RESIDENTS of a West Limerick nursing home were found to be at risk of falling from an upstairs balcony when the care home was inspected by HIQA earlier this year.
And inspectors found a second instance of “major non-compliance” with standards when a resident of Cahermoyle House Nursing Home in Ardagh was found to be inappropriately restrained.
Thirty people were resident at the care home when the unannounced inspection took place on May 27.
Inspectors had intended to monitor the care home against two standards - end-of-life care and food and nutrition - but had “identified two major non-compliances relating to risk management that presented a potential risk to the health and safety of residents”, the report states.
One related to “unsecured access to an upstairs outdoor balcony” which HIQA said “carried the potential risk of falling from a height”.
“This issue had also been identified during a previous inspection,” HIQA further observed.
When the issue was brought to the attention of staff, the access door had been immediately secured.
On examining paperwork at Cahermoyle House, a HIQA inspector found “no specific risk assessment” on the balcony which would “be expected given the level of risk present”.
“A general risk assessment relating to access of unattended areas was in place; however the control measures that specified to keep areas locked when unattended had not been implemented by the provider.”
In its response to the HIQA report, management at Cahermoyle House stated: “following the inspector’s findings; the area in question was risk assessed and in order to further enhance the safety of our residents, a second gate was added to the stairwell leading to this area and all upstairs doors are now securely locked”.
The other incident of major non-compliance highlighted related to the use of restraints. A resident had been found “inappropriately restrained in a chair as the buckle of the restraint (a lap-belt) had broken and had been tied together using a knot”.
“Inspectors observed that the resident, who was unattended at the time, was attempting to rise from his chair and was at risk of slipping and sliding down in the chair. As the belt was knotted, it would not have released in such a circumstance, which carried the potential risk of injury, e.g. of entrapment.”
The situation had been immediately resolved by staff when brought to their attention and in its response to the report, management noted there would be a review “of all aspects of restraint management and to ensure that only appropriate equipment is in use so that the safety of our residents is not compromised”.
More generally, HIQA found there was no system to review the quality and safety of care in the home, as required by the regulations.
“With the exception of medication management audits, there were no other audits in the centre. This issue was identified at a previous inspection in 2012,” the report states.
“The lack of review on key areas meant that the provider had not identified the significant issues in relation to restraint management and risk management such as the recurrence of the risk in relation to the...balcony.”
Other shortcomings identified concerned paperwork. Some care planning documents did not reflect “the good care delivered” as observed by the inspectors.
Cahermoyle House performed relatively well on the standards HIQA had set out to measure.
“With respect to the outcomes relating to end-of-life care and food and nutrition; inspectors found that overall, the residents’ end-of-life care and nutritional needs were substantially met and inspectors found evidence of good practice across both outcomes,” the report states.