Seanchara Community Unit, 515, nursing home inspection ... - hiqa.ie

Health Information and Quality Authority
Social Services Inspectorate
Inspection report
Designated centres for older people
Centre name: Seanchara Community Unit
Centre ID:
Centre address:
0515
St Canice’s Road
Glasnevin
Dublin 11
Telephone number: 01-704 4400
Fax number: 01-704 4200
Email address: siobhan.byrne@hse.ie
Type of centre: Private Voluntary Public
Registered provider: Health Service Executive
Person in charge: Mary Flanagan
Date of inspection: 21 January 2010
Time inspection took place:
Lead inspector: Sheila McKevitt
Support inspector(s): Nuala Rafferty
Type of inspection:
Start: 08:30 hrs Completion: 17:30 hrs
Registration
Scheduled
Announced
Unannounced
Page 1 of 29

About inspection
The purpose of inspection is to gather evidence on which to make judgments about
the fitness of the registered provider and to report on the quality of the service. This
is to ensure that providers are complying with the requirements and conditions of
their registration and meet the standards; that they have systems in place to both
safeguard the welfare of service users and to provide information and evidence of
good and poor practice.
In assessing the overall quality of the service provided, inspectors examine how well
the provider has met the requirements of the Health Act 2007, the Health Act 2007
(Care and Welfare of Residents in Designated Centres for Older People) Regulations
2009 and the National Quality Standards for Residential Care Settings for Older
People in Ireland under the following topics:
1. Governance and leadership: how well the centre is organised.
2. The quality of the service.
3. How well the healthcare needs of residents are met.
4. Premises and equipment: appropriateness and adequacy.
5. Communication: information provided to residents, relatives and staff.
6. Staffing: the recruitment, supervision and competence of staff.
This report summarises the findings of the inspection under some or all of these
topics, highlighting areas of good practice as well as areas where improvements
were required as follows:
Evidence of good practice – this means that an acceptable standard was reached
and the provider demonstrated a culture of review and improvement and aimed to
drive forward best practice.
Some improvements required – this means that practice was generally
satisfactory but there were areas that need attention.
Significant improvements required – this means that unacceptable practice was
found.
The report also identifies minor issues, where applicable, to which the provider
should give consideration to enhance the quality of the service.
The report is available to residents, relatives, providers of services and members of
the public, and is published on our website www.hiqa.ie.
Acknowledgements
The inspectors wish to acknowledge the cooperation and assistance of the residents,
relatives, provider and staff during the inspection.
Page 2 of 29

About the centre
Description of services and premises
Claremont Residential and Community Services are based in Dublin North Central.
The services are divided into three units and Seanchara Community Unit is one of
these.
Clarehaven Home, Anam Chara housing care unit and a day care facility are all
situated on the same site. The latter two are directly accessible via a lift from
Seanchara Community Unit.
Seanchara Community Unit is a 48-bedded purpose-built single-storey residential unit
for people over the age of 65 years.
There are six single bedrooms, five twin rooms and eight four-bedded rooms spread
over two wings. Four of the single rooms share two en suites showers and toilets.
There are three large sitting rooms, two of which are also used as dining space.
There is one large dining room accessible directly from one of the sitting rooms.
There is one main kitchen and a kitchenette for each wing. Staff have their own
restaurant, rest room and changing facilities.
Other facilities include an oratory, a visitors’ room, an activities room, a snozelen
room, a physiotherapy room, a complimentary therapy room, a reception area, a
porters desk and administration offices.
There are two enclosed gardens, one accessible off each wing which residents can
access freely.
There are ample car parking around the building.
Location
Seanchara Community Unit is situated in parish of Ballygall, Glasnevin, Dublin. It is
located in a residential area.
Dependency level of
current residents
Number of residents
Management structure
Max High Medium Low
16 12 7 2
The nominee on behalf of the Health Service Executive (HSE) is Gerry Reid who
reports to the Local Health Officer, Mary Maguire. Jim O’ Riordan, Manager of
Services, Pat Lane, Administration Manager and Mary Flanagan, the Person in Charge
all report to Gerry Reid. The Assistant Director of Nursing, the Practice Development
Page 3 of 29

Officer and the Catering Manager, report to the Person in Charge. Administration
staff report to Pat Lane.
The Assistant Director of Nursing and the Practice Development Officer are
supported by two Clinical Nurse Managers grade II and two Clinical Nurse Managers
grade I to whom all staff nurses and care assistants report. The catering staff report
to the catering manager.
A contract cleaning company supply the cleaning staff and they report to a company
supervisor.
Staff
designation
Number of
staff on duty
on day of
inspection
Person
in
Charge
1 9
Nurses Care
staff
3 7
Page 4 of 29
Catering
staff
Cleaning
and
laundry
staff
6
Admin
staff
2
Other
Staff
4

Summary of findings from this inspection
The inspection was unannounced and took place over the course of one day. It was
the first inspection of this centre by the Health Information and Quality Authority
(the Authority).
Residents received appropriate healthcare including access to allied heath
professionals. Attention to assessment was good and the involvement of residents
and their families in the care planning process was evident. Nursing documentation
was of a good standard. There were facilities in place to support end of life care
including the facility for family members to stay over night.
Staff demonstrated their respect for the privacy and dignity of residents and staff
supported residents to maximise their independence. Daily routines and care
practices encouraged the residents to exercise choice. There were a variety of
organised and informal activities which made the day interesting and fulfilling for
residents. Religious practice was facilitated.
Inspectors found that staffing levels and skills mix were adequate to meet the needs
of residents. Staff were supported in their work by ongoing training, supervision, and
opportunities for professional development, including access to a staff library.
However, at the time of inspection not all staff had completed training in elder
abuse.
Good levels of cleanliness and hygiene were maintained and infection control
measures were thorough. Bedrooms were personalised and communal areas were
nicely decorated with soft furnishings and residents’ art work. Excellent signage
supported those residents who were cognitively impaired. However, there were
insufficient numbers of showers/bathrooms to meet the needs of residents.
There were a number of other areas which required improvement. There was no risk
management plan in place although two areas of risk were identified on inspection.
These relate to radiators that were very hot and posed a risk to residents and the
storage of medication. Improvements were also needed to ensure that all
documentation was comprehensive, met the requirements of regulation, and where
appropriate, was made available to residents. More robust recording of residents’
finances was required. These issues are discussed in the report and included in the
action plan at the end of the report.
Residents’ and relatives’ comments
Inspectors spoke to 11 residents over the course of the inspection. These residents
spoke very highly of staff, particularly of their patient and kind approach.
A number of residents stated that they enjoyed living in Seanchara and that even
though they had good fun between themselves, there was no place like their own
home.
Page 5 of 29

Residents stated that they had choice over their daily routine and how they lived
their lives.
One issue raised during inspection was that some residents felt that lunch was
served too early. This issue was brought to the attention of the person in charge at
the feedback meeting.
Page 6 of 29

Overall findings
1. Governance: how well the centre is organised
Outcome: The centre is well organised and managed and complies with the
requirements of the Health Act 2007, the regulations and standards.
Good governance involves the effective and efficient deployment of
resources in accordance with the stated purpose and function of the
centre. Governance includes setting clear direction for the service, a
commitment to continual improvement and having a system in place to
effectively assess and manage risk.
Evidence of good practice
The person in charge demonstrated good leadership and was actively involved in the
day to day operation of the centre.
A clear organisational structure was in place. All staff interviewed demonstrated a
good understanding of their roles and responsibilities and were able to describe the
staff structure and the reporting mechanisms in place to ensure appropriate
delegation, supervision and competence in the delivery of care to residents.
There was a very clear and concise emergency plan in place. The responsibilities of
staff in the event of an emergency was precise. Staff spoken to displayed a good
understanding of their role in the plan.
The health and safety statement was assessed as being in line with the regulatory
requirement. The health and safety committee, which comprised staff, met on a
regular basis.
The quality of care provided was audited monthly by management on the following
areas of practice: falls sustained by residents, forms of restraint used, pressure
ulcers, residents with infections and any other new infections. Information from the
audit was then used to inform future practice.
Some improvements required
The statement of purpose did not meet the legislative requirement. A draft format
was reviewed by inspectors. However, it did not contain all the information required
as per schedule one of the Health Act 2007 (Care and Welfare of Residents in
Designated Centres for Older People) Regulations 2009.
Page 7 of 29

Significant improvements required
A risk management policy was not available.
The radiators on the corridors posed a potential risk to residents as they were very
hot to touch.
Access to the key of the safe, where residents’ money was stored, was not secure.
The receptionist stated the key was stored in a locked filing cabinet. The key of the
filing cabinet was kept in an unlocked drawer within a key-coded office. However, a
number of staff members had access to this office and therefore had access to the
key.
The record of residents’ money was not being kept in an accurate or confidential
manner. A large brown envelope with columns for cash in, out, running total and
received by, was in place for each individual resident who had cash held in the safe.
The inspector reviewed residents’ individual brown envelopes and found what was
written on the envelope did not accurately reflect the amount of cash within the
envelope.
Residents whose relatives collected their weekly cash allowance were requested to
sign on a pre-printed sheet of paper. This sheet of paper showed details of other
residents’ names and weekly cash allowance and therefore did not maintain their
privacy.
Insurance documentation was available for inspection. However, it did not include
the name of the centre; the inspector could not identify the centre by the code on
the insurance document. It did not state that liability to any resident shall not exceed
€1,000 for any one item except where the property was deposited.
A draft contract of care was available for review, however a contract of care had not
been sent to individual residents. The person in charge stated that this document
was being finalised and would be given out to residents as soon as it was completed.
Page 8 of 29

2. Quality of the service
Outcome: Residents receive a good standard of service, appropriate
treatment and are treated with courtesy and respect.
A quality service is one where residents are protected from harm or abuse,
where practice is person-centred, where rights are protected, where
residents are enabled to play an active part in the centre and where
management, staff and residents work together towards continuous
improvement.
Evidence of good practice
Residents stated that staff were very courteous towards them. They called them by
their name and respected their dignity and privacy. Inspectors observed staff
drawing curtains around beds in shared rooms prior to attending to residents, and
ensuring that the shower door was closed prior to assisting the resident within.
Cleaning staff were observed knocking on bedroom doors prior to entering.
Staff promoted residents’ independence. Inspectors observed staff providing
assistance to residents at lunch time. This was done in a very relaxed, unrushed
manner. Staff were seen to observe some residents closely allowing them the
opportunity to be independent or offering assistance as required. All condiments
were within residents’ reach so independence could be maintained.
Residents could exercise choice in their daily routines. They could stay in bed if they
so wished. One lady who was in bed stated she “worked hard enough” - some days
she got up and some days she stayed in bed, “it was her liking”. Another resident
said they had a choice of meals and staff came around prior to meal time to check
the residents’ preference.
Residents informed inspectors that sometimes they were offered a plain omelette,
burger or pancake and then were given a choice of ingredients to garnish them with.
They enjoyed this choice as “you could have what filling you liked”.
Residents’ religious needs were catered for. Residents had their own oratory. Daily
mass was transmitted from the parish church across the road to a flat screen
television. Funerals and other religious events were also relayed and residents
informed inspectors that they enjoyed this service.
Two residents informed the inspector that they lead the rosary together every
evening in the sitting room. The chaplain stated that she offered Holy Communion to
residents on a weekly basis.
The chaplain, a member of the local community, provided support to residents and
their families whenever required. On the day of inspection, the chaplain was
supporting the family of a resident who was receiving end-of-life care. Staff stated
Page 9 of 29

that the chaplain provided a great service as she lived locally and was able to attend
the centre within a short period of time. The chaplain informed inspectors that she
ran a monthly family support group meeting which was well attended by residents’
families and also provided bereavement support to residents’ relatives.
Some improvements required
Privacy of residents’ documents was not being maintained. Residents’ care plans
were stored over their beds in their shared bedrooms.
There was no advocate or advocacy service available to residents.
Significant improvements required
Residents informed inspectors that they had monthly meetings and if they wanted
anything done, this was raised at these meetings. Inspectors reviewed minutes and
noted that previous meeting minutes were not revisited. Two residents informed
inspectors that they felt lunch was too early and that they had brought up the issue
in September 2009. However, they had heard nothing since then and lunch continues
to be served at noon.
Page 10 of 29

3. Healthcare needs
Outcome: Residents’ healthcare needs are met.
Healthcare is integral to meeting individual’s needs. It requires that
residents’ health, personal and social care needs are assessed and
reviewed on an on-going basis, within a care planning process, that is
person centred. Emphasis is firmly placed on health promotion,
independence and meaningful activity.
Evidence of good practice
The nursing documentation was of a good standard. Each resident was fully assessed
on admission and re-assessed three monthly thereafter. Inspectors reviewed some
residents’ care plans which reflected their social and personal needs and these were
reviewed on a three-monthly basis. The involvement of residents and their families in
the care planning process was evident.
There was evidence that residents received appropriate medical care. Medical
records indicated that residents were reviewed on a regular basis. Evidence of
hospital appointments and investigation results were available in their records. Staff
nurses and the medical practitioner reviewed medications on a three-monthly basis.
Residents stated that they saw the doctor whenever they wanted.
End-of-life care was well managed. Personnel from the local hospice had provided
training on end-of-life care to staff. Services from this hospice were available to, and
often sought for, residents in Seanchara.
There was a portable bed available in the visitors’ room for residents’ families to stay
over if they so requested. Families had the option to have their relative waked in the
oratory if this was their preference. Residents told inspectors that when a person
died, they rested overnight in the chapel.
There was a physiotherapist, an occupational therapist, a speech and language
therapist and a dietician employed and available to residents on referral.
Significant improvements required
Medications were not securely stored. The door of the storage room where the drug
trolleys were stored did not close fully and the drug trolleys were not secured to the
wall of the storeroom.
The process of documentation relating to resuscitation was not been practiced
according to the units’ policy. Records of discussions between residents, their
relatives, doctors and nurses, did not state who attended or exactly what was
discussed.
Page 11 of 29

4. Premises and equipment: appropriateness and adequacy
Outcome: The residential care setting provides premises and equipment
that are safe, secure and suitable.
A good physical environment is one that enhances the quality of life for
residents and is a pleasant place to live. It meets residents’ individual and
collective needs in a comfortable and homely way, and is accessible, safe,
clean and well maintained. Equipment is provided in response to the
assessed needs of each of the residents and maintained appropriately.
Evidence of good practice
There was a good standard of hygiene. All areas were seen to be extremely clean,
tidy and clutter-free.
There was excellent signage to help residents orientate themselves. Doors had large
pictures of the facilities provided within the room and/or large written words
attached.
There was a choice of activities available on a daily basis as well as evening and
weekend activities. The activities timetable was displayed on notice boards in each
wing and in the main corridor. Fourteen residents were observed playing skittles with
the activities co-ordinator. One resident said she liked the hand massage, another
resident stated that she loved the skittles and bingo. One resident informed the
inspector that she was going shopping in Finglas the following day with the activities
co-ordinator.
The infection control measures in place were thorough. Personal protective clothing
was available for staff in each sluice, cleaning room and outside the rooms of
residents who had infections. Inspectors observed that adequate hand-washing
facilities and sterilising hand gel were available for staff. Staff were seen washing
their hands between caring for residents.
The kitchen was kept in pristine condition. The inspector observed a large and
diverse amount of dry, fresh and frozen food stored for residents’ use.
Corridors, communal sittings and dining rooms were nicely decorated with soft
furnishings and residents’ art work. Residents’ bedrooms had personal photos and
pictures hanging on their walls. Residents in shared bedrooms had their bed areas
personalised.
Significant improvements required
The centre is not fit for purpose in regard to the provision of sanitary facilities for
residents. There are an insufficient number of showers/bathrooms to meet the
required needs of residents.
Page 12 of 29

5. Communication: information provided to residents, relatives
and staff
Outcome: Information is relevant, clear and up to date for residents.
Information is accessible, accurate, and appropriate to residents’ and staff
needs. Feedback is actively sought from residents and relatives and this
informs future planning and service provision. Information is recorded and
maintained in accordance with legal requirements and best practice and is
communicated to staff on a need to know basis to ensure residents’
privacy is respected.
Evidence of good practice
There was lots of literature on services available to residents, an information booklet
for Claremount residential and Community Services was available to residents, which
included information about Seanchara Community Unit. A brochure was also
available.
There was a stand near the porters’ desk which contained numerous leaflets on
services and information available to older persons.
A variety of books were available and residents had access to televisions in each of
the sitting rooms and in some of the bedrooms.
A folder with information for relatives was available at the front desk by the visitors’
sign-in book. This included a booklet on dementia and Alzheimer’s care, end-of-life
care, and a booklet on mental health.
There was a notice board for residents on each wing and on the main corridor. These
contained information about the next residents’ committee meeting, bereavement
support group, family support group and activities timetable.
Communication between staff was good. Staff meetings took place on a monthly
basis, minutes of which were reviewed by inspectors. There was a multi-disciplinary
managers meeting on a monthly basis. Prior to this meeting there was a journal club
where a staff member presented a research paper to the group, to which all staff
were invited.
Some improvements required
The good practice in relation to communication was not supported with a policy for
the provision of information to residents. The Residents’ Guide did not include all the
information required.
Page 13 of 29

Significant improvements required
There were no telephone facilities which residents could access in private. If a
resident wanted to make a call, they had to ask a member of staff for use of the
portable telephone or alternatively, they could use a public phone available on the
corridor.
Page 14 of 29

6. Staff: the recruitment, supervision and competence of staff
Outcome: Staff are competent and recruited in sufficient numbers to meet
residents’ needs
Staff numbers and skill-mix are determined by the size and complexity of
the service and there should be sufficient competent staff on duty, both
day and night, to meet the needs of residents. Robust recruitment and
selection procedures ensure the appointment of suitably qualified and
experienced staff. Staff are supported in their work by ongoing training
and supervision.
Evidence of good practice
Three staff files were reviewed by the inspector all contained the required documents
together with a contract of employment and a job description.
There was good nursing supervision. Each wing had a clinical nurse manager on duty
every day and they were supported by the Assistant Director of Nursing. A number of
staff nurses and care assistants working on each wing supported the clinical nurse
managers. Catering and domestic staff both had supervisors to support them.
Inspectors found that staffing levels and skill mix were adequate to meet the needs
of residents.
The unit facilitated both pre and post registration students from two different
colleges. There was a staff library containing a number of research journals and
relevant textbooks available to staff and students. This ensured that staff working
with residents had access to the theory to support the nursing care they provided.
All staff had received moving and handling, fire and cardio-pulmonary resuscitation
(CPR) training. Evidence that staff had received training on continence promotion,
prevention of constipation, medication, care planning, falls prevention, nutrition, nonviolent
crisis intervention together with phlebotomy training and preceptor training
was provided to inspectors.
A number of staff had received elder abuse training. Names of those who had
attended recent training was available to inspectors and dates of future planned
training was also provided.
There were a number of working groups established. These included:
continence promotion
restraint
activities
falls
Page 15 of 29

dementia.
health, safety and quality
policy committee.
New staff were supernumerary for their first week of employment. They were
provided with an introduction folder and checklist. This had to be completed by the
end of their probationary period which was usually three months.
Staff had professional development plans completed on an annual basis. Inspectors
noted completed plans in staff files.
Changing facilities were available for staff. Staff had there own separate restaurant
and rest room.
Some improvements required
A number of staff had received elder abuse training. Names of those who had
attended recent training was available to inspectors and dates of future planned
training was provided to inspectors. However, a number of staff have yet to receive
this training.
Minor issues to be addressed
There was a high use of agency staff. On the day of inspection eight agency staff
had signed the agency sign-in book viewed by the inspector. All agency staff could
not be identified on the staff rota.
Report compiled by:
Sheila McKevitt
Inspector of Social Services
Social Services Inspectorate
Health Information and Quality Authority
26 January 2010
Page 16 of 29

Health Information and Quality Authority
Social Services Inspectorate
Action Plan
Provider’s response to inspection report
Centre: Seanchara Community Centre
Centre ID: 0515
Date of inspection:
Date of response:
Requirements
21 January 2010
22 February 2010
These requirements set out what the registered provider must do to meet the Health
Act 2007, the Health Act 2007 (Care and Welfare of Residents in Designated Centres
for Older People) Regulations 2009 and the National Quality Standards for
Residential Care Settings for Older People in Ireland.
1. The provider is failing to comply with a regulatory requirement in the
following respect:
The statement of purpose does not meet the regulatory requirements.
Action required:
Review the statement of purpose and ensure it specifically reflects the centre, its aims,
objectives and ethos together with all items outlined in schedule one of the Health Act
2007(Care and Welfare of Residents in Designated Centres for Older People) Regulations
2009.
Reference:
Health Act, 2007
Regulation 5: Statement of Purpose
Standard 28: Purpose and Function
Page 17 of 29

Please state the actions you have taken or are planning to
take with timescales:
Provider’s response:
The statement of purpose and function is currently being reviewed
to ensure that it specifically reflects the unit and contains all items
outlined in schedule one of the Health Act 2007 (Care and Welfare
of Residents in Designated Centres for Older People) Regulations
2009.
Page 18 of 29
Timescale:
February 2010
2. The provider is failing to comply with a regulatory requirement in the
following respect:
There is no advocate or advocate service available for residents’ use.
Action required:
Put in place a mechanism where residents have access to an advocate or advocacy
service.
Reference:
Health Act, 2007
Regulation 10: Residents’ Rights, Dignity and Consultation
Standard 3: Privacy and Dignity
Please state the actions you have taken or are planning to
take with timescales:
Provider’s response:
The unit management recognised this gap existed and advised the
inspectors on the day of the inspection that the Director of Nursing
cancelled an appointment that day with the programme manager of
the National Advocacy Programme. She has since met with her and
a volunteer advocate has been identified. The volunteer advocate
has commenced her training programme and will start her work
placement in the unit in March.
Timescale:
March 2010

3. The provider is failing to comply with a regulatory requirement in the
following respect:
All reasonable measures have not been taken to protect the residents from abuse.
Action required:
Ensure every member of staff has received training in elder abuse.
Reference:
Health Act, 2007
Regulation 6: General Welfare and Protection
Standard 8: Protection
Please state the actions you have taken or are planning to
take with timescales:
Provider’s response:
All nurse managers attended elder abuse training in November 2009
and a scheduled role-out of training which was given to the
inspectors has commenced early in 2010. The person in charge will
expedite this schedule to ensure every member of staff has received
training.
Page 19 of 29
Timescale:
End of March
2010
4. The provider is failing to comply with a regulatory requirement in the
following respect:
Records regarding resuscitation discussions with residents and / or their families were
not kept in a complete and accurate manner.
Action required:
Ensure all records regarding resuscitation are kept in a complete and accurate manner.
Reference:
Health Act, 2007
Regulation 22: Maintenance of Records
Standard 16: End of Life Care
Please state the actions you have taken or are planning to
take with timescales:
Provider’s response:
On the day of the inspection, the records seen by the inspectors did
not reflect the communication processes that had been undertaken
Timescale:
April 2010

with the families. In one case, a single family member attended the
meeting to represent the entire family and their views; however this
was not made clear to the inspectors.
The guidelines for cardio-pulmonary resuscitation are currently
under review and will reflect the actions required by the inspectors.
5. The provider is failing to comply with a regulatory requirement in the
following respect:
Written operational policies and procedures for the provision of information to residents
were not available.
Action required:
Develop and implement a policy for the provision of information to residents.
Reference:
Health Act, 2007
Regulation 21: Provision of Information to Residents
Standard 1: Information
Please state the actions you have taken or are
planning to take with timescales:
Provider’s response:
This policy has now been drafted and following consultation
shall be implemented in the unit.
Page 20 of 29
Timescale:
March 2010
6. The provider is failing to comply with a regulatory requirement in the
following respect:
The residents’ guide did not include all the information required.
Action required:
Develop a residents’ guide which includes all the information outlined in the legislation
referenced below.
Action required:
Provide a copy of the residents’ guide to each resident.
Reference:
Health Act, 2007
Regulation 21: Provision of Information to Residents
Standard 1:Information

Please state the actions you have taken or are
planning to take with timescales:
Provider’s response:
The residents’ guide will be updated to reflect all the
regulatory requirements.
Page 21 of 29
Timescale:
March 2010
7. The provider has failed to comply with a regulatory requirement in the
following respect:
The insurance certificate provided did not include the name of the centre and did not
state that liability to any resident shall not exceed €1,000 for any one item.
Action required:
Review the insurance policy to ensure the name of the building insured is clearly
identified on the insurance certificate.
Action required:
Ensure that the insurance policy clearly outlines that the liability to any resident shall not
exceed €1,000 for any one item.
Reference:
Health Act, 2007
Regulation 26: Insurance Cover
Standard 31: Financial Procedures
Please state the actions you have taken or are planning to
take following the inspection with timescales:
Provider’s response:
A corporate response on the issues outlined above has been sought.
Attached is communication received from the states claims agency.
Timescale:
Feb 2010
8. The provider has failed to comply with a regulatory requirement in the
following respect:
All records of money or valuables deposited, received, returned or used at the request of
the resident must be accurately recorded.
Action required:
Ensure an accurate and private record is kept of all individual residents’ financial affairs
managed by the centre.

Reference:
Health Act, 2007
Regulation 22: Maintenance of Records
Standard 9: The Residents’ Finances
Please state the actions you have taken or are planning to
take with timescales:
Provider’s response:
Records have been reviewed to ensure that accurate and private
record is kept of all individual residents’ financial affairs managed by
the centre. Residents’ cash transactions will be audited bi-monthly
by the administrator.
All residents now have individual records to maintain their privacy.
Page 22 of 29
Timescale:
Completed
Completed
9. The provider is failing to comply with a regulatory requirement in the
following respect:
There is no risk management policy in place in the centre and therefore there is no
precautions in place to control the risks identified on inspection: radiators too hot to
touch in the main corridors and unsecure safe keeping of safe key.
Action required:
Develop and implement a risk management policy to include precautions in place to
control risks identified specified risks as outlined in the legislation
Reference:
Health Act, 2007
Regulation 31: Risk Management Procedures
Standard 26: Health and Safety
Standard 9: The Residents’ Finances
Please state the actions you have taken or are planning to
take with timescales:
Provider’s response:
The unit is committed to operating safely and has a number of
measures in place to minimise risks. It is noted that the inspectors
read the units safety statement which refers to risk assessments
appropriate to the unit. These risk assessments which had been
completed could have been made available to the inspectors had
they sought them e.g. pregnant employees, fire, manual handling
etc.
Timescale:

5 staff have received specific training to carry out risk assessments.
Potential and actual risks are identified through a number of sources
e.g. incidents and accidents.
A risk assessment on the radiators in the corridors has been carried
out and appropriate action instigated. The secure safe keeping of
the safe key has been addressed.
The local risk management policies will be reviewed by the Health &
Safety committee to reflect the requirements of the Health Act
2007.
Page 23 of 29
Completed
March 2010
10. The provider is failing to comply with a regulatory requirement in th
e following respect:
There was no contract of care agreed with individual residents.
Action required:
Decide on a final contract of care and provide one to each individual resident for
agreement.
Reference:
Health Act, 2007
Regulation 28: Contract of Provision of Services
Standard 7: Contract/Statement of Terms and Conditions
Please state the actions you have taken or are planning to
take with timescales:
Provider’s response:
Final contract of care has been approved and provided to each
resident / representative.
Timescale:
February 2010
11. The provider is failing to comply with a regulatory requirement in the
following respect:
Facilitate, insofar as is reasonably practicable, consultation and participation in the
organisation of the designated centre.
Action required:
Ensure issues raised by residents’ at monthly meeting are re-visited at the next and
feedback is provided.

Reference:
Health Act, 2007
Regulation 10: Resident’ Rights, Dignity and Consultation
Standard 2: Consultation and Participation
Please state the actions you have taken or are planning to
take with timescales:
Provider’s response:
The Assistant Director of Nursing will attend the beginning of each
residents meeting to ensure that issues raised are revisited and
feedback is provided.
Page 24 of 29
Timescale:
Completed
12. The provider is failing to comply with a regulatory requirement in the
following respect:
Facilitate, insofar as is reasonably practicable, consultation and participation in the
organisation of the designated centre.
Action required:
Review the time lunch is served as requested by the residents.
Reference:
Health Act, 2007
Regulation 10: Resident’ Rights, Dignity and Consultation
Standard 2: Consultation and Participation
Please state the actions you have taken or are planning to
take with timescales:
Provider’s response:
As per the request of the residents, the lunches have been moved
to a later time and residents’ feedback will be sought at the next
Residents Meeting.
Timescale:
Completed

13. The provider is failing to comply with a regulatory requirement in the
following respect:
Residents care plans are stored over the residents’ bed in shared rooms.
Action required:
Consult with residents about the storage of their care plans.
Action required:
Revise the policy on storage of records to reflect the required arrangement decided
upon by residents.
Reference:
Health Act, 2007
Regulation 22: Maintenance of Records
Standard 32: Register and Residents’ Records
Please state the actions you have taken or are planning to
take with timescales:
Provider’s response:
The unit will consult with residents and relatives about the storage
of their care plans and take action accordingly.
Page 25 of 29
Timescale:
March 2010
14. The provider is failing to comply with a regulatory requirement in the
following respect:
There are an insufficient number of assisted showers / bathrooms to meet the needs of
residents.
Action required:
Ensure there are a sufficient number of assisted showers / bathrooms having regard to
the number of dependent persons in the centre.
Reference:
Health Act, 2007
Regulation 19: Premises
Standard 25: Physical Environment
Please state the actions you have taken or are planning to
take with timescales:
Timescale:

Provider’s response:
It is noted that an insufficient number of assisted showers /
bathrooms to meet the needs of residents is available in the unit as
per the National Quality Standards for Residential Care settings for
Older People in Ireland. Two unused bathrooms are currently used
as storage. An alternative arrangement will be put in place for
storage and these bathrooms will be reused.
Page 26 of 29
End of 2010
15. The provider is failing to comply with a regulatory requirement in the
following respect:
The centre does not have appropriate and suitable practices and written policies for the
storage of medications.
Action required:
Provide a chain and a lock for each individual drug trolley to ensure it can be secured to
the wall of the store room when not in use.
Action required:
Repair the door of the store room to ensure it closes fully.
Action required:
Revise the policy for the storage of medications and ensure all staff nurses are aware of
this change in policy.
Reference:
Health Act, 2007
Regulation 33: Ordering, Prescribing, Storing and Administration of
Medicines
Standard 14: Medication Management
Please state the actions you have taken or are planning to
take with timescales:
Provider’s response:
The policy for storage of medication trolleys has been reviewed and
the appropriate action taken, i.e. drug trolleys are locked to a fixed
surface.
The door of the store room has been reported to maintenance.
Timescale:
February 2010
February 2010

16. The provider is failing to comply with a regulatory requirement in the
following respect:
Residents have no telephone facility to use in private.
Action required:
Provide telephone facilities that each resident can access in private.
Reference:
Health Act, 2007
Regulation 11: Communication
Standard 4: Privacy and Dignity
Please state the actions you have taken or are planning to
take with timescales:
Provider’s response:
The unit has a 2 cordless telephone which can use in private.
However an additional phone is being installed that can be accessed
in private by the residents.
Page 27 of 29
Timescale:
March 2010

Recommendations
These recommendations are taken from the best practice described in the
National Quality Standards for Residential Care Settings for Older People
in Ireland and the registered provider should consider them as a way of
improving the service.
Standard Best practice recommendations
Standard 23:
Staffing
Levels and
Qualifications
Consider reviewing staff rota to ensure all staff on duty have there
names and hours reflected on the one rota including agency staff.
Consider reviewing the high use of agency staff on an ongoing basis
Page 28 of 29

Any comments the provider may wish to make:
Provider’s response:
The person in charge and staff at Seanchara Community unit welcome the inspectors
comments and acknowledge that it highlights areas of good practice and
opportunities for improvement in particular as this inspection was unannounced and
the first such inspection of the unit.
The unit had undertaken a person-centred dementia programme, which was evident
to the inspectors e.g. excellent signage. This has a direct impact on areas of practice
such as communication & activities. The staff are implementing the Poole activity
level and the inspectors were made aware of this. The staff are very proud of the
services they deliver to all residents/clients.
We welcome the recommendation in relation to the high use of agency staff in the
unit as this is a cause of concern for the person in charge.
Provider’s name: Gerry Reid
Date: 22 February 2010
Page 29 of 29