained in hard copy. 2. From 31st October 2019, a copy of the planned roster will also be printed and filed to ensure compliance with the regulatory requirement. 3. From 31st October 2019, unplanned leave occurring daily will be noted on the allocation sheet and used to update Timepoint within 24 hours. 4. From 31st October 2019, a copy of the allocation sheet will be maintained at reception and available to emergency services/managers in the event of an emergency to ensure that all staff on duty in the building can be accounted for.

Regulation 23: Governance and management

Not Compliant

Outline how you are going to come into compliance with Regulation 23: Governance and management: 1. By 30th November 2019, the governance meeting template will be reviewed to ensure actions agreed and recorded are time bound and person responsible is clearly outlined and that outstanding items are reviewed at each meeting. 2. By 31st October 2019, all meeting minutes will be easily available for inspection and all managers will be aware of their location and purpose 3. By 15th November 2019, an annual programme of audit will be scheduled and approved at the clinical governance meeting and adherence to this and the audit outcomes will be reviewed monthly

Regulation 4: Written policies and procedures

Substantially Compliant

Outline how you are going to come into compliance with Regulation 4: Written policies and procedures: 1. By 15th November 2019, the recruitment policy will be revised to include reference to the requirement for staff to have TLC Garda vetting in place prior to commencement of

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work 2. By 30th November 2019, the medication management policy will be reviewed to ensure it reflects best practice and staff training will be scheduled to ensure that all staff are aware of the requirement to adhere to the policy. 3. By 31st December 2019, a medication management audit will be completed to ensure compliance with the policy and best practice 4. By 5th December 2019, 10% of all HR files will have been audited to ensure compliance with the recruitment policy. The outcome of the audit will be discussed at the monthly management meeting

Regulation 13: End of life

Substantially Compliant

Outline how you are going to come into compliance with Regulation 13: End of life: 1. By 30th November 2019, a schedule of regular MDT meetings with the GP will be agreed to ensure each resident’s care plans are discussed and professional decision making is facilitated and documented with the residents’ best interests protected. This will be done in collaboration with the resident and family 2. By 31st December 2019, staff will receive training and support to engage in End of Life discussions with residents and families to ensure that medical and nursing judgement is clearly articulated and also to ensure resident best interest is reflected in decision making.

Regulation 26: Risk management

Substantially Compliant

Outline how you are going to come into compliance with Regulation 26: Risk management: 1. By 15th November 2019, the risk register will be reviewed and updated to reflect all current risks. The risk register will be reviewed in detail at each monthly governance meeting.

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Regulation 27: Infection control

Substantially Compliant

Outline how you are going to come into compliance with Regulation 27: Infection control: 1. By 31st October 2019, a system will be put in place to ensure that deep cleaning is recorded clearly when it is completed as well as the reasons why scheduled deep cleaning is not performed 2. By 31st October 2019, a standard operating procedure will be drafted to outline the frequency of bed linen changes and all residents’ preferences outside of this will be documented and communicated to all staff.

Regulation 29: Medicines and pharmaceutical services

Not Compliant

Outline how you are going to come into compliance with Regulation 29: Medicines and pharmaceutical services: 1. By 30th November 2019, a comprehensive medication audit will be designed and agreed. The audit will be conducted monthly as part of a KPI programme, to ensure that staff are compliant with storage, administration, prescribing and disposal policy. Staff will be provided with feedback and timeframes for improvements in practice. CNMs will be accountable for improvement plans in their area of responsibility. 2. Monthly medication audit conducted by pharmacist/technician and action plan implemented next audit 22nd November

Regulation 5: Individual assessment and care plan

Substantially Compliant

Outline how you are going to come into compliance with Regulation 5: Individual assessment and care plan: 1. By 15th November 2019, a regular audit of care plans will be scheduled to ensure that care plans are comprehensive and reflective of resident care needs. Staff will be given feedback on the outcome of the audits and a timebound improvement plan will be put in place. This process will be monitored by the CNMs on each floor and then overseen and monitored at a centre level at the clinical governance meeting monthly. 2. By 30th November 2019, 10% of all care plans will have been audited and feedback provided to staff. 3. By 31st October 2019, a weekly review of newly admitted residents will be put in place and completed to ensure all relevant assessments and care plans are in place.

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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 13(1)(a)

Where a resident is approaching the end of his or her life, the person in charge shall ensure that appropriate care and comfort, which addresses the physical, emotional, social, psychological and spiritual needs of the resident concerned are provided.

Substantially Compliant

Yellow

31/12/2019

Regulation 16(1)(b)

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

Not Compliant Orange

15/11/2019

Regulation 16(1)(c)

The person in charge shall ensure that staff are informed of the Act and any regulations made under it.

Not Compliant Orange

31/10/2019

Regulation 19(1) The registered provider shall establish and maintain a

Not Compliant Orange

31/10/2019

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Directory of Residents in a designated centre.

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

Not Compliant Orange

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

31/10/2019

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.

Not Compliant Orange

30/11/2019

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 Orange

15/11/2019

Regulation 26(1)(a)

The registered provider shall ensure that the

Substantially Compliant

Yellow

15/11/2019

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risk management policy set out in Schedule 5 includes hazard identification and assessment of risks throughout the designated centre.

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.

Substantially Compliant

Yellow

31/10/2019

Regulation 29(4) The person in charge shall ensure that all medicinal products dispensed or supplied to a resident are stored securely at the centre.

Not Compliant Orange

30/11/2019

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 any advice provided by that resident’s pharmacist regarding the

Not Compliant Orange

30/11/2019

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appropriate use of the product.

Regulation 29(6) The person in charge shall ensure that a medicinal product which is out of date or has been dispensed to a resident but is no longer required by that resident shall be stored in a secure manner, segregated from other medicinal products and disposed of in accordance with national legislation or guidance in a manner that will not cause danger to public health or risk to the environment and will ensure that the product concerned can no longer be used as a medicinal product.

Not Compliant Orange

30/11/2019

Regulation 04(1) The registered provider shall prepare in writing, adopt and implement policies and procedures on the matters set out in Schedule 5.

Substantially Compliant

Yellow

31/12/2019

Regulation 5(3) The person in charge shall prepare a care plan, based on the assessment referred to in paragraph (2), for a resident no later than 48 hours after that resident’s

Substantially Compliant

Yellow

30/11/2019

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admission to the designated centre concerned.