HIQA: Cahercalla making significant strides towards compliance

SIGNIFICANT progress has been made bringing Cahercalla Community Hospital and Hospice into compliance with national regulations, according to a report produced by an independent watchdog.

An inspection by the Health Information and Quality Authority (HIQA) of the Ennis long-stay residential facility last September found non-compliance across multiple regulations.

A meeting was held with the registered provider and representatives following the previous inspection as an escalation.

On this inspection, inspectors followed up on the last inspection findings and found that significant progress had been made to bring the centre into compliance with the requirements of the regulations.

The governance and management structures had been strengthened and were now in line with the centre’s statement of purpose and function.

In addition, the provider has increased the monitoring and auditing of the service, which lead to improved oversight of the service provided to the residents.

However, inspectors found one area relating to the availability of staff in the direct provision of care had not been fully addressed.

There were 88 residents in residence when two inspectors completed an unannounced visit on January 13 last. The centre is registered to accommodate 112 residents.

The centre was compliant in relation to regulations on training and staff development, notification of incidents, complaints procedure, record keeping, visits, risk management, individual assessment and care plan and health care.

It was substantially compliant for standards on staffing, governance and management, infection control, fire precautions and residents’ rights.

Mowlam Healthcare Services is participating in the management of the service and is operating the day-to-day running of the service.

HIQA stated the governance and management structure in place had been sufficiently strengthened since the last inspection.

The director of nursing was supported by an assistant director and both were working full-time in management roles. In addition, the person in charge (PIC) was also supported by three full-time clinical nurse managers.

The PIC had implemented Mowlam’s Auditing Management system (MAMS). The audit schedule covered a wide range of topics, including falls, restrictive practice, wound care, care plans and medication.

Audits reviewed were seen to be thorough, and any actions that were needed to drive improvement were being progressed.

The management team was working together to oversee residents’ care and undertook reviews of the care and support being provided.

In response to issues raised by HIQA, the centre confirmed there is a robust recruitment plan in place to address identified staffing deficits.

The roster is reviewed on an ongoing basis to ensure that staffing levels and skill mix are always sufficient to meet residents’ assessed care needs and to provide required services. Agency staff is used to fill any vacant shifts.

The PIC will ensure that equipment has a cleaning record attached to it which staff will complete once equipment has been cleaned. Any equipment deemed to be unfit for use will be de-commissioned and replaced.

The PIC will ensure that a full review of all fire doors is completed and will ensure that seals are replaced as necessary.

Overall, residents provided positive feedback to the inspectors. Residents said that they were satisfied with the care and service provided. Some residents stated that the staff were very kind and caring, they were well looked after and they were happy living in the centre.

When residents were asked about the staff, one resident stated ‘’they never let me down.’’

Residents spoken with were satisfied with the time it took to have their call-bells answered.

During the last inspection, inspectors found that the timing of meals had been very early in the day and that meals were task driven and not a social engagement.

The most recent residents’ survey held on January 4 and 6, 2022 identified that the timing of the serving of meals continued to be a source of dissatisfaction for some residents.

While some progress had been made, inspectors found that further action is required. This was discussed with the management team who were committed to addressing the dissatisfaction.