Gap Analysis for Skibbereen Residential Care Centre

“As the Registered Provider I felt it was important to undertake an analysis of our Quality and Safety Management System to ensure we had appropriate COVID-19 preparedness plans in place, were regulatory compliant and that we implemented the recommendations from the COVID-19 Nursing Homes Expert Panel Report. HCI really impressed us with their thorough assessment. They are extremely knowledgeable on the regulatory requirements and provided us with a detailed roadmap to address the areas for improvement. HCI’s guidance has given my staff and I reassurance that we have best practice procedures in place to support us in prioritising resident safety and the delivery of high quality care.”

Colette Moyles

Registered Provider, Skibbereen Residential Care Centre

Background

Skibbereen Residential Care Centre (SRCC) is a 50 bed private nursing home situated in Co. Cork. The centre provides long-term residential care and respite care to residents with a range of needs from low-dependency convalescence to full-time nursing care in relation to illness and age-related conditions, such as dementia.

In light of the COVID-19 pandemic and the enhanced responsibilities for nursing homes, SRCC felt the need to assess their preparedness plans by requesting HCI conduct a GAP Analysis of their Quality and Safety Management System (QSMS) against the National Regulations (SI. No. 415) and incorporating the relevant recommendations identified in the COVID-19 Nursing Homes Expert Panel Report.

Objectives

Determine the current status of the QSMS.
Identify if the key controls to prevent / manage a COVID-19 outbreak are in place at SRCC in order to minimise risks to residents and staff.
Identify any gaps within SRCC’s QSMS against the recommendations from the COVID-19 Nursing Homes Expert Panel Report.
Provide a report identifying areas for good practice and opportunities for improvement in relation to the QSMS and SRCC’s COVID-19 preparedness plans.
Identify the relevant Quality Improvement Plans (QIP) required to continuously improve care and services and safeguard residents during the COVID-19 pandemic.

Solution

In order to ensure a comprehensive GAP Analysis was completed, HCI provided the following service:

Development of project plan.

Two-day onsite audit consisting of document review, staff interviews and process observation.

Feedback discussed with client at the end of each day.

Analysis of findings.

Development of Draft Report and QIP list.

Client reviews Draft Report and provides feedback to HCI and Final Report is then presented to client.

Challenge

Due to COVID-19, the auditors were unable to engage directly with residents. However, a resident feedback survey was provided to get a snapshot of residents’ experience at SRCC.

Outcome

HCI presented SRCC with a detailed GAP Analysis Report which identified areas of good practice and areas for improvement against the S.I. No. 415, the National Standards for Residential Settings for Older People in Ireland and incorporating the relevant recommendations from the COVID-19 Nursing Homes Expert Panel Report. HCI provided a judgement of compliance against each regulation along with a risk rating where relevant. The report also proposed a set of QIPs to address the areas for improvement.

This report gave the Registered Provider (RP) a clear assessment of the current situation of SRCC’s QSMS along with a roadmap to achieve regulatory compliance. Since receiving the report SRCC have implemented HCI’s recommended QIPs.

Benefits

Thorough and independent analysis of SRCC’s COVID-19 Preparedness Plans, IPC measures and quality and safety practices in general.
Reassurance to the RP that the correct measures are in place to address all regulatory requirements.
Reassurance to Management and staff that best practice procedures are in place in the event an infectious disease outbreak occurs.
A detailed roadmap for improvement provides guidance and a structure for Management to work towards.
The GAP Analysis is conducted in line with a HIQA inspection process.
HIQA regulatory and quality and safety knowledge is transferred to staff during the onsite GAP Analysis.