TLC City West 0692 nursing home inspection report - hiqa.ie

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Some improvements requiredThe policies and procedures documents viewed by the inspectors were not specific tothe centre. One example was the missing person policy which stated “after 20minutes contact Northwood Park Security”. This was not the procedure for thiscentre.The person in charge showed the inspectors a computerised spreadsheet identifyingall staff training. This was not comprehensively completed. For example, it was notpossible to determine if all staff had received mandatory training in manual handling.The person in charge told the inspectors that this information was available andwould be put onto the system.There was no record of each resident’s personal property taken on admission to thecentre. The person in charge informed the inspectors on the second day of theinspection that a book had been ordered and a record of residents’ property wouldbe made.The person in charge had begun gathering information for monitoring areas such asmedication management, falls and nursing documentation. Data was not collected onresidents who had pressure sores, in-dwelling catheters and those takingpsychotropic drugs (including sleeping tablets) and those who experienced significantweight loss.Significant improvements requiredThe register of residents reviewed by the inspectors was not in compliance with theHealth Act 2007 (Care and Welfare of Residents in Designated Centres for OlderPeople) Regulations 2009. The register viewed did not accurately reflect the currentnumber of residents in the centre on the day of the inspection.There was no written statement of purpose.The complaints policy was not in line with the Health Act 2007 (Care and Welfare ofResidents in Designated Centres for Older People) Regulations 2009. Residents andrelatives told inspectors that they would report any issues to a member of staff onduty or at the reception. Residents were not aware that there was a complaintspolicy. The complaints policy was on display on the wall near the visitors’ sign inbook, but was placed high on the wall and was not accessible to residents or visitorswho were unable to stand. A register of complaints was not maintained in thenursing home and there was no evidence of learning and improving practice as aresult of monitoring complaints.Page 8 of 30
2. Quality of the serviceOutcome: Residents receive a good standard of service, appropriatetreatment 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, whereresidents are enabled to play an active part in the centre and wheremanagement, staff and residents work together towards continuousimprovement.Evidence of good practiceThe inspectors saw that the privacy and dignity of residents was respected andpromoted by staff. Staff members knocked and waited before entering residents’bedrooms and ensured doors were closed and curtains drawn while deliveringpersonal care. The inspectors observed that the manner in which residents wereaddressed by staff was pleasant and respectful. Residents spoke highly of the staffwithin the home.There were eight communal areas of varying sizes throughout the centre. Theinspectors saw residents using these areas throughout the day. Many residents mettogether at the open seating area near the nurses’ desk at 11am for tea, coffee andsnacks. The snacks included a variety of chopped fresh fruit, scones and biscuits.Residents sat and chatted with each other. They introduced other residents to theinspectors as friends. Tea, coffee and snacks were also taken by staff to other areas.The choice, quality and presentation of meals were of a high standard. Inspectorsobserved residents having their meals in a bright, relaxed environment. There was amix of rectangular and round tables and the seating arrangements were conducive tocommunication among residents. The tables were set with wine glasses, napkins,table mats and cutlery and residents were able to help themselves to condiments. Aselection of drinks such as cranberry juice, orange juice, milk and water were servedto residents by catering staff. The chef served the food from an open serving stationand portion sizes were adjusted in accordance with residents stated preference.A different member of staff was required to taste the food each day, prior to lunchbeing served, to ensure that it was of a high standard. Staff told the inspectors thatif there was a problem with the food, for example the gravy was too salty, it wouldbe returned to the kitchen and made again. All food was presented in an attractivemanner, including modified consistency diets. The inspectors joined the residents forlunch and found it appetising. Some relatives sat with residents at dinner time andsome assisted their family member to eat. Residents said meal times were enjoyable,social and relaxing occasions.Page 9 of 30
Page 1 and 2: Health Information and Quality Auth
Page 3 and 4: About the centreDescription of serv
Page 5 and 6: Summary of findings from this inspe
Page 7: Overall findings1. Governance: how
Page 11 and 12: Meals were not served in the dining
Page 13 and 14: 4. Premises and equipment: appropri
Page 15 and 16: Significant improvements requiredTh
Page 17 and 18: Significant improvements requiredSe
Page 19 and 20: Please state the actions you have t
Page 21 and 22: Please state the actions you have t
Page 23 and 24: 8. The provider is failing to compl
Page 25 and 26: Santry and Mrs Tanya Spellman, DON
Page 27 and 28: 14. The provider has failed or is f
Page 29 and 30: RecommendationsThese recommendation

TLC City West 0692 nursing home inspection report - hiqa.ie

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