Marymount Care Centre, 65, nursing home inspection report - hiqa.ie

Health Information and Quality Authority
Social Services Inspectorate
Regulatory Monitoring Visit Report
Designated centres for older people
Centre name:
Marymount Care Centre
Centre ID: 0065
Centre address:
Westmanstown, Lucan,
Co. Dublin
Telephone number: 01 8204500
Fax number: 01 8238910
Email address:
info@marymountcarecentre.ie
Type of centre: Private Voluntary Public
Registered providers:
Person in charge:
Maureen McNulty
Maureen McNulty
Date of inspection: 21 September 2010
Time inspection took place: Start: 08:30 hrs Completion: 16:10 hrs
Lead inspector:
Support inspector:
Mary Costelloe
N/A
Type of inspection: Announced Unannounced
Purpose of this inspection visit
Application to vary registration conditions
Notification of a significant incident or event
Notification of a change in circumstance
Information received in relation to a complaint or
concern
Regulatory Monitoring Visit Report
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About the 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 (as
amended) and the National Quality Standards for Residential Care Settings for Older
People in Ireland.
Additional inspections take place under the following circumstances:
• to follow up on specific matters arising from a previous inspection to ensure that
the action required of the provider has been taken
• following a change in circumstances; for example, following a notification to the
Health Information and Quality Authority’s Social Services Inspectorate that a
provider has appointed a new person in charge
• arising from a number of events including information received in relation to a
concern/complaint or notification to the SSI of a significant event affecting the
safety or well-being of residents
• for centres that have not previously been inspected within a specific timeframe, a
one-day regulatory monitoring visit may be carried out to focus on key regulatory
requirements.
All inspections can be announced or unannounced, depending on the reason for the
inspection and may take place at any time of day or night.
All inspection reports produced by the Health Information and Quality Authority will be
published. However, in cases where legal or enforcement activity may arise from the
findings of an inspection, the publication of a report will be delayed until that activity is
resolved. The reason for this is that the publication of a report may prejudice any
proceedings by putting evidence into the public domain.
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About the centre
Description of services and premises
Marymount Care Centre is a purpose-built, two-storey building which opened in 1987. It
was extended and refurbished in 2008 and has places for 91 residents. At the time of
inspection there were 84 residents living in the centre; two residents were under 65 years
of age and some residents had dementia.
The building is set in a large, landscaped site. The main entrance is to the front of the
building which opens into a central reception area. The centre is made up of two sections,
namely the Maple and the Orchard. The Maple is a single-storey section to the left of the
main reception area, while the Orchard is two- storey and on the right.
There are 37 single bedrooms with en suite shower and toilets, 11 twin bedrooms with
shower and toilet en suite, and four single and two twin bedrooms without en suite
facilities on the ground floor. There are 14 single and five twin bedrooms, all with en suite
toilet and shower on the first floor. The centre has six additional assisted bathrooms with
specialised baths located throughout the building.
There are a variety of communal spaces throughout the building, including four sitting
rooms, a library, as well as several seating alcoves and a computer workstation area. The
main dining room is on the ground floor of the Orchard area beside the kitchen and
additional dining areas are also provided in the Maple and Orchard areas. Residents also
have access to the ground floor oratory, shop, gymnasium, hairdressing and therapy
rooms.
Residents have access to several garden and outdoor seating areas. There are two
enclosed secure garden areas, a sensory garden, roof terrace and balcony. Residents can
also go out into the extensive landscaped grounds surrounding the building.
There are two lifts and three staircases between floors. There is a nurses’ station,
kitchenette, sluice cum utility room provided in each area and on each floor. The laundry
is on the first floor.
The building is wheelchair accessible throughout. There is adequate parking for staff and
visitors provided around the building.
Location
The centre is located approximately two kilometres from Lucan village in County Dublin.
There is a bus stop at the main entrance.
Date centre was first established: 1987
Number of residents on the date of
inspection 84
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Dependency level of
current residents
Max High Medium Low
Number of residents 22 20 27 15
Management structure
The Provider and Person in Charge is Maureen McNulty and she is referred to as the
Person in Charge throughout the report. Fergus McNulty, the Financial Director, Kay
Downey-Ennis the Quality and Education Director, Conor McNulty the Business Manager
and Karla Walsh the Assistant Director of Nursing (ADON) form the management team
who all report directly to the Person in Charge. Clinical Nurse Managers (CNMs), staff
nurses and care assistants report to the ADON who in turn reports to the Person in
Charge. Housekeeping and catering staff report directly to their manager/supervisor who
in turn report to the Business Manager.
Staff
designation
Number of
staff on duty
on day of
inspection
Person
in
Charge
Nurses
Care
staff
Catering
staff
Cleaning
and
laundry
staff
Admin
staff
Other
staff
1 6 13 4 7 * 6
* Other staff working on the day of inspection included: I Receptionist, 2 Maintenance, 1
Activities coordinator, 1 Business Manager, I Director of Quality and Education.
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Summary of findings from this inspection
This was the first inspection carried out by the Health Information and Quality Authority
(the Authority) and it was an unannounced regulatory monitoring inspection. The
inspector focussed on key regulatory requirements of governance, resident care and
environment to assess the extent to which the management of care ensured positive and
safe outcomes for residents.
The inspector met with residents, relatives, ADON, business manager, director of quality
and education, CNM, staff nurses, and other members of staff. Records examined included
staff rotas, register of residents, written policies on health and safety as well as fire safety
records and accident/incident report forms.
On the day of inspection, the inspector was satisfied that residents received a good quality
of care in a safe environment and that their nursing and healthcare needs were being met.
Some improvements were required to update the register of residents and finalise the
emergency plan.
These areas for improvement are addressed in the Action Plan at the end of the report.
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Comments by residents and relatives
The inspector spoke with a number of residents and some relatives during the inspection.
Residents were satisfied with the level of care they received, commenting “Everything is
great here, no complaints at all”, “We are all very happy here”.
Residents were complimentary about the staff, stating that staff were very kind and
caring; comments included “Staff are very good and very caring” and “Everybody is lovely
here”. Residents and relatives spoken to said that all staff were very approachable and
they listened to what was being said.
Residents told the inspector that the centre was family run, comments included “The
person in charge and her family are always here, they are very approachable, they have a
presence here all of the time”.
Residents were satisfied with meals, choice of food and portion sizes. They stated that the
food was always very good, and that they could have whatever they wanted.
Many residents spoken to said that they enjoyed the variety of activities available,
commenting that “we have lots to do, we are kept busy”. Residents told the inspector that
they can choose to do as they wish, for example, get up and go to bed when they wish,
have meals in the dining room or in their bedroom and receive visitors at any time.
Relatives stated that the ethos of care was very good: “During the bad weather some staff
stayed over in case staff could not get to work in the morning”. “This is like a home from
home”, and “There is always something going on, we have had lovely days as a family
here”.
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Governance
Article 5: Statement of Purpose
The person in charge had submitted the statement of purpose in advance of the
inspection which had been developed in accordance with the requirements of the
Regulations. It reflected the categories of care provided at the time of inspection. Most
residents were over 65 years of age with general care needs and many had dementia.
There were two residents under 65 years of age, one of whom was receiving respite care.
Article 15: Person in Charge
The person in charge worked full-time. She had 22 years management experience of
operating a designated centre and was on leave at the time of inspection. The inspector
spoke with the ADON who deputised in the absence of the person in charge. She told the
inspector that she and the person in charge were on call at week ends and out-of-hours
and that both are rostered on-duty on alternative weekends.
The ADON told the inspector that there was a CNM on-duty each day and that there was
always a senior nurse on-duty to supervise the delivery of care. Staff spoken to and
staffing rotas reviewed by the inspector confirmed this to be the case.
Article 16: Staffing
The inspector noted that there were adequate numbers of staff on-duty to meet the needs
of residents. The roster showed that there were usually five staff nurses, 13 care
assistants, a clinical nurse manager and the person in charge or ADON on-duty during the
daytime, while two staff nurses and four carers were on-duty at night-time. The assistant
director of nursing told the inspector that one care assistant always remained on the first
floor at night-time to attend to residents’ needs. There were adequate catering and
housekeeping staff on-duty. Two activities coordinators worked from Monday to Friday
and staffing rotas confirmed this. Staff and residents said they were satisfied with the
present staffing levels.
All staff spoken to said that they had received mandatory training in fire safety and
evacuation and moving and handling. Training records reviewed by the inspector indicated
that the majority of staff had received such training and further training was scheduled for
recently recruited staff and to update existing staff. The inspector was shown
documentation indicating that moving and handling training was scheduled to take place
on the 24 September 2010 and fire safety training on the 20 October 2010 and 2
November 2010.
The inspector reviewed documentation for a number of staff and confirmed that up-todate
registration numbers were recorded for nursing staff. Confirmation of Garda Síochána
clearance was in place for most staff and the remaining applications were being
processed.
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Article 23: Directory of Residents
The inspector reviewed the directory of residents and noted that the required details were
not fully completed in the case of a number of residents. The dates of transfer to and from
hospital had not been recorded in the case of one resident.
Article 31: Risk Management Procedures
The inspector found that robust risk management procedures were in place.
The inspector reviewed the process for recording incidents and accidents. A detailed
clinical incident report form was completed for each incident and maintained on the
residents’ file. The incidents were also logged on the computerised system. A root cause
analysis and monthly audit was completed by the director of quality and education. A
matrix had been completed of all residents at high risk of falls. Evidence of learning and
improvements made were documented. For example, sensor mats, chair sensors, floor
sensors and low profile beds were in use for some residents. The inspector reviewed the
file of a resident who had fallen and noted that the recommendations made by managers
had been documented and implemented. The falls risk assessment had been reviewed and
an updated care plan was in place.
The inspector reviewed the risk management policy dated January 2010 and the health
and safety policy dated May 2010. Both were found to be comprehensive; hazards were
identified and risks were assessed in-line with the requirements of the Regulations. A
health and safety committee was in place made up of all grades of staff; meetings were
held monthly and issues identified were acted upon. The inspector read the minutes of the
last meeting displayed on the staff notice board.
The inspector was shown the draft emergency plan which was in the process of being
finalised. The plan was comprehensive and gave clear guidance to staff on what to do in
the event of a variety of emergency situations, including fire, bomb threat, loss of power,
heating failure, flooding and evacuation of residents.
Article 39: Complaints
The inspector reviewed the complaints policy and found that it was comprehensive. It
contained a quick reference guide to the management of complaints and the details of an
independent appeals process. The complaints procedure was clearly displayed in the
entrance area. A complaints officer had been appointed. Separate forms were available to
document both written and verbal complaints. Complaints were all logged on the
computerised system. The director of quality and education told the inspector that no
written complaints had been received to date this year. She provided details of 24 verbal
complaints and the inspector observed that all complaints had been resolved and closed
off. Most complaints had been resolved quickly. Outcomes and actions taken on foot of
the complaints were documented.
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Article 36: Notification of incidents
The assistant director of nursing was aware of the legal requirement to notify the Chief
Inspector regarding incidents and accidents. To date all relevant incidents had been
notified to the Chief Inspector by the person in charge.
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Resident Care
Article 9: Health Care
All residents had access to general practitioner (GP) services and could choose to retain
their own GP if they so wished. There was an out-of-hours service available. The
medication prescribing records checked by the inspector confirmed that all medications
were reviewed on a three-monthly basis.
The inspector noted that residents had access to a wide range of allied health
professionals and the records of appointments were maintained in residents’ files.
Physiotherapy was available in-house on a weekly basis and more often if required on
referral from the GP. The dietician visited residents on a monthly basis and was available
to give advice as required. The chiropodist attended every two weeks and was available
more often if necessary. Occupational therapy (OT) and speech and language therapy
were available on referral from the GP. The optician visited annually and assessed
residents as required. Arrangements were made locally with the dental clinic for residents
requiring dental care. The centre had strong links with the psychiatry of later life team
from Connolly Hospital who visited and were also available for advice.
Article 33: Ordering, Prescribing, Storing and Administration of Medicines
The inspector reviewed the medication policy which was found to be comprehensive and
gave clear guidance to nursing staff on areas such as medication prescribing,
administration and storage.
The inspector spoke to the clinical nurse manager about the medication policy, medication
administering procedures and found her to be knowledgeable in relation to the policy,
legislation and best practice.
Medications requiring strict controls were appropriately stored and managed in a double
locked cupboard in the clinical room. Records indicated that these were counted and
signed by two nurses at each change of shift.
Medications requiring strict temperature control were stored appropriately in a refrigerated
unit in the locked clinical room. The temperature of the refrigerator was monitored and
recorded on a daily basis.
Medication audits were being carried out on a six-monthly basis by the pharmacist. The
last audit was completed in March 2010. Documentation reviewed by the inspector
showed that actions highlighted in the audits had been acted upon and their completion
date had been recorded.
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Article 6: General Welfare and Protection
The inspector reviewed the policy on the prevention and detection of elder abuse dated
February 2010 which was found to be comprehensive. Staff spoken to confirmed that they
had received training in relation to elder abuse and were knowledgeable on the issue.
Training records reviewed confirmed that the majority of staff had received training in this
area; further training was scheduled for recently recruited staff on 24 September. Two
members of staff had qualified as ‘train the trainers’ in the prevention and detection of
elder abuse which meant that all staff could receive in-house training.
There had been one allegation of abuse during the past 12 months. An investigation had
been carried out by the director of quality and education and this complaint was not
upheld. The inspector was satisfied that this allegation had been dealt with appropriately
and in accordance with the policy. The details regarding this complaint had been notified
to the Chief Inspector.
There were two activities coordinators employed and there were a variety of activities
going on during the inspection so that residents had opportunities for meaningful
occupation. Staff informed the inspector that a resident assessment and activity plan was
completed for all residents; the inspector observed this in residents’ files. Residents
spoken to said that they enjoyed the variety of activities taking place, such as baking,
painting, quizzes, music, bingo, arts and crafts. Many told the inspector that they enjoyed
outings during the summer to the ‘Titanic’ exhibition, the Guinness brewery, Newbridge
Silver and the Concert Hall as well as garden parties and treasure hunts on the grounds.
Staff informed the inspector that they were presently in the process of developing a ‘My
life history book’ for all residents. Staff had completed it for some residents and said that
they found it beneficial, particularly when reminiscing with residents who had dementia.
Article 20: Food and Nutrition
The inspector observed that residents were offered a varied and nutritious diet. Some
residents required special diets or a modified consistency diet and their needs were met.
The quality, choice and presentation of the meals were of a high standard and residents
confirmed this. Residents were offered a daily choice at lunch and evening meals. The
daily menu was displayed in the dining room. The inspector met with the chef who was
able to show documentation about residents’ likes, dislikes, special dietary needs and
recommendations from the dietician. There was a four-weekly rolling menu and the chef
told the inspector that residents’ preferences were taken into account when compiling
them. She said that she regularly chatted with residents and asked them if there was
anything that they would like. Residents confirmed this, saying that they could have
anything they wish.
The inspector noted that all residents were offered a variety of drinks with their meals and
were encouraged to take drinks throughout the day. Kitchenettes were located in each
area and on each floor. Residents confirmed that they could have drinks and refreshments
as desired.
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The clinical nurse manager told the inspector that all residents were nutritionally assessed
using a validated tool and that their weights were routinely recorded on a monthly basis.
She stated that residents who were nutritionally at risk were weighed more often. The
inspector reviewed some residents’ files and nutritional assessments and monthly weights
were recorded. The inspector noted that a resident who had been losing weight had been
referred to the dietician and to the GP.
The dietician’s recommendations were documented and the care plan reflected the
recommendations made. The chef was aware of these recommendations and had a copy
on file in the kitchen. The GP had also prescribed drink supplements.
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Environment
Article 19: Premises
The building was found to be clean and bright throughout. The front entrance reception
area was welcoming and was carpeted and furnished with comfortable chairs. There were
lamps, side tables, framed wall pictures, a fire place and vases of fresh flowers in this
area. The receptionist sat at the reception desk and the inspector noted that residents
chatted with the receptionist as they passed by.
The design of the building was suitable for its purpose. The circulation areas, such as
corridors, were wide and allowed plenty of space for wheelchair access. The building was
designed around two internal garden courtyards; the gardens were easily accessible from
the corridors and day areas. The gardens were landscaped and well maintained with a
variety of outdoor furniture provided for residents’ use. Residents could access the sensory
garden which also housed a chicken coup for interest and stimulation.
There was a variety of day areas provided; the rooms were comfortably furnished and
domestic in character. Residents could also sit and relax in the front hallway, the library
and outdoor verandas. The inspector saw residents using all the day areas and some
residents confirmed that they enjoyed the views of the gardens.
Bedroom accommodation met residents’ needs for privacy, leisure and comfort. All
bedrooms were spacious and furnished with high quality coordinating curtains and bed
linen. The décor and colour schemes created a restful, relaxing environment. There were
specialised beds, ample personal storage space, screens in shared rooms, wall mounted
TV, telephone line, internet access, nurse call bell facilities and a variety of armchairs.
Residents had personalised their own rooms with furniture, photographs and religious
ornaments.
The inspector visited the kitchen and found it to be clean, spacious and well-equipped.
Separate staff toilet and changing facilities were provided for catering staff.
The inspector noted that infection control practices in hand hygiene were robust. Wall
mounted dispensers containing hand sanitising gel were located at the front entrance and
throughout the building. Wash-hand basins were provided for staff on the corridors
adjacent to bedroom areas. Suitable signage was in place reminding people to wash their
hands and use the sanitisers; staff were observed to be vigilant in their use.
The front door was fitted with a coded key pad. The door leading to the Maple area was
also fitted with a coded key pad to ensure additional security for residents with dementia.
The inspector had a concern that the doors to the sluice/utility rooms were open. Cleaning
chemicals and equipment were stored in these areas and posed a potential risk to
residents and visitors.
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Article 32: Fire Precautions and Records
The inspector reviewed fire policies and procedures. Records indicated that all fire fighting
equipment had been serviced in January 2010 and the fire alarm had been serviced in
June 2010. Fire orders were displayed throughout the centre and all means of escape
were found to be unobstructed. Staff interviewed were knowledgeable on what to do in
the event of fire. The last fire drill and fire training took place in September 2010. Two
recently recruited staff had not received fire safety training, this training was scheduled for
20 October 2010.
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Closing the visit
At the close of the inspection visit a feedback meeting was held with deputy person in
charge, business manager and director of quality and education to report on the
inspector’s findings, which highlighted both good practice and where improvements were
needed.
Acknowledgements
The inspectors wish to acknowledge the cooperation and assistance of the residents,
relatives, provider and staff during the inspection.
Report compiled by:
Mary Costelloe
Inspector of Social Services
Social Services Inspectorate
Health Information and Quality Authority
22 September 2010
Page 15 of 19

Health Information and Quality Authority
Social Services Inspectorate
Action Plan
Provider’s response to inspection report
Centre:
Marymount Care Centre
Centre ID: 0065
Date of inspection: 21 September 2010
Date of response: 20 October 2010
Requirements
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 (as amended) and the National Quality Standards for Residential
Care Settings for Older People in Ireland.
1. The person in charge has failed to comply with a regulatory requirement in
the following respect:
The directory of residents did not contain the required details as required by the
Regulations.
Action required:
Ensure that the directory of residents includes the information specified in schedule 3 of
the Regulations.
Reference:
Health Act, 2007
Regulation 23: Directory of Residents
Standard 32: Register and Residents’ Records
Please state the actions you have taken or are planning to
take with timescales:
Timescale:
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Provider’s response:
The directory of residents is now updated and maintained as per
Schedule 3 of the Regulations.
Complete
2. The provider has failed to comply with a regulatory requirement in the
following respect:
The emergency plan was in draft format and had not been finalised.
Action required:
Ensure that there is an emergency plan in place for responding to emergencies.
Reference:
Health Act, 2007
Regulation 31: Risk Management Procedures
Standard 26: Health and Safety
Please state the actions you have taken or are planning to
take with timescales:
Timescale:
Provider’s response:
The emergency plan has been finalised and is now in place.
Complete
3. The provider has failed to comply with a regulatory requirement in the
following respect:
Cleaning chemicals were stored in the unlocked sluice rooms on both floors.
Action required:
Ensure that a comprehensive risk management policy is in place that covers the
identification and assessment of all risks throughout the centre.
Reference:
Health Act, 2007
Regulation 31: Risk Management Procedures
Standard 26: Health and Safety
Please state the actions you have taken or are planning to
take following the inspection with timescales:
Timescale:
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Provider’s response:
The comprehensive risk management policy which was in place at the
time of inspection has been amended to include ‘the storage of
household chemicals are maintained under a locked coded system’.
Complete
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Any comments the provider may wish to make:
Provider’s response:
On behalf of the management and staff of Marymount Care Centre we wish to express our
thanks to the Inspector for her professionalism and courtesy shown during the inspection
visit.
Provider’s name: Maureen McNulty
Date: 20 October 2010
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