HIQA outlines more concerns at St Joseph’s Nursing Unit

An inspection report carried out at St Joseph's Community Nursing Unit in Trim has found that an incident where a resident sustained a serious injury as a result of an accident in the garden and died in hospital four days later was not formally reviewed at senior management level. The independent inspection was carried out by the Health and Information Quality Authority (HIQA) over a three-day period in July 2010 and follows previous registration inspections carried out in September 2009 and February 2010 when a large number of shortcomings were identified. In their latest report, inspectors had concerns that the centre did not meet the required standards. They found significant deficits with the governance of the centre and stated that the “the person in charge and the provider did not ensure the provision of a high-quality, safe service for residentsâ€. The inspectors noted that residents were not adequately protected against elder abuse with some agency staff who were employed not trained in the detection of elder abuse, and that the investigation and reporting of elder abuse did not follow policy. The report added that infection control practices were poor, with dirty commodes found in two sluice rooms and clinical equipment was inappropriately stored. Staff were not appropriately supervised by management at night time when a high level of poor manual handling practices were observed. In terms of governance, the inspectors found there were significant improvements required, with leadership described as poor. “Governance of the centre was not good. The action plan from the previous inspection report dated 10th February 2010 had not been appropriately addressed; for example, the supervision of staff remained inadequate. There was no nurse manager on duty at night time.†It went on: “Inspectors observed staff waking residents with dementia at 23.30 to give them their medications, which included night sedation. Staff were observed using manual handling practices which are not in line with contemporary evidence-based practice.†A serious incident occurred in the centre and, upon reviewing the records, the HIQA inspectors found that the centre risk management policy had not been followed. A motorised wheelchair-bound resident had fallen down steps in the internal garden and sustained a serious injury, but the appropriate evidence was not preserved for proper inspection, with the person in charge not knowing where the wheelchair involved in the incident was or if it had been tagged as being involved in a serious incident. Although the accident occurred on a Saturday, the director of nursing was not informed until the following Tuesday. The person in charge did not advise HIQA inspectors at the open meeting of the incident but a clinical nurse manager did. “The person in charge failed to manage and lead the investigation in an appropriate manner,†the inspection reported said. Inspectors found that the actions to ensure all risks identified in the hazard control sheets were minimised were not complete. There was no formal review of accidents at senior management level and, therefore, staff received no learning and there were no changes or improvements made to prevent reoccurances. Examples cited included a resident who sustained a serious injury as a result of two staff allegedly conducting an illegal under-arm drag lift on a resident. Inspectors observed several staff using the same illegal lift on numerous occasions during the inspection. Another example was a resident who sustained a serious injury as a result of an accident in the garden and died in hospital four days later. The area of the garden was cordoned off after the incident and risk assessement carried out, with a number of risks identified. The risks were addressed according to the hazard and control sheet reviewed by inspectors. However, the garden was not decomissioned until four weeks after the accident and, on inspection, two doors leading into the garden were opened. When inspectors walked the garden, the steps involved were cordoned off but a second set of external steps remained accessible to wheelchair-bound residents. Pathways were partially covered in moss and were slippery, particularly the ramped areas, handrails were also partially covered in green moss. One investigation of elder abuse reviewed indicated that an agency staff member may have been involved. On review of this agency staff file, there was no evidence that the staff member had completed any training in elder abuse. As part of their report, inspectors spoke with 32 residents and eight relatives who were visiting the centre and they also reviewed six questionaires completed by residents and relatives in advance of the inspection. Residents gave a positive account of their life and the centre and said they felt safe and cared for, with staff being caring and attentive to their needs. One resident did express concern about the period of time he waits to go to the toilet and one relative raised concerns that there were too many residents in one of the suites. In general, relatives said they were made feel welcome when they visited and were satisified with the care provided. An action plan has been agreed between HIQA and the providers with 39 actions to be addressed before the unit can receive its registration. In its response to the inspection report, the HSE's David Gaskin said that the management and staff welcomed the findings of the inspection report and said that while there are many actions outlined in the report, a significant number of these have already been completed and the remainder will be addressed within the stated timeframes. “The significant and ongoing bed reduction programme presents a unique opportunity to reconfigure existing suites and reduce the number of residents in multi-occupancy rooms. This programme will, by necessity, have to be completed on a phased basis over a number of months. Suite reconfiguration will focus on the enhancement of both personal and communal space for residents which will further support the person centred approach.†St Joseph's Community Nursing Unit is a 132-bed facility and currently has eight vacancies. One of the actions agreed with HIQA to allow residents more space in multiple occupancy rooms is to reduce the number of residents in the unit to 110 by the end of the year.