AN INSPECTION REPORT on a nursing home in Kerry has raised concerns after inspectors identified a “significant risk to the lives of residents and staff” in relation to its fire safety management. 

The unannounced inspection at Lystoll Lodge Nursing Home took place between 7 and 8 November. Nine areas, such as management and social needs, were examined by the Health Quality and Information Authority (Hiqa) during the inspection. Eleven areas were found to be non-complaint. 

Lystoll Lodge was one of 34 nursing homes recently inspected by Hiqa. Inspectors found evidence of non-compliance in 15 of the centres for older people. In these centres, the care provider failed to ensure that the service delivered to residents was effectively monitored in line with the regulations and standards. 

On the day of inspection at Lystoll Lodge, there were 46 residents present. The inspectors met with the residents, relatives and staff members.

Residents told inspectors that they were happy with the staff and their accommodation.

Mattress evacuation 

In the report, inspectors found a “significant risk to the lives of residents and staff” in relation to fire safety management of the nursing home and that adequate precautions against the risk of fire had not been taken. 

Inspectors noted that three oxygen cylinders were stored in a bedroom with two residents, neither of which required oxygen. Staff were not aware of their location and there was no signage in place to indicate the presence of oxygen, nor were they stored on a suitable stand.

Fire doors at the centre required urgent review as inspectors found they did not appear to be capable of “adequately containing smoke and fire due to gaps down the centre where the smoke seals were located”.

A smoke seal on one door was seen to be repaired with sticky tape and there was a section of the smoke seal missing on the door of the smokers’ room where three residents regularly smoked.

The fire door to the laundry room was held open with a wooden wedge while there was a lot of dust and lint visible on the back of the tumble drier, which presented a high risk of fire.

When it came to the fire drills, they did not include a simulated full or partial evacuation of the upstairs area where there were a large number of highly dependent residents requiring evacuation on a mattress.

 ”Staff had no practical experience of doing this type of evacuation. It was therefore not possible to ascertain if all residents in the centre could be evacuated to a place of safety in a timely manner in the event of a fire,” the inspection stated. 

Fire evacuation equipment was also found to be not adequate. Inspectors stated that they could not identify, “nor were staff able to demonstrate that appropriate assistive equipment was available for residents who require them to evacuate”.

“Fire evacuation ‘ski-sheets’ were not available for all residents requiring same. There were only 4 such evacuation aids on the premises.”

When it came to the fire alarms there was no evidence that it was serviced on a quarterly basis. 

‘Significant concern’

The report also found deficiencies when it came to records. Resident records were found to be not securely stored. The staff roster was not complete as all staff were not included on this, mostly the cleaning, laundry, activity and the kitchen staff.

Four staff, three of which were on duty during the inspection did not have the required garda vetting in place. 

Inspectors also found that not all staff had the required two references on file and that not all CVs were complete. 

Inspectors noted that a “significant concern” remained in relation to the absence of the signatures of some nurses who checked or administered the controlled drugs.

Signatures were not available for all such transactions, similar to findings on the previous inspection.

This was a repeat non-compliance and a similar issue had formed part of a serious concern previously notified to the Office of the Chief Inspector. This poor practice had the potential for a serious error

In addition, discrepancies were noted in the duplication of signing times and days and not all drugs were transcribed properly. For example, paracetamol was transcribed in the drug administration sheet without a dosage or times of administration for the resident involved.

When it came to the food nutrition of the residents, inspectors found the food to be plentiful and nicely presented but noted in the report that “one resident who had been assessed as requiring a chopped diet was seen to be served a pork chop on the day of inspection”.

In response to the inspection, the home said a fire risk assessment is currently being completed and it has engaged an external consultant to mentor the management team and staff on implementation of recommendations arising from the report.