Sunday 21 July 2019

Nursing homes create detailed action plans for improvements

Measures follow inspections into dementia care by HIQA at three facilities located around Bray

Earlsbrook House
Earlsbrook House
Kylemore House

Mary Fogarty

Three Bray nursing homes were deemed non-compliant in a number of areas inspected by HIQA, according to reports published relating to residents with dementia.

Earlsbrook, Kylemore and San Remo were all subject to unannounced dementia care inspections.

In each case, action plans were put in place to bring about improvements. The reports also identified areas in which the facilities displayed positive outcomes.

The purpose of the inspections is to safeguard and ensure that the health, well-being and quality of life or residents is promoted and protected, as well as to drive continuous improvement so that they have better, safer and more fulfilling lives.

These inspections focussed on the quality of life of people with dementia and compliance with regulations regarding people with dementia.


At Earlsbrook, they were compliant in four of seven inspected categories. The inspector met with residents and staff members, tracking the journey of a number of residents with dementia within the services.

The report identified some improvements needed, such as updating of records, reviewing of care plans, and adequate assistance during mealtimes, as well as to the activity programme. The report also said some amendments to the complaints policy were required.

The report found that residents had access to a full suite of healthcare.

Palliative care was one of the subjects of the report, which found that there were care practices and facilities in place so that residents received end-of-life care in a way that met their individual needs and wishes. Staff spoken with stated that the centre received support and advice from the local palliative care team. Staff had linked with the hospice friendly hospital (HFH) initiatives, such as the use of the spiral symbol to alert others to be respectful whenever a resident was dying. Staff spoken with confirmed that meals and refreshments were made available to relatives and facilities were set aside if relatives wished to stay overnight.

The inspector also found that measures were in place to protect residents from being harmed or abused and their privacy and dignity were respected.

There were no restrictions to visiting in the centre and many residents were observed spending time with family or friends.

The nursing home and the inspector prepared an agreed action plan to address any matters arising.

In the category 'Health and Social Care Needs', it was found that there was limited evidence of consultation with the resident concerned, or where appropriate that resident's family, prior to care plan reviews.

The nursing home said in the action plan that following feedback from the inspection, consultation with this resident and their family in relation to care plans by nursing staff commenced and is ongoing.

Following feedback from the inspection, consultation with this resident and their family in relation to care plans by nursing staff commenced and is ongoing.

In the category 'self care and support', it was found that adequate assistance was not available, resulting in some meals getting cold. It was also noted that the tables were not laid in one dining area, nor were any trays or condiments in use. Drinks were not provided at the observed mealtime.

According to the facility, on the second day of the inspection, at mealtime, an emergency occurred with a resident in another area of the home, resulting in less staff being available to support mealtime in the day room observed by the inspector.

That said, following the inspection it was decided to review mealtimes in consultation with the kitchen manager, and a new system of serving has been agreed so that mealtimes are approached in a more socially conducive manner with meal times to be available in two sittings.

To support this initiative the home is investing in additional catering equipment, for this day room, and providing an additional table for drinks and condiments. This new initiative will provide staff with more than adequate time to provide assistance to residents at mealtime as required.

Mealtime audits and food survey audits are completed monthly to ensure residents and or their families have the opportunity to give feedback on the revised system. The action plan also included measures to ensure that food and fluid intake is recorded.

In 'safeguarding and safety', restrictive practice use was not consistently in line with national guidelines.

The person in charge and the care team have been actively seeking to reduce the use of restraining bedrails in consultation with residents and families, and according to their feedback they have made 'great strides' in this area.

Also in the action plan is the management of pensions. The person in charge and financial team have completed all processes where pensions are managed, in line with national guidelines.

In one instance, a staff member was seen putting clothes protectors on residents without asking their permission, contrary to the 'person-centred care and support' requirements.

Ongoing staff communication and education regarding the importance of gaining consent from residents prior to using a clothing protector has been conveyed to all staff with reminders at handover and staff meetings. A monthly audit of staff interaction in lounges during meal times is being carried out to achieve consistency.


Kylemore House was compliant in two of seven outcomes. While improvements had been made, significant improvement was found to be necessary in the government and management systems to ensure an effective and appropriate standard of clinical care was delivered to residents.

Staffing levels and skill-mix were not appropriate to meet the needs of residents and the provider revised staffing arrangements immediately to address that, the report said.

There were policies and procedures available to inform safeguarding of residents from abuse. A restraint free environment was promoted and care practices and interactions between staff and residents were respectful and courteous.

From the files examined, it was evident that the assessment and management of behaviours and psychological symptoms of dementia was not in line with the centre's policy. HIQA inspectors met with residents, their relatives and staff members. Residents who spoke with inspectors said they felt safe and expressed their satisfaction and contentment with living in the centre.

Good efforts were made to support residents with dementia to maintain links with their community but improvements were necessary to ensure each resident was facilitated to enjoy meaningful and fulfilling recreational activities that met their interests and capabilities.

The inspectors found that there was good communication and low number of falls or injuries, and residents were encouraged to maintain their independence.

Residents said that staff were always respectful and courteous towards them. Their money was held securely and available to residents as they wished.

It was found, however, that residents were not given sufficient opportunities to participate in meaningful activities. The activity was on leave during the time of inspection.

There was a lot of emphasis on maintaining residents' links with the community and supporting them to continue to attend various day centres in the locality after they moved into the centre. Some residents were encouraged to continue to enjoy going out to the local town and the seafront with their family and friends.

The provider also employed people to accompany residents with going for walks in around the local area. Inspectors found that residents with dementia were mostly supported to exercise personal choices about how they wished to spend their day.

For example, some residents liked to get up late in the morning and this was facilitated. Staff were also observed offering choices to residents about menu options and where they wished eat their meals or sit during the day in ways that suited their communication needs.

However, independent choice to freely access the external environment was restricted for residents with memory impairment, due to key code locks placed on doors to the outdoor enclosed balcony and garden area.

In an action plan in the report, it was agreed that care plans would be allocated to individual staff nurses who will have responsibility for ensuring that their designated resident's car plans are sufficiently detailed.

Part of the action plan dealt with residents at risk of developing pressure ulcers, with catheters, and with issues surrounding supervision while eating and transcription of medications. Documentation given to staff after each handover will deal with those matters.

With regard to activities, the nursing home said that the existing full range activity programme will be kept under active review by the Person In-Charge and manager of Social Programmes to ensure that the activities offered meet the social, occupational and recreational needs of the residents. The 'A Key to Me' plan for residents is documented on hard copy, to be transferred to the electronic system for all residents.

Following this input of information, an audit was to be carried out to ensure the needs of the residents were met.

Three care staff completed training in a gentle exercise programme called Fit for Life last year, and four staff including the activity provider have completed Sonas training.

A locked downstairs door will be unlocked to allow access to an outdoor area. Staffing levels will also be addressed.


San Remo was compliant in three of six categories. The inspector found that residents had been assessed to ensure the service could meet their needs. The inspector noted that there was a family support manager in post, to assist families during the admission and settling in periods.

The inspection found that residents were assessed prior to admission to ensure the service could meet their needs and to determine the suitability of the placement. Following admission, residents had a comprehensive assessment undertaken.

Some improvements were required to ensure that meals and mealtimes were an enjoyable experience for all residents. The inspector saw many examples of good practices in relation to maintaining residents' privacy and dignity but improvements were also identified. Measures were in place to protect residents from harm or suffering abuse and to respond to allegations, disclosures and suspicions of abuse. Recruitment practices met the requirements of the regulations and staff were offered a range of training opportunities including a range of specific dementia training courses The planned building works need to be completed to ensure that premises meets the needs of the residents living there.

The inspector found that planned building works need to be completed to ensure that premises meets the needs of the residents living there. Works to redevelop the premises are expected to begin this month.

The inspector queried 'unconventional' mealtimes of 11.45 a.m. for dinner and 3.45 p.m. for tea. San Remo said in their response that the timings have been reviewed. Lunch starts at noon and the evening meal starts being served at 4 p.m. This will remain under review. The report also found that there was insufficient assistance available to a resident at lunch time on the day of inspection. In the action plan, the nursing home said that supports during meal times have been reviewed to ensure that there is adequate help for each resident.

The inspector heard two staff members discussing the condition of a resident in the company of other residents, the report read. In the action plan, the home said that meetings have been conducted to re-educate the staff involved in the identified interaction as well as the broader staff team. Mandatory training on residents' rights, dignity and consultation will continue to be provided as part of the induction training and will be updated at least two-yearly.

Bray People