STANDARDS of hygiene at the Nazareth House nursing home in Fahan were criticised in a top level report today.
The Health Information & Quality Authority (HIQA) also criticised warning systems at the home where seven people died from a flu outbreak in March and April this year.
Procedures for dealing with such an outbreak were poor, said the report.
The report also criticised how the home dealt with the crisis, noting: “There were insufficient nurses on duty to address the increased workload particularly queries from families and the additional care required by residents who were ill.
“The person in charge could not carry out her role fully, as she could not be on duty in the residential area which increased the workload for the nursing staff. Furthermore, two nurses were unavailable to undertake additional work due to holiday and illness leave.”
On cleanliness at the home, the report said: “The inspectors found deficits in the overall standard of cleanliness that impacted on good infection control management.
“For example some commodes and bath chairs had not been cleaned effectively and were stained or damaged by rust. There was dust on the floor in some bedrooms. There was inappropriate storage of items such as, a hair brush and vases in the sluice. Shower tray outlets were also noted to be unclean and there was no system in place for the regular cleaning or limescale removal from shower heads.”
And on how the home reported the outbreak, HIQA reported: “A number of residents had respiratory-type illness and there were clear indicators that there was an outbreak of an infectious illness. Notification was not submitted to the Chief Inspector in a timely manner as required by the regulations.”
YOU CAN READ THE REPORT IN FULL BELOW:
About the inspection
The purpose of inspection is to gather evidence on which to make judgments about the fitness of the registered provider and to report on the quality of the service. This is to ensure that providers are complying with the requirements and conditions of their registration and meet the Standards, that they have systems in place to both safeguard the welfare of service users and to provide information and evidence of good and poor practice.
In assessing the overall quality of the service provided, inspectors examine how well the provider has met the requirements of the Health Act 2007, the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009 and the National Quality Standards for Residential Care Settings for Older People in Ireland.
Additional inspections take place under the following circumstances:
to follow up on specific matters arising from a previous inspection to ensure that the action required of the provider has been taken
following a change in circumstances; for example, following a notification to the Health Information and Quality Authority’s Social Services Inspectorate that a provider has appointed a new person in charge
arising from a number of events including information received in relation to a concern/complaint or notification to the SSI of a significant event affecting the safety or well-being of residents
to randomly “spot check” the service. All inspections can be announced or unannounced, depending on the reason for the
inspection and may take place at any time of day or night.
All inspection reports produced by the Health Information and Quality Authority will be published. However, in cases where legal or enforcement activity may arise from the findings of an inspection, the publication of a report will be delayed until that activity is resolved. The reason for this is that the publication of a report may prejudice any proceedings by putting evidence into the public domain.
2About the centre
Description of services and premises
Nazareth House is a single-storey building which was built as a nursing home in 1981. It is owned and operated by the Sisters of Nazareth Religious Congregation. The centre is registered to provide care for 48 male and female residents who have long-term palliative or convalescent care needs. Respite care is also provided.
The building has an entrance hall that leads into a large foyer/reception area which is furnished with comfortable armchairs and a hall table. The main administrative services are located here and include the office of the person in charge and the administrator. There is also a phone booth, recreational hall, visitors’ room and a chapel located off this area.
There is a central kitchen where food is prepared, cooked and served to the adjoining dining room. There are three large sitting rooms and a conservatory area that overlooks Lough Swilly to the front of the building. A separate smoking room is also available. Other facilities include the chapel which adjoins the convent where the provider and religious community reside.
Bedroom accommodation for residents consists of 18 single bedrooms and 15 double rooms some with shared and individual en suite shower and toilet facilities. In addition to the en suite facilities, there are three assisted bathrooms (with bath and toilet included) and six assisted toilets for residents’ use. A separate visitors’ toilet is also available.
There is a driveway from the main road to the centre through a well maintained large garden and lawn. There is outdoor seating and tables available for residents’ use. The centre is wheelchair accessible and there is car parking for staff and visitors located at the front of the building.
Nazareth House is situated in Fahan, Buncrana, Co Donegal on the 238 roadway. The centre adjoins the convent premises occupied by the Sisters of Nazareth Religious Congregation.
*On day-two of the inspection there were 38 residents in the centre. One resident was in hospital.
Location
Date centre was first established:
1995
DAY/MONTH/YEAR
Number of residents on the date of
*39
inspection
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Dependency level of Max High Medium Low current residents Number of residents 23 11 4 1
Management structure
The nominated provider on behalf of the Sisters of Nazareth religious congregation is Sr. Alice Kirwan. She has overall responsibility for the management of the centre and reports to the order’s Regional Superior Sr. Cataldus Courtney and the Regional Director John O’ Mahoney, who both report to Sr. Mary Ann Monaghan, Superior General who is based in London.
Wilma Hezil D’Souza is the Person in Charge and she reports to Sr. Alice Kirwan. The staff team report to the Person in Charge. This includes nurses, care assistants, housekeeping and laundry staff. There is also a catering manager, catering and dining room staff as well as maintenance and grounds staff. In addition, there are two administrative staff who provide clerical support for the centre.
Staff Person Nurses Care Catering Cleaning Admin Other
designation in staff staff Charge laundry
staff Numberof 1* 2 8 2 3 1 3●
staff on duty on day of inspection
* During this inspection the person in charge was working off site following medical advice.
● This number included the nominated provider on behalf of the Nazareth House community, the organisation’s chief executive and the maintenance man.
and staff staff
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Background
The two inspections carried out by the Authority on 2, 3 and 4 April 2012 were triggered by a report of a significant number of resident deaths in the centre during March and April. At the time of the Authority’s inspections seven residents had died. In all nine residents died during the period 22 March to 8th April. Seven of these deaths are currently classified as possibly consequent to an influenza related illness. The remaining two residents died of unrelated causes. Five residents died in the centre and four died in Letterkenny General Hospital. No other residents were hospitalised. The average age of those who died was 89 years. Post mortems were not undertaken on any of those who died. The timeline of deaths is outlined below:
1st: 22 March 2nd 23 March 3rd: 29 March 4th :29 March 5th :31 March 6th :01 April 7th :02 April 8th :06 April 9th:08 April
The area public health team and infection control nurse were reviewing the situation on site. The inspections were undertaken to monitor the arrangements in place to ensure that the care and welfare of residents was appropriate during this outbreak.
The first inspection was conducted on the night/morning of 2/3 April 2012. The interim guidelines for influenza management, the staff arrangements and infection control measures were discussed with the provider’s representative during this inspection. She assured the inspector that the availability of appropriate staff resources was a priority as well as controlling the outbreak. A copy of the interim guidelines compiled by the Health Service Executive (HSE) on the management of an influenza outbreak was left with the provider .
The inspector identified the following actions to protect the health and welfare of residents to:
ensure adequate staffing in centre ensure that a clear communication strategy was in place for relatives and
residents follow guidance provided by HSE public health officials ensure that cleaning practices and procedures were reviewed and in line with
good practice standards.
The provider said she had discussed the deployment of staff with HSE and had been advised to consider employing agency staff, staff from other Nazareth Nursing homes or the HSE if needed.
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Arrangements for the management of situation on site:
The second inspection was conducted during the afternoon and evening of 3 April 2012 and during the day of 4 April 2012. The inspectors were updated by HSE Public Health on arrival. At that time the inspectors were told that the public health team were reviewing the circumstances of the seven residents who had recently died, ensuring preventative actions were in place for the remaining 38 residents in the centre and reviewing any changes to their health status. The residents who had influenza-like symptoms were being treated with antibiotics and with Tamiflu twice a day. Residents who did not have symptoms were treated with Tamiflu once a day. The inspectors were told that all residents were confined to their rooms and infection control measures were in place.
There were 27 residents reported as symptomatic and swabs for analysis had been taken from 19 residents and one staff member. The results of the 20 swabs were received on the afternoon of 3 April 2012 and indicated that there were three confirmed cases of AH3 virus, five results were “weakly positive” and 12 were negative. The infection control nurse was repeating the “weakly” positive swabs and hoping to swab the remaining 18 residents. (There was a problem for the public health team as there was an insufficient supply of swabs to procure all samples on the first day.) There was one resident who was assessed as critically ill.
Notices indicating that restricted visiting was in place were on display and all staff had been instructed by the infection control nurse to follow the standard infection control procedures.
The public health personnel held regular national teleconference-calls with the Virus Reference Laboratory, the national health surveillance team and the media.
The environmental health officers had been called in by public health staff and were on site. They had been asked to review the kitchen arrangements, the water supply and testing arrangements and the cleaning of equipment such as shower heads.
The lead inspector outlined the role of the Authority and it was agreed that the inspectors would share their findings and conclusions with the HSE team. It was also agreed that the information being collated by the HSE such as the tracking of the infection would be provided to the inspectors when complete.
Staff
The person in charge was on duty but away from the residential site in the convent area following medical advice. She was coordinating contacts with relatives and the supply of information to the public health team and to the Authority’s inspectors.
The inspectors were told that there were 65 staff employed and at least three had been ill during the last few weeks. All staff had been requested to confirm if they had received the seasonal influenza vaccination. At lunchtime on Tuesday only one member of staff had confirmed this and arrangements were made to set up a clinic to administer the vaccination. This was very well attended and provided an opportunity for staff to have
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their queries about the vaccination and the outbreak answered. The majority of staff received the vaccination.
Previous regulatory activity
This centre has had two previous inspections. The registration inspection was conducted on 18 May 2010 and a follow-up inspection took place on 18 May and 15 June 2011.
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Summary of findings from this inspection
Nursing and care staff were very busy when the inspectors arrived at lunchtime on 3 April. The nurse in charge was responding to requests from relatives for information and coordinating the activities of the staff team. However, there were insufficient nurses on duty to address the increased workload particularly queries from families and the additional care required by residents who were ill. The person in charge could not carry out her role fully, as she could not be on duty in the residential area which increased the workload for the nursing staff. Furthermore, two nurses were unavailable to undertake additional work due to holiday and illness leave.
The inspectors found that in general the health care arrangements for residents was satisfactory with significant interventions and specialist advice from local doctors and other professionals such as speech and language therapists recorded in the care records examined. Residents who exhibited symptoms of illness were seen expediently by their doctors or by the out-of-hours service and these contacts were recorded. There were also good contacts with hospital services and with the local palliative care team.
Staff were familiar and knowledgeable about residents’ care needs. The inspectors noted that records and communication on the current health status were conveyed clearly at each handover, and the staff team were also noted to work well together to share the workload and monitoring arrangements.
There were some deficits in the standard of cleanliness and hygiene and the maintenance arrangements for equipment. A number of shower chairs and commodes were not in a satisfactorily clean condition and were rusty.
There appeared to be no established procedure to enable early detection of influenza in the nursing home. There was a lack of coordination of information available about residents with respiratory illness being cared for in the designated centre and residents who were admitted with respiratory problems to the general hospital. The inspectors concluded that a protocol to guide and inform professionals attending the centre, the person in charge and the acute hospital would be of benefit to ensure that outbreaks are appropriately identified, reported and contained. The inspectors are aware that the presentation of illness was not characteristic of influenza in all cases and that some residents presented with more acute symptoms than would be usual for influenza.
There was a complete record outlining which residents had the flu vaccine. Only two residents did not have this and this was due to one resident being admitted to the centre after the vaccine had been administered and the other resident was ill on the day of administration. The resident group were noted to be highly dependant with 60% assessed as being of maximum dependency and 28% in the high dependency category.
The majority of residents were in advanced old age with 35% of residents in the 70-80 age group and the remaining 65% of residents aged between 80 and 100.
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Inspectors convened a meeting on Tuesday evening with HSE personnel, the Chief Executive for Nazareth House and others including one of the regular general practitioners. The inspectors outlined their findings in relation to staff workload particularly for the two staff nurses on duty during the day, the absence of cleaners after 15:00 hrs and the scheduling of only one nurse for night duty. The inspectors outlined their concerns regarding infection control and some of the inadequate practices that had been observed.
The inspectors issued an immediate action letter to the provider requiring that:
a nurse be nominated to take over the role of the person in charge for the period that she would be absent that infection control procedures and hygiene standards were implemented to a satisfactory standard in accordance with good practice guidance
appropriate facilities for communication were provided for residents confined to their rooms.
At the conclusion of the inspection on 4 April 2012, the inspectors were informed that all matters were receiving attention and this has been confirmed in subsequent conversations with the provider. A nurse on the staff team had been appointed to take charge while the person in charge was off duty, a designated telephone was made available for residents to use in private when they received calls, and additional nursing staff had been employed during the day and night. The hours worked by cleaning staff had been extended. Weekly reports that outlined details of residents’ progress and how the outbreak was being contained were sent to the Authority. Throughout the inspection staff cooperated fully and provided information in a timely and organised manner.
Infection Control Arrangements
Cleaning and Hygiene
During the course of Tuesday afternoon the inspectors reviewed the premises, staff activity and care practice. The inspectors found staff had adequate supplies of person-protective equipment such as gloves, aprons and masks and were using these diligently. A carer told inspectors that precautions were dealt with in the following way:
aprons and masks were in use at all times and masks were changed half hourly gloves were changed after each contact and all were disposed of in containers in each room staff were working in designated areas and not moving around the centre.
The inspectors noted that hand gels were in use. However, these were not located in permanent positions, but were available on changing trolleys and tables.
The inspectors found that some hand gels in critical areas such as sluices were not replenished in a timely way and one corridor, D, had no hand gel supply. Some yellow disposal bags were not securely fastened.
Issues covered on inspection
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Two household staff confirmed that they have a schedule for daily, weekly and monthly cleaning. They had safety information sheets that outlined the use of chemicals and what chemicals were to be used for specific situations. Carpets and floors were hoovered and cleaned daily. Bed tables and furniture were dusted and wiped clean. Curtains were laundered on a regular basis. The care staff have responsibility for cleaning equipment such as commodes and bathroom equipment.
The inspectors found deficits in the overall standard of cleanliness that impacted on good infection control management. For example some commodes and bath chairs had not been cleaned effectively and were stained or damaged by rust. There was dust on the floor in some bedrooms. There was inappropriate storage of items such as, a hair brush and vases in the sluice. Shower tray outlets were also noted to be unclean and there was no system in place for the regular cleaning or limescale removal from shower heads.
The laundry area was inspected. One of the regular laundry staff was on duty. The area was clean, tidy and well organised. She described the way laundry was managed. Soiled laundry is collected from the sluices in the residential areas by laundry staff. There is a designated entrance for soiled laundry and a designated exit for washed clean laundry. Laundry in red bags is secured when collected and this is placed directly in washing machines and washed at a temperature of 60 degrees Celsius. Clean laundry such as sheets are ironed with the rotary press, folded and returned to the linen storage cupboards.
Sluice areas
New bed pan washers had been installed approximately two years ago. The bedpan washer was noted to have the facility to clean only one bedpan at a time. Inspectors noted a commode waiting to be washed in the sluice area on day 2 and staff informed the inspector that they were required to wait for the cycle to finish and in the circumstances there was a delay. No review of the situation had taken place during the outbreak. Records for the servicing of some equipment such as hoists and the bedpan washers were not available. The company CEO was advised of this by inspectors and made arrangements for the servicing of all three bedpan washers for 5 April 2012.
Water management
There were four drinking water dispensers units in situ. These were located in areas such as the activity/relaxation room and sitting rooms. The inspectors saw that there was a collection of stagnant water in one of the dispensing units.
Inspectors met with the environmental health officer who inspected the kitchen area and the water storage and dispensing arrangements on 3 April 2012. She had reviewed the kitchen and she told inspectors she was satisfied that appropriate safe catering systems were in place. She informed inspectors that the temperature of cold water in the kitchenette in the areas known as B corridor was slightly elevated and a sample had been sent for analysis. The inspectors interviewed the maintenance person on day two. From the discussion, it was clear that there was no established process for legionella prevention. There was no regular routine for cleaning shower heads / shower outlets or
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for flushing showers/ activating water taps in vacant rooms. Hot water temperatures were monitored monthly the inspectors were told.
Waste management
The waste management system in place was found to be satisfactory. The maintenance person was responsible for removing waste from the centre during the week and during evenings, nights and weekends a member of care staff is responsible for removing the waste when this staff member is off duty. The waste disposal area was noted to be clean and all bins were noted to be securely closed. Clinical waste is removed regularly by the Health Service Executive and there is a tracing system in place with a receipt issued at the time of collection.
Staff arrangements
Staff were busily engaged with residents’ care. The staff allocation was operating the same as normal when the inspectors arrived. There were two nurses on duty with one taking charge during the period of the person in charge’s absence. The other nurse was from the HSE. The availability of nursing staff was depleted by the absence of the person in charge and the absence of two other nurses due to illness and holiday leave.
There were eight carers on duty – all were regular staff. In addition there were three housekeeping staff on duty, two catering staff and one laundry staff member. The inspectors found that all housekeeping staff were scheduled to go off duty at 3 pm meaning that any cleaning that was required would revert to care and nursing staff. The centre also had a student undertaking a training course on placement at this time. The inspectors were told that there was appropriate insurance and Garda Síochána vetting in place. However, the system in place for the employment of staff was not in accordance with good practice guidance for the recruitment of staff to work with vulnerable people. There was no confirmation that indicated the student was medically and physically fit to undertake work with vulnerable people and the required three references were not available.
The nurse in charge was engaged with telephone calls to concerned relatives, providing information to the teams on site and overseeing nursing care. There was a substantial number of telephone calls to attend to as visiting had ceased on Monday. From Friday to Monday visiting had been restricted to one visitor. There were also telephone calls from the media and media presence at the front door to contend with.
The inspectors formed the view that there were insufficient nursing staff on duty to address the increased workload consequent to:
the need to orientate new nurses due to the shortfall in the centre’s own staff
the need to provide information to relatives and others on site the increased clinical vigilance required as a result of antibiotic treatment
and residents’ changing conditions added supervision requirements as residents were confined to their rooms
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Premises
The centre was generally comfortable and had many positive features such as spacious sitting areas, a good dining space with well spaced tables and an accessible garden area. The inspectors noted that the temperature in some rooms such as the smoking area and hairdressing room was cool, however these rooms were not in use during the isolation period. Records of temperatures recorded by the maintenance person also indicated that residents’ bedrooms were below the minimum recommended temperature of 21 degrees centigrade required where residents can sit out during the day.
There was a designated smoking area and space to meet visitors in private. There was a range of assistive equipment such as specialist chairs and beds. However, the inspectors noted that some equipment such as hoists in bathrooms and specialist bath hoists did not appear to be serviced on a regular basis and the date on one bath hoist indicated it was last serviced in June 2009. An air bed pump in the nurses’ office had a notice indicating it was out of order since February 2012 and there did not appear to be a system in place for the timely repair of this equipment. The hand gel container in the hairdressing area was empty.
Communication
It was unclear to the person in charge and provider where the report of the suspected flu virus had been generated. The inspectors were told that the visiting doctor had made contact with the public health office on the evening of Sunday 1 April 2012 as there were concerns expressed by staff about residents who were on antibiotic treatment and who were not responding as expected. The inspectors noted from the residents’ records examined, that changes in the health status of residents were reported in a timely manner to their doctors and that residents who were ill were seen expediently and reviewed on a number of occasions. The public health team advised the person in charge and provider about the suspected outbreak and the action that they would be taking to investigate the situation on Monday 2 April. There was no communication to the Chief Executive Officer of Nazareth House during the day and he only became aware of the situation at 18:15 hrs on Monday evening and was on site on Tuesday and met with the Health Service Executive staff and the Authority’s inspectors. The inspectors found that the governance arrangements between the person in charge/provider representative on site and the company head office were inadequate and did not facilitate the provision of adequate support to the person in charge and the staff team during the early stages of this critical event.
The inspectors found that there was a need for better awareness among clinicians and staff in the centre to ensure that they were alert to the possibility of influenza as a cause of respiratory problems. As described earlier there was no established procedure to enable early detection of influenza in the nursing home. Communication between doctors attending the centre, the person in charge and the acute hospital required better coordination to ensure that the probability of an outbreak is considered, reported and contained to minimise risk. As a consequence of this outbreak the Authority, the Health Service Executive and the provider are completing an exercise to identify what
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aspects of the management of the outbreak worked well and what areas need improvement.
Staff were informed on Tuesday afternoon that the outbreak was confirmed as Influenza AH3 which is a recognised category of human influenza as defined by the World Health Organisation. Staff were also told that vaccinations would be available in the designated areas during the afternoon of 4 April. The need to ensure that staff allocated for duty had the flu vaccination, were dedicated to the centre and did not go to another centre for at least two days was highlighted by the public health team, as a precautionary measure.
Residents were confined to their rooms as part of the required precautions for infection control. Inspectors found that many bedrooms did not have TVs, radios, or ready access to telephones, this left them very isolated. Communal areas did have televisions and radios. Arrangements to address this matter were put in place when this was identified. Residents were provided with a radio if they wished and the Chief Executive told inspectors that a telephone was provided for residents to enable them to speak with callers in private if they wished.
The inspectors found that mobile telephone access and connection to the internet via Wi Fi was a constant challenge for anyone trying to access the internet in this manner during the outbreak. Residents’ care records and other documentation that were maintained on the computer system were accessible as hard wire internet connection was available. The poor arrangements for internet access compromised the ability of outside professionals to obtain and relay information in a timely manner.
The inspectors found that there was good communication between the staff team and between staff, residents and families. Staff knew residents very well, were very engaged with them when undertaking personal care and were familiar with their personal preferences and choices. They were noted to spend time talking with residents and family members when they telephoned and reassuring them about the need for isolation and the actions that were being taken to ensure the outbreak was under control. Nurses provided comprehensive information to their colleagues during handovers. The inspectors were present for the handover to night staff on 3 April and for the morning handover the next day. Information was relayed about residents who were ill and who needed additional care and developments during the day/night. There were records maintained of the regular observations and changes and an overview of the situation was provided.
There was visual signage on the front door in relation to visiting restrictions, however, there was no signage that described the specific measures that help reduce further contamination such as respiratory /cough etiquette. Once brought to the attention of staff, this was addressed.
There were no complaints of and no incidents of elder abuse recorded for 2012. A relative told inspectors that she was very satisfied with care and support from nursing staff and said that the care provided to her relative was satisfactory in all aspects.
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Healthcare
The inspectors found that in general the healthcare arrangements for residents was satisfactory with a significant number of contacts from local doctors and other professionals such as speech and language therapists available in the care records examined. Residents who exhibited symptoms of illness were seen expediently by their doctors or by the out-of-hours service and these contacts were recorded. There was also good contacts with hospital services and with the local palliative care team.
The information on residents’ healthcare needs was easy to access. There was for example a complete record outlining which residents had the flu vaccine. Only two residents did not have this and this was due to one resident being admitted to the centre after the vaccine had been administered and the other resident was ill on the day of administration. The resident group were noted to be highly dependant with 60% assessed as being of maximum dependency and 28% high dependency. Inspectors found that 35% of residents were in the 70-80 age group and the remaining 65% of residents were aged between 80 and 100.
The inspectors examined the medical care records of nine residents including the records of the seven residents who had died during the past month. The centre had good access and support from local primary care services. There were details of all medical contacts, changes in healthcare status and treatments ordered in the residents’ files. During March there were four residents admitted to the centre and three of these admissions were short-term respite care admissions. One person was admitted twice in March. Each admission lasted one week after which she returned home. One respite resident who was discharged home in the first week of March was re-admitted to the centre from the general hospital having been admitted from home. There were four residents admitted to hospital. Two were admitted for treatment for pneumonia and pulmonary oedema respectively. The other two residents were admitted for investigations relating to falls and one was receiving care from the palliative care team at the time of admission. The cause of death in this case was recorded as myocardial infarct/sudden death. The deaths of the three residents who died in the centre were attributed to pneumonia in two cases and to a cardiovascular accident and possible chest infection in the third instance. The inspectors noted that all residents had been medically reviewed on a number of occasions during February and March.
The inspectors did not examine medication management arrangements during this inspection as the findings of inspectors during the follow up inspection conducted on 18 May and 15 June 2011 indicated that deficits in medication management identified during the registration inspection had been appropriately addressed. The inspectors did note that nursing staff organised well for medication rounds and ensured that trolleys were locked when they were in rooms administering medication. Vaccines were stored appropriately in the fridge and there was an alarm to alert staff if the temperature was not adequate.
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Training
The training record maintained by the person in charge outlined the qualifications and training attained by staff. The record conveyed that the staff team had received training on the statutory topics of moving and handling, elder abuse prevention and fire safety during 2011. Training on other topics such as infection control and health and safety had also been provided for staff in July 2011 however it was noted that only 22 out of 65 staff had attended infection control training.
Risk management
The inspectors found that there were deficits in assessing risk and potential hazards.
The centre did not have adequate contingency arrangements in place for staff shortfalls. Although there were a number of staff who worked part-time hours there was a deficit in the nursing time available to cover illness and holiday absence. There was insufficient cover for the absence of the person in charge. The nurse nominated to take charge only worked two days each week. The inspectors were told that a recruitment drive for nurses was underway and that interviews had taken place and posts were due to be offered to the successful applicants.
There were no systems in place for the monitoring and prevention of hazards such as legionella or for the timely repair of essential equipment such as air beds.
The kitchenettes in the residential area did not have dishwashers. These had been removed and it was not clear if this change had been appropriately risk assessed. Staff now take crockery and cutlery to the main kitchen to be washed which could present an infection control hazard during an outbreak.
There was no information available during the inspection that indicated that all deaths had been notified to the coroner. The inspectors have been informed that the deaths that occurred on 1 and 2 April were notified on 3 April. The notification that an infectious illness was present in the centre had not been made to the Health Information and Quality Authority without delay as required by Regulation 36; Notification of Incidents. The notification was made on 4 April following confirmation of the diagnosis of influenza on the afternoon of 3 April.
There were records maintained of accidents and incidents. However, the information recorded when residents’ sustained falls did not indicate if the fall was witnessed or if the resident was alone. There was no information that indicated if neurological observations were recorded if a fall was unwitnessed or if a resident sustained a head injury.
Policies and procedures that guide practice in infection control and risk management needed revision. The emergency plan also needed revision to include the arrangements in place to address an outbreak of infectious illness, the contingency measures to address staff shortfalls and the management of communication during a critical event.
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In this situation the tracing of residents and staff movements in and out of the centre and the tracking of staff who worked in this centre and other areas was identified as a possible hazard to other vulnerable persons. The public health team were reviewing this as part of their enquiries. The inspectors requested that the provider compile a list of staff who worked part-time in the centre and who were known to work in other clinical areas and this was forwarded to the team.
Report compiled by:
Brid McGoldrick and Geraldine Jolley Inspector of Social Services Social Services Inspectorate Health Information and Quality Authority
Date: 10 April 2012
Chronology of previous HIQA inspections
Date of previous inspection:
Type of inspection:
18 and 19 May 2010
Registration
Scheduled Follow-up inspection
Announced
Unannounced
18 May 2011 and 15 June 2011
Registration Scheduled Follow-up inspection
Announced
Unannounced
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Health Information and Quality Authority
Social Services Inspectorate
Action Plan
Provider’s response to inspection report
Centre:
Nazareth House
Centre ID as provided by
0368
the Authority:
Date of inspection:
2,3 and 4 April 2012
DAY/MONTH/YEAR
Date of response:
08/05/2012
DAY/MONTH/YEAR
Requirements
These requirements set out what the registered provider must do to meet the Health Act
2007, the Health Act 2007 (Care and Welfare of Residents in Designated Centres for
Older People) Regulations 2009 and the National Quality Standards for Residential Care
settings for Older People in Ireland.
1. The provider is failing to comply with a regulatory requirement in the following respect:
While the Person in Charge was off duty due to medical advice from the public health team there was no designated person in charge. The arrangements to cover the absence of the person in charge were not adequate as the nurse nominated for this role only worked two days each week.
Action required:
Put in place an appropriately qualified and experienced person in charge.
Reference:
Health Act 2007 Regulation 15: Person in Charge Standard 27: Operational Management.
Please state the actions you have taken or are planning to
Timescale:
take with timescales:
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Provider’s response:
A senior nurse was appointed acting nurse manager during the short term absence of the person in charge until the outbreak was decalred over.
04/04/2012
2. The provider is failing to comply with a regulatory requirement in the following respect:
Aspects of infection prevention and control required improvement as a result of the confirmed outbreak of influenza A (H3N2). There were deficits in aspects of infection prevention and practice and areas where supervision was required. Some areas did not have appropriate accessible supplies of products such as hand gels to assist in good infection control management and some equipment and areas of the premises were not in a satisfactorily clean condition. Staff training records indicated that not all staff had attended training on infection prevention and control.
Action required:
Implement in full the guidelines and practices as outlined in relation to influenza and infection control in: 6: H
Interim Guidelines on the Prevention and Management of Influenza Outbreaks in Residential Care Facilities in Ireland 2011/2012
Heath Information and Quality Authority’s National Standards for the Prevention and Control of Healthcare Associated Infections (2009)
Action required:
Ensure that responsibility for infection prevention and control is clearly defined and that there are clear lines of accountability for infection prevention and control throughout the designated centre.
Action required:
Ensure equipment is clean and maintained in a hygienic condition to minimise the spread of infection and that supplies of equipment and products for good infection control management are readily available.
Reference:
Health Act 2007 Regulation 31: Risk Management Procedures Standard 26: Health and Safety
Please state the actions you have taken or are planning to
Timescale:
take with timescales:
Provider’s response:
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The Health Information and Quality Control National Standards for the Prevention and Control of Healthcare Associated Infections and the HSE – Interim Guidelines on the Prevention and Management of Influenza Outbreaks in Residential Care Facilities in Ireland 2011-2012 were implemented
A named person responsible for Infection Prevention and Control is in place with clear lines of accountability throughout the centre.
As part of the monthly Infection Control Audit for all departments, the person in charge will ensure that equipment is clean and maintained in a hygenic condition and products for good infection control are readily availble.
Immediately Immediately
Immediately
3. The provider has failed to comply with a regulatory requirement in the following respect:
There was insufficient staff or skill mix to meet the assessed needs of residents taking into account the declared dependency levels, clinical monitoring requirements, changing needs, the number of residents accommodated and the size and layout of the centre. There was no household staff available after 3pm daily and there was inadequate nursing staff available to cover absences due to illness and holidays.
Action required:
Ensure that the numbers and skill mix of staff are appropriate to the assessed needs of residents and the size and layout of the designated centre.
Action required:
Have cleaning and ancillary staff available throughout the day in accordance with the assessed needs of residents.
Reference:
Health Act 2007 Regulation 16:Staffing Standard 23: Staffing Levels and Qualifications
Please state the actions you have taken or are planning to
Timescale:
take with timescales:
Provider’s response:
The staff numbers and skill mix to meet the assessed needs of residents and the size and layout of the centre during the outbreak were reviewed and addressed by the provider
Immediately
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Additonal nurses were engaged from the HSE and from recruitment agencies during the outbreak period to meet the changing needs of the residents and to cover absences due to illness and holidays
Household staff were made available for two additional hours each day in accordance with the assessed needs of residents.
Immediately Immediately
4. The provider has failed to comply with a regulatory requirement in the following respect:
Robust communication procedures were not in place. Senior management was not communicated with in a timely manner and there was a lack of clarity and accountability about how information on the outbreak had been reported. There was a lack of coordination of the information available where residents were diagnosed with a respiratory illness and were being cared for in the designated centre or in hospital. There was no system to alert professionals to the possibility of an influenza outbreak which created additional risk.
Action required:
Have in place a risk management policy that covers, but is not limited to, the identification and assessment of risks throughout the designated centre and the precautions in place to control the risks identified.
Action required:
Have in place a protocol for communicating with general practitioners (GPs), community provider services and other designated centres to ensure locally appropriate arrangements are in place for reporting suspected outbreaks of infectious illness.
Action required:
Revise the policies and procedures on communication to reflect learning consequent to this outbreak and ensure that there are clear communication pathways outlined in the emergency plan and in the communication procedure.
Action required:
Have in place appropriate systems for communication to ensure that risks, such as infection
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control problems can be adequately managed.
Reference:
Health Act 2007 Regulation 11: Communication Standard 20: Social Contacts Standard 29: Management Systems
Please state the actions you have taken or are planning to
Timescale:
take with timescales:
Provider’s response:
The risk management policy covering the identification and assessment of risks throughout the centre and the precautions in place to control identified risks are under review and a revised policy will be put in place.
A protocol for communicating with GPs, community provider services and other designated centres will be developed to ensure locally apporpriate arrangements are in place for reporting suspected outbreaks of infectious diseases. Continuing discussions/debriefings with the local public health body should help provide the centre develop a robust communication procedure document.
Revised policies and procedures to reflect the learning consequent to the outbreak will be completed with clear communication pathways outlined in the emergency plan and in the communications procedure
Appropriate systems for communication to adequately manage risks such as infection control are in place
While the designated centre fully upgraded its IT systems and internal cabling (CAT 5) eighteen months ago, the internet providers have an under-developed residential and business broadband service in the Fahan area with poor levels of DSL and cable modem adoption compared with major cities in Ireland. The centre was informed that limited coverage, for both mobile phone services and for the internet in the Fahan area, like in many non-urban areas in other parts of the country, will remain
15/06/2012
30/06/2012
30/06/2012 Immediately
Ongoing
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5. The person in charge has failed to comply with a regulatory requirement in the following respect:
A number of residents had respiratory-type illness and there were clear indicators that there was an outbreak of an infectious illness. Notification was not submitted to the Chief Inspector in a timely manner as required by the regulations.
Action required:
The person in charge shall ensure that notice is given to the Chief Inspector without delay of the occurrence in the designated centre of outbreaks of any infectious disease.
Action required:
Have in place procedures to guide and inform staff on the records to be maintained and the notifications to be made to the Authority.
Reference:
Health Act 2007 Regulation 36: Notification of Incidents. Standard 26: Health and Safety
Please state the actions you have taken or are planning to
Timescale:
take with timescales:
Provider’s response:
Residents with respiratory illness were reviewed regularly and were treated for bacterial infection. An oubreak was not suspected until late 01.04.2012.
The person in charge was informed regarding a suspected outbreak on the afternoon of 02.04.2012 by the public health and who also informed the centre that the Health Information Quality Authority had been notified.
The person in charge will ensure that notice is given to the Chief Inspector without delay of the occurrence of outbreaks of any infectious disease in the centre
Procedures are in place to guide and inform staff on the records to be maintained in the centre and the notifications to be made to the Authority.
Immediately
Immediately
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6. The provider has failed to comply with a regulatory requirement in the following respect:
There were aspects of the premises that required remedial action.
While new boilers had been installed, the temperatures recorded were below the recommended minimum temperatures in some bedrooms and the smoking and hairdressing areas were noted to be cool.
Not all equipment had up-to-date service records. There was no clear process for managing equipment that required repair.
Dish washers in the small kitchen areas had been removed and crockery and cutlery had to be conveyed to the main kitchen to be washed which created an infection control hazard .
Action required:
Ensure that ventilation, heating and lighting suitable for residents, is provided in all parts of the designated centre which are used by residents.
Action required:
Ensure that equipment provided at the designated centre or used by residents or persons who work at the designated centre is maintained in good working order.
Action required:
Ensure that appropriate equipment is provided to enable staff to operate appropriate infection control measures.
Reference:
Health Act, 2007 Regulation 19: Premises Regulation 31: Risk Management Procedures Standard 25: Physical Environment
Please state the actions you have taken or are planning to
Timescale:
take following the inspection with timescales:
Provider’s response:
Ventialtion, heating and lighting suitable for residents is provided in all parts of the centre .The hairdressing and smoking rooms are used infrequently and are heated when in use. Room temperatures are monitored in all areas of the building on a regular basis.
A clear process is in place to ensure the timely repair and
Immediately
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maintenance of the equipment. Maintenance contracts for equipment where one did not exist have been sourced
Checklists/audits are carried out to ensure approporiate equiment is in place to enable appropriate infection control
The provider had removed a domestic diswasher from the kitchenette located in the bedroom area of the centre so that all dishes/cutlery are washed in the main kitchen washup area which has an industrial dishwasher. This was undertaken so that clean dishes left the kitchenette and only clean ones were returned.
Immediately 30/05/2012
Ongoing
7. The provider has failed to comply with a regulatory requirement in the following respect:
There was a deficit in the management of potential risks and hazards. Shower tray outlets were noted to be unclean and there was no system in place for regular cleaning or limescale removal from shower heads.
Action required:
Have in place a comprehensive risk management policy that is implemented throughout the designated centre.
Action required:
Ensure that the risk management policy includes arrangements for the cleaning of parts of the premises and equipment that may present hazards in accordance with good practice guidance.
Reference:
Health Act 2007 Regulation 31: Risk Management Procedures Standard 26: Health and Safety
Please state the actions you have taken or are planning to
Timescale:
take with timescales:
Provider’s response:
A comprehensive revised risk management policy is implemented throughout the centre which includes a schedule for monthly shower head and shower tray outlet cleaning to be carried out by the maintenance person
Audits/checklists are carried out to ensure that arrangements are in place for the cleaning of parts of the premises and equipment that may present hazards in accordance with good practice guidance
Immediately
Immediately
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8. The provider has failed to comply with a regulatory requirement in the following respect:
Residents’ care records were maintained on a computer system and other information needed to be conveyed in a timely manner. However, the poor arrangements for internet access and poor telephone coverage compromised the ability of staff to communicate or access information or provide information in a timely manner when required.
Action required:
Ensure that the arrangements in place for maintaining residents’ records and for relaying information can be supported by the structures in place and that precautions are in place to control the risks identified such as poor internet access.
Reference:
Health Act 2007 Regulation 31: Risk Management Procedures Standard 26: Health and Safety
Please state the actions you have taken or are planning to
Timescale:
take with timescales:
Provider’s response:
While the designated centre has a modern fully upgraded IT system, including a computerised care records sytem, and internal cabling (CAT 5), the internet providers have an under-developed residential and business broadband service in the Fahan area with poor levels of DSL and cable modem adoption compared with major cities in Ireland. The centre was informed that limited coverage, for both mobile phone services and for the internet in the Fahan area, like in many non-urban areas in other parts of the country, will remain.
The computerised resident’s care records were fully accessible during the inspection.
Contingency plans are in place in the event of internet failure. The daily nurse’s handover report is now revised to include specific information regarding resident’s condition and treatment .Written documentation of a daily record is already available in the event of poor internet access.
Ongoing
Immediately
9. The person in charge has failed to comply with a regulatory requirement in the following respect:
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There were records maintained of accidents and incidents. However, the information recorded when residents sustained falls did not indicate if the fall was witnessed or if the resident was alone. There was no information that indicated if neurological observations were recorded if a fall was unwitnessed or if a resident sustained a head injury.
Action required:
Have in place a record of accidents and incidents that describes the event fully and that indicates the actions taken following the event to protect residents.
Reference:
Health Act 2007 Regulation 36: Notification of Incidents Standard 26: Health and Safety
Please state the actions you have taken or are planning to
Timescale:
take with timescales:
Provider’s response:
An amended Accident and Incident form is now in place to include recorded neurological assessments, witnessed or unwitnessed events and actions taken following the event
Immediately
10. The provider has failed to comply with a regulatory requirement in the following respect:
A number of polices were not comprehensive and did not provide sufficient guidance for staff. This included the infection control procedure and the emergency plan which required revision to include the arrangements in place to address an outbreak of infectious illness, the contingency measures to address staff shortfalls and the management of communication during a critical event.
Action required:
Have in place the records, policies and procedures to be maintained in designated centres as outlined in schedules 4 and 5.
Reference:
Health Act 2007 Regulation 31: Risk Management Procedures Standard 26: Health and Safety
Please state the actions you have taken or are planning to
Timescale:
take with timescales:
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Provider’s response:
The Infection control policy and emergency policy are now revised to include the arrangements to address an outbreak of infectious illness, the contingecy measures to address staff shortfalls and the management of communication during a critical event.
The records , policies and procedures as outlined in schedule 4 S. I . No 36 of 2010 and schedule 5 S.I. No 36 of 2009 are maintained in the centre
Immediately
11. The provider has failed to comply with a regulatory requirement in the following respect:
The procedures in place for vetting staff who work with vulnerable people were not in accordance with legislation and good practice guidance. There were no references and no evidence of medical and physical fitness for a member of staff employed.
Action required:
Ensure that the designated centre has written policies and procedures relating to the recruitment, selection and vetting of staff.
Action required:
Persons shall not be employed at the designated centre unless the provider has obtained in respect of that person the information and documents specified in Schedule 2 which includes references from three sources and evidence of medical and physical fitness.
Reference:
Health Act 2007 Regulation 18: Recruitment Standard 22: Recruitment
Please state the actions you have taken or are planning to
Timescale:
take with timescales:
Provider’s response:
Written Policies and procedures relating to the recruitment ,selection and vetting of staff are updated to include procedures and policies on the engagement of students on work placement and that the information and documents in relation to these persons is in place prior to commencing work in the centre
Immediately
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Any comments the provider may wish to make:
Provider’s response:
The provider, person in charge and staff, as well as the Public Health team on site during the outbreak,found the inspection to be constructive and helpful.
The inspection team were professional and courteous to residents, visitors and staff.
The debriefing sessions since the inspections with the inspectors, the Public Health team and the centre and the inspector’s recommendations inform learning for future management of outbreak situations in nursing homes.
The management and staff of Nazareth House Fahan wish to thank the inspection team for their support and are committed to addressing the recomendations in the report.
Provider’s name: Sr Alice Kirwan on behalf of the Sisters of Nazareth Date: 09/05/2012
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