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Report of inspection visit to: Honorable Henry Carlyle Every Home of Saba, 17 to 20 June PDF

Report of inspection visit to: Honorable Henry Carlyle Every Home of Saba, 17 to 20 June 2014 Amsterdam, October 2014 Page 1 of 33 Draft report of inspection visit to: Honorable Henry Carlyle Every Home
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Report of inspection visit to: Honorable Henry Carlyle Every Home of Saba, 17 to 20 June 2014 Amsterdam, October 2014 Page 1 of 33 Draft report of inspection visit to: Honorable Henry Carlyle Every Home of Saba, 17 to 20 June 2014 Oct Contents Introduction 3 Background 3 Method 4 1 Leadership, strategy and policy 6 Organization and management 6 Internal supervision ( Supervisory Board ) 6 Cooperation with other care providers and institutions 6 Expertise of staff 6 Capacity planning 7 Client focus 7 Complaints procedures, independent Complaints Committee 8 Emergency plans, practice drills, maintenance of building and equipment 8 2 Quality 9 Protocols and procedures 9 Staff training 9 Annual Quality Report 9 Incidents and accidents (MIP/FONA reporting system) 9 3 Care provision 10 Care plans 10 Food, nutrition and hydration 10 General housekeeping and cleanliness 11 Maintenance and comfort of living accommodation 11 Use of the dayroom 11 Clients daily routine 12 Incontinence 12 Physiotherapy 12 Activities and occupational therapy 13 Fall prevention 13 Multidisciplinary consultation and input of geriatric care specialist 14 Patient hoist 14 Use of restrictive measures, such as bedrails and security (restraining) blankets 14 Hygiene 15 Use of cameras 15 Alleged theft of valuables 15 Volunteers 15 Confidence in the Board and management 15 Pharmaceutical care 16 4 General remarks 17 5 Conclusions 18 6 Measures 27 Appendix 1: Written notification of enhanced supervision and the Home s response 30 Page 2 of 33 Introduction In accordance with its regulatory responsibilities, the Health Care Inspectorate conducts inspection visits to institutions which provide health care services. The inspection framework applied during such visits is provided by the Wet zorginstellingen BES (BES Care Institutions Act) and the implementation of the Act by the public bodies of Bonaire, Sint Eustatius and Saba (the BES islands). Background The Inspectorate s previous visit, which was part of the Inspectorate s regular monitoring activities, to the Honorable Henry Carlyle Every Home of Saba (hereafter the Home ) was conducted on 11 March 2014 and a report submitted to the Home s Board of Directors on 7 April During this visit, the findings of earlier inspections (October and November 2013 and January 2014) were discussed. Those findings, and the measures to be taken by the Home, were included in the report of 7 April Between April and June 2014, the Inspectorate received several complaints and reports from relatives and concerned friends or neighbours of the Home s residents ( clients ). These complaints and reports relate to the standard of care provided, which complainants consider to be below the level which can be termed adequate. Allegations include non-compliance with hygiene regulations, inadequate supervision of staff, inadequate expertise on the part of staff, and a lack of interest in good care on the part of the Board and management. It was further claimed that insufficient attention is devoted to the prevention of health problems, to the adequate use of patient hoists and to dietary requirements. There is little or no team consultation, staff are unaware of protocols or choose not to follow them, complaints from relatives are not being given due consideration, and no formal complaints procedure or Complaints Committee are in place. Other grievances related to the strict enforcement of visiting hours, the time at which clients are put to bed, incidents involving falls, allegations of mistreatment, insecure storage of medication, irregular replacement of incontinence materials, refusal to allow clients to use the lavatory or a bedpan (resulting in their having to spend lengthy periods wearing soiled or wet clothing), inadequate staff training, issuing medication without proper knowledge or supervision, the lack of a double check when administering medication, theft of money and valuables, the seclusion and restraint of clients with dementia, inadequate wound care, social neglect, and impatience towards difficult clients. The Inspectorate was asked to instigate a formal investigation as a matter of urgency. The majority of complainants indicated that they did not wish to lodge a formal, written complaint for fear of reprisals, but were prepared to meet with the Inspectorate to discuss their concerns. The Inspectorate was specifically requested to take into account the island culture which characterizes the small community on Saba. Further to these complaints and reports, and in view of the findings of previous inspection visits, the Inspectorate decided to conduct a thorough investigation of the situation in the Home on top of its previous monitoring visit, observing staff and clients over the course of several consecutive days. The objective was to arrive at a adequate and impartial assessment of the quality of care provision, whereby attention would be given to the allegations made by the complainants. Page 3 of 33 At the time of the inspection visit, the Home had 17 clients in residence, representing various care requirements and indications: somatic complaints, visual impairment, severe physical disability, Alzheimer and varying degrees of dementia, in the age range from approximately 40 to 101. Method The inspection visit was conducted from 17 to 20 June It was an announced visit, the purpose being communicated in advance by letter and telephone to the Board and management. To arrive at a adequate assessment, the Inspectorate opted to apply the Dutch guidelines Norm Verantwoorde zorg 2005 ( Standard for Adequate Care, Toetsingskader normen voor Verantwoorde Zorg 2005, appendix 1 and Op weg naar normen voor Verantwoorde Zorg, appendix 2) and Veilige principes in de medicatieketen ( Safe principles within the medication chain, appendix 3). Both guidelines are based on current Dutch legislation and the field norms that are derived from it, as developed and implemented by the relevant professional federations and client organizations. Due to the special status and scale of Saba, it would be inappropriate to apply the standard 2014 framework, as used in the Netherlands itself, at this time, as the requirements for adequate care in the latest version are much more stringent than in the 2005 version. The local situation was taken into account at all stages of the production of the current report. The Inspectorate scrutinized various documents and conducted interviews with the members of the Board, the (general) manager, nursing and domestic staff, clients, the visiting GP and physiotherapists from the Edwards Medical Center, a representative of the health insurance agency, a police officer, and with several relatives or friends of the clients. Over the course of four days, inspectors observed the manner in which (medical) care was being provided within the Home. The interviews with relatives and friends were, at own request, held at various neutral locations on Saba to avoid the attention of the Board, management and staff of the Home. Once the Inspectorate s presence on the island and the purpose of its visit became known, several further s, phone calls and social media messages were received from people who had not yet come forward but who now wished to voice their concerns about the standard of care provided by the Home. On 7 July 2014, the draft report of the inspection visit was sent to the Board and Director of the Home for their comment and proposals for factual correction. On 18 August 2014, the Home sent some questions and general remarks concerning the inspection visit, as well as proposals for correction of the draft report, accompanied by the following documents: A Plan of Action for the quality system of the Home (as drafted by an external consultant) A signed agreement with the external consultant for consultancy development of a quality system (dated 13 May 2014) An organization chart A role and responsibility chart for the Board and management team (dated April 2014) Among other things, the questions and general remarks concerned the following matters: Page 4 of 33 Currently, the Wet zorginstellingen BES (BES Care Institutions Act) is applicable on Saba, not the (Dutch) Kwaliteitswet zorginstellingen (Care Institutions (Quality) Act). The Home would have appreciated to have been informed of the norms and the methods of inspection beforehand. The Home is fully aware that there is a significant gap between the level of quality of care offered in the Netherlands and on the BES islands, in this case Saba. Sharing information and allowing room for discussion of the interpretation of guidelines and standards that are directly adopted from the Dutch system and situation is essential in order to effect change while keeping the local situation in mind. The Home is aware that that there are issues that need to be addressed, and the Home is committed to discuss any practical and workable suggestions to effect improvement in addition to the steps that have already been initiated. In the final report, the Inspectorate has based its conclusions and measures on the facts and findings as described in the report and on the laws, acts and standards that are applicable in the Caribbean Netherlands. Page 5 of 33 1 Leadership, strategy and policy Organization and management The management structure of the Home has yet to be formally established. The Board of Directors has five elected members, all unpaid volunteers. There is a manager who is adequate for the day-to-day running of the home, assisted by a head nurse, a kitchen supervisor, a facility supervisor, and a financial administrator. The Home has a total of 27 staff, of whom four are Registered Nurses (RN) and four are Licensed Practical Nurses (LPN). The other employees are care assistants, kitchen staff and domestic staff. A full job description has been produced for each role. The Home has neither a Management Information System nor a quality policy. There is no long-term strategy plan and no annual plan. An organization chart with two new roles (Quality Officer and Activity Nurse) was attached to the Home s response of 18 August 2014 to the draft inspection report. Internal supervision ( Supervisory Board ) The home is run by a manager who is expected to refer important decisions to the Board of five elected directors, all residents of Saba. There is no supervision by a Supervisory Board or any other independent body. The Board regards itself as an executive board of management rather than as a supervisory body. Cooperation with other care providers and institutions There are no formal cooperation agreements with other care providers or institutions. The input of physiotherapists is based on a fixed-hours contract which does not stipulate the form or content of the services to be provided. There is informal contact with the nursing home on Sint Maarten. Agreements have been made with the Edwards Medical Center to cover emergency care and visits by a general practitioner, but these agreements have not been formalized. Expertise of staff In the past year, the Home has recruited two experienced RNs from Suriname, where they gained their qualification. Two LPNs are currently studying for their RN qualification on Sint Maarten. Currently, two Nursing Assistants are studying to become LPNs. These are the only changes to the situation since earlier inspection visits, the reports of which describe the expertise and qualifications of the staff in detail. According to the Home, the training enjoyed by staff at IFE Curaçao is fully recognized in the Netherlands. In its response concerning training of staff, the Home states the following: From 2009 to 2010, all Nursing Assistants participated in a training program to obtain level two nursing training (in accordance with the Dutch standard). Unfortunately, and beyond the control of the Home, the trainer did not return to Saba, so the students were unable to take the exam. In 2011, three nursing aides were hired, who received basic nursing training from a certified Dutch nursing trainer. Page 6 of 33 Between November 2012 and May 2013, four employees received training to become Nursing Assistants via St. Maarten Medical Center under auspices of IFE. They have passed the training and currently hold the appropriate certification. This year, two Nursing Assistants are being trained to become LPNs via St. Maarten Medical Center under auspices of IFE. Next year, the Home intends to have two LPNs start the training to become RNs, also under auspices of IFE. The nurses employed by the Home are not included on the national professional register, the BIG Register. Interviews revealed that staff are not aware of the legislation and field norms which have applied in the Netherlands for several years, the purpose of which is to ensure that adequate care is provided at all times within the residential care setting. Capacity planning Staff work according to a set roster which covers three shifts: day, evening and night. There is a sufficient number of care staff, including three RNs. In theory, one RN can be assigned to each of the three shifts. This creates the impression that overall capacity planning is adequate. In practice, however, it is not possible to ensure that there is an RN on duty around the clock, seven days a week. The expertise of other staff may not be such as to meet all care requirements, although it should be remembered that reserved or high-risk interventions of an incidental nature can be referred to qualified staff at the Edwards Medical Center. Client focus The Home does not have a Client Council and has no plans to introduce one. Clients are able to make personal requests, which may or may not be honoured. Where a request is refused, reasons are not always given. Clients and relatives state that they have little or no influence over the day-to-day running of the Home. Based on its observations, the Inspectorate concludes that there are indeed enough staff with enough time to provide assistance in eating and drinking. However, meals and drinks are served according to a very rigid schedule, with little concern for the requirements of clients themselves and how they might wish to structure their own daily routine. It is understandable that a client may not be ready to eat at the prescribed time, whereupon he or she may not eat enough over the course of the day. Moreover, meals are served at the set times even when there is no supervision or appropriate assistance available. The Inspectorate sees this as a risk, since it is known that many clients, and particularly those with dementia, do require help and supervision. Many clients eat their meals in their own room; those meals are delivered to the room when the staff who could assist them are on duty elsewhere. The clients begin their meal, and may have almost finished before assistance is on hand. Based on its observations, the Inspectorate concludes that there is a significant choking hazard due to the size of the portions served. Clients and their relatives regard the manner in which staff interact with clients as a matter of particular concern. It is the subject of many of the complaints received by the Inspectorate. Interviewees stated that clients are not always treated with dignity and respect. They suggested that this is because some staff do not understand the behaviour of clients with dementia and are unable respond in an appropriate manner. Although many staff members have already worked at the Home for many years, some do not have enough knowledge and skills to deal with Page 7 of 33 the type of person likely to be a resident in a care home, and with his or her special needs. This can give rise to a somewhat heavy-handed, abrupt approach, and perhaps cause staff to make inappropriate remarks in the presence of others. It was difficult for the Inspectorate to assess how staff interact with clients during the observations. However, at certain moments a passive, inattentive attitude on the part of carers was indeed evident; they failed to respond to obvious needs such as a runny nose or dribbling. Even though they knew they were being observed, some staff spent their time reading the newspaper or making private telephone calls, seeking no interaction with clients whatsoever. This cannot be deemed respectful to either clients or visitors, and is very far removed from the professional attitude which this type of work demands. As far as could be ascertained, supervisors made no attempt to admonish the staff concerned. Complaints procedures, independent Complaints Committee The Home has recently established a formal complaints procedure and has appointed a Complaints Officer. Complaints forms are now available, as is a box near the main entrance into which the completed forms can be deposited. As yet, however, there is no formal (legally mandatory) Complaints Committee or similar tribunal. Given the culture of fear conspicuous within the Home and throughout the Saba community, the Inspectorate regards the appointment of a Complaints Committee as a high priority. Emergency plans, practice drills, maintenance of building and equipment The alarm buttons in the clients rooms are out of order. Management does not know how long they have been inoperative nor when they are likely to be repaired. The Inspectorate regards this situation as a serious risk to client safety, since clients (and their visitors) are unable to summon staff in an emergency. In its response, the Home states that the alarm buttons will be operational by 1 September Fire extinguishers are installed at various points in the Home. They have recently passed a safety inspection. The other norms on emergency plans, practice drills and maintenance of building and equipment were not reassessed during the most recent inspection visit. Page 8 of 33 2 Quality Quality system The Home does not yet have a quality system. It appears that management does not appreciate the value of such a system. There are plans to implement a quality system with the help of external partners, but as yet no affirmative steps have been taken. In June 2014, nothing was mentioned to the inspectors about the execution of the Plan of Action that was sent as an attachment to the Home s response of 18 August The Home claims that currently (August 2014), discussions with a prospective candidate from the Netherlands for the position of Quality Officer are at an advanced state. He is expected to be in Saba for a six-week working period in November and to return to Saba for a longer working period in February Protocols and procedures The Home has a set of protocols covering blood glucose measurement, catheterization, readmission following discharge from hospital, temperature measurement, decubitus, and wound management. All protocols have an evaluation date but no source is stated. They were compiled with the help of staff on Sint Maarten. Staff training A training budget is available for It will fund the tuition fees of two LNPs studying for their RN qualification on Sint Maarten, and an HACCP course (food safety and hygiene) for kitchen staff and domestic personnel. The Inspectorate notes that it has been several years since staff received any (refresher) training in subjects of direct relevance to client care, such as decubitus, personal interaction, fall prevention, wound management, medication safety, dysphagia, Alzheimer, incontinence and behavioural issues. Annual Quality Report The Home has not produced a Quality Report. Incidents and accidents (MIP/FONA reporting system) The Home does not have a system which records incidents and forwards reports to the relevant authorities. During the past year, however, greater efforts have been made to report incidents to management and a form for this purpose has been produced. At the time of the Inspectorate s visit, management was unaware of precisely what constitutes an incident, and the types of incident wh
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