admission unit & st edna's unit, st loman's hospital · ac0006 admission unit &...

2018 COMPLIANCE RATINGS

23

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2

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Inspection Team:

Mary Connellan, Lead Inspector

Marianne Griffiths

Martin McMenamin

Siobhán Dinan

Inspection Date: 23 – 26 October 2018

Inspection Type: Unannounced Annual Inspection

Previous Inspection Date: 7 – 10 October 2017

The Inspector of Mental Health Services:

Dr Susan Finnerty MCRN009711

Date of Publication: Thursday 2nd May 2019

RULES AND PART 4 OF THE MENTAL HEALTH

ACT 2001

Compliant

Admission Unit & St Edna's Unit, St Loman's Hospital

ID Number: AC0006

2018 Approved Centre Inspection Report (Mental Health Act 2001)

Admission Unit & St Edna's Unit,

St Loman's Hospital

Delvin Road

Mullingar

Co Westmeath

Approved Centre Type:

Acute Adult Mental Health Care Continuing Mental Health Care/Long Stay

Most Recent Registration Date:

1 March 2017

Conditions Attached: Yes

Registered Proprietor:

HSE

Registered Proprietor Nominee:

Ms Ger McCormack, General Manager

Mental Health Services, MLM CHO

REGULATIONS

CODES OF PRACTICE

Non-compliant

Not applicable

AC0006 Admission Unit & St Edna's Unit, St Loman's Hospital Approved Centre Inspection Report 2018 of 86

RATINGS SUMMARY 2016 – 2018

Compliance ratings across all 39 areas of inspection are summarised in the chart below.

Chart 1 – Comparison of overall compliance ratings 2016 – 2018

Where non-compliance is determined, the risk level of the non-compliance will be assessed. Risk ratings

across all non-compliant areas are summarised in the chart below.

Chart 2 – Comparison of overall risk ratings 2016 – 2018

4 3 3

12 13 10

25 2526

0

5

10

15

20

25

30

35

40

45

2016 2017 2018

Not applicable Non-compliant Compliant

3 3

45

3

55

7

0

2

4

6

8

10

12

14

2016 2017 2018

Low Moderate High Critical


Contents 1.0 Introduction to the Inspection Process ............................................................................................ 4

2.0 Inspector of Mental Health Services – Review of Findings .............................................................. 6

3.0 Quality Initiatives ............................................................................................................................. 8

4.0 Overview of the Approved Centre ................................................................................................. 10

4.1 Description of approved centre ............................................................................................. 10

4.2 Conditions to registration ...................................................................................................... 10

4.3 Reporting on the National Clinical Guidelines ....................................................................... 11

4.4 Governance ............................................................................................................................ 11

4.5 Use of restrictive practices ..................................................................................................... 11

5.0 Compliance ..................................................................................................................................... 12

5.1 Non-compliant areas on this inspection ................................................................................ 12

5.2 Areas of compliance rated “excellent” on this inspection ..................................................... 12

5.3 Areas that were not applicable on this inspection ................................................................ 13

6.0 Service-user Experience ................................................................................................................. 14

7.0 Feedback Meeting .......................................................................................................................... 15

8.0 Inspection Findings – Regulations .................................................................................................. 16

9.0 Inspection Findings – Rules ............................................................................................................ 58

10.0 Inspection Findings – Mental Health Act 2001 ............................................................................ 60

11.0 Inspection Findings – Codes of Practice ....................................................................................... 62

Appendix 1: Corrective and Preventative Action Plan Template……………………………………………………….71

http://mhc-sharepoint/RegulatoryProcess/Approved%20Centres/St%20Loman's%20Hospital/Inspection%20Trail/Inspection%202018/AC0006%20Admission%20Unit%20+%20St%20Edna's%20Unit,%20St%20Loman's%20Hospital.docx#_Toc4061121












The principal functions of the Mental Health Commission are to promote, encourage and foster the

establishment and maintenance of high standards and good practices in the delivery of mental health

services and to take all reasonable steps to protect the interests of persons detained in approved centres.

The Commission strives to ensure its principal legislative functions are achieved through the registration and

inspection of approved centres. The process for determination of the compliance level of approved centres

against the statutory regulations, rules, Mental Health Act 2001 and codes of practice shall be transparent

and standardised.

Section 51(1)(a) of the Mental Health Act 2001 (the 2001 Act) states that the principal function of the

Inspector shall be to “visit and inspect every approved centre at least once a year in which the

commencement of this section falls and to visit and inspect any other premises where mental health services

are being provided as he or she thinks appropriate”.

Section 52 of the 2001 Act states that, when making an inspection under section 51, the Inspector shall

a) See every resident (within the meaning of Part 5) whom he or she has been requested to examine

by the resident himself or herself or by any other person.

b) See every patient the propriety of whose detention he or she has reason to doubt.

c) Ascertain whether or not due regard is being had, in the carrying on of an approved centre or other

premises where mental health services are being provided, to this Act and the provisions made

thereunder.

d) Ascertain whether any regulations made under section 66, any rules made under section 59 and 60

and the provision of Part 4 are being complied with.

Each approved centre will be assessed against all regulations, rules, codes of practice, and Part 4 of the 2001

Act as applicable, at least once on an annual basis. Inspectors will use the triangulation process of

documentation review, observation and interview to assess compliance with the requirements. Where non-

compliance is determined, the risk level of the non-compliance will be assessed.

The Inspector will also assess the quality of services provided against the criteria of the Judgement Support

Framework. As the requirements for the rules, codes of practice and Part 4 of the 2001 Act are set out

exhaustively, the Inspector will not undertake a separate quality assessment. Similarly, due to the nature of

Regulations 28, 33 and 34 a quality assessment is not required.

Following the inspection of an approved centre, the Inspector prepares a report on the findings of the

inspection. A draft of the inspection report, including provisional compliance ratings, risk ratings and quality

assessments, is provided to the registered proprietor of the approved centre. Areas of inspection are

deemed to be either compliant or non-compliant and where non-compliant, risk is rated as low, moderate,

high or critical.

1.0 Introduction to the Inspection Process


The registered proprietor is given an opportunity to review the draft report and comment on any of the

content or findings. The Inspector will take into account the comments by the registered proprietor and

amend the report as appropriate.

The registered proprietor is requested to provide a Corrective and Preventative Action (CAPA) plan for each

finding of non-compliance in the draft report. Corrective actions address the specific non-compliance(s).

Preventative actions mitigate the risk of the non-compliance reoccurring. CAPAs must be specific,

measurable, achievable, realistic, and time-bound (SMART). The approved centre’s CAPAs are included in

the published inspection report, as submitted. The Commission monitors the implementation of the CAPAs

on an ongoing basis and requests further information and action as necessary.

If at any point the Commission determines that the approved centre’s plan to address an area of non-

compliance is unacceptable, enforcement action may be taken.

In circumstances where the registered proprietor fails to comply with the requirements of the 2001 Act,

Mental Health Act 2001 (Approved Centres) Regulations 2006 and Rules made under the 2001 Act, the

Commission has the authority to initiate escalating enforcement actions up to, and including, removal of an

approved centre from the register and the prosecution of the registered proprietor.

COMPLIANCE, QUALITY AND RISK RATINGS The following ratings are assigned to areas inspected:

COMPLIANCE RATINGS are given for all areas inspected. QUALITY RATINGS are generally given for all regulations, except for 28, 33 and 34. RISK RATINGS are given for any area that is deemed non-compliant.

COMPLIANCE RATING

COMPLIANT

EXCELLENT

LOW

QUALITY RATING

RISK RATING

NON-COMPLIANT

SATISFACTORY

MODERATE REQUIRES IMPROVEMENT

INADEQUATE HIGH

CRITICAL


Inspector of Mental Health Services Dr Susan Finnerty

As Inspector of Mental Health Services, I have provided a summary of inspection findings under the headings

below.

This summary is based on the findings of the inspection team under the regulations and associated

Judgement Support Framework, rules, Part 4 of the Mental Health Act 2001, codes of practice, service user

experience, staff interviews and governance structures and operations, all of which are contained in this

report.

In brief The approved centre comprised of two units, the Admissions Ward and St Edna’s Ward. It was located on

the campus of St Loman’s Hospital on the outskirts of Mullingar. St Edna’s Ward provided continuing care

for male residents, all who had been in the approved centre for longer than six months and many for a

number of years. St. Edna’s Ward had accommodation for up to 20 residents; there were 11 residents at the

time of inspection. The Admissions Ward was an acute facility providing care and treatment for residents

from five community sector teams and a rehabilitation and recovery team. Two residents were in the ward

for longer than six months and there were eight vacancies on the first day of the inspection. There had been

at least a four-month period where there had been up to ten vacancies.

There was one condition attached to the registration of this approved centre at the time of inspection.

Condition: To ensure adherence to Regulation 26(4): Staffing the approved centre shall implement a plan to

ensure all healthcare professionals working in the approved centre are up-to-date in mandatory training

areas. The approved centre shall provide a progress update on staff training to the Mental Health Commission

in a form and frequency prescribed by the Commission.

The approved centre was non-compliant with Regulation 26 Staffing on this inspection for the third

consecutive year, although there was some improvement.

Compliance with regulations, rules and codes of practice was 72% in this inspection. This was a modest

improvement from 68% in 2016 and 66% in 2017. Nine compliances with regulations were rated as excellent.

Safety in the approved centre Each resident had at least two unique identifiers for administration of medication and other interventions.

Food safety was audited regularly and the kitchen area was clean. Ligature points were evident in the

approved centre, despite efforts to reduce them. All health care professionals were trained in the Mental

2.0 Inspector of Mental Health Services – Review of Findings


Health Act 2001 and Children First. However, not all healthcare staff were up to date with fire safety training,

Therapeutic Management of Violence and Aggression (TMVA) or Breakaway and Basic Life Support (BLS).

Considerable improvements had been made with mandatory training since the previous inspection.

Arrangements for responding to emergencies were not adequate evidenced by an area of St Edna’s Ward

where the alarm system was known not to work.

Appropriate care and treatment of residents All residents had a multi-disciplinary individual care plan which was developed and reviewed with the

resident. The therapeutic services and programmes provided by the approved centre did not meet the

assessed needs for all the residents, as documented in their individual care plans. Residents had no regular

access to occupational therapy, and there was no occupational therapist employed directly in the approved

centre at the time of inspection. Nursing groups were frequently cancelled due to staff shortages and

residents had reported to the advocate that there were not enough activities. The services and programmes

that were provided were not always evidence based.

While each resident had a physical assessment at least every six months, monitoring of essential indices had

not taken place in all cases. A number of the residents in St Edna’s Ward had psychogenic polydipsia and

required a specific management plan. It was reported at the feedback meeting that plans to manage this

group separately had not progressed.

The approved centre was compliant with the relevant codes of practice on ECT and admission, transfer and

discharge.

Respect for residents’ privacy, dignity and autonomy Both wards were locked and the entrance to St Edna’s was through a double set of locked doors. Staff

reported this was historical, as opposed to a being a risk management strategy. Sleeping accommodation

was mainly in single rooms with en suite facilities. There were three double bedrooms in the Admission Ward

but all the residents were accommodated in single rooms at the time of the inspection.

Residents could meet visitors in private and were free to communicate externally. They wore their own

clothes and maintained control over their own property.

The approved centre was compliant with Part 4 of the Mental Health Act Consent to Treatment.

There were 11 non-compliances with the Rules Governing the Use of Seclusion which constituted a breach

of human rights. The approved centre was non-compliant with these Rules for the third consecutive year.

There were four non-compliances with the Code of Practice on the Use of Physical Restraint.

Responsiveness to residents’ needs


There was a good range of recreational activities although two residents complained that there was not

enough to do.

The approved centre was described by residents as clean; however, it was stated the bedrooms could be

cold and one resident described the seclusion facility as notably cold. It was noted that the temperature on

the Admission Ward was an agenda item for the clinical governance meeting in February 2018 and in all

subsequent minutes for 2018.

On inspection, the approved centre was not clean and hygienic, nor was it in a good state of repair, with

broken ceiling panes, cracked glass in the conservatory, and two broken doors noted. There was not an

adequate programme of maintenance and maintenance was reactive in nature.

There was excellent information provided about the approved centre and residents’ diagnoses and

medication. The formal complaints process was not consistent or standardised. The service reported that

HSE’s Your Service Your Say process was not used to address clinical complaints. There was evidence that

two such complaints were appropriately handled by the clinical director.

A further two non-clinical complaints were not written in the complaints log and the nominated complaints

person did not have any knowledge of these complaints. The reply and follow up to one of the complainants

was not dated and therefore it was not known if the complaint had been investigated promptly.

Governance of the approved centre The approved centre was part of the Midland Louth Meath Community Healthcare Organisation, formerly

CHO8. The Catchment Management Team meetings for Longford/Westmeath Mental Health Services were

held monthly and minutes for the year to date evidenced a strategic and all-encompassing agenda. The

approved centre was referenced occasionally but was not a standalone agenda item for discussion.

The monthly Quality and Safety meetings dealt with specific items pertaining to the approved centre and

included a progress report, complaints, incidents, serious reportable events, and any other business as

applicable.

Each ward had a separate clinical governance meeting every second month. Agenda items related directly

to the running of the two wards and the care and treatment for residents.

While the approved centre did have a risk management policy it was not comprehensive and had not been

implemented fully throughout the approved centre. The risk management policy did not cover the process

of identification, assessment, treatment, reporting, and monitoring of all risks throughout the approved

centre specifically, structural risks and health and safety risks to the residents, staff, and visitors. The risk

register had not been regularly reviewed and risks dated 2010 had not been treated or closed out.

It was evident that there were systems in place to support quality improvement that included the HSE Best

Practice Guidance for Mental Health Service, National Mental Health Quality and Service User Safety Team

(QSUS) and the monthly Quality and Patient Safety meetings.

3.0 Quality Initiatives


The following quality initiatives were identified on this inspection:

1. A monthly Pop-Up Café commenced in July 2018. The aim was to empower service users and

residents in a meet and greet forum that was recovery focused.

2. A Complaints Resolution Form and a Complaints Escalation Form had been introduced into the

approved centre and wider service to improve and enhance the processes for the management of

complaints.

3. The Individual Care Planning template had been reviewed and a new pro forma had been introduced.

4. A Transition/Preparation for Discharge group had commenced in the Admissions Unit.

5. A Patient Satisfaction Survey and a Food Satisfaction Survey had been conducted for the approved

centre.

6. A Food and Diet Resource folder had been introduced. It had pictures of meals and a nutrition report

identifying all the foodstuffs available, including calorie content.

7. New policies implemented included a Transgender Policy and a Standard of Dress Policy.

8. A Physical Restraint Checklist had been introduced.

9. A number of staff were involved with the National Mental Health Quality and Service User Safety

Team (QSUS). The team met twice monthly and were working on training and self-assessment.


4.1 Description of approved centre The approved centre comprised of two units, the Admissions Ward and St Edna’s Ward. It was located on

the campus of St Loman’s Hospital on the outskirts of Mullingar. Separated by a main reception, both wards

were of similar design and had been partially refurbished within the last ten years. Both wards were locked

and the entrance to St Edna’s was through a double set of locked doors. Staff reported this was historical, as

opposed to a being a risk management strategy. Sleeping accommodation was mainly in single rooms with

en suite facilities. There were three double bedrooms in the Admission Ward but all the residents were

accommodated in single rooms at the time of the inspection.

St Edna’s Ward provided continuing care for male residents, all who had been in the approved centre for

longer than six months and many for a number of years. A number of the residents in St Edna’s Ward had

psychogenic polydipsia and required a specific management plan. It was reported at the feedback meeting

that plans to look at this group separately had not progressed. St. Edna’s Ward had accommodation for up

to 20 residents; there were 11 residents at the time of inspection.

The Admissions Ward was an acute facility providing care and treatment for residents from five community

sector teams and a rehabilitation and recovery team. Two residents were in the ward for longer than six

months and there were eight vacancies on the first day of the inspection. Staff reported, and it was noted

from bed occupancy numbers, that there had been at least a four-month period where there had been up

to ten vacancies.

The resident profile on the first day of inspection was as follows:

Resident Profile

Number of registered beds 44

Total number of residents 27

Number of detained patients 4

Number of wards of court 3

Number of children 0

Number of residents in the approved centre for more than 6 months 13

Number of patients on Section 26 leave for more than 2 weeks 0

4.2 Conditions to registration

There was one condition attached to the registration of this approved centre at the time of inspection.

Condition: To ensure adherence to Regulation 26(4): Staffing the approved centre shall implement a plan to

ensure all healthcare professionals working in the approved centre are up-to-date in mandatory training

areas. The approved centre shall provide a progress update on staff training to the Mental Health

Commission in a form and frequency prescribed by the Commission.

4.0 Overview of the Approved Centre


4.3 Reporting on the National Clinical Guidelines

The service reported that it was cognisant of and implemented, where indicated, the National Clinical

Guidelines as published by the Department of Health.

4.4 Governance

The approved centre was part of the Midland Louth Meath Community Healthcare Organisation, formerly

CHO8. Under the governance of Longford/Westmeath Mental Health Services, the wider management

structure included Laois Offaly Mental Health Services.

The Catchment Management Team meetings for Longford/Westmeath Mental Health Services were held

monthly and minutes for the year to date evidenced a strategic and all-encompassing agenda. The approved

centre was referenced occasionally but was not a standalone agenda item for discussion.

The monthly Quality and Safety meetings dealt with specific items pertaining to the approved centre and

included a progress report, complaints, incidents, serious reportable events, and any other business as

applicable.

The approved centre held local clinical governance meetings monthly, rotating bi-monthly for each ward;

therefore, each ward had a separate clinical governance meeting every second month. Agenda items related

directly to the running of the two wards and the care and treatment for residents. Examples included

individual care planning, therapeutic activities including the development of groups such as the transitioning

group, compliments and complaints, and staffing. It was noted that the temperature on the Admission Ward

was an agenda item in February 2018 and in all subsequent minutes for 2018.

The Mental Health Commission’s Governance questionnaire was completed by the approved centre’s Clinical

Director, Principal Psychology Manager, Occupational Therapy Manager, Community Dietitian Manager,

Principal Social Worker, and the Area Director of Nursing. These indicated that there were clear reporting

systems for all disciplines and the management had received training on clinical risk management, the

National Incident Management System, and Health and Safety. Operational risks identified across the

departments focussed mainly on staff shortages and recruitment difficulties, and where applicable these

had been escalated to the risk register. For those departments with no staff performance appraisal system

clinical supervision was provided. It was evident that there were systems in place to support quality

improvement that included the HSE Best Practice Guidance for Mental Health Service, QSUS and the monthly

Quality and Patient Safety meetings.

4.5 Use of restrictive practices The door into the Admissions Ward was locked at all times. There were two locked doors into St Edna’s

Ward, the rational for having a double locked door entry was explained as historical.

All bedrooms and bathrooms in St Edna’s were kept locked due to the assessed treatment needs of a cohort

of residents with psychogenic polydipsia. Staff ensured that the residents had access to drinking water, but

nonetheless this was a restrictive practice.


5.1 Non-compliant areas on this inspection

Non-compliant (X) areas on this inspection are detailed below. Also shown is whether the service was

compliant () or non-compliant (X) in these areas in 2017 and 2016 and the relevant risk rating when the

service was non-compliant:

Regulation/Rule/Act/Code Compliance/Risk Rating 2016

Compliance/Risk Rating 2017

Compliance/Risk Rating 2018

Regulation 16: Therapeutic Services and Programmes

X High X High X High

Regulation 19: General Health X High

Regulation 22: Premises X High X High

Regulation 23: Ordering, Prescribing, Storing and Administration of Medicines

X Low X High

Regulation 26: Staffing X High X High X Moderate

Regulation 31: Complaints Procedures X Moderate X High

Regulation 32: Risk Management Procedures

X Low X High

Rules Governing the Use of Seclusion X Moderate X Moderate X High

Code of Practice on the Use of Physical Restraint

X Moderate X Moderate

Code of Practice Relating to the Admission of Children

Not applicable

X High X Moderate

The approved centre was requested to provide Corrective and Preventative Actions (CAPAs) for areas of non-

compliance. These are included in Appendix 1 of the report.

5.2 Areas of compliance rated “excellent” on this inspection

Regulation

Regulation 4: Identification of Residents

Regulation 5: Food and Nutrition

Regulation 10: Religion

Regulation 11: Visits

Regulation 13: Searches

Regulation 14: Care of the Dying

Regulation 15: Individual Care Plan

Regulation 20: Provision of Information

Regulation 30: Mental Health Tribunals

5.0 Compliance


5.3 Areas that were not applicable on this inspection

Regulation/Rule/Code of Practice Details

Regulation 17: Children’s Education As no child with educational needs had been admitted to the approved centre since the last inspection, this regulation was not applicable.

Rules Governing the Use of Electro-Convulsive Therapy

As no involuntary patient had received ECT since the last inspection, this rule was not applicable.

Rules Governing the Use of Mechanical Means of Bodily Restraint

As the approved centre did not use mechanical means of bodily restraint, this rule was not applicable.


The Inspector gives emphasis to the importance of hearing the service users’ experience of the approved

centre. To that end, the inspection team engaged with residents in a number of different ways:

The inspection team informally approached residents and sought their views on the approved centre.

Posters were displayed inviting the residents to talk to the inspection team.

Leaflets were distributed in the approved centre explaining the inspection process and inviting

residents to talk to the inspection team.

Set times and a private room were available to talk to residents.

In order to facilitate residents who were reluctant to talk directly with the inspection team, residents

were also invited to complete a service user experience questionnaire and give it in confidence to

the inspection team. This was anonymous and used to inform the inspection process.

The Irish Advocacy Network (IAN) representative was contacted to obtain residents’ feedback about

the approved centre.

With the residents’ permission, their experience was fed back to the senior management team. The

information was used to give a general picture of residents’ experience of the approved centre as outlined

below.

The inspection team met with six residents. Residents were complimentary about the service and in

particular the staff. The approved centre was described by residents as clean; however, it was stated the

bedrooms could be cold and one resident described the seclusion facility as notably cold. Two residents

stated that there was not enough to do during the day.

One completed resident questionnaire was returned to the inspectors. This indicated that the resident

understood their care plan, and they knew who their key worker was. The resident indicated that they had

space for privacy and that their privacy and dignity were respected. The resident indicated that there were

not enough activities during the day. On a scale of 1-10, with 1 being poor and 10 being excellent, the

resident rated 8 out of 10 for overall experience of care and treatment.

The IAN visited the approved centre weekly. There was a notice naming the IAN representative and contact

details. The inspector met with the IAN representative to discuss issues and positive aspects as reported by

residents. It had been reported to the advocate that staff were friendly, that residents felt safe and secure

and overall the food was good. Residents had reported to the advocate that there were not enough activities,

and that there had been a vacant social work position for a considerable time.

6.0 Service-user Experience


A feedback meeting was facilitated prior to the conclusion of the inspection. This was attended by the

inspection team and the following representatives of the service:

Clinical Director

Temporary Principal Social Worker

Principal Psychology Manager Longford Westmeath

Temporary Occupational Therapy Manager

Clinical Nurse Manager 3

Clinical Nurse Manager 2 X 2

Registered Psychiatric Nurse

Assistant Director of Nursing and representing Area Director of Nursing

Acting Assistant Director of Nursing

General Manager and Registered Proprietor Nominee

Sector Administrator

The inspection team outlined the initial findings of the inspection process and provided the opportunity for

the service to offer any corrections or clarifications deemed appropriate.

7.0 Feedback Meeting


8.0 Inspection Findings – Regulations

The following regulations are not applicable Regulation 1: Citation Regulation 2: Commencement and Regulation Regulation 3: Definitions

EVIDENCE OF COMPLIANCE WITH REGULATIONS UNDER MENTAL HEALTH ACT 2001 SECTION 52 (d)


Regulation 4: Identification of Residents

The registered proprietor shall make arrangements to ensure that each resident is readily identifiable by staff when receiving medication, health care or other services.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the identification of residents, which was last reviewed in May 2017. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for identifying residents, as set out in the policy. Monitoring: An annual audit had been undertaken to ensure that there were appropriate resident identifiers on clinical files. Documented analysis had been completed to identify opportunities for improving the resident identification process. Evidence of Implementation: The approved centre used a minimum of two resident identifiers, which were appropriate to the resident group profile and individual needs. Two appropriate resident identifiers were used before administering medications, undertaking medical investigations, and providing other health care services. An appropriate resident identifier was used prior to the provision of therapeutic services and programmes. Identifiers were appropriate to the residents’ communication abilities and were person specific. Stickers alerted staff to residents with the same, or similar, names. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.

COMPLIANT Quality Rating Excellent


Regulation 5: Food and Nutrition

(1) The registered proprietor shall ensure that residents have access to a safe supply of fresh drinking water.

(2) The registered proprietor shall ensure that residents are provided with food and drink in quantities adequate for their needs, which is properly prepared, wholesome and nutritious, involves an element of choice and takes account of any special dietary requirements and is consistent with each resident's individual care plan.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to food and nutrition, which was last reviewed in June 2017. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for food and nutrition, as set out in the policy. Monitoring: A systematic review of menu plans had been undertaken to ensure that residents were provided with wholesome and nutritious food in line with their needs. Documented analysis had been completed to identify opportunities for improving the processes for food and nutrition. Evidence of Implementation: The dietitian approved menus to ensure nutritional adequacy in accordance with residents’ needs. Residents were provided with a variety of wholesome and nutritious food, which was presented in an attractive and appealing manner. The approved centre had a fortnightly menu cycle. Menus were posted in user-friendly format for lunch and dinner and were prominently displayed outside each dining room. Residents had at least two meal choices, including daily hot meals. Residents gave positive feedback concerning taste and the selection of food available to them. Residents had access to safe, fresh drinking water and hot and cold drinks were provided. In the admission unit, cold drinks were available in the sitting room and offered with every meal and by request. Several residents in St Edna’s had psychogenic polydipsia, so there was no free access to drinking water. Water was restricted throughout the unit, with bedroom and bathroom doors locked; however, residents were given drinks regularly throughout the day. Following admission to the approved centre, all residents’ nutrition and hydration needs were assessed by nursing staff. For residents with special dietary needs, nutritional and dietary needs were assessed and addressed in residents’ individual care plans. Individual dietary requirements were met with regard to vegetarian, soft, diabetic, gluten free and acute needs such as a renal friendly diet, or in relation to cultural or religious requirements. The dietitian was responsible for carrying out a full nutritional assessment upon receipt of a written referral, and the dietitian reviewed resident needs regularly. Residents and their representatives were educated about resident diets and their interaction with medication. An evidence-based nutrition assessment tool was used (the Malnutrition Universal Screening Tool (MUST) tool), and weight, input, and output charts were maintained where appropriate. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.



Regulation 6: Food Safety

(1) The registered proprietor shall ensure:

(a) the provision of suitable and sufficient catering equipment, crockery and cutlery

(b) the provision of proper facilities for the refrigeration, storage, preparation, cooking and serving of food, and

(c) that a high standard of hygiene is maintained in relation to the storage, preparation and disposal of food and related refuse.

(2) This regulation is without prejudice to:

(a) the provisions of the Health Act 1947 and any regulations made thereunder in respect of food standards (including labelling) and safety;

(b) any regulations made pursuant to the European Communities Act 1972 in respect of food standards (including labelling) and safety; and

(c) the Food Safety Authority of Ireland Act 1998.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to food safety, which was last reviewed in September 2017. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for food safety, as set out in the policy. All staff handling food had up-to-date training in food safety commensurate with their role. This training was documented, and evidence of certification was available. Monitoring: Food safety audits had not been completed periodically. Food temperatures were recorded in line with food safety recommendations. A food temperature log sheet was maintained and monitored. Documented analysis had not been completed to identify opportunities to improve food safety processes. Evidence of Implementation: Food was prepared in a manner that reduced risk of contamination, spoilage, and infection. Hygiene was maintained to support food safety requirements. There were proper facilities for the refrigeration, storage, preparation, cooking, and serving of food. Appropriate protective and catering equipment was used during the catering process. Appropriate hand-washing areas were provided for catering services. Residents were provided with crockery and cutlery that addressed their specific needs. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the monitoring pillar.

COMPLIANT Quality Rating Satisfactory


Regulation 7: Clothing

The registered proprietor shall ensure that:

(1) when a resident does not have an adequate supply of their own clothing the resident is provided with an adequate supply of appropriate individualised clothing with due regard to his or her dignity and bodily integrity at all times;

(2) night clothes are not worn by residents during the day, unless specified in a resident's individual care plan.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to residents’ clothing, which was last reviewed in May 2017. The policy addressed requirements of the Judgement Support Framework, except for the process and procedure for recording the wearing of nightclothes during the day in the resident’s individual care plan. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for residents’ clothing, as set out in the policy. Monitoring: The availability of an emergency supply of clothing for residents was monitored on an ongoing basis. This was documented. Evidence of Implementation: Residents were supported to keep and use personal clothing, which was clean and appropriate to their needs. Residents had an adequate supply of individualised clothing, which were clean and appropriate to their needs. The supply of emergency clothing was appropriate and took account of resident preferences, dignity, bodily integrity, religious, and cultural practices. Residents changed out of nightclothes during daytime hours, except for one resident, and this was indicated in their individual care plan. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the processes pillar.



Regulation 8: Residents’ Personal Property and Possessions

(1) For the purpose of this regulation "personal property and possessions" means the belongings and personal effects that a resident brings into an approved centre; items purchased by or on behalf of a resident during his or her stay in an approved centre; and items and monies received by the resident during his or her stay in an approved centre.

(2) The registered proprietor shall ensure that the approved centre has written operational policies and procedures relating to residents' personal property and possessions.

(3) The registered proprietor shall ensure that a record is maintained of each resident's personal property and possessions and is available to the resident in accordance with the approved centre's written policy.

(4) The registered proprietor shall ensure that records relating to a resident's personal property and possessions are kept separately from the resident's individual care plan.

(5) The registered proprietor shall ensure that each resident retains control of his or her personal property and possessions except under circumstances where this poses a danger to the resident or others as indicated by the resident's individual care plan.

(6) The registered proprietor shall ensure that provision is made for the safe-keeping of all personal property and possessions.

INSPECTION FINDINGS Processes: The approved centre had a written operational policy in relation to residents’ personal property and possessions, which was last reviewed in May 2017. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for residents’ personal property and possessions, as set out in the policy. Monitoring: Personal property logs were monitored in the approved centre. Documented analysis had not been completed to identify opportunities for improving the processes relating to residents’ personal property and possessions. Evidence of Implementation: Residents were entitled to bring personal possessions to the approved centre. Resident property checklists were compiled on admission and updated as needed. Checklists were kept separately to the resident’s individual care plan (ICP) and were available to residents. Where the approved centre assumed responsibility for a resident’s personal property and possessions, they were safeguarded appropriately. Secure facilities were provided for the safekeeping of the residents’ personal property. There was a patient property room and facilities to lodge money. Residents were supported to manage their own property, unless this posed a danger to the resident or others, as indicated in their ICP. Access to, and use of, resident monies was overseen by two staff members and the resident or their representative. Where money belonging to the resident was handled by staff, signed records of the staff issuing the money was retained and where possible counter-signed by the resident or their representative. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the monitoring pillar.



Regulation 9: Recreational Activities

The registered proprietor shall ensure that an approved centre, insofar as is practicable, provides access for residents to appropriate recreational activities.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the provision of recreational activities, which was last reviewed in December 2017. The policy addressed requirements of the Judgement Support Framework, with the following exceptions:

The roles and responsibilities relating to the provision of recreational activities within the approved centre.

Determining resident needs, likes, and dislikes in relation to activities.

The process for developing recreational activity programmes. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for recreational activities, as set out in the policy. Monitoring: A record was maintained of the occurrence of planned recreational activities, including a log of resident uptake and attendance. Documented analysis had been completed to identify opportunities for improving the processes relating to recreational activities. Evidence of Implementation: The approved centre provided access to recreational activities appropriate to the resident group profile. Activities were provided throughout the week, with indoor and outdoor exercise opportunities provided. Nursing staff facilitated recreational activities, including; word wheel, arts and crafts, movie nights, table quizzes, walking groups and social outings. There were lounge areas with TVs, activities rooms, and quiet rooms available to residents. Residents also had access to books, and magazines, DVDs, and CDs. The recreational activities were appropriately resourced. Communal areas were provided that were suitable for recreational activities. Despite this, residents had reported that there was not always enough to do in the approved centre. Information was provided to residents on the types and frequency of activities in an accessible format. Individual risk assessments were completed to help select activities. Recreational activities programmes were developed, implemented, and maintained for residents, with resident involvement. Residents were free to choose whether to participate and their decisions were respected and documented. Logs of participation were maintained for recreational activities. Additionally, a weekly activities plan was completed by the multi-disciplinary team at the individual care plan review meetings. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the processes pillar.



Regulation 10: Religion

The registered proprietor shall ensure that residents are facilitated, insofar as is reasonably practicable, in the practice of their religion.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the facilitation of religious practice by residents, which was last reviewed in May 2017. The policy included all of the requirements of the Judgement Support Framework.

Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for facilitating residents in the practice of their religion, as set out in the policy. Monitoring: The implementation of the policy to support residents’ religious practices was reviewed to ensure that it reflected the identified needs of residents. This was documented. Evidence of Implementation: Residents’ rights to practice religion were facilitated within the approved centre insofar as was practicable. Facilities were provided within the approved centre for residents’ religious practices and residents were supported to attend local religious services, if appropriate. Residents also had access to multi-faith chaplains. Care and services were respectful of the residents’ religious beliefs and values. Any specific religious requirements relating to the provision of services, care, and treatment were clearly documented. Residents were facilitated to observe or abstain from religious practice in accordance with their wishes. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.



Regulation 11: Visits

(1) The registered proprietor shall ensure that appropriate arrangements are made for residents to receive visitors having regard to the nature and purpose of the visit and the needs of the resident.

(2) The registered proprietor shall ensure that reasonable times are identified during which a resident may receive visits.

(3) The registered proprietor shall take all reasonable steps to ensure the safety of residents and visitors.

(4) The registered proprietor shall ensure that the freedom of a resident to receive visits and the privacy of a resident during visits are respected, in so far as is practicable, unless indicated otherwise in the resident's individual care plan.

(5) The registered proprietor shall ensure that appropriate arrangements and facilities are in place for children visiting a resident.

(6) The registered proprietor shall ensure that an approved centre has written operational policies and procedures for visits.

INSPECTION FINDINGS Processes: The approved centre had a written policy and procedures in relation to visits, which was last reviewed in December 2017. The policy and procedures included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for visits, as set out in the policy. Monitoring: Restrictions on residents’ rights to receive visitors were monitored and reviewed on an ongoing basis. Documented analysis had been completed to identify opportunities for improving visiting processes. Evidence of Implementation: Visiting times were appropriate and reasonable, and were publicly displayed. A separate visitors’ area was provided where residents met visitors in private, if appropriate. There was an alternative room that staff could use, which was used for visiting families and children. The visiting area was suitable for visiting children, and children could enter from a side entrance directly and not have to go through the entire unit. Children visiting were accompanied at all times to ensure their safety, and this was communicated to all relevant individuals publicly. The clinical file documented the names of visitors the resident did not wish to see. Appropriate steps were taken to ensure the safety of residents and visitors during visits. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.



Regulation 12: Communication

(1) Subject to subsections (2) and (3), the registered proprietor and the clinical director shall ensure that the resident is free to communicate at all times, having due regard to his or her wellbeing, safety and health.

(2) The clinical director, or a senior member of staff designated by the clinical director, may only examine incoming and outgoing communication if there is reasonable cause to believe that the communication may result in harm to the resident or to others.

(3) The registered proprietor shall ensure that the approved centre has written operational policies and procedures on communication.

(4) For the purposes of this regulation "communication" means the use of mail, fax, email, internet, telephone or any device for the purposes of sending or receiving messages or goods.

INSPECTION FINDINGS Processes: The approved centre had a written operational policy and procedures in relation to resident communication, which was last reviewed in May 2017. The policy and procedures addressed requirements of the Judgement Support Framework, but did not outline the individual risk assessment requirements in relation to limiting resident communication activities. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for communication, as set out in the policy. Monitoring: Documented analysis had been completed to identify ways of improving communication processes. There were no restrictions on resident communication at the time of inspection. Evidence of Implementation: Residents had access to telephone and mail. There was no internet access on the ward; however, most residents had their own mobile phone. Individual risk assessments were completed and documented in relation to any risks associated with the residents’ external communication. The clinical director, or senior staff member designated by the clinical director, only examined incoming and outgoing resident communication if there was reasonable cause to believe the communication may result in harm to the resident or to others. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the processes and evidence of implementation pillars.



Regulation 13: Searches

(1) The registered proprietor shall ensure that the approved centre has written operational policies and procedures on the searching of a resident, his or her belongings and the environment in which he or she is accommodated.

(2) The registered proprietor shall ensure that searches are only carried out for the purpose of creating and maintaining a safe and therapeutic environment for the residents and staff of the approved centre.

(3) The registered proprietor shall ensure that the approved centre has written operational policies and procedures for carrying out searches with the consent of a resident and carrying out searches in the absence of consent.

(4) Without prejudice to subsection (3) the registered proprietor shall ensure that the consent of the resident is always sought.

(5) The registered proprietor shall ensure that residents and staff are aware of the policy and procedures on searching.

(6) The registered proprietor shall ensure that there is be a minimum of two appropriately qualified staff in attendance at all times when searches are being conducted.

(7) The registered proprietor shall ensure that all searches are undertaken with due regard to the resident's dignity, privacy and gender.

(8) The registered proprietor shall ensure that the resident being searched is informed of what is happening and why.

(9) The registered proprietor shall ensure that a written record of every search is made, which includes the reason for the search.

(10) The registered proprietor shall ensure that the approved centre has written operational policies and procedures in relation to the finding of illicit substances.

INSPECTION FINDINGS Processes: The approved centre had a written operational policy and procedures in relation to the implementation of resident searches, which was last reviewed in December 2017. The policy and procedures addressed all of the requirements of the Judgement Support Framework, including the following:

The management and application of searches of a resident, his or her belongings, and the environment in which he or she is accommodated.

The consent requirements of a resident regarding searches and the process for carrying out searches in the absence of consent.

The process for dealing with illicit substances uncovered during a search. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the searching processes, as set out in the policy. Monitoring: A log of searches was maintained. Each search record had been systematically reviewed to ensure that the requirements of the regulation had been complied with. Documented analysis had been completed to identify ways of improving search processes. Evidence of Implementation: Searches were only conducted for the purpose of creating and maintaining a safe and therapeutic environment for residents and staff. Risk was assessed prior to a search of a resident or their property. Resident consent was sought prior to all searches, which was documented. Where consent was not received, the process relating to searches without consent was implemented. The resident search policy and procedure was communicated to all residents. Staff informed residents of what was happening during a search and why. Policy requirements were implemented when illicit substances were found.



At least two clinical staff were in attendance at all times when searches were conducted. Searches were implemented with due regard to the resident’s dignity, privacy, and gender; at least one of the staff members conducting the search was the same gender as the resident being searched. A written record of every search of a resident or property was available, which included the reason for the search, the names of both staff members who undertook the search, and details of who attended the search. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.


Regulation 14: Care of the Dying

(1) The registered proprietor shall ensure that the approved centre has written operational policies and protocols for care of residents who are dying.

(2) The registered proprietor shall ensure that when a resident is dying:

(a) appropriate care and comfort are given to a resident to address his or her physical, emotional, psychological and spiritual needs;

(b) in so far as practicable, his or her religious and cultural practices are respected;

(c) the resident's death is handled with dignity and propriety, and;

(d) in so far as is practicable, the needs of the resident's family, next-of-kin and friends are accommodated.

(3) The registered proprietor shall ensure that when the sudden death of a resident occurs:

(a) in so far as practicable, his or her religious and cultural practices are respected;

(b) the resident's death is handled with dignity and propriety, and;

(c) in so far as is practicable, the needs of the resident's family, next-of-kin and friends are accommodated.

(4) The registered proprietor shall ensure that the Mental Health Commission is notified in writing of the death of any resident of the approved centre, as soon as is practicable and in any event, no later than within 48 hours of the death occurring.

(5) This Regulation is without prejudice to the provisions of the Coroners Act 1962 and the Coroners (Amendment) Act 2005.

INSPECTION FINDINGS Processes: The approved centre had a written operational policies and protocols in relation to care of the dying:

Unexpected death in hospital, which was last reviewed in May 2017.

Care of the Dying Patient, which was last reviewed in December 2017.

Resuscitation Incorporating Decision-Making in relation to ‘Do Not Resuscitate’ Directives, which was last reviewed in September 2018.

The policies and protocols included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policies. Relevant staff interviewed were able to articulate the processes for end of life care, as set out in the policies. Monitoring: Systems analysis was undertaken in the event of a sudden or unexpected death in the approved centre. Evidence of Implementation: Two unexpected deaths had occurred since the last inspection. The sudden deaths were managed in accordance with the resident’s religious and cultural practices, with dignity and propriety, and in a way that accommodated the resident representatives, family and friends. The deaths were also managed in accordance with legal requirements. The residents’ family and friends were accommodated and offered support following the unexpected deaths. Support was given to residents and staff following a resident’s death. The deaths of residents were notified to the Mental Health Commission within 48 hours. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.



Regulation 15: Individual Care Plan

The registered proprietor shall ensure that each resident has an individual care plan.

[Definition of an individual care plan:“... a documented set of goals developed, regularly reviewed and updated by the resident’s multi-disciplinary team, so far as practicable in consultation with each resident. The individual care plan shall specify the treatment and care required which shall be in accordance with best practice, shall identify necessary resources and shall specify appropriate goals for the resident. For a resident who is a child, his or her individual care plan shall include education requirements. The individual care plan shall be recorded in the one composite set of documentation”.]

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the development, use, and review of individual care plans (ICPs), which was last reviewed in December 2017. The policy included all of the requirements of the Judgement Support Framework. Training and Education: All clinical staff had signed the signature log to indicate that they had read and understood the policy. All clinical staff interviewed were able to articulate the processes relating to individual care planning, as set out in the policy. All multi-disciplinary team (MDT) members had received training in individual care planning. Monitoring: Residents’ ICPs were audited on a monthly basis to determine compliance with the regulation. Documented analysis had been completed to identify ways of improving the individual care planning process. Evidence of Implementation: Ten ICPs were reviewed on inspection. Each resident was initially assessed at admission and an ICP was completed to address immediate needs of resident. ICPs were developed by an MDT following a comprehensive assessment, within seven days of admission. The comprehensive assessment included appropriate information and assessments. Each ICP was a composite set of documents, stored in the clinical file, identifiable and uninterrupted, and kept separately from progress notes. ICPs identified residents’ goals, treatment, care, and the resources required to meet residents’ needs. However, the resources required were vague in some ICPs. ICPs included a preliminary discharge plan, where deemed appropriate, and a risk management plan. A key worker was identified to ensure continuity in the implementation of each ICP. ICPs were developed with the participation of residents and, where appropriate, their representatives. Resident’s views of their ICPs were sought before and after MDT meetings. Evidence-based assessments were used where possible. Each ICP was reviewed by the MDT in consultation with the resident. ICPs were reviewed weekly for acute residents, quarterly for one resident, or as needed. ICPs were updated following review and residents were kept informed of any changes. Residents were offered a copy of their ICP, including any reviews. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.




(1) The registered proprietor shall ensure that each resident has access to an appropriate range of therapeutic services and programmes in accordance with his or her individual care plan.

(2) The registered proprietor shall ensure that programmes and services provided shall be directed towards restoring and maintaining optimal levels of physical and psychosocial functioning of a resident.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the provision of therapeutic services and programmes, which was last reviewed in May 2017. The policy addressed requirements of the Judgement Support Framework, with the following exceptions:

The planning of therapeutic services and programmes within the approved centre.

The resource requirements of the therapeutic services and programmes.

The review and evaluation of therapeutic services and programmes.

Training and Education: Not all clinical staff had signed the signature log to indicate that they had read and understood the policy. All clinical staff interviewed were able to articulate the processes relating to therapeutic activities and programmes, as set out in the policy. Monitoring: The range of services and programmes provided in the approved centre was monitored on an ongoing basis to ensure that the assessed needs of residents were met. Documented analysis had been completed to identify opportunities for improving the processes relating to therapeutic services and programmes. Evidence of Implementation: The therapeutic services and programmes provided by the approved centre did not meet the assessed needs for all the residents, as documented in their individual care plans. Residents had no regular access to occupational therapy, and there was no occupational therapist employed directly in the approved centre at the time of inspection. Nursing groups were frequently cancelled due to staff shortages. The services and programmes that were provided were not always evidence based, and due to limited resources available, they did not ensure optimal levels of physical and psychosocial functioning for all the residents. Adequate facilities were available in the approved centre. Where no internal service existed, an appropriate external service with an approved, qualified health professional was found. A list of services and programmes provided in the approved centre was available to residents. A record was maintained of participation, engagement, and outcomes achieved through the therapeutic programme in residents’ ICPs or clinical files. The approved centre was non-compliant with this regulation because programmes and services available were not adequate to restore or maintain optimal levels of physical and psychosocial functioning, 16(2).

NON-COMPLIANT Quality Rating Requires Improvement Risk Rating


Regulation 18: Transfer of Residents

(1) When a resident is transferred from an approved centre for treatment to another approved centre, hospital or other place, the registered proprietor of the approved centre from which the resident is being transferred shall ensure that all relevant information about the resident is provided to the receiving approved centre, hospital or other place.

(2) The registered proprietor shall ensure that the approved centre has a written policy and procedures on the transfer of residents.

INSPECTION FINDINGS Processes: The approved centre had a written policy and procedures in relation to the transfer of residents, which was last reviewed in May 2017. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for the transfer of residents, as set out in the policy. Monitoring: A log of transfers was maintained. Each transfer record had not been systematically reviewed to ensure all relevant information was provided to the receiving facility. Documented analysis had not been completed to identify opportunities for improving the provision of information during transfers. Evidence of Implementation: The clinical file of one emergency transfer was reviewed on inspection. An assessment of the resident was completed and documented prior to transfer, including an individual risk assessment. A nurse accompanied the resident and had information on the reasons for transfer, care and treatment plans, and the resident’s accompaniment requirements. A non-consultant hospital doctor was called in advance of the transfer, and written and verbal information was provided to the receiving facility. Communications between the approved centre and receiving facility were documented and followed up with a written referral. Documented consent from the resident was available. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the monitoring pillar.



Regulation 19: General Health

(1) The registered proprietor shall ensure that:

(a) adequate arrangements are in place for access by residents to general health services and for their referral to other health services as required;

(b) each resident's general health needs are assessed regularly as indicated by his or her individual care plan and in any event not less than every six months, and;

(c) each resident has access to national screening programmes where available and applicable to the resident.

(2) The registered proprietor shall ensure that the approved centre has written operational policies and procedures for responding to medical emergencies.

INSPECTION FINDINGS Processes: The approved centre had the following written operational policies and procedures in relation to the provision of general health services and the response to medical emergencies:

Maintenance of general health of patients, which was last reviewed in December 2017.

Procedure for checking Emergency Equipment, which was last reviewed in May 2017.

Responding to Medical Emergencies, which was last reviewed in September 2017 The policies and procedures addressed requirements of the Judgement Support Framework, with the following exceptions:

The staff training requirements in relation to Basic Life Support.

The resource requirements for general health services, including equipment needs. Training and Education: Not all clinical staff had signed the signature log to indicate that they had read and understood the policies. All clinical staff interviewed were able to articulate the processes relating to the provision of general health services and the response to medical emergencies, as set out in the policies. Monitoring: Residents’ take-up of national screening programmes was not recorded and monitored, where applicable. A systematic review had not been undertaken to ensure that six-monthly general health assessments of residents occurred. Analysis had not been completed to identify opportunities for improving general health processes. Evidence of Implementation: Five clinical files were reviewed for general health assessment on inspection. Residents received appropriate general health care interventions in line with their individual care plans. Registered medical practitioners assessed residents’ general health needs at admission and on an ongoing basis as indicated by the residents’ needs. Residents’ general health needs were monitored and assessed as indicated by the residents’ specific needs, but at least every six months. The six-monthly general health assessment included a physical examination, family and personal history, blood pressure, weight, waist circumference, body mass index (BMI) smoking and nutritional status, and a medication review. However, two files did not indicate waist circumference, one did not indicate BMI and no file referenced a dental review. Residents on antipsychotic medication received an annual assessment that considered glucose regulation and heart health via an electro-cardiogram exam. However, two of the five files did not include blood lipids or prolactin levels.



Residents could access general health services and be referred to other health services. Residents had information on, and could access, appropriate national screening programmes, including breast checks, cervical screening, retina checks, and bowel screening. There was a localised policy on tobacco use. Medical emergencies, and the care provided, were recorded. Residents’ completed general health checks and associated results were recorded. The approved centre had an emergency trolley and staff had access at all times to an automated external defibrillator. Both were checked weekly. The approved centre was non-compliant with this regulation because:

a) The six monthly physical examinations did not include dental health checks, 19(1) (b) b) The six monthly physical examination for two residents did not document waist circumference,

and for one resident BMI, 19(1) (b) c) Not all residents in receipt of anti-psychotic medication had been assessed annually for blood

lipids and prolactin levels 19 (1) (b).


Regulation 20: Provision of Information to Residents

(1) Without prejudice to any provisions in the Act the registered proprietor shall ensure that the following information is provided to each resident in an understandable form and language:

(a) details of the resident's multi-disciplinary team;

(b) housekeeping practices, including arrangements for personal property, mealtimes, visiting times and visiting arrangements;

(c) verbal and written information on the resident's diagnosis and suitable written information relevant to the resident's diagnosis unless in the resident's psychiatrist's view the provision of such information might be prejudicial to the resident's physical or mental health, well-being or emotional condition;

(d) details of relevant advocacy and voluntary agencies;

(e) information on indications for use of all medications to be administered to the resident, including any possible side-effects.

(2) The registered proprietor shall ensure that an approved centre has written operational policies and procedures for the provision of information to residents.

INSPECTION FINDINGS Processes: The approved centre had a written policy and procedures in relation to the provision of information to residents, which was last reviewed in May 2017. The policy and procedures included all of the requirements of the Judgement Support Framework. Training and Education: All staff had signed the signature log to indicate that they had read and understood the policy. All staff interviewed were able to articulate the processes relating to the provision of information to residents, as set out in the policy. Monitoring: The provision of information to residents was monitored on an ongoing basis to ensure it was appropriate and accurate, particularly where information changed. Documented analysis had been completed to identify opportunities for improving the processes relating to the provision of information to residents. Evidence of Implementation: An information booklet was provided to residents and their representatives at admission in the required format. The booklet was clearly and simply written, and outlined the required information on care, services, and housekeeping practices, including arrangements for personal property, mealtimes, visiting times, and visiting arrangements, the complaints procedure, relevant advocacy and voluntary agencies, residents’ rights, and details of the multi-disciplinary team. A variety of diagnosis and medication-related information, including risks and potential side effects, was available on request and provided to residents as appropriate. Information included evidence-based information about diagnosis, unless the provision of such information would be detrimental to a resident’s health and well-being. The justification for restricting information was documented. Information was accessible and residents had access to interpretation and translation services as required. Documentation was appropriately reviewed and approved prior to use. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.



Regulation 21: Privacy

The registered proprietor shall ensure that the resident's privacy and dignity is appropriately respected at all times.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to resident privacy, which was last reviewed in May 2017. The policy addressed requirements of the Judgement Support Framework, with the exception of the approved centre’s process for addressing a situation where resident privacy and dignity is not respected by staff. Training and Education: All staff had signed the signature log to indicate that they had read and understood the policy. All staff interviewed could articulate the processes for ensuring resident privacy and dignity, as set out in the policy. Monitoring: A documented annual review had not been undertaken to ensure that the policy was being implemented and that the premises and facilities in the approved centre were conducive to resident privacy. Analysis had not been completed to identify opportunities for improving the processes relating to residents’ privacy and dignity. Evidence of Implementation: Residents were addressed by their preferred names, and staff members were observed to interact with residents in a respectful manner. Staff used discretion when discussing medical conditions or treatment. Staff sought the resident’s permission before entering their room. All bathrooms, showers, toilets, and single bedrooms had locks with an override function on the inside of the door, unless there was an identified risk to a resident. All residents were wearing clothes that respected their privacy and dignity. Residents were facilitated to make private phone calls. Where residents shared a room, bed screening ensured that their privacy was not compromised. All observation panels on doors of treatment rooms and bedrooms were fitted with blinds, curtains, or opaque glass. Rooms were not overlooked by public areas. Noticeboards did not display resident names or other identifiable information. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the processes and monitoring pillars.



Regulation 22: Premises

(1) The registered proprietor shall ensure that:

(a) premises are clean and maintained in good structural and decorative condition;

(b) premises are adequately lit, heated and ventilated;

(c) a programme of routine maintenance and renewal of the fabric and decoration of the premises is developed and implemented and records of such programme are maintained.

(2) The registered proprietor shall ensure that an approved centre has adequate and suitable furnishings having regard to the number and mix of residents in the approved centre.

(3) The registered proprietor shall ensure that the condition of the physical structure and the overall approved centre environment is developed and maintained with due regard to the specific needs of residents and patients and the safety and well-being of residents, staff and visitors.

(4) Any premises in which the care and treatment of persons with a mental disorder or mental illness is begun after the commencement of these regulations shall be designed and developed or redeveloped specifically and solely for this purpose in so far as it practicable and in accordance with best contemporary practice.

(5) Any approved centre in which the care and treatment of persons with a mental disorder or mental illness is begun after the commencement of these regulations shall ensure that the buildings are, as far as practicable, accessible to persons with disabilities.

(6) This regulation is without prejudice to the provisions of the Building Control Act 1990, the Building Regulations 1997 and 2001, Part M of the Building Regulations 1997, the Disability Act 2005 and the Planning and Development Act 2000.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to its premises, which was last reviewed in May 2017. The policy addressed requirements of the Judgement Support Framework, with the following exceptions:

The approved centre’s utility controls and requirements.

The provision of adequate and suitable furnishings in the approved centre.

The identification of hazards and ligature points in the premises. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed could articulate the processes relating to the maintenance of the premises, as set out in the policy. Monitoring: The approved centre had not completed a hygiene audit. The approved centre had completed a ligature audit using a validated audit tool. Documented analysis had not been completed to identify opportunities for improving the premises. Evidence of Implementation: Residents had access to personal space and room to move about. Each ward had access to an internal courtyard and gardens. There were suitable furnishings and supports to assist resident independence and comfort. There were enough toilets and showers, which were appropriately placed and identified. There was a sluice room, cleaning room, dedicated therapy room, and laundry room. Rooms were well ventilated. Residents noted the approved centre could be cold, and inspectors found that parts of the approved centre were cold. Heating was controlled centrally, and could not be changed in individual resident rooms. The approved centre had adequate lighting, appropriate signage and sensory aids, and no excessive noise was noted. Hazards were appropriately identified and minimised. There was



a cleaning schedule; however, the approved centre was not clean and hygienic. Windows and conservatory tiles in the approved centre were dirty. White radiators had grey marks on them. There was rubbish on the ground of the courtyard in the Admission unit and there were cigarette butts in the garden. The finish on the paving in the courtyard of the Admissions unit was dirty at the time of the inspection. Current national infection control guidelines were followed. The approved centre was not in a good state of repair, with broken ceiling panes, cracked glass in the conservatory, and two broken doors noted. There was not an adequate programme of maintenance, as maintenance was reactive in nature. Where faults or problems were identified, this was not adequately communicated through an appropriate maintenance reporting process; with the maintenance team responding to issues logged on an informal and reactive basis, often by telephone or email. The approved centre had access to back-up power. Ligature points were evident in the approved centre, despite efforts to reduce them. Remote or isolated areas were monitored. The approved centre was non-compliant with this regulation for the following reasons:

a) The premises were not clean and maintained in good structural and decorative condition, 22 (1)(a).

b) The premises were not adequately heated, as the heating did not function well and both wards were cold at times, 22 (1)(b).

c) A programme of routine maintenance and renewal of the fabric and decoration of the premises was not developed and implemented, as there were broken doors and cracked glass in the conservatory, 22 (1)(c).

d) The condition of the physical structure and the overall approved centre environment was not developed and maintained with due regard to the specific needs of residents and patients and the safety and well-being of residents, staff, and visitors as there were outstanding ligature points, 22 (3).



(1) The registered proprietor shall ensure that an approved centre has appropriate and suitable practices and written operational policies relating to the ordering, prescribing, storing and administration of medicines to residents.

(2) This Regulation is without prejudice to the Irish Medicines Board Act 1995 (as amended), the Misuse of Drugs Acts 1977, 1984 and 1993, the Misuse of Drugs Regulations 1998 (S.I. No. 338 of 1998) and 1993 (S.I. No. 338 of 1993 and S.I. No. 342 of 1993) and S.I. No. 540 of 2003, Medicinal Products (Prescription and control of Supply) Regulations 2003 (as amended).

INSPECTION FINDINGS Processes: The approved centre had written policies in relation to the ordering, storing, prescribing, and administration of medication, all last reviewed in May 2017:

Medication Management.

Administering of intra-muscular medication without consent.

Procedure for the checking of emergency equipment.

Labelling, supply and storage of insulin. The policies addressed all of the requirements of the Judgement Support Framework. Training and Education: All nursing and medical staff had signed the signature log to indicate that they had read and understood the policies. All nursing and medical staff interviewed could articulate the processes relating to the ordering, prescribing, storing, and administering of medicines, as set out in the policies. Staff had access to comprehensive, up-to-date information on all aspects of medication management. All nursing and medical staff had received training on the importance of reporting medication incidents, errors, or near misses. The training was documented. Monitoring: Quarterly audits of Medication Prescription and Administration Records (MPARs) had been undertaken to determine compliance with the policies and procedures and the applicable legislation and guidelines. Incident reports were recorded for medication incidents, errors, and near misses. Analysis had been completed to identify opportunities for improving medication management processes. Evidence of Implementation: Ten MPARs were reviewed on inspection. All entries were legible, written in black, indelible ink, and used two appropriate identifiers. MPARs had dedicated space for routine, once-off, and “as-required” medications. A record of all medications administered to residents was kept, as well as the medication dosage, allergies status, and generic and full name. MPARs included the Medical Council Registration Number of every medical practitioner prescribing medication, and MPARs were signed by the medical practitioner after each entry. However:

Two MPARs did not indicate the frequency of administration.

One did not indicate the administration route for the medication.

Two did not have a record of all medications administered to the resident.

One did not include a clear record of the date of initiation for each medication.

One did not include a clear record of the date of discontinuation for each medication.

The expiration date of medication was checked prior to administration; expired medications were not administered. Good hand-hygiene techniques were implemented during the dispensing of medications. Schedule 2 controlled drugs were: checked by two staff members, including one registered nurse, against



the delivery form; details were entered on the controlled drug book; and signed by both staff members. The controlled drug balance corresponded with the balance recorded in the controlled drug book. When a resident’s medication was withheld, the justification was noted in the MPAR and documented in a clinical file. Medication was stored in an appropriate environment. Medication storage areas were clean, and free from damp, mould, litter, dust, pests, spillage or breakage. Food and drink was not stored in areas used for medication storage. Medication storage areas were incorporated in the cleaning and housekeeping schedules. Where medication required refrigeration, a log of the temperature of the refrigeration storage unit was not taken. Medication dispensed or supplied to residents was stored securely in a locked storage unit, with the exception of medication that was recommended to be stored elsewhere. The medication trolley and medication administration cupboard were locked at all times and secured in a locked room. Schedule 2 and 3 controlled drugs were locked in a separate cupboard from other medicinal products to ensure further security. Medication was reviewed and rewritten at least six-monthly, or more frequently as appropriate; this was documented in clinical files. In one case, medical practitioners did not rewrite prescriptions where alteration was required. The approved centre implemented a system of stock rotation and completed a monthly inventory of medications; however, the inventory did not include the name and dose of medication. Medications that were no longer required were stored in a secure manner, segregated from other medication. However, some stock items were identified that were no longer required by residents. The approved centre was non-compliant with this regulation because the approved centre did not have appropriate and suitable practices relating to the ordering, prescribing and administration of medicines to residents, 23 (1):

a) Two MPARs did not have a record of all medications administered to the resident. b) One MPAR did not record the administration route of medication. c) One MPAR did not record the date of discontinuation for each medication. d) One MPAR did not have a clear record of the date of initiation for each medication. e) Where medication required refrigeration, a log of the temperature of the refrigeration storage

unit was not taken.


Regulation 24: Health and Safety

(1) The registered proprietor shall ensure that an approved centre has written operational policies and procedures relating to the health and safety of residents, staff and visitors.

(2) This regulation is without prejudice to the provisions of Health and Safety Act 1989, the Health and Safety at Work Act 2005 and any regulations made thereunder.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to health and safety of residents, staff, and visitors, which was last reviewed in May 2017. It also had an associated safety statement, dated June 2017. The policies and safety statement addressed some of the requirements of the Judgement Support Framework, but with the following exceptions:

The specific roles to be allocated to the registered proprietor in relation to the achievement of health and safety legislative requirements.

Infection control measures, including o Provision and required use of personal protective equipment (PPE). o Safe handling and disposal of health care risk waste. o Management of spillages. o Raising awareness of residents and their visitors to infection control measures. o Hand washing. o Linen handling. o Covering of cuts and abrasions. o Availability of staff vaccinations and immunisations. o Management and reporting of an infection outbreak. o Support provided to staff following exposure to infectious diseases. o Specific infection control measures in relation to infection types, e.g. C.diff, MRSA,

Norovirus.

First aid response requirements.

Falls prevention initiatives.

Vehicle controls.

The staff training requirements in relation to health and safety.

The monitoring and continuous improvement requirements implemented for the health and safety processes.

Training and Education: All staff had signed the signature log to indicate that they had read and understood the policies. All staff interviewed were able to articulate the processes relating to health and safety, as set out in the policies. Monitoring: The health and safety policy was monitored pursuant to Regulation 29: Operational Policies and Procedures. Evidence of Implementation: Regulation 24 was only assessed against the approved centre’s written policies and procedures. Health and safety practices within the approved centre were not assessed. The approved centre was compliant with this regulation.

COMPLIANT


Regulation 25: Use of Closed Circuit Television

(1) The registered proprietor shall ensure that in the event of the use of closed circuit television or other such monitoring device for resident observation the following conditions will apply:

(a) it shall be used solely for the purposes of observing a resident by a health

professional who is responsible for the welfare of that resident, and solely for the purposes of ensuring the health and welfare of that resident;

(b) it shall be clearly labelled and be evident;

(c) the approved centre shall have clear written policy and protocols articulating its function, in relation to the observation of a resident;

(d) it shall be incapable of recording or storing a resident's image on a tape, disc, hard drive, or in any other form and be incapable of transmitting images other than to the monitoring station being viewed by the health professional responsible for the health and welfare of the resident;

(e) it must not be used if a resident starts to act in a way which compromises his or her dignity.

(2) The registered proprietor shall ensure that the existence and usage of closed circuit television or other monitoring device is disclosed to the resident and/or his or her representative.

(3) The registered proprietor shall ensure that existence and usage of closed circuit television or other monitoring device is disclosed to the Inspector of Mental Health Services and/or Mental Health Commission during the inspection of the approved centre or at any time on request.

INSPECTION FINDINGS Processes: The approved centre had a written policy and protocols in relation to the use of CCTV, which was last reviewed in December 2017. The policy addressed requirements of the Judgement Support Framework, including the purpose and function of using CCTV for observing residents in the approved centre. The policy did not include the following:

The measures used to ensure the privacy and dignity of residents when the approved centre uses CCTV cameras or other monitoring equipment.

The maintenance of CCTV cameras by the approved centre.

The process to cease monitoring a resident using CCTV in certain circumstances. Training and Education: All relevant staff had signed the signature log to indicate that they had read and understood the policy. All staff interviewed were able to articulate the processes relating to the use of CCTV, as set out in the policy. Monitoring: The quality of the CCTV images was not checked regularly to ensure that the equipment was operating appropriately. Analysis had not been completed to identify opportunities for improving the processes relating to the use of CCTV. Evidence of Implementation: There were clear signs in prominent positions where CCTV cameras (or other monitoring systems) were located. Residents were monitored solely for the purposes of ensuring their health, safety, and welfare. CCTV was not used to monitor a resident if they started to act in a way that compromised their dignity. CCTV cameras were incapable of recording or storing a resident’s image. CCTV cameras did not transmit images other than to a monitor that was viewed solely by the health professional responsible for the resident. The usage of CCTV was disclosed to the Mental Health Commission.



The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the processes and monitoring pillars.


Regulation 26: Staffing

(1) The registered proprietor shall ensure that the approved centre has written policies and procedures relating to the recruitment, selection and vetting of staff.

(2) The registered proprietor shall ensure that the numbers of staff and skill mix of staff are appropriate to the assessed needs of residents, the size and layout of the approved centre.

(3) The registered proprietor shall ensure that there is an appropriately qualified staff member on duty and in charge of the approved centre at all times and a record thereof maintained in the approved centre.

(4) The registered proprietor shall ensure that staff have access to education and training to enable them to provide care and treatment in accordance with best contemporary practice.

(5) The registered proprietor shall ensure that all staff members are made aware of the provisions of the Act and all regulations and rules made thereunder, commensurate with their role.

(6) The registered proprietor shall ensure that a copy of the Act and any regulations and rules made thereunder are to be made available to all staff in the approved centre.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to its staffing requirements, which was last reviewed in December 2017. The policy and procedures addressed requirements of the Judgement Support Framework, including the following:

The roles and responsibilities for the recruitment, selection, vetting, and appointment processes for all staff within the approved centre.

The recruitment, selection, and appointment process of the approved centre, including the Garda vetting requirements.

The policy and procedures did not address the following:

The methods applied for the communication of rotas to staff.

Staff performance and evaluation requirements.

The process for transferring responsibility from one staff member to another.

The required qualifications of training personnel.

The evaluation of training programmes. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes relating to staffing, as set out in the policy. Monitoring: The implementation and effectiveness of the staff training plan was reviewed on an annual basis. This was documented. The numbers and skill mix of staff had been reviewed against the levels recorded in the approved centre’s registration. Analysis had been completed to identify opportunities to improve staffing processes and respond to the changing needs and circumstances of residents. Evidence of Implementation: The numbers and skill mix of staff was not sufficient to meet resident needs. At the time of inspection the lack of occupational therapy in the approved centre was noted. Staff were recruited and vetted in accordance with the approved centre’s policy and procedure. Staff had the appropriate qualifications to carry out their duties. The required number of staff were on duty at night to ensure safety of residents in the event of a fire or other emergency. A planned and actual staff rota was



maintained and an appropriately qualified staff member was on duty and in charge at all times; this was documented. There was an organisational chart to identify the leadership, management structure, and lines of authority and accountability. Where agency staff were used, there was a comprehensive contract between the approved centre and registered staffing agency, which set out the vetting requirements for potential staff. There was no staffing plan for the approved centre. Annual staff training plans had been completed to identify required training and skills development. New staff completed orientation and induction training. All health care professionals were trained in the Mental Health Act 2001 and Children First. However, not all healthcare staff were up to date with fire safety training, Therapeutic Management of Violence and Aggression (TMVA) or Breakaway and Basic Life Support (BLS). Considerable improvements had been made with mandatory training since the previous inspection. Staff had also received a range of other training, including manual handling, risk management, incident reporting, and protection of children and vulnerable adults. Opportunities were made available and communicated to staff, and staff were supported to undertake further education. In-service training was completed by appropriately trained and competent individuals. Facilities and equipment were available for staff in-service education and training. Staff training was documented and staff training logs were maintained. The Mental Health Act 2001, the associated regulation (S.I. No.551 of 2006) and Mental Health Commission Rules and Codes, and all other relevant Mental Health Commission documentation and guidance were available to staff throughout the approved centre. The following is a table of clinical staff assigned to the approved centre.

Clinical Nurse Manager (CNM), Registered Psychiatric Nurse (RPN), CNM3- One W.T.E for the Approved Centre. * Shared CNM 3 between both Admission Ward and St Edna’s Ward.

The approved centre was non-compliant with this regulation for the following reasons:

a) The numbers and skill mix of staffing was not appropriate to the assessed needs of residents, 26(2).

b) Not all healthcare professionals were up to date with the required mandatory training, 26 (4).

Ward or Unit Staff Grade Day Night

Admission Ward

CNM3 CNM2 RPN Occupational Therapist

1* 1 5 Vacant

1* 0 3

Ward or Unit Staff Grade Day Night

St Edna’s Ward

CNM3 CNM2 RPN Occupational Therapist

1* 1 5 Vacant

1* 0 3


Regulation 27: Maintenance of Records

(1) The registered proprietor shall ensure that records and reports shall be maintained in a manner so as to ensure completeness, accuracy and ease of retrieval. All records shall be kept up-to-date and in good order in a safe and secure place.

(2) The registered proprietor shall ensure that the approved centre has written policies and procedures relating to the creation of, access to, retention of and destruction of records.

(3) The registered proprietor shall ensure that all documentation of inspections relating to food safety, health and safety and fire inspections is maintained in the approved centre.

(4) This Regulation is without prejudice to the provisions of the Data Protection Acts 1988 and 2003 and the Freedom of Information Acts 1997 and 2003.

Note: Actual assessment of food safety, health and safety and fire risk records is outside the scope of this Regulation, which refers only to maintenance of records pertaining to these areas.

INSPECTION FINDINGS Processes: The approved centre had a written policy and procedures in relation to the maintenance of records, which was last reviewed in March 2018. The policy and procedures addressed requirements of the Judgement Support Framework, including the following:

The roles and responsibilities for the creation of, access to, retention of, and destruction of records.

The required resident record creation and content.

Those authorised to access and make entries in residents’ records.

Record retention periods.

The destruction of records. The policy and procedures did not address the retention of inspection reports relating to food safety, health and safety, and fire inspections. Training and Education: All clinical staff and other relevant staff had signed the signature log to indicate that they had read and understood the policy. All clinical staff and other relevant staff interviewed were able to articulate the processes relating to the creation of, access to, retention of, and destruction of records, as set out in the policy. Not all clinical staff had been trained in best-practice record keeping. Monitoring: Resident records were audited to ensure their completeness, accuracy, and ease of retrieval. This was documented. Analysis had been completed to identify opportunities to improve the processes relating to the maintenance of records. Evidence of Implementation: The approved centre maintained a record for every resident who was assessed or provided with care. Records had unique identifiers, were secure, up to date, in good order, and maintained in line with national guidelines and legislative requirements. Only authorised staff could access data and make new entries, and residents’ could access records in line with data protection legislation. Staff had access to the information needed to carry out their job. Records were maintained appropriately, including being factual, consistent, written legibly in indelible black ink. The records reflected the residents’ current status, used date and time (using the 24 hour clock), and were signed appropriately. The approved centre also maintained a record of signatures used in



resident record. All entries made by student nurses or clinical training staff were countersigned by a registered nurse or clinical supervisor. Where errors were made, they were corrected appropriately. Where a member of staff made a referral, or consulted with a colleague, this person was clearly identified by their full name and title. Information or advice were given over the phone was documented. Documentation of food safety, health and safety, and fire inspections was maintained. Records were retained or destroyed in accordance with legislative requirements. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the processes and training and education pillars.


Regulation 28: Register of Residents

(1) The registered proprietor shall ensure that an up-to-date register shall be established and maintained in relation to every resident in an approved centre in a format determined by the Commission and shall make available such information to the Commission as and when requested by the Commission.

(2) The registered proprietor shall ensure that the register includes the information specified in Schedule 1 to these Regulations.

INSPECTION FINDINGS The approved centre had a documented register of residents, which was up to date. It contained all of the required information listed in Schedule 1 to the Mental Health Act 2001 (Approved Centres) Regulations 2006. The approved centre was compliant with this regulation.

COMPLIANT


Regulation 29: Operating Policies and Procedures

The registered proprietor shall ensure that all written operational policies and procedures of an approved centre are reviewed on the recommendation of the Inspector or the Commission and at least every 3 years having due regard to any recommendations made by the Inspector or the Commission.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the development and review of operating policies and procedures required by the regulations, which was last reviewed in May 2017. It addressed requirements of the Judgement Support Framework, with the following exceptions:

The process for reviewing and updating operating policies and procedures, at least every three years.

The process for training on operating policies and procedures, including the requirements for training following the release of a new or updated operating policy and procedure.

The process for making obsolete and retaining previous versions of operating policies and procedures.

The standardised operating policy and procedure layout used by the approved centre. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Not all relevant staff had been trained on approved operational policies and procedures. Relevant staff interviewed could articulate the processes for developing and reviewing operational policies, as set out in the policy. Monitoring: An annual audit had been undertaken to determine compliance with review time frames. Analysis had been completed to identify opportunities for improving the processes of developing and reviewing policies. Evidence of Implementation: The operating policies and procedures were developed with input from clinical and managerial staff and in consultation with relevant stakeholders. The policies incorporated relevant legislation, evidence-based best practice, and clinical guidelines. The policies were appropriately formatted, approved, and communicated to all relevant staff. Relevant policies had been reviewed within the past three years. Obsolete versions of operating policies and procedures were retained but removed from access by staff. Generic policies were appropriate to the approved centre and the resident group profile. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the processes and training and education pillars.



Regulation 30: Mental Health Tribunals

(1) The registered proprietor shall ensure that an approved centre will co-operate fully with Mental Health Tribunals.

(2) In circumstances where a patient's condition is such that he or she requires assistance from staff of the approved centre to attend, or during, a sitting of a mental health tribunal of which he or she is the subject, the registered proprietor shall ensure that appropriate assistance is provided by the staff of the approved centre.

INSPECTION FINDINGS Processes: The approved centre had a written policy and procedures in relation to the facilitation of Mental Health Tribunals, which was last reviewed in May 2017. The policy and procedures included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed could articulate the processes for facilitating Mental Health Tribunals, as set out in the policy. Monitoring: Analysis had been completed to identify opportunities for improving the processes for facilitating Mental Health Tribunals. Evidence of Implementation: The approved centre provided private facilities and adequate resources to support the Mental Health Tribunal process. Staff attended Mental Health Tribunals and provided assistance, as necessary, when the patient required assistance to attend or participate in the process. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.



Regulation 31: Complaints Procedures

(1) The registered proprietor shall ensure that an approved centre has written operational policies and procedures relating to the making, handling and investigating complaints from any person about any aspects of service, care and treatment provided in, or on behalf of an approved centre.

(2) The registered proprietor shall ensure that each resident is made aware of the complaints procedure as soon as is practicable after admission.

(3) The registered proprietor shall ensure that the complaints procedure is displayed in a prominent position in the approved centre.

(4) The registered proprietor shall ensure that a nominated person is available in an approved centre to deal with all complaints.

(5) The registered proprietor shall ensure that all complaints are investigated promptly.

(6) The registered proprietor shall ensure that the nominated person maintains a record of all complaints relating to the approved centre.

(7) The registered proprietor shall ensure that all complaints and the results of any investigations into the matters complained and any actions taken on foot of a complaint are fully and properly recorded and that such records shall be in addition to and distinct from a resident's individual care plan.

(8) The registered proprietor shall ensure that any resident who has made a complaint is not adversely affected by reason of the complaint having been made.

(9) This Regulation is without prejudice to Part 9 of the Health Act 2004 and any regulations made thereunder.

INSPECTION FINDINGS Processes: The approved centre had a written operational policy and procedures in relation to the management of complaints, which was last reviewed in May 2017. The policy and procedures addressed all of the requirements of the Judgement Support Framework, including the process for managing complaints, including the raising, handling, and investigation of complaints from any person regarding any aspect of the services, care, and treatment provided in or on behalf of the approved centre. Training and Education: Not all relevant staff had been trained on the complaints management process. All staff had signed the signature log to indicate that they had read and understood the policy. All staff interviewed were able to articulate the processes for making, handling, and investigating complaints, as set out in the policy. Monitoring: Audits of the complaints log and related records had been completed. Audits were documented and the findings were acted upon. Complaints data was not analysed. A quality initiative to improve the complaints management process had been introduced. Evidence of Implementation: Residents and their representatives were provided with information on the complaints process, with information being well publicised and accessible. Residents and their representatives were assisted to make complaints using appropriate methods and were facilitated to access an advocate. There was a nominated complaints officer who was responsible for dealing with complaints, who was clearly identified. There was a method for addressing minor complaints; and there was a system for logging or recording them. The registered proprietor ensured that the quality of the service, care, and treatment of a resident was not adversely affected because of the complaint being made.



The formal complaints process was not consistent or standardised. The service reported that HSE’s Your Service Your Say process was not used to address clinical complaints. There was evidence that two such complaints were appropriately handled by the clinical director. A further two non-clinical complaints were not written in the complaints log and the nominated complaints person did not have any knowledge of these complaints. Because of this, the nominated person had not dealt with every complaint and complaints were not properly recorded. The reply and follow up to one of the complainants was not dated and therefore it was not known if the complaint had been investigated promptly. The approved centre was non-compliant with this regulation for the following reasons:

a) There was no evidence to support a complaint had been investigated promptly, 31(5). b) The nominated complaints person did not have a record of all complaints relating to the

approved centre, 31(6).



(1) The registered proprietor shall ensure that an approved centre has a comprehensive written risk management policy in place and that it is implemented throughout the approved centre.

(2) The registered proprietor shall ensure that risk management policy covers, but is not limited to, the following:

(a) The identification and assessment of risks throughout the approved centre;

(b) The precautions in place to control the risks identified;

(c) The precautions in place to control the following specified risks:

(i) resident absent without leave,

(ii) suicide and self harm,

(iii) assault,

(iv) accidental injury to residents or staff;

(d) Arrangements for the identification, recording, investigation and learning from serious or untoward incidents or adverse events involving residents;

(e) Arrangements for responding to emergencies;

(f) Arrangements for the protection of children and vulnerable adults from abuse.

(3) The registered proprietor shall ensure that an approved centre shall maintain a record of all incidents and notify the Mental Health Commission of incidents occurring in the approved centre with due regard to any relevant codes of practice issued by the Mental Health Commission from time to time which have been notified to the approved centre.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to risk management and incident management procedures, which was last reviewed in June 2017. The policy addressed requirements of the Judgement Support Framework, including the following:

The process for rating identified risks.

The methods for controlling risks associated with resident absence without leave, suicide and self-harm, assault, and accidental injury to residents or staff.

The process for managing incidents involving residents of the approved centre.

The process for responding to emergencies.

The process for protecting children and vulnerable adults in the care of the approved centre. The policy did not address the following:

The person with overall responsibility for risk management.

The process of identification, assessment, treatment, reporting, and monitoring of risks throughout the approved centre, including:

o Organisational risks. o Structural risks, including ligature points. o Capacity risks relating to the number of residents in the approved centre o Health and safety risks to the residents, staff, and visitors. o Risks to the resident group during the provision of general care and services. o Risks to individual residents during the delivery of individualised care.

The process for responding to specific emergencies, including: o The roles and responsibilities of key staff. o The sequence of required actions.



o The process for communication. Training and Education: Relevant staff had received training in the identification, assessment, and management of risk. Clinical staff were trained in individual risk management processes. Management were trained in organisational risk management. All staff had been trained in incident reporting and documentation. All staff had signed the signature log to indicate that they had read and understood the policy. Not all staff interviewed were able to articulate the risk management processes, as set out in the policy. All training was documented. Monitoring: The risk register was not reviewed at least quarterly to determine compliance with the approved centre’s risk management policy. Analysis of incident reports had not been completed to identify opportunities for improving risk management processes. Evidence of Implementation: The risk management procedures did not reduce identified risks to the lowest practicable level of risk. Clinical and corporate risks were identified, assessed, treated, reported, monitored, and documented in risk registers. However, not all health and safety risks were identified. For example, the following risks were identified by inspectors, but not on the risk register:

Broken or missing tiles. This was noted during the previous inspection.

Some areas were cold, specifically the seclusion room in St Etna’s and the sensory room.

Ongoing concerns relating to the conservatory windows and rain water leaking. It was reported that an alarm system was not working in a specific area of St Edna’s ward. This risk had been identified but had not been remedied. Structural risks were not removed or effectively mitigated, such as the mentioned conservatory windows. A plan was implemented to reduce risks to residents while works to the premises were ongoing. The person with responsibility for risk was not identified and known by all staff. Responsibilities were not allocated at management level and throughout the approved centre to ensure their effective implementation. There was a Quality and Patient Safety (QPS) meeting and responsibilities were allocated at management level by attendance at the QPS meeting. However, the overall management and governance of risk appeared fragmented. Each ward had a folder that contained a local risk register, mainly documented on risk assessment forms. Some risk assessments dated back to 2010 with the names of the person responsible no longer in the service. These names had been crossed out and ‘management’ inserted. Individual risk assessments were completed prior to and during resident transfer, discharge, seclusion, physical restraint, and specialised treatments, and in conjunction with medication requirements or administration. Multi-disciplinary teams, residents, and their representatives were involved in the development, implementation, and review of individual risk management processes. Incidents were recorded and risk-rated in a standardised format. A designated risk manager did not review incidents for any trends or patterns occurring in the services, and this position had been vacant for the past year. Clinical incidents were reviewed by the multi-disciplinary team at their regular meeting. A record was maintained of that review and recommended actions. The Mental Health Commission was provided with a six-monthly summary report of all incidents, with information anonymised at a resident level. The requirements for the protection of children and vulnerable adults were appropriate and implemented. There was an emergency plan that specified responses by staff to possible emergencies, including evacuation procedures.


The approved centre was non-compliant with this regulation for the following reasons:

a) While the approved centre did have a risk management policy it was not deemed comprehensive and had not been implemented fully throughout the approved centre, 32(1).

b) The risk management policy did not cover the process of identification, assessment, treatment, reporting, and monitoring of all risks throughout the approved centre specifically, structural risks and health and safety risks to the residents, staff, and visitors, 32(2)(a).

c) The risk register had not been regularly reviewed and risks dated 2010 had not been treated or closed out, 32(2) (b).

d) Arrangements for responding to emergencies were not adequate evidenced by an area of St Etna’s Ward where the alarm system was known not to work, 32(2) (e).


Regulation 33: Insurance

The registered proprietor of an approved centre shall ensure that the unit is adequately insured against accidents or injury to residents.

INSPECTION FINDINGS The approved centre’s insurance certificate was provided to the inspection team. It confirmed that the approved centre was covered by the State Claims Agency for public liability, employer’s liability, clinical indemnity, and property. The approved centre was compliant with this regulation.

COMPLIANT


Regulation 34: Certificate of Registration

The registered proprietor shall ensure that the approved centre's current certificate of registration issued pursuant to Section 64(3)(c) of the Act is displayed in a prominent position in the approved centre.

INSPECTION FINDINGS The approved centre had an up-to-date certificate of registration with one condition to registration attached. The certificate was displayed prominently in the main entrance reception. The approved centre was compliant with this regulation.

COMPLIANT


9.0 Inspection Findings – Rules

EVIDENCE OF COMPLIANCE WITH RULES UNDER MENTAL HEALTH ACT 2001 SECTION 52 (d)


Section 69: The Use of Seclusion

Mental Health Act 2001 Bodily restraint and seclusion Section 69 (1) “A person shall not place a patient in seclusion or apply mechanical means of bodily restraint to the patient unless such seclusion or restraint is determined, in accordance with the rules made under subsection (2), to be necessary for the purposes of treatment or to prevent the patient from injuring himself or herself or others and unless the seclusion or restraint complies with such rules. (2) The Commission shall make rules providing for the use of seclusion and mechanical means of bodily restraint on a patient. (3) A person who contravenes this section or a rule made under this section shall be guilty of an offence and shall be liable on summary conviction to a fine not exceeding £1500. (4) In this section “patient” includes –

(a) a child in respect of whom an order under section 25 is in force, and (b) a voluntary patient.

INSPECTION FINDINGS Processes: The approved centre had a written policy on the use of seclusion. It had been reviewed annually and was dated December 2017. The policy addressed who may implement seclusion and the provision of information to the resident. It did not address ways to reduce rates of seclusion. Training and Education: There was a written record to indicate that staff involved in seclusion had read and understood the policy. Monitoring: An annual report on the use of seclusion had been completed. Evidence of Implementation: Three episodes of seclusion were reviewed on inspection. Seclusion was only used in rare and exceptional circumstances and in residents’ best interests, when the resident posed immediate threat of serious harm to self or others. Seclusion was only initiated after all other interventions to manage resident’s unsafe behaviour were considered. In one episode it was not documented that an assessment had occurred. Seclusion was initiated by a registered medical practitioner or nurse. A consultant psychiatrist was notified as soon as practicable of the use of seclusion. Seclusion orders did not last longer than eight hours. In one case, the resident was not informed of reasons for, likely duration of, and circumstances leading to discontinuation of seclusion. The reason for not informing the resident was not recorded. In two cases, it was not documented whether the resident was informed of the ending of an episode of seclusion. In one case, the reason for ending seclusion was not recorded in a clinical file. Cultural awareness and gender sensitivity was demonstrated. In two cases, the residents’ clothing did not respect their right to dignity, bodily integrity, and privacy. The reason for this was not indicated in their individual care plans. In these two cases, the use of refractive clothing did not comply with residents’ documented risk assessment or management plan. In one case, a written record of the resident was not made by a nurse every 15 minutes. Following risk assessment, a nursing review took place every two hours. During this review, at least two staff entered the seclusion room. A medical review of the patient was undertaken no later than four hours after the commencement of the episode of seclusion, and then reviewed every four hours.

NON-COMPLIANT Risk Rating


The seclusion initiation was not recorded in the clinical file for one episode reviewed. The seclusion register was signed by the responsible consultant psychiatrist or duty consultant psychiatrist within 24 hours. In one case, the resident’s representative was not informed, and the reason for this was not recorded. A copy of the seclusion register had been placed in the respective clinical files. There was no documentary record that the episodes were reviewed by members of the multi-disciplinary team within two working days. Seclusion facilities were not furnished, maintained, and cleaned to ensure respect for resident dignity and privacy, as the seclusion room was cold. Residents in seclusion had access to adequate toilet and washing facilities. All furniture and fittings were of a design and quality so as not to endanger patient safety. The approved centre was non-compliant with this rule for the following reasons:

a) The written policy did not address ways of reducing rates of seclusion use, 10.2(a). b) Seclusion facilities were not furnished, maintained, and cleaned to ensure respect for resident

dignity and privacy, as the seclusion room was cold, 8.2. c) When seclusion was initiated :

a. In one episode reviewed, an assessment which must include a risk assessment had not been documented, 3.3 (a).

b. In one episode reviewed, seclusion initiation was not recorded in a clinical file 3.3(b). d) Residents were not always informed of reasons for, likely duration of, and circumstances leading

to discontinuation of seclusion, unless detrimental to resident. In the event that this did not occur, a record explaining why it had not occurred had not been entered in the clinical file 3.6.

e) Next of kin or representative were not always informed of the use of seclusion. Where they were not informed, the reason for this was not recorded in a clinical file, 3.7(a).

f) Clothing did not respect the right of resident to dignity, bodily integrity, and privacy. The reason for this was not documented in the individual care plan (ICP), 4.2(a).

g) The use of refractive clothing did not comply with resident’s documented risk assessment and management plan, 4.2(b).

h) A written record of the resident was not made by a nurse every 15 minutes in one episode reviewed, 5.2.

i) Residents were not always informed of the ending of an episode of seclusion, 7.3. j) Seclusion was not always clearly recorded in clinical file, 9.1. k) It was not documented whether episodes were reviewed by members of the MDT and

documented in clinical file within two working days, 10.3.

10.0 Inspection Findings – Mental Health Act 2001


Part 4 Consent to Treatment

EVIDENCE OF COMPLIANCE WITH PART 4 OF THE MENTAL HEALTH ACT 2001

COMPLIANT


56.- In this Part “consent”, in relation to a patient, means consent obtained freely without threat or inducements, where – a) the consultant psychiatrist responsible for the care and treatment of the patient is satisfied that the patient is

capable of understanding the nature, purpose and likely effects of the proposed treatment; and b) The consultant psychiatrist has given the patient adequate information, in a form and language that the patient can

understand, on the nature, purpose and likely effects of the proposed treatment. 57. - (1) The consent of a patient shall be required for treatment except where, in the opinion of the consultant psychiatrist responsible for the care and treatment of the patient, the treatment is necessary to safeguard the life of the patient, to restore his or her health, to alleviate his or her condition, or to relieve his or her suffering, and by reason of his or her mental disorder the patient concerned is incapable of giving such consent.

(2) This section shall not apply to the treatment specified in section 58, 59 or 60. 60. – Where medicine has been administered to a patient for the purpose of ameliorating his or her mental disorder for a continuous period of 3 months, the administration of that medicine shall not be continued unless either-

a) the patient gives his or her consent in writing to the continued administration of that medicine, or b) where the patient is unable to give such consent –

i. the continued administration of that medicine is approved by the consultant psychiatrist responsible for the care and treatment of the patient, and

ii. the continued administration of that medicine is authorised (in a form specified by the Commission) by another consultant psychiatrist following referral of the matter to him or her by the first-mentioned psychiatrist,

And the consent, or as the case may be, approval and authorisation shall be valid for a period of three months and thereafter for periods of 3 months, if in respect of each period, the like consent or, as the case may be, approval and authorisation is obtained. 61. – Where medicine has been administered to a child in respect of whom an order under section 25 is in force for the purposes of ameliorating his or her mental disorder for a continuous period of 3 months, the administration shall not be continued unless either –

a) the continued administration of that medicine is approved by the consultant psychiatrist responsible for the care and treatment of the child, and

b) the continued administration of that medicine is authorised (in a form specified by the Commission) by another consultant psychiatrist, following referral of the matter to him or her by the first-mentioned psychiatrist,

And the consent or, as the case may be, approval and authorisation shall be valid for a period of 3 months and thereafter for periods of 3 months, if, in respect of each period, the like consent or, as the case may be, approval and authorisation is obtained.

INSPECTION FINDINGS The clinical file of one patient who had been in the approved centre for more than three months and who had been in continuous receipt of medication was examined. There was documented evidence that the responsible consultant psychiatrist had undertaken a capacity assessment, or equivalent, following administration of medication for a continuous period of three months. A written record of consent was completed, which outlined:

The name of the medication(s) prescribed.

Confirmation of the assessment of the patient’s ability to understand the nature, purpose, and likely effects of the medication(s).

Details of discussion with the patient, including the nature, purpose, effects of the medication(s).

Any supports provided to the patient in relation to the discussion and their decision-making. The approved centre was compliant with Part 4 of the Mental Health Act 2001: Consent to Treatment.

EVIDENCE OF COMPLIANCE WITH CODES OF PRACTICE – MENTAL HEALTH ACT 2001 SECTION 51 (iii)

11.0 Inspection Findings – Codes of Practice


Use of Physical Restraint

Please refer to the Mental Health Commission Code of Practice on the Use of Physical Restraint in Approved Centres, for further guidance for compliance in relation to this practice.

INSPECTION FINDINGS



Processes: The approved centre had a written policy on the use of physical restraint. The policy had been reviewed annually and was dated December 2017. It addressed the following:

The provision of information to the resident

Who can initiate and who may implement physical restraint.

Child protection process where a child is physically restrained. Training and Education: There was a written record to indicate that staff involved in the use of physical restraint had read and understood the policy. Monitoring: An annual report on the use of physical restraint in the approved centre had been completed. Evidence of Implementation: Three episodes of physical restraint were reviewed on inspection. In all cases, physical restraint was used in rare, exceptional circumstances, and in the best interests of the resident. Physical restraint was only exercised where a resident posed immediate threat of serious harm to self or others, after all alternative interventions had been considered, and based on a risk assessment. Orders for physical restraint did not last for longer than 30 minutes. In no case was the resident informed of reasons for, likely duration of, or circumstances leading to discontinuation. The reasons for not informing the residents were not recorded. Physical restraint was initiated by an appropriate health professional in line with the physical restraint policy. A designated staff member was responsible for leading the physical restraint and monitoring the head and airway of the resident. The consultant psychiatrist or duty consultant psychiatrist was notified as soon as was practicable. This was documented. Cultural awareness and gender sensitivity was demonstrated. A same sex staff member was present at all times during physical restraint where practicable. Staff were aware of relevant considerations in individual care plan. A registered medical professional completed a medical examination within three hours of the end of the episode. As soon as practicable, and with resident’s consent, the resident’s representative was informed of the use of physical restraint; this was recorded. Where the representative was not informed, this was justified and recorded. Residents were afforded an opportunity to discuss the episode with members of their multi-disciplinary team. Each episode of physical restraint was documented in a clinical file. In one case, the clinical practice form had not been signed by a clinical psychiatrist within 24 hours. Episodes of physical restraint were not reviewed by members of the multi-disciplinary team (MDT) and documented within two working days. Residents did not have the opportunity to speak with the MDT about the episode. The approved centre was non-compliant with this code of practice for the following reasons:

a) In one episode reviewed the clinical practice form had not been signed by the clinical psychiatrist within 24 hours, 5.7c.

b) There was no documentation indicating that the resident had been informed of the reasons for, likely duration of and circumstances that would lead to the discontinuation of physical restraint in any of the three cases examined. The reason for not informing the resident was not documented in any case reviewed, 5.8.

c) Residents were not afforded an opportunity to discuss the episode with members of the MDT as soon as was practicable, 7.2.

d) In none of the three cases were the episodes of physical restraint reviewed by the MDT within two working days of the episode, 9.3.


Admission of Children

Please refer to the Mental Health Commission Code of Practice Relating to the Admission of Children under the Mental Health Act 2001 and the Mental Health Commission Code of Practice Relating to Admission of Children under the Mental Act 2001 Addendum, for further guidance for compliance in relation to this practice.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the admission of a child, which was last reviewed in September 2018. It addressed the following:

A policy requiring each child to be individually risk-assessed.

Policies and procedures in place in relation to family liaison, parental consent, and confidentiality.

Procedures for identifying the person responsible for notifying the Mental Health Commission of the child admission.

Training and Education: Staff had received training in relation to the care of children. Evidence of Implementation: Age-appropriate facilities and a programme of activities were not provided by the approved centre. Provisions were in in place to ensure the safety of a child, respond to a child’s special needs as a young person in an adult setting, and to ensure the right of a child to have their views heard. Children had their rights explained and information about the ward and facilities provided in an understandable way; this was recorded. Consent for treatment was obtained from one or both parents. Appropriate visiting arrangements and accommodation was provided. Segregated bedroom and bathroom areas were available for children. Observation arrangements, including assignment of a designated staff member, was provided as considered clinically appropriate and acknowledged gender sensitivity. Advice from the Child and Adolescent Mental Health Service was available. Copies of the Child Care Act 1991, Children Act 2001, and Children First guidelines were available to relevant staff. The Commission was notified of children admitted to the approved centre for adults within 72 hours of admission using the associated notification form. Staff who had contact with children had undergone Garda vetting. The approved centre was non-compliant with this code of practice because age-appropriate facilities and a programme of activities were not provided by the approved centre, 2.5(b).



Use of Electro-Convulsive Therapy (ECT) for Voluntary Patients

Please refer to the Mental Health Commission Code of Practice on the Use of Electro-Convulsive Therapy for Voluntary Patients, for further guidance for compliance in relation to this practice.

INSPECTION FINDINGS Processes: The approved centre had a written policy and procedures on the use of Electro-Convulsive Therapy (ECT) for voluntary patients. The policy had been reviewed annually and was dated May 2018. It contained protocols that were developed in line with best international practice, including:

How and where the initial and subsequent doses of Dantrolene were stored.

Management of cardiac arrest.

Management of anaphylaxis.

Management of malignant hyperthermia. Training and Education: All staff involved in ECT had been trained in line with best international practice. All staff involved in ECT had appropriate training in Basic Life Support techniques. Evidence of Implementation: The approved centre had a dedicated suite for the delivery of ECT, including a private waiting room and adequately equipped treatment and recovery rooms. High-risk residents were treated in a rapid-intervention area. A named consultant psychiatrist and anaesthetist had overall responsibility for ECT management and anaesthesia respectively. There were at least two registered nurses in the ECT suite at all times, one of whom was a designated ECT nurse. Materials and equipment in the ECT suite were in line with best international practice. Up-to-date protocols for management of cardiac arrest, anaphylaxis, and malignant hyperthermia, were prominently displayed. There was a facility for monitoring electroencephalogram (EEG) on two channels. ECT machines were regularly maintained and serviced; this was recorded. The clinical file of one resident who received ECT was reviewed. An assessment of capacity was undertaken and recorded by a consultant psychiatrist prior to obtaining consent. A wide range of appropriate and accessible information on ECT was provided by the consultant psychiatrist to enable the resident to make a decision whether to consent to treatment. The resident was given 24 hours to reflect on the information if they wished. The resident was informed of their right to access an advocate at any stage. Resident questions were answered, and ECT discussions were documented in a clinical file. Consent was received for each programme of ECT. The anaesthesia and ECT were prescribed, administered, and recorded appropriately. Resident’s clinical and cognitive status was assessed before, during, and after each ECT session and programme. The continued use of ECT was reviewed by the consultant psychiatrist in consultation with the resident. The approved centre was compliant with this code of practice.

COMPLIANT


Admission, Transfer and Discharge

Please refer to the Mental Health Commission Code of Practice on Admission, Transfer and Discharge to and from an Approved Centre, for further guidance for compliance in relation to this practice.

INSPECTION FINDINGS Processes: The approved centre had separate written policies in relation to admission, transfer, and discharge. Admission: The approved centre had the following written policies in relation to admission, which included all of the policy-related criteria for this code of practice:

Admission Policy, which was last reviewed in December 2017.

Admission and Discharge of a Patient with Intellectual Disability, which was last reviewed in December 2017.

Involuntary Admission, which was last reviewed in May 2017.

Detention of a Voluntary Patient for the Processes of Making an Involuntary Admission Order, which was last reviewed in September 2017.

Transfer: The transfer policy, which was last reviewed in May 2017, included all of the policy-related criteria for this code of practice.

Discharge: The approved centre had written policies in relation to discharge, which included all of the policy-related criteria for this code of practice:

Discharge from Hospital, which was last reviewed in September 2017.

Discharge - Homelessness, which was last reviewed in May 2017.

Discharge - Older Persons, which was last reviewed in May 2017. Training and Education: There was documentary evidence that relevant staff had read and understood the admission, transfer, and discharge policies. Monitoring: Audits had been completed on the implementation of and adherence to the admission, transfer, and discharge policies. Evidence of Implementation: Admission: All admissions were on the basis of mental illness or mental disorder. Residents received an admission assessment, which included presenting problem, past psychiatric history, family history, medical history, current and historic medication, current mental state, a risk assessment, and any other relevant information such as work situation, education, and dietary requirements. The resident received a full physical examination. Resident’s representatives were involved in the admission process, with the resident’s consent. A key worker system was in place. Transfer: The approved centre complied with Regulation 18: Transfer of Residents.

COMPLIANT


Discharge: The approved centre maintained discharge plans, which included documented communication with relevant health professionals, an estimated date of discharge, references to early warning signs of relapse and risks, and a follow-up plan. Discharge meetings were attended by residents and their representatives, key worker, and relevant members of multi-disciplinary team. Discharge assessments addressed medical and informational needs. Discharges were coordinated by a key worker. Discharge summaries included details such as medical information, follow-up arrangements, and names and contact details of key people. Resident representatives were involved in the discharge process. A timely follow-up appointment was made. The approved centre was compliant with this code of practice.

Appendix 1: Corrective and Preventative Action Plan Template – St Loman’s Hospital - 2018 Inspection Report


Report reference: Page 32

Area(s) of non-compliance Specific Measureable Achievable / Realistic Time-bound

1. Programmes and services available were

not adequate to restore or maintain

optimal levels of physical and

psychosocial functioning, 16(2).

Reoccurring

Corrective Action(s):

Appointment of 2 WTE Occupational

Therapists to the Admission Unit and

St Edna Unit

Post-Holder(s) responsible:

T/Principal Occupational Manager

2 WTE Occupational

Therapists appointed to

the Admission Unit and

St Edna Unit

Achievable and Realistic Completed

Preventative Action(s):

Multidisciplinary Therapeutics

Activities Committee established


MDT Managers

CNMIII

Committee to meet on a

monthly basis

Audit

Achievable and Realistic 30th June 2019

Regulation 19: General Health

Report reference: Pages 34 & 35


2. The six monthly physical examinations

did not include dental health checks,

19(1) (b)

New


Six monthly physical examination to

include dental health checks.


Clinical Director

Six monthly physical

examination to include

dental health checks.

Achievable and Realistic 31st March 2019


Audit


Clinical Director

Audit 6 monthly

Achievable and Realistic 31st October 2019

3. The six monthly physical examination for

two residents did not document waist

circumference, and for one resident BMI,

19(1) (b)

New


Further training will be provided to

NCHDs


Clinical Director

Training Achievable and Realistic 31st March 2019


Audit


Clinical Director

Audit 6 monthly


4. Not all residents in receipt of anti-

psychotic medication had been assessed

annually for blood lipids and prolactin

levels 19 (1) (b).

New



NCHDs


Clinical Director

Training Achievable and Realistic 31st March 2019


Audit


Clinical Director

Audit 6 monthly


Regulation 22: Premises



5. The premises were not adequately

heated, as the heating did not function

well and both wards were cold at times,

22 (1)(b).

Reoccurring


Report on Heating System to be

carried out


Estates, Maintenance Manager

Report on Heating

System to be carried out.



Monitoring of temperatures


Estates, Maintenance Manager

Monitoring of

temperatures

Achievable and Realistic 30th April 2019

6. The premises were not clean and

maintained in good structural and

decorative condition, 22 (1)(a).

7. A programme of routine maintenance

and renewal of the fabric and decoration

of the premises was not developed and

implemented, as there were broken

doors and cracked glass in the

conservatory, 22 (1)(c).

Reoccurring

Corrective Action(s): Maintenance and

cleaning plan to be put in place.

Submission for funding re/ fabric and

decoration of the premises where

applicable will be submitted for Minor

Capital Funding


T/ADON, Maintenance Manager,

Registered Proprietor

Maintenance and

Cleaning programme to

be put in place

Funding 30th September 2019


Checklist, Audit


Cleaning programme

checklist

Audit 6 monthly

Achievable and Realistic 30th September 2019

T/ADON, Hospital Administrator

8. The condition of the physical structure

and the overall approved centre

environment was not developed and

maintained with due regard to the

specific needs of residents and patients

and the safety and well-being of

residents, staff, and visitors as there

were outstanding ligature points, 22 (3).

Reoccurring


Ligature audit completed. Funding will

be requested to minimise any

identified ligature points.


Registered Proprietor

Funding will be

requested to minimise

any identified ligature

points.

Funding 30th September 2019


Ligature Audit completed


Ligature Audit

completed





9. Two MPARs did not have a record of all

medications administered to the

resident, 23(1).

10. One MPAR did not record the he

administration route of medication.

11. One MPAR did not record the date of

discontinuation for each medication.

12. One MPAR did not have a clear record of

the date of initiation for each

medication.

New



Medical and Nursing Staff


Clinical Director, T/ADON

Training Achievable and Realistic 30th June 2019


Audit


Clinical Director, CNMIII

Audit quarterly Achievable and Realistic 30th June 2019

13. Where medication required refrigeration,

a log of the temperature of the

refrigeration storage unit was not taken

Reoccurring


Purchase of refrigeration storage unit

to include temperature monitoring


T/ADON, Registered Proprietor

Purchase of refrigeration

storage unit



Audit

Post-Holder(s) responsible:CNMIII

Audit 6 monthly Achievable and Realistic 30th June 2019

Regulation 26: Staffing



14. The numbers and skill mix of staffing was

not appropriate to the assessed needs of

residents, 26(2).

Reoccurring


Appointment of 2 WTE Occupational

Therapists to the Admission Unit and

St Edna Unit


T/Principal Occupational Manager

2 WTE Occupational



St Edna Unit




2 WTE Occupational



St Edna Unit


15. Not all healthcare professionals were up

to date with the required mandatory

training, 26 (4).

Reoccurring

Monitor as

per

condition1

1 To ensure adherence to Regulation 26(4): Staffing the approved centre shall implement a plan to ensure all healthcare professionals working in the approved centre are up-to-date in mandatory training areas. The approved centre shall provide a progress update on staff training to the Mental Health Commission in a form and frequency prescribed by the Commission.

Regulation 31: Complaints Procedures



16. There was no evidence to support a

complaint had been investigated

promptly, 31(5)

New

Corrective Action(s): Staff will ensure

that complaints policy will be adhered

to.


T/ADON, CNMIII

Staff will ensure that

complaints policy will be

adhered to.

Achievable and Realistic 30th September 2019


Training


T/ADON, CNMIII

Training Achievable and Realistic 30th September 2019

17. The nominated complaints person did

not have a record of all complaints

relating to the approved centre, 31(6).

New

Corrective Action(s): A system will be

put in place to capture all complaints

relating to the approved centre.


T/Hospital Administrator

A system will be put in

place to capture all

complaints relating to

the approved centre



Audit


T/Hospital Administrator

Audit 6 monthly Achievable and Realistic 30th June 2019


Report reference: Pages 54, 55 & 56


18. While the approved centre did have a risk

management policy it was not deemed comprehensive

and had not been implemented fully throughout the

approved centre, 32(1).

19. The risk management policy did not cover the process

of identification, assessment, treatment, reporting, and

monitoring of all risks throughout the approved centre

specifically, structural risks and health and safety risks

to the residents, staff, and visitors, 32(2)(a).

New

Corrective Action(s): Policy to be

updated.

Post-Holder(s) responsible: Policy

Review & Development Group

Policy will be

updated by Policy

Review and

Development Group

who will meet on 15th

March, 2019.

Achievable and Realistic

30th March 2019

Preventative Action(s): Policy to be

updated.


Review & Development Group,

CNMIII

Policy will be

circulated.

Memo will be sent

to all Catchment

Management Team,

ADONs, CNMIII and

all Ward Managers.

Audit quarterly


30thMarch 2019

30th June 2019

20. The risk register had not been regularly reviewed and

risks dated 2010 had not been treated or closed out,

32(2)(b).

New

Corrective Action(s): Risk Register will

be review on a quarterly basis.


Quality & Safety Committee

Risk Register will be

reviewed at the

Quality & Safety

Committee meetings

on a quarterly basis


Completed

Corrective Action(s):Agenda item


Quality & Safety Committee

Agenda Item at

Quality & Safety

Committee meetings


Completed

21. Arrangements for responding to emergencies were not

adequate evidenced by an area of St Etna’s Ward

Corrective Action(s): Alarm System

repairs were carried out.


Alarm system in

working order


Completed

where the alarm system was known not to work,

32(2)(e).

New Preventative Action(s):


Maintenance

contract in situ.


Completed

Rules: The Use of Seclusion



22. The written policy did not address ways of reducing

rates of seclusion use, 10.2(a). Reoccurring

Corrective Action(s): Policy to be

updated.



Policy to be updated

by Policy Review &

Development Group


31st July 2019

Preventative Action(s): updated policy

will be issued.



Issue of policy Achievable and Realistic

31st July 2019

23. Seclusion facilities were not furnished, maintained,

and cleaned to ensure respect for resident dignity

and privacy, as the seclusion room was cold, 8.2.

Reoccurring

Corrective Action(s):Seclusion facility

repairs have been carried out


Maintenance Supervisor

Seclusion facility

repairs have been

carried out.


Completed



24. When seclusion was initiated :

a. In one episode reviewed an assessment which

must include a risk assessment had not been

documented, 3.3 (a).

b. In one episode reviewed seclusion initiation was

not recorded in a clinical file 3.3(b).

New


Further training, implement checklist

and revise seclusion care plan.

Post-Holder(s) responsible: CD,CNMIII

Training – Nursing

and Medical staff

Implement Seclusion

Checklist

Revise Seclusion Care

Plan to ensure

compliance.

Achievable and

Realistic

30th March 2019


Audit

Post-Holder(s) responsible: CNMIII

Audit quarterly Achievable and

Realistic

30th June 2019

25. Residents were not always informed of reasons for,

likely duration of, and circumstances leading to

discontinuation of seclusion, unless detrimental to

resident. In the event that this did not occur, a

record explaining why it had not occurred had not

been entered in the clinical file 3.6.

26. Next of kin or representative were not always

informed of the use of seclusion. Where they were

not informed, the reason for this was not recorded in

a clinical file, 3.7(a).

27. Residents were not always informed of the ending of

an episode of seclusion, 7.3.

New



and revise seclusion care plan

Post-Holder(s) responsible: CD, CNMIII


and Medical staff

Implement Seclusion

Checklist


Plan to ensure

compliance.

Achievable and

Realistic

30th March 2019


Audit


CNMIII


Realistic

30th June 2019

28. Clothing did not respect the right of resident to

dignity, bodily integrity, and privacy. The reason for

this was not documented in the individual care plan

(ICP), 4.2(a).

29. The use of refractive clothing did not comply with

resident’s documented risk assessment and

management plan, 4.2(b).

New



and revise seclusion care plan

Post-Holder(s) responsible: CD, CNMIII


and Medical staff

Implement Seclusion

Checklist


Plan to ensure

compliance.

Achievable and

Realistic

30th June 2019


Audit



Realistic

30th June 2019

30. A written record of the resident was not made by a

nurse every 15 minutes in one episode reviewed,

5.2.

31. Seclusion was not always clearly recorded in clinical

file, 9.1.

New


Memo to Nursing staff, Further

training, implement checklist and

revise seclusion care plan

Post-Holder(s) responsible: ADON,

CNMIII

Memo to CNMIIs to

ensure that all

paperwork is in order

regarding each

episode of seclusion.


staff

Implement Seclusion

Checklist

Achievable and

Realistic

30thMarch 2019


Plan to ensure

compliance.


Audit

Post-Holder(s) responsible:CNMIII


Realistic

30th June 2019

32. It was not documented whether episodes were

reviewed by members of the MDT and documented

in clinical file within two working days, 10.3.

Reoccurring

Corrective Action(s): Review of

Seclusion episodes will be carried out

within two working days.


CD, Area DON, Heads of Disciplines.

ADON will be

contacted by Ward

Manager regarding

every episode of

seclusion who will

ensure that CD/

Acting CD and CNMIII

are notified and will

ensure that members

of the MDT review

same within 2

working days.

Achievable and

Realistic

30thMarch 2019

Preventative Action(s): Audit



Realistic

30th June 2019

Code of Practice on the Use of Physical Restraint


Area(s) of non-compliance Specific Measureable Achievable /

Realistic

Time-bound

33. In one episode reviewed the clinical practice form

had not been signed by the clinical psychiatrist within

24 hours, 5.7.

Reoccurring

Corrective Action(s): Consultant

Psychiatrist will sign episode within 24

hours


Responsible Consultant, CD

Consultant Psychiatrist

will sign episode within

24 hours. Further

training will be provided

to Medical Staff

Achievable and

Realistic

30th March 2019

Preventative Action(s): Further

training will be provided to Medical

Staff.

Audit


CD


Realistic

30th June 2019

34. There was no documentation indicating that the

resident had been informed of the reasons for, likely

duration of and circumstances that would lead to the

discontinuation of physical restraint in any of the

three cases examined. The reason for not informing

the resident was not documented in any case

reviewed, 5.8.

Reoccurring



Nursing Staff


CNMIII

Further training will be

provided to Nursing Staff

Achievable and

Realistic

30th March 2019


Audit



Realistic

30th June 2019

35. Residents were not afforded an opportunity to

discuss the episode with members of the MDT as

soon as was practicable, 7.2.

New

Corrective Action(s): Residents will be

afforded an opportunity to discuss

episode with members of the MDT.

Review of physical restraint episodes

ADON will be contacted

by Ward Manager

regarding every episode

of physical restraint who

Achievable and

Realistic

30th March2019

36. In none of the three cases were the episodes of

physical restraint reviewed by the MDT within two

working days of the episode, 9.3.

will be carried out within two working

days


CD, Area DON, Heads of Disciplines.

will ensure that

CD/Acting CD and CNMIII

are notified and will

ensure that members of

the MDT review same

within 2 working days.

Preventative Action(s): Audit



Realistic

30th June 2019

Code of Practice Relating to the Admission of Children

Report reference: Page 67


37. Age-appropriate facilities and a

programme of activities were not

provided by the approved centre, 2.5(b).

Reoccurring

Corrective Action(s): Procedures

implemented.


Registered Proprietor, YAMHS (Young

Adult Mental Health Service) Team

The following

procedures are

implemented:-

Child is admitted to

single ensuite room with

gender appropriate

special.

Corridor is cordoned off

where possible from

adult inpatients.

Child is allocated a

separate room for their

own use with

recreational games and

access to their own

garden area.

Child is looked after by

YAMHS team who will

jointly work with

Occupational Therapist

on the Unit to develop

an appropriate

programme of activities.

Achievable and realistic Completed

Preventative Action(s): YAMHS Team

continue to seek age appropriate

facilities.

YAMHS Team continue

to seek age appropriate

facilities in the event of a

Achievable and realistic Completed


YAMHs team, CNMIII

child been considered

for admission.

Audit 6 monthly

30th September 2019

admission unit & st edna's unit, st loman's hospital · ac0006 admission unit &...

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