Summary of HIQA Inspection Findings in Nursing Homes from May to August 2023

Introduction

HCI completed a review of twenty-five (25) randomly selected Health Information and Quality Authority (HIQA) Inspection Reports for residential care settings for older people. This review highlights the trends in inspection findings, those being ‘Compliant’ and ‘Not Compliant’ as detailed by HIQA in the inspection reports. All inspections were completed by HIQA between May to August 2023.

Summary of Findings

Some of the key findings under the related regulations include:

Regulation 23 Governance and Management (63% NC of the 24 assessed):

• The Registered Provider had not ensured that there was an effective management structure in place, with clear lines of accountability and responsibility. For example, accountability, responsibility and oversight of key aspects of the service appeared to be allocated to both the Person in Charge and General Manager, with poor systems in place to escalate risk to the Registered Provider. This resulted in ineffective action being taken to address risks to residents.
• The position of Clinical Nurse Manager was vacant since April 2022 and the position of General Manager had reduced to a part-time position.
• The Registered Provider had not ensured that there were sufficient staffing resources in place to maintain planned nursing staff levels. Consequently, the nursing management were required to cover vacant nursing shifts as a result of planned and unplanned leave. This impacted on effective oversight of the service.
• Risk management systems were not effectively monitored or implemented. The residential centre’s risk register did not contain known risks in the residential centre.
• The auditing system was not effective in identifying deficits and risk in the service. Disparities between the high levels of compliance reported in the residential centre’s own audits did not reflect the Inspectors’ findings during the inspection.
• The systems of monitoring, evaluating and improving the quality and safety of the service were not effectively implemented. For example, improvement action plans were not consistently subject to time frames, or progress review.

Regulation 16 Training and Staff Development (16% NC of the 19 assessed):

• Staff did not have access to appropriate training. For example, five staff did not have their manual handling training completed but were providing direct patient care.
• Staff were not appropriately supervised. For example, staff providing one-to-one care to specific residents did not know the residents’ care needs and there was no other staff member available to supervise or support them in their role.
• The records showed that the manual handling training was delivered online only. Inspectors observed instances where staff members used inappropriate manual handling techniques while assisting residents with their mobility needs. As a result, Inspectors were not assured that the online delivery of manual handling training was effective.
• There was inadequate supervision during mealtimes, as Inspectors observed unsafe practices in respect of the support provided to residents with swallowing difficulties, which was not in line with residents’ care plans and assessments.

Regulation 15 Staffing (15% NC of the 19 assessed):

• The number and skill mix of staff was not appropriate having regard to the needs of the residents and the size and layout of the residential centre.
  • There was not enough staff in the day room of the dementia unit to supervise residents appropriately.
  • The only nurse on duty in one area was delayed by over two hours administering the medication as they were required to supervise in the dining room.
  • The Assistant Director of Nursing was required to spend over two hours with one resident as they were presenting with responsive behaviours; no other staff member was available.

Regulation 4 Written Policies and Procedures (30% NC of the 10 assessed):

• Policies, as required under Schedule 5 of the regulations required full review. For example, Inspectors found:
  • Policies had not been updated at intervals not exceeding three years.
  • There was no Fire safety management policy in place.
  • The medicine policy was not updated in line with best practice guidelines such as NMBI Guidance for Registered Nurses and Midwives on Medicine Administration (2020).
  • Some policies and procedures did not have references.
  • Some policies were not centre specific or contained generic information that did not inform staff practice.

Regulation 21 Records (21% NC of the 19 assessed):

• It was noted that the door to the nurses’ office remained open. Residents’ documentation was un-secured, which enabled unauthorised access to confidential information.
• The roster did not reflect the full names of people available on the ground. For example, the name used in different parts was the first name of the staff only. Inspectors observed that white correction fluid was used on the roster.
• Nursing progress notes were inconsistent in detailing residents’ health, condition and treatment given. Some of the notes were copied from the previous day and did not provide an accurate overview of the most recent resident’s condition or day spent.

Regulation 8 Protection (35% NC of the 17 assessed):

• The residential service did not have a separate resident client account, therefore, residents’ monies were paid into the centre’s current account.
• The current account of the service contained a sum of money belonging to four residents. On review of records, it was evident that only one of these residents currently resides in the residential centre. Three residents were deceased, and their funds had yet to revert to their estates.
• The centre’s current account regularly dropped below the amount that is the property of these residents. This suggested that at times, residents or their estates, would not have been able to access their monies, should they wish avail of them and that their money was used to support the day-to-day operations of the residential centre.

Regulation 28 Fire Precautions (55% NC of the 20 assessed):

• There were eight oxygen cylinders being stored within the treatment room. Three cylinders were loose and at risk of damage if knocked over.
• There was no fire extinguisher present at the oxygen storage area.
• The Inspectors were not assured in regard to the level of gas detection in the laundry area, as a gas detector could not be found.
• The procedure in relation to shutting off the gas in the event of a gas leak was unclear to staff.
• There was a lack of signage to indicate the location of the gas valve in the kitchen.
• The Inspectors noted a fire blanket located in a smoking area was undersized for its intended use.
• Personal emergency evacuation plans (PEEPS) were only available on the electronic system and therefore were not readily accessible in an emergency.
• While all staff were up-to-date with fire safety training, Inspectors noted staff were not fully knowledgeable on the fire safety procedures to be followed.
• Some staff were not confident in using an evacuation chair.

Regulation 17 Premises (55% NC of the 20 assessed):

• Floor coverings were uneven, torn, and lifting in parts and walls were visibly chipped, cracked, and damaged with exposed plaster.
• The external grounds were not appropriately maintained or suitable for use by residents. The ground was uneven and posed a tripping hazard.
• Some external areas did not provide suitable boundary security as they were not adequately fenced off from a neighboring dwelling.
• In a twin bedroom, one bed was placed against a wall where the only window was located, access to natural light from this window was only afforded to one resident when the resident closest to the window had their privacy curtain closed.

Regulation 12 Personal Possessions (30% NC of the 10 assessed):

• Residents in some twin bedrooms had limited space to store their clothes. The was evidenced by the following:
  • The wardrobes were half the size of the wardrobes in the single bedrooms and as a result clothes were packed tightly into the wardrobe space available.
  • Some residents’ wardrobes were placed along an opposite wall outside their bedspace, they could not maintain control of their personal clothing and possessions.
  • Residents did not have a suitable surface or shelf to display their personal photographs. For example, residents were using the window ledges to place their photographs on.

Regulation 9 Residents Rights (29% NC of the 21 assessed):

• The Registered Provider had failed to provide sufficient opportunities for residents to participate in activities in accordance with their interests and capacities. Residents spent the majority of the day in one day room without supervision, stimulation or interaction.
• A resident had been relocated from a single room to a multi-occupancy rooms to facilitate staff supervision. There was no evidence of consultation with the resident in their nursing documentation or from discussion with the resident.
• There was a practice in the centre of allocating some single bedrooms to respite (short stay) residents. This did not promote the rights or preferences of long stay residents to live in single bedrooms.

Regulation 6 Health Care (21% NC of the 19 assessed):

• A high standard of evidence-based nursing care in accordance with professional guidelines was not provided to residents regarding their wound care. Descriptors such as the wound edge, exudate, or wound size were not recorded.
• Inspectors found that where the resident experienced weight loss, this information was not recognised and followed up with appropriate action by the management of the centre. The MUST assessment was not calculated correctly, and there was no further professional expertise sought from a dietician.

Regulation 27 Infection Control (19% NC of the 21 assessed):

• While antibiotic usage was monitored, there was no evidence of multidisciplinary targeted antimicrobial stewardship quality improvement initiatives, audit, guidelines or training.
• There was no appropriately qualified IPC Link Practitioner in place to increase awareness of IPC and antimicrobial stewardship issues locally.
• Surveillance of MDRO colonisation was not undertaken. There was some ambiguity among staff and management regarding which residents were colonised with MDROs. This meant that appropriate precautions may not have been in place when caring for these residents.

Conclusion

This review details the continuing trends in HIQA findings in relation to residential care settings for older people in meeting the relevant requirements. The trends show that high risk findings are still evident in the areas of Governance and Management with many residential centres requiring improvements in key areas such as Records, Fire Precautions, Policies and Procedures, Resident Rights, Premises, Staffing and Training and Staff Development.

Good practice was identified in relation to Statement of Purpose, Persons in Charge, Insurance, End of Life, and Notification of Procedures and Arrangements for periods when Person in Charge is absent from the designated centre.

If you would like further information on HCI’s HIQA Regulatory Compliance support offerings for nursing homes, contact HCI at +353 (0)1 629 2559 or email info@hci.care.