Regulation 6: Food Safety
Reason ID : 10001258 The registered proprietor did not ensure that proper facilities for the storage of food was maintained to support food safety requirements, 6(4)4.
Specific Measurable Achievable/Realistic Time-bound Post-Holder(s)
Corrective Action Discuss with
domestic
supervisor/staff to reiterate correct storage of food.
Remove any food products and place in correct storage facility. Signage fixed to store room door indicating storage facility.
On the spot checks wil be conducted by the CNM2
Achieved 01/08/2020 ADON, CNM2 and
Domestic Supervisor
Preventative Action 6/12 audit against JSF (MHC, 2018)
Regulation 6 to improve compliance
6 monthly audits achievable 31/12/2020 ADON, CNM2 and
Domestic Supervisor
Regulation 8: Residents' Personal Property and Possessions
Reason ID : 10001259 The registered proprietor did not ensure that an accurate record was maintained of each resident's money: cash balances did not always correspond with the balance recorded in available records, 8 (3).
Specific Measurable Achievable/Realistic Time-bound Post-Holder(s)
Corrective Action Cash was balanced to correctly correspond with records. A new cash record was initiated indicating signature columns for two staff members and the service user.
3/12 audit against JSF (MHC, 2018)
Regulation 8 to improve compliance
Complete 01/08/2020 ADON, CNM2 and
Nursing Staff
Preventative Action At the end of each shift the signature sheet is checked for any omissions or cash imbalances. The cash balance is checked at the end of the shift pass.
3/12 audit against JSF (MHC, 2018)
Regulation 8 to improve compliance
achievable 30/11/2020 ADON, CNM2 and
Nursing Staff
Regulation 18: Transfer of Residents
Reason ID : 10001257 The approved centre did not ensure that all relevant information about the resident was provided to the receiving facility upon transfer, 18(1).
Specific Measurable Achievable/Realistic Time-bound Post-Holder(s)
Corrective Action Meeting with medical team and nursing staff to ensure all relevant
documentation is provided to receiving hospital
Review and monitor transfers in the approved centre specifically on documentation is correctly handed over to the receiving hospital
Achievable 30/09/2020 ADON, CNM2, Medical
Team
Preventative Action 3/12 audit against JSF (MHC, 2018)
Regulation 18 to improve compliance.
3 monthly audits Achievable 30/09/2020 ADON, CNM2 and
Medical Team
Regulation 21: Privacy
Reason ID : 10001255 The bedroom area was locked from early morning until approximately 21:30; a restrictive practice that was not conducive to resident privacy and dignity.
Specific Measurable Achievable/Realistic Time-bound Post-Holder(s)
Corrective Action The role of the HCA is to compliment the existing staff skill mix in allowing staff keep the downstairs bedroom area open during the day.
Controlled swipe access has been added to non bedroom areas. The role was advertised and interviewed however the campaign was not successful in that the identified post holders no longer wished to take up the posts offered. A Cork Kerry Community Healthcare recruitment campaign was undertaken and interviews were scheduled for the week of 23.11.2020.
It is anticipated that
Management will fill the approved HCA posts. Introduction of the Healthcare assistant role to support the patients and staff of St.
Catherine's.
Additional swipe access controls added to non-patient
designated areas
Achievable. Interview held
week of 23.11.2020 31/01/2021 DON, ADON, General Manager, HR
the successful candidates will be available to comence in post by
31.01.2020.
Preventative Action The role of the HCA is to compliment the existing staff skill mix in allowing staff keep the downstairs bedroom area open during the day.
Controlled swipe access has been added to non bedroom areas. The role was advertised and interviewed however the campaign was not successful in that the identified post holders no longer wished to take up the posts offered. A Cork Kerry Community Healthcare recruitment campaign was undertaken and interviews were scheduled for the week of 23.11.2020.
Introduction of the Healthcare assistant role to support the patients and staff of St. Catherine's.
Additional swipe access controls added to non-patient
designated areas
Achievable. Interview held
week of 23.11.2020 31/01/2021 ADON, Area Administrator
the successful candidates will be available to comence in post by
31.01.2020.
Regulation 22: Premises
Reason ID : 10001249 The physical structure of the approved centre was not maintained with due regard to the safety and well-being of residents as ligature points had not been minimised, 22(3).
Specific Measurable Achievable/Realistic Time-bound Post-Holder(s)
Corrective Action Updated Ligature Audit undertaken in January 20.
This has been used to develop program of associated works to reduce ligature points and provide direction for maintenance department
Program of Works has been costed by maintenance department with works now commenced.
21/08/2020 ADON, Area Administrator Maintenance Department
Preventative Action Bi-monthly inspection to be undertaken on the units by cross- functional team from Nursing, Area
Administrator and Maintenance Dept.
Records will be maintained for inspections and audit
This is both Achievable and Realistic. It will also assist with Budget preparation and accessing funds to progress works in a planned and co- ordinated manner.
01/07/2020 ADON, Area Administrator Maintenance Department
Reason ID : 10001250 There was no programme of general or decorative maintenance, 22(1)(c). The external courtyard area was littered with cigarette butts and other rubbish, 22(1)(a).
Specific Measurable Achievable/Realistic Time-bound Post-Holder(s)
Corrective Action To initiate and review current programme for decorative maintenance. To keep courtyard free from cigarette butts and rubbish
Create a folder which will be kept in the CNM2 office which will indicate
maintenance requests and programmes. To monitor courtyard for rubbish and cigarette butts.
Each time staff issue a maintenance request this will be logged in the folder along with a copy of the email request. Cleaning staff will sweep the courtyard daily and service users will be reminded to use
appropriate waste facilities.
21/08/2020 ADON Maintenance Department
Preventative Action To continue and review the maintenance programme and to monitor courtyard for cigarette butts and rubbish. Bi-monthly inspection to be undertaken on the units by cross-
functional team from Nursing, Area
Administrator and Maintenance Dept.
The maintenance folder will be updated and reviewed following completed
maintenance work and planned
decorative works will be evident in the folder. There will be a cleaning log for the courtyard. 3/12 audit against JSF (MHC, 2018) Regulation 22 to
Achievable & Realistic 31/07/2020 ADON Maintenance Department Area Administrator
Regulation 23: Ordering, Prescribing, Storing and Administration of Medicines
Reason ID : 10001260 One MPAR did not record the date of discontinuation of each medication, 23(1). One MPAR did not record the date of initiation for each medication 23(1). Six MPARs did not record all
medications administered to the resident, 23(1).
Specific Measurable Achievable/Realistic Time-bound Post-Holder(s)
Corrective Action Liaise with the medical team to discuss the omission on the MPAR and to discuss with nursing staff. Audit results are to be inlcuded in audit reviews by the South Lee Audit Group to assit with training and learning outcomes. Audit members to sit on the widened audit committee.
3/12 audit against JSF (MHC, 2018)
Regulation 23 to improve compliance.
Achievable 30/09/2020 medical team, ADON,
CNM2 and Nursing Staff
Preventative Action At the end of each shift the nurse allocated to the medication round will also check all MPARs for omissions. Audit results are to be inlcuded in audit reviews by the South Lee Audit Group to assit with training and learning outcomes.
3/12 audit against JSF (MHC, 2018)
Regulation 23 to improve compliance.
achievable 30/09/2020 Medical Team, ADON,
CNM2 and Nursing Staff
Regulation 26: Staffing
Reason ID : 10001263 The numbers and skill mix of staff was not appropriate to the assessed needs of the resident, 26(2). The numbers and skill mix of staff was not appropriate to the assessed needs of the residents and to facilitate the bedroom area being accessible to the residents as appropriate, 26(2).
The approved centre did not provide an acceptable CAPA for Regulation 26: Stafing in time for the publication of this report.