HIQA report outlines health and safety risk to Sunbeam resident

A PERSON being cared for at Dunavon in Rathdrum wasn’t brought to their GP for four days after engaging in a ‘prolonged incident of self injurious behaviour’, according to a report by the Health Information and Quality Authority (HIQA).

Dunavon is operated by Sunbeam House Services and eight residents with disabilities were residing at the centre when inspectors made an unannounced visit in October of last year.

The HIQA report found that a resident had engaged in a prolonged incident of self injurious behaviour on October 6 resulting in significant bruising to their body. Despite these injuries, the resident had not been brought to their General Practitioner (GP) for a medical review until October 10, four days later.

The inspection report stated: ‘Despite these injuries the resident had not been brought to their General Practitioner (GP) for a medical review until 10 October, four days after the incident. Given the resident’s medical condition, the degree of injury and on-going issues with serious incidents of self injurious behaviour, this posed a risk to the health and safety of the resident’.

It was also noted that a call doctor reviewed the residents on September 30 and advised that the centre should make arrangements for them to see their GP the next day. The appointment was never organised.

It was observed that the centre had three different persons in charge over a six-month period and no nominated person was in charge from September 21 to October 8.

‘The current person in charge (who had only been appointed to the centre on 10 October) had responsibility for three centres overall. Taking into account the issues found on this inspection and the significant complex needs of the residents, the inspectors were not assured that the arrangements in place for person in charge were sufficient to provide adequate oversight of the centre’.

Since the inspection, interviews have taken place for a full-time person in charge and a number of organisational changes have taken place. Residents’ care plans also now stated clearly that when anyone became unwell, or following an incident where there had been an injury, the nurse or care worker in charge of the shift must contact the client’s GP or out-of-hours doctor to seek their advice. If the injury was deemed serious or life threatening, an ambulance must be called.

Staffing regulations were deemed substantially compliant as the roster in the centre was not adequately maintained and didn’t indicate the hours staff worked,

With regard to the regulations over the records of residents, the centre was judged not compliant because some of the information on file in the registered centre was not being updated and had conflicting information.

Governance and management regulations were deemed not compliant because Dunavon did not have adequate systems in place to ensure that the service provided was responsive to the needs of the residents or effectively monitored.

The statement of purpose did not accurately reflect the service being provided to the residents and was also judged not compliant.

The process of managing risk required review, the report found. There were adequate fire precautions in place, though one personal evacuation emergency plan required updating.

However, the report found that the residents were ‘relaxed and at ease in the company of staff ’ and the staff interacted with the residents in a ‘caring and kind manner’. It was also observed that the staff ‘knew and respected their communication style and preference’ of the different residents.

Meanwhile, a HIQA report into Sunny Gardens in Arklow found one incident of non-compliance where Sunbeam House Services had failed to notify HIQA of a change to management at the centre.

The inspection was announced and took place on September 18, 2018.

In a statement, the Sunbeam House Services Family Advocacy Group expressed disappointment at the reports.

‘We are very disappointed by the lack of persons in charge, poor governance and management again brought into focus. We thought we had left all that in the past. We are also disappointed at the fact a service user was left without medical treatment for a prolonged period resulting in this service user being left in a distressed state,’ the group said in a statement.

A spokesperson for Sunbeam House Services was unavailable for comment.