Nenagh’s St Conlon’s Community Nursing Unit received a more or less clean bill of health following an inspection from Hiqa last May.
However, while the facility was found to be compliant or substantially compliant under 10 of the 18 headings scrutinised, it was found to be major non-compliant in two and moderately non-compliant in six.
The two major non-compliant areas related to medication management and the unit being a safe and suitable premises. The inspectors found that some action or actions required from the previous inspection were not satisfactorily implemented.
The inspection, which was carried out on May 6 and 7, was the tenth inspection of the centre. Inspectors reviewed documentation, including policies and procedures, medical and nursing documentation, health and safety and fire safety records, observed and reviewed practice and spoke with staff and residents.
They further reviewed information submitted to Hiqa by the provider by way of notifications prior to the inspection and this information was also incorporated into the inspection process.
As this was a renewal of registration inspection and a new management structure was in place fit-person interviews were conducted with the person in charge and the nominated person to deputise for the person in the charge. The inspectors were satisfied that they were both fit persons. Prior to the inspection residents and relatives were invited by Hiqa to provide on a voluntary basis feedback on the care and services provided in the centre. The feedback received was predominately positive, but an area identified by 50 per cent of respondents as requiring improvement was the provision of meaningful activity and engagement. Where more specific negative feedback was received inspectors were satisfied that this concurred with issues already managed by the provider through their complaints management system.
There were 26 residents living in the centre and one vacant bed. Staff had assessed the needs of 18 of the residents as in the high to maximum category. Inspectors noted that residents looked well and were aware of the inspection process and the role of inspectors. The feedback received from residents was positive with the exception of meaningful activity and social engagement.
Inspectors were satisfied that staff were informed as to residents’ needs and preferences and that residents had input into their care and routines.
Management and staff articulated and demonstrated a commitment to the delivery of safe quality services to residents; there was transparency in relation to deficits and any deviations from care and a commitment to learning and improvement.
While there was substantial evidence of good practice and a clear commitment to ongoing review and improvement regulatory non-compliance was evidenced. Some of this non-compliance emanated from the failure to satisfactorily implement actions required for learning and improvement following adverse events and incidents. This failing applied to governance and management, safeguarding and protection, medication management and the prevention and management of falls.
All of the private accommodation provided to residents does not meet regulatory requirements in relation to the space available.
Of the full 18 areas inspected, the provider was judged to be in compliance with six, in substantial compliance with four, in moderate non-compliance with six and in major non-compliance with two; medication management and the premises.
The full report is available at www.hiqa.ie