rehab and recovery mental health unit · 4 inspection team: carol brennan-forsyth, lead inspector...

2017 COMPLIANCE RATINGS

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Inspection Team:

Carol Brennan-Forsyth, Lead Inspector

Noeleen Byrne

Leon Donovan

Inspection Date: 24 – 27 October 2017

Inspection Type: Unannounced Annual Inspection

Previous Inspection Date: 29 November – 1 December 2016

Focused Inspection: 8 – 11 August 2017

The Inspector of Mental Health Services:

Dr Susan Finnerty MCRN009711

Date of Publication: 1 March 2018

RULES AND PART 4 OF THE MENTAL HEALTH ACT 2001

Compliant

Rehab and Recovery Mental Health Unit St. John’s Hospital Campus

ID Number: AC0101

2017 Approved Centre Inspection Report (Mental Health Act 2001)

Rehab and Recovery Mental Health Unit

St. John’s Hospital Campus

Ballytivnan

Sligo

Approved Centre Type:

Continuing Mental Health Care/Long Stay Mental Health Rehabilitation

Most Recent Registration Date:

17 November 2016

Conditions Attached: Yes

Registered Proprietor:

HSE

Registered Proprietor Nominee:

Ms Teresa Dykes, General Manager,

Mental Health, CHO 1

REGULATIONS

CODES OF PRACTICE

Non-compliant

Not applicable

AC0101 Rehab and Recovery Mental Health Unit, St. John’s Hospital Campus Approved Centre Inspection Report 2017 of 89

RATINGS SUMMARY 2015 – 2017

Compliance ratings across all 41 areas of inspection are summarised in the chart below.

Chart 1 – Comparison of overall compliance ratings 2015 – 2017

Note: As the approved centre was registered for the first time in November 2016, ratings for 2015 do not apply.

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 2015 – 2017

Note: As the approved centre was registered for the first time in November 2016, ratings for 2015 do not apply.

9 10

13 12

19 19

0

5

10

15

20

25

30

35

40

45

2015 2016 2017

Not applicable Non-compliant Compliant

32

37

73

0

2

4

6

8

10

12

14

2015 2016 2017

Low Moderate High Critical


Contents 1.0 Introduction to the Inspection Process ............................................................................................ 5

2.0 Inspector of Mental Health Services – Summary of Findings .......................................................... 7

3.0 Quality Initiatives ........................................................................................................................... 11

4.0 Overview of the Approved Centre ................................................................................................. 12

4.1 Description of approved centre ............................................................................................. 12

4.2 Conditions to registration ...................................................................................................... 12

4.3 Reporting on the National Clinical Guidelines ....................................................................... 12

4.4 Governance ............................................................................................................................ 13

5.0 Compliance ..................................................................................................................................... 14

5.1 Non-compliant areas from 2016 inspection .......................................................................... 14

5.2 Non-compliant areas on this inspection ................................................................................ 15

5.3 Areas of compliance rated Excellent on this inspection ........................................................ 15

6.0 Service-user Experience ................................................................................................................. 16

7.0 Interviews with Heads of Discipline ............................................................................................... 17

8.0 Feedback Meeting .......................................................................................................................... 18

9.0 Inspection Findings – Regulations .................................................................................................. 19

10.0 Inspection Findings – Rules .......................................................................................................... 60

11.0 Inspection Findings – Mental Health Act 2001 ............................................................................ 64

12.0 Inspection Findings – Codes of Practice ....................................................................................... 66

Appendix 1: Corrective and Preventative Action Plan Template – RRMHU, St John’s Hospital Campus74


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, realistic, achievable 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 given for all regulations, except for 28, 33 and 34. RISK RATINGS

are given for any area that is deemed non-compliant.

COMPLIANCE

COMPLIANT

EXCELLENT

LOW

QUALITY RISK

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.

Safety in the approved centre The approved centre had a written policy in relation to health and safety, and a safety statement. The

approved centre had three written policies in relation to risk management but these were incomplete.

Relevant staff had received training in the identification, assessment, and management of risk and in health

and safety risk management. Not all clinical incidents were reviewed by the MDT at their regular meeting,

and the person with responsibility for risk management had not reviewed incident reports for any trends or

patterns occurring in the service.

The approved centre used a photograph and identification sticker to identify residents, and these were

checked before the administration health care services. Food safety audits were completed periodically.

Hygiene was maintained to support food safety, and catering areas and associated equipment were

appropriately cleaned.

Ligature points had not been mitigated, and numerous ligature points were observed in bathrooms and

bedrooms during the inspection. Apart from the fact that directions to crush medication had not been signed

by the medical practitioner, the ordering, prescribing, storage and administration of medicines was carried

out in a safe manner.

Staff were appropriately qualified for their roles, and an appropriately qualified staff member was on duty

and in charge at all times. The numbers and skill mix of staff were sufficient to address resident needs.

Not all health care professionals had up-to-date mandatory training in fire safety, Basic Life Support, the

management of aggression and violence, and the Mental Health Act 2001.

AREAS REFERRED TO Regulations 4, 6, 22, 23, 24, 26, 32, Rule Governing the Use of Seclusion, Code of Practice on the Use of Physical Restraint, the Rule and Code of Practice on the Use of ECT, service user experience, and interviews with staff.

2.0 Inspector of Mental Health Services – Summary of Findings


Appropriate care and treatment of residents Each resident had an individual care plan (ICP) but these were not developed by the multidisciplinary team

but by nursing staff only. Residents had access to their ICPs and were kept informed of any changes. All ICPs

identified the residents’ assessed needs, however, in some cases the goals were vague, some ICPs did not

have mental health goals, and the resources required to provide the care and treatment identified were not

documented in any of the ICPs.

There was no evidence of therapeutic programme being provided in the approved centre. At the time of

inspection, resources were mainly directed towards assessments and there were few resources for the

development of therapeutic programmes. There was no dedicated room or kitchen in which therapeutic

programmes could be delivered. A Snoezelen room had opened, but training in its use had not commenced.

Residents received appropriate general health care interventions in line with their individual care plans, and

their general health needs were monitored and assessed every three months. However, the approved centre

did not have its own operational policy and procedures for responding to medical emergencies.

Residents’ records were secure, up to date, were developed and maintained in a logical sequence and in

good order. They were easy to find and navigate and contained factual, consistent, and accurate entries.

Mechanical restraint was used because of an enduring risk of harm to the resident or others and to address

an identified clinical need. It was implemented when less restrictive alternatives were unsuitable and was in

compliance with the rule governing its use.

The approved centre was non-compliant with nine elements of the code of practice on admission, transfer

and discharge.

AREAS REFERRED TO Regulations 5, 14, 15, 16, 17, 18, 19, 23, 25, 27, Part 4 of the Mental Health Act 2001, Rule Governing the Use of Seclusion and Mechanical Means of Bodily Restraint, Rule Governing the Use of ECT, Code of Practice on Physical Restraint, Code of Practice on the Admission of Children, Code of Practice on the Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities, Code of Practice on Admission, Transfer and Discharge, service user experience, and interviews with staff.

Respect for residents’ privacy and dignity Residents were supported to keep and wear their personal clothing. Clothing and shoe suppliers attended

the approved centre periodically, at which time residents could purchase new clothes. Residents’ clothing

was observed to be clean and appropriate to their needs and was individualised.

Bathrooms, showers, toilets, and single bedrooms had locks on the inside of the doors. All observation panels

on doors of treatment rooms and bedrooms were appropriately screened, and rooms that were overlooked

by public areas were fitted with privacy film.

Residents could bring personal possessions into the approved centre and were supported to manage their

own property. Secure facilities were provided for the safe-keeping of residents’ monies and valuables.


The death of residents was managed in line with the resident’s religious and cultural practices, with dignity

and propriety, and in a way that accommodated the resident’s representatives, family, next of kin, and

friends.

AREAS REFERRED TO Regulations 7, 8, 13, 14, 21, 25, Rule Governing the Use of Seclusion, Code of Practice on Physical Restraint, Code of Practice on the Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities, service user experience, and interviews with staff.

Responsiveness to residents’ needs The approved centre’s menus were approved by a dietitian to ensure nutritional adequacy in accordance

with residents’ needs. Residents were provided with a variety of wholesome and nutritious food choices and

food, including modified consistency diets, was presented in an appealing manner. The approved centre

provided a range of recreational activities appropriate to the resident group profile. Two multi-task

attendants along with nursing staff facilitated activities during the week and at weekends.

Residents were facilitated in the practice of their religion. They also had access to multi-faith chaplains.

There was a designated room in the approved centre where residents could meet visitors in private. They

had access to mail, fax, a cordless phone, and the Internet.

Residents were provided with an information booklet, but it did not contain adequate approved centre-

specific information. It did not reference housekeeping arrangements, the complaints procedure, visiting

times and arrangements, mealtimes, or residents’ rights and was not written in an easy to read format. There

was a satisfactory complaints procedure in place.

No written information on diagnosis or medication, including risks and other potential side-effects, was

readily available.

Residents had access to ample personal space. Sufficient spaces were provided for residents to move about,

including an enclosed outdoor space with benches. The corridors of the approved centre had been newly

painted and were clean and bright. A cleaning schedule was implemented in the approved centre, which was

clean.

The approved centre was not in a good state of repair internally. Not all rooms were adequately ventilated

In the male shower room there was lack of ventilation and mould was observed on the ceiling. Cracked and

mouldy tiles were observed in bathrooms. There were numerous window handles missing throughout the

approved centre.

AREAS REFERRED TO Regulations 5, 9, 10, 11, 12, 20, 22, 30, 31, Code of Practice on the Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities, service user experience, and interviews with staff.

Governance of the approved centre The approved centre was governed by the Sligo Leitrim Mental Health Service area mental health

management team. It was part of the Community Healthcare Organisation (CHO) 1, which included Donegal/

Sligo/Leitrim/West Cavan and Cavan/Monaghan Mental Health Services. The clinical director chaired a


monthly Sligo/Leitrim Mental Health Service Area Mental Health Management Team Meeting in which the

Rehabilitation and Recovery Unit was a standing agenda item. Items addressed included establishment of a

multi-disciplinary team, premises, regulatory compliance and operational matters.

Both the clinical director and the area director of nursing visited the approved centre at least once a

fortnight. Clear lines of responsibility were evident in all departments, with heads of discipline attending

regular meetings with staff and departments providing supervision to their staff. All heads of discipline

identified strategic aims for their staff and discussed potential operational risks with their departments,

Management of the approved centre had yet to clearly define the future direction of the facility after

December 2017. There was no long-term strategic plan available at the time of inspection.

Operating policies and procedures were developed with input from clinical and managerial staff and in

consultation with all relevant stakeholders. All of the operating policies and procedures required by the

regulations had been reviewed within three years.

Deaths and incidents were not reviewed to identify and correct any problems and improve the quality of

processes.

AREAS REFERRED TO Regulations 26 and 32, interviews with heads of discipline, and minutes of area management team meetings.


The following quality initiatives were identified on this inspection:

1. The corridors and dining area in the approved centre had been painted. These areas were clean and

bright.

2. The approved centre had introduced a multisensory room for residents.

3. The visitor’s room had been newly decorated, it was bright, comfortable and welcoming.

4. The approved centre had started reviewing, analysing and auditing their service.

3.0 Quality Initiatives


4.1 Description of approved centre

The Rehabilitation and Recovery Mental Health Unit was located on the ground floor of St. John’s Community

Hospital campus on the Ballytivian Road in Sligo town. The building had opened in 1999 but did not become

an approved centre until 2016. There were two locked doors at the entrance to the approved centre. There

were seven residents in the facility at the time of inspection. Residents were accommodated in single and

shared rooms. Access to outdoor areas included an internal courtyard garden. Parts of the approved centre

had been painted since last inspection. Communal areas were clean and bright and appropriately sized.

Residents were under the care of the newly appointed consultant psychiatrist; this was a temporary

appointment until January 2018. Residents’ care needs were being assessed and the approved centre was

making appropriate provisions for their on-going care needs, as detailed in the Conditions of Registration.

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

Resident Profile

Number of registered beds 20

Total number of residents 7

Number of detained patients 0

Number of Wards of Court 1

Number of children 0

Number of residents in the approved centre for more than 6 months 7

4.2 Conditions to registration

There were two conditions attached to the registration of this approved centre at the time of inspection. Condition 1: The Mental Health Commission prohibits the admission or transfer of persons to the Rehab and Recovery Mental Health Unit, St. John’s Hospital Campus.

Condition 2: The Mental Health Commission requires that an assessment of the needs of current residents of the Rehab and Recovery Mental Health Unit, St. John’s Hospital Campus is carried out, with residents appropriately placed in accordance with their assessed needs by no later than 31st December 2016.

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.

4.0 Overview of the Approved Centre


4.4 Governance

The approved centre was governed by the Sligo Leitrim Mental Health Service area mental health

management team. It was part of the Community Healthcare Organisation (CHO) 1, which included Donegal,

Sligo/Leitrim/West Cavan and Cavan/Monaghan Mental Health Services. The clinical director chaired a

monthly Sligo Leitrim Mental Health Service Area Mental Health Management Team Meeting in which the

Rehabilitation and Recovery Unit was a standing agenda item. Items addressed included establishment of a

multi-disciplinary team, premises, regulatory compliance and operational matters. The minutes of the area

wide monthly Quality and Risk Group meetings addressed risk management, complaints/compliments, and

Corrective and Preventative Actions updates. Minutes of these meetings were available to the inspection

team.

Management of the approved centre had yet to clearly define the future direction of the facility after

December 2017. There was no long-term strategic plan available at the time of inspection.


5.1 Non-compliant areas from 2016 inspection

The previous inspection of the approved centre on 29 November – 1 December 2016 identified the following

areas that were non-compliant. The approved centre was requested to provide Corrective and Preventative

Actions (CAPAs) for areas of non-compliance and these were published with the 2016 inspection report.

Regulation/Rule/Act/Code 2017 Inspection Findings

Regulation 9: Recreational Activities Compliant

Regulation 15: Individual Care Plan Non-Compliant

Regulation 16: Therapeutic Services and Programmes Non-Compliant

Regulation 22: Premises Non-Compliant

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

Non-Compliant

Regulation 26: Staffing Non-Compliant

Regulation 27: Maintenance of Records Compliant

Regulation 28: Register of Residents Compliant

Regulation 32: Risk Management Procedures Non-Compliant

Rules Governing the Use of Mechanical Means of Bodily Restraint Compliant

Code of Practice on the Use of Physical Restraint in Approved Centres Not Applicable

Code of Practice for Mental Health Services on Notification of Deaths and Incident Reporting

Non-Compliant

Code of Practice on Admission, Transfer and Discharge to and from an Approved Centre

Non-Compliant

5.0 Compliance


5.2 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 2016:

Regulation/Rule/Act/Code 2016 Compliance

2017 Compliance

Regulation 8: Residents’ Personal Property and Possessions X

Regulation 14: Care of the Dying X

Regulation 15: Individual Care Plan X X

Regulation 16: Therapeutic Services and Programmes X X

Regulation 19: General Health X

Regulation 20: Provision of Information to Residents X

Regulation 22: Premises X X


X X

Regulation 26: Staffing X X

Regulation 32: Risk Management Procedures X X

Code of Practice for Mental Health Services on Notification of Deaths and Incident Reporting

X X

Code of Practice on Admission, Transfer and Discharge to and from an Approved Centre

X X

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.

5.3 Areas of compliance rated Excellent on this inspection

The following areas were rated excellent on this inspection:

Regulation

Regulation 7: Clothing

Regulation 10: Religion


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.

Two residents and one relative met with the inspection team. Participants were very complimentary

regarding the staff, food and the recreational activities, particularly the outings. Feedback suggested that

the bedrooms were very comfortable and that residents were happy living in the approved centre.

The inspection team did not receive any feedback with regard to the Rehab and Recovery Mental Health

Unit from the IAN.

6.0 Service-user Experience


The inspection team sought to meet with heads of discipline during the inspection. The inspection team

met with the following individuals:

Area Director of Nursing

Clinical Director

Occupational Manager

Team Leader, Social Worker.

Principal Psychologist

Heads of discipline from medical, nursing, and health and social care professionals provided an overview of

the governance within their respective departments. Both the clinical director and the area director of

nursing visited the approved centre at least once a fortnight. Clear lines of responsibility were evident in all

departments, with heads of discipline attending regular meetings with staff and departments providing

supervision to their staff. All heads of discipline identified strategic aims for their staff and discussed

potential operational risks with their departments, including difficulties in covering leave and getting

approval for additional posts. The future direction of the approved centre was also an issue for discussion

during interviews.

7.0 Interviews with Heads of Discipline


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:

Area Director of Nursing

Consultant Psychiatrists x 2

Clinical Nurse Manager 3

Clinical Nurse Manager 2

Assistant Director of Nursing

Principal Psychologist

Team Leader, Social Worker

Occupational Therapy Manager

Registered proprietor

Compliance Quality Patient Safety Manager

Compliance Quality Patient Safety Officer

Student Nurse

Finance Compliance Officer

Support Service Supervisor

Medical Officer/Visiting Physician

Maintenance Foreman

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. There was discussion around

putting policies online and the policy on premises is to be a service-wide policy. Do Not Attempt

Resuscitation orders were to be discussed at the next MDT meeting. The future direction of the approved

centre after December 2017 was discussed and feedback suggested that it is yet to be determined.

8.0 Feedback Meeting


9.0 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 November 2016. It included all of the requirements of the Judgement Support Framework. Training and Education: Not all 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 clinical files contained appropriate resident identifiers. Documented analysis had been completed to identify opportunities for improving the resident identification process. Evidence of Implementation: The approved centre used a photograph and identification sticker to identify residents, and these were evidenced on all clinical files. The identifiers, which were person-specific, were checked before the administration of medication, the undertaking of medical investigations, and the provision of other health care services. An appropriate resident identifier was used prior to the provision of therapeutic services and programmes. 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 training and education pillar.

COMPLIANT Quality Rating Satisfactory


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 the provision of appropriate food and nutrition to residents, which was last reviewed in February 2017. It included all of the requirements of the Judgement Support Framework. Training and Education: Not all 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 was undertaken every three months to ensure that residents received wholesome and nutritious food in accordance with their needs. Documented analysis had been completed to identify opportunities for improving the processes for food and nutrition. Evidence of Implementation: The approved centre’s menus were approved by a dietitian to ensure nutritional adequacy in accordance with residents’ needs. Residents were provided with a variety of wholesome and nutritious food choices within the approved centre’s menus. Food, including modified consistency diets, was presented in an appealing manner, and hot meals were served daily. Residents were offered hot and cold drinks regularly, and they were supplied with safe, fresh drinking water. The approved centre used the Malnutrition Universal Screening Tool to evaluate residents’ dietary requirements. At the time of inspection, no residents had been assessed as having special nutritional requirements. Where necessary, nutritional and dietary needs were addressed in the residents’ individual care plans. Residents, their representatives, family, and next of kin were educated about residents’ diets, where required. 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 training and education pillar.



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 food safety policy, which was last reviewed in February 2017. It included requirements of the Judgement Support Framework, with the following exceptions:

Food disposal controls.

The processes for adhering to the relevant food safety legislative requirements.

The process for managing catering and food safety equipment. Training and Education: Not all 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 food safety, as set out in the policy. All staff handling food had up-to-date, documented training in the application of Hazard Analysis and Critical Control Point (HACCP). Monitoring: Food safety audits were completed periodically. Food temperatures were recorded in line with food safety recommendations, and temperature log sheets were maintained and monitored. Documented analysis had been completed to identify opportunities for improving food safety processes. Evidence of Implementation: The approved centre had appropriate hand-washing areas for catering staff as well as suitable and sufficient catering equipment. Food was prepared in the main hospital kitchen and delivered to the approved centre in a hot box. The approved centre had appropriate facilities for the refrigeration, storage, and preparation, cooking, and serving of food. Hygiene was maintained to support food safety, and catering areas and associated equipment were appropriately cleaned. Residents were provided with a supply of suitable crockery and cutlery. 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 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 January 2017. It addressed 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 residents’ clothing, as set out in the policy. Monitoring: An emergency supply of clothing was maintained and monitored by the acting clinical nurse manager 2. At the time of inspection, no residents were wearing nightclothes during the day. Evidence of Implementation: Residents were supported to keep and wear their personal clothing. Clothing and shoe suppliers attended the approved centre periodically, at which time residents could purchase new clothes. Residents’ clothing was observed to be clean and appropriate to their needs. Clothing was sent out of the approved centre for laundering, and all items were labelled. Residents had an adequate supply of individualised clothing. An appropriate supply of emergency clothing was available that took account of residents’ preferences, dignity, bodily integrity, and religious and cultural practices. At the time of inspection, all residents changed out of nightclothes during the day. The approved centre was compliant with this regulation. The quality assessment was excellent because the approved centre met all criteria of the Judgement Support Framework.

COMPLIANT Quality Rating Excellent


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 policy in relation to residents’ personal property and possessions, which was last reviewed in May 2017. It addressed 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 relating to residents’ property and possessions, as set out in the policy. Monitoring: Personal property logs were not maintained for residents. Analysis had been completed to identify opportunities for improving the processes relating to residents’ personal property and possessions. Evidence of Implementation: Residents could bring personal possessions into the approved centre and were supported to manage their own property, unless this posed a danger to themselves or others, as indicated in their individual care plans (ICPs). Residents’ personal property and possessions were safeguarded in a secure room when the approved centre assumed responsibility for them. Secure facilities were provided for the safe-keeping of residents’ monies and valuables. The approved centre did not maintain signed property checklists, detailing each resident’s personal property and possessions. A property book was in use, which was started after some of the residents had been admitted and was not, therefore, comprehensive. Two members of staff oversaw the access to and use of resident money, and signed records of staff issuing residents’ money were retained. The approved centre was non-compliant with this regulation because it did not maintain a record of each resident’s property and possessions, 8(3).

NON-COMPLIANT Quality Rating Requires Improvement Risk Rating LOW


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 March 2017. It addressed requirements of the Judgement Support Framework, with the following exceptions:

The facilities available for recreational activities, including the identification of suitable locations within and outside of the approved centre.

The process for supporting resident involvement in planning and reviewing recreational activities. 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 recreational activities, as set out in the policy. Monitoring: A record was maintained in the nurses’ station of the occurrence of planned recreational activities, including a record of resident uptake/attendance. Documented analysis had been completed to identify opportunities for improving the processes relating to recreational activities. Evidence of Implementation: The approved centre provided a range of recreational activities appropriate to the resident group profile. Two multi-task attendants along with nursing staff facilitated activities during the week and at weekends, when outings took place. A timetable of recreational activities was provided to residents in an accessible format, and recreational activities programmes were developed, implemented, and maintained with resident input. Activities included DVD’s, games, art and crafts. Where deemed appropriate, individual risk assessments were completed for residents in relation to the selection of activities. Records of resident attendance at events were maintained. Residents’ decisions on whether or not to participate in activities were respected and documented. Opportunities were available for outdoor exercise and physical activity. Residents had access to an internal garden and to an outdoor area where they could walk. Adequate communal areas suitable for recreational activities were provided. 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 November 2017. It 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 policy’s implementation to support residents’ religious practices had been reviewed to ensure that it reflected the identified needs of residents, and this was documented. Evidence of Implementation: Residents were facilitated in the practice of their religion insofar as was practicable. Facilities were provided in the approved centre in support of residents’ religious practices. Residents could attend the chapel, which was located outside of the approved centre but within the same building. They also had access to multi-faith chaplains. Residents attended local religious services if it was deemed appropriate, following a risk assessment. The care and services provided within the approved centre were respectful of residents’ religious beliefs and values, and residents were facilitated in observing or abstaining from religious practice in line with their wishes. At the time of inspection, no residents had particular religious requirements relating to their care and treatment. The approved centre was compliant with this regulation. The quality assessment was excellent because the approved centre met all criteria of the Judgement Support Framework.

COMPLIANT Quality Rating Excellent


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 in relation to visits, which was last reviewed in August 2016. It addressed requirements of the Judgement Support Framework, with the following exceptions:

The availability of appropriate locations for resident visits.

The required visitor identification methods. 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 visits, as set out in the policy. Monitoring: At the time of inspection, there were no restrictions on residents’ rights to receive visitors. Documented analysis had been completed to identify opportunities for improving visiting processes. Evidence of Implementation: Visiting times, which were appropriate and reasonable, were publicly displayed at the entrance to the approved centre. There was a designated room in the approved centre where residents could meet visitors in private, unless there was an identified risk to the resident or to others or a health and safety risk. Appropriate steps were taken to ensure the safety of residents and visitors during visits. Children were welcome when accompanied by an adult to ensure their safety. Visiting areas were suitable for children, and a good supply of toys 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 processes pillar.



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 policy in relation to resident communication, which was last reviewed in February 2017. It addressed requirements of the Judgement Support Framework, with the following exceptions:

The communication services available to the resident, including mail, fax, e-mail, Internet, and telephone.

The process for assessing resident communication needs.

Training and Education: Not all 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 communication, as set out in the policy. Monitoring: Residents’ communication needs and restrictions on communication were not monitored on an ongoing basis. Documented analysis had been completed to identify opportunities for improving communication processes. Evidence of Implementation: Residents had access to mail, fax, a cordless phone, and the Internet. At the time of inspection, no residents required risk assessment in relation to their communications. Additionally, no resident communication was being examined by the clinical director or a designated senior staff member on the basis that there was reasonable cause to believe that the communication may result in harm to the resident or 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, training and education, and monitoring 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 policy in relation to searches, which was last reviewed in January 2017. It 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 was accommodated.

The consent requirements of a resident regarding searches and the process for conducting 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 could articulate the processes for undertaking a search, as set out in the policy. As no searches had been undertaken in the approved centre since the last inspection, the monitoring and evidence of implementation pillars for this regulation were not inspected against. The approved centre was compliant with this regulation.

COMPLIANT


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 policy in relation to care of the dying, which was last reviewed in November 2015. It included all of the requirements of the Judgement Support Framework. Training and Education: Not all 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 end of life care, as set out in the policy. Monitoring: End of life care provided to residents was systematically reviewed to ensure that section 2 of the regulation was complied with. Systems analysis was undertaken in the event of a sudden or unexpected death in the approved centre. Analysis had not been completed to identify opportunities for improving the processes for care of the dying. Evidence of Implementation: End of life care provided in the approved centre was appropriate to residents’ physical, emotional, social, psychological, and spiritual needs. This was documented in residents’ individual care plans. Residents were offered a single room during the provision of end of life care. Insofar as was practicable, religious and cultural practices were respected at end of life. Residents’ representatives, family, next of kin, and friends were involved, supported, and accommodated during end of life care. There had been one resident death since the last inspection, but it had not been notified to the Mental Health Commission within the required 48-hour time frame. The death of the resident was managed in line with the resident’s religious and cultural practices, with dignity and propriety, and in a way that accommodated the resident’s representatives, family, next of kin, and friends. At the time of inspection, no residents had advanced directives relating to end of life care or Do Not Attempt Resuscitation orders. The approved centre was non-compliant with this regulation because the death of a resident had not been notified to the Mental Health Commission within the required 48-hour time frame, 14(4).

NON-COMPLIANT Quality Rating Requires Improvement Risk Rating LOW


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 February 2017. It included all of the requirements of the Judgement Support Framework. Training and Education: Not all clinical staff had signed the signature log to indicate that they had read and understood the policy. Not all clinical staff interviewed could articulate the processes relating to individual care planning, as set out in the policy. Multi-disciplinary team (MDT) members were not trained in individual care planning. Monitoring: Resident ICPs were audited on a quarterly basis to assess compliance with the regulation. Documented analysis had been completed to identify opportunities for improving the individual care planning process. Evidence of Implementation: The ICPs of the seven residents in the approved centre were inspected. Each was a composite set of documents stored in the clinical file, was identifiable and uninterrupted, and was not amalgamated with progress notes. As there had been no new admissions since the last inspection, the requirement to develop the ICP within seven days of admission did not apply. Residents had access to their ICPs and were kept informed of any changes, where appropriate. All residents were offered copies of their ICPs, but not all had the capacity to sign or understand their ICPs; this was recorded. Where residents declined or refused a copy of their ICP, this was documented, along with a reason. The ICPs were not developed by the MDT but by nursing staff only. In three ICPs, there was no evidence of family input into the care planning process. There was no structure for including family or next of kin in MDT reviews of the ICPs. The ICPs were reviewed weekly by the MDT in consultation with the residents and were updated as indicated by residents’ changing needs, condition, circumstances, and goals. Where appropriate, ICPs included a preliminary discharge plan. All of the ICPs included a risk-management plan. All ICPs identified the residents’ assessed needs, however, in some cases the goals were vague and some ICPs did not have mental health goals. Each specified the care and treatment required to meet the goals identified. However, the resources required to provide the care and treatment identified were not documented in any of the ICPs. At the time of inspection, a new ICP template was being introduced, which will help staff to document resources.

NON-COMPLIANT Quality Rating Inadequate Risk Rating


As children were not admitted to the approved centre, educational requirements did not apply. The approved centre was non-compliant with this regulation for the following reasons:

a) The ICPs were not developed by the MDT. b) None of the ICPs detailed the resources required to provide the care and treatment identified.


Regulation 16: Therapeutic Services and Programmes

(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 to residents, which was last reviewed in April 2017. It addressed all of the requirements of the Judgement Support Framework. Training and Education: Not all clinical staff had signed the signature log to indicate that they had read and understood the policy. Not all clinical staff interviewed could articulate the processes for therapeutic activities and programmes, as set out in the policy. Monitoring: Therapeutic services were monitored on an ongoing basis to ensure that residents’ assessed needs were met. Documented analysis had been completed to identify opportunities for improving the processes for therapeutic services and programmes. Evidence of Implementation: There was no evidence of therapeutic programme being provided in the approved centre. At the time of inspection, the occupational therapist (OT) was in attendance for three hours per week, in an overtime capacity. The OT was in the process of conducting seating and functional assessments. There were plans to run group therapy programmes when the assessments were completed. A speech and language therapist had completed resident assessments, the social worker was processing Fair Deal applications, and the psychologist was working with two residents. As there was no evidence of therapeutic programmes being provided, residents did not have access to programmes that were directed towards restoring and maintaining optimal levels of physical and psychosocial functioning. At the time of inspection, resources were mainly directed towards assessments and there were few resources for the development of therapeutic programmes. Additionally, there was no dedicated room or kitchen in which therapeutic programmes could be delivered. Since the last inspection, a Snoezelen room had opened, but training in its use had not commenced.

Where residents required therapeutic services or programmes that were not provided internally, arrangements were not in place for services to be provided by an approved, qualified health professional in a suitable location. Not all therapeutic programmes documented in the residents’ individual care plans (ICPs) were provided. In two ICPs inspected, music and art therapy were specified but no therapist was delivering these programmes.

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

a) Residents did not have access to appropriate therapeutic programmes in accordance with their ICPs, 16(1).

NON-COMPLIANT Quality Rating Requires Improvement Risk Rating


b) Therapeutic programmes were not directed towards restoring and maintaining optimal levels of physical and psychosocial function of residents, 16(2).


Regulation 17: Children’s Education

The registered proprietor shall ensure that each resident who is a child is provided with appropriate educational services in accordance with his or her needs and age as indicated by his or her individual care plan.

INSPECTION FINDINGS As children were not admitted to the approved centre, this regulation was not applicable.

NOT APPLICABLE


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 in relation to the transfer of residents, which was last reviewed in May 2017. It included all of the requirements of the Judgement Support Framework. Training and Education: Not all 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 resident transfer, as set out in the policy. Monitoring: The approved centre maintained a transfer log, and each transfer record was systematically reviewed to ensure that all relevant information was provided to the receiving facility. Documented analysis had been completed to identify opportunities for improving the provision of information during transfers. Evidence of Implementation: The clinical file of one resident who had been transferred to Sligo General Hospital in an emergency was inspected. The communication records with the receiving facility were documented. Relevant information regarding the resident was transferred to the receiving facility, and the approved centre completed a checklist to ensure comprehensive resident records were transferred. A pre-transfer clinical assessment, including a risk assessment, was not recorded for the resident. A copy of the referral letter was not retained in the resident’s clinical file. 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 training and education and evidence of implementation pillars.



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 a general health policy, dated March 2017. It also had a medical emergency response policy, dated January 2017. The policies addressed all of the requirements of the Judgement Support Framework. However, the emergency response policy was not site-specific and included both the street address and Eircode of another hospital in its procedures for dealing with a medical emergency. 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 could articulate the processes for providing general health services and responding to medical emergencies, as set out in the policies. Monitoring: Resident take-up of national screening programmes was recorded and monitored. A systematic review had been undertaken to ensure that six-monthly general health assessments of residents occurred. Analysis had been completed to identify opportunities for improving general health processes. Evidence of Implementation: The approved centre had an emergency medication box. Staff had access at all times to an Automated External Defibrillator, located nearby in St. John’s Community Hospital, which was responsible for its maintenance. Records were available in relation to the eight medical emergencies that occurred in the approved centre since the last inspection, including details of the care provided and of outcomes. There had been no admissions since the last inspection. A registered medical practitioner assessed residents on an ongoing basis. Residents received appropriate general health care interventions in line with their individual care plans, and their general health needs were monitored and assessed every three months. Adequate arrangements were in place for residents to access general health services and for their referral to other health services, as required. Transport was available for this purpose where necessary, but most general health services were delivered on-site. Records were maintained of general health checks and the associated results. Residents had access to appropriate national screening programmes, and information was provided in relation to the screening programmes available through the approved centre. The approved centre was non-compliant with this regulation because it did not have its own operational policy and procedures for responding to medical emergencies, 19(2).



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 in relation to the provision of information to residents, which was last reviewed in June 2016. It addressed requirements of the Judgement Support Framework, with the following exceptions:

The information provided to residents on an ongoing basis.

The process for identifying residents’ preferred ways of receiving and giving information.

The methods for providing information to residents with specific communication needs. Training and Education: Not all staff had signed the signature log to indicate that they had read and understood the policy. Staff interviewed could articulate the processes for providing information to residents, as set out in the policy. Monitoring: The provision of information to residents was not 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 around the provision of information.

Evidence of Implementation: Residents were provided with an information booklet, but it did not contain much approved centre-specific information. It did not reference housekeeping arrangements, the complaints procedure, visiting times and arrangements, mealtimes, or residents’ rights. The information booklet included information regarding voluntary and advocacy services. While the booklet had attractive formatting it was not written in an easy to read format. Details of visiting times and mealtimes were displayed publicly. Residents received information about their multi-disciplinary team. Verbal information on diagnosis could be provided to residents, but no written information on diagnosis or medication, including risks and other potential side-effects, was readily available.

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

a) Written information was not provided to residents in relation to their diagnosis, 20(1)(c).



b) Written information on indications for use of all medications, including potential side-effects, was not available to residents, 20(1)(e).


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 January 2017. It addressed requirements of the Judgement Support Framework, with the following exceptions:

The roles and responsibilities for the provision of resident privacy and dignity.

The method for identifying and ensuring, where possible, residents’ privacy and dignity expectations and preferences.

Training and Education: Not all staff had signed the signature log to indicate that they had read and understood the policy. Staff interviewed were able to articulate the processes for ensuring resident privacy and dignity, as set out in the policy. Monitoring: An annual review had been undertaken to ensure that the policy was being implemented and that the premises and facilities were conducive to resident privacy. Analysis had 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 were discreet when discussing residents’ condition or treatment needs. They were dressed in a manner that was respectful of residents’ privacy and dignity, and they sought permission before entering residents’ rooms. Residents were observed to wear clothing that respected their privacy and dignity. Bathrooms, showers, toilets, and single bedrooms had locks on the inside of the doors, and these had an override facility. Where residents shared rooms, adequate bed screening was in place to ensure that resident privacy was not compromised. All observation panels on doors of treatment rooms and bedrooms were appropriately screened, and rooms that were overlooked by public areas were fitted with privacy film. Residents were facilitated to make private phone calls. Noticeboards in view of residents or visitors did not display any identifiable resident 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 training and education 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 did not have a written policy in relation to its premises. Training and Education: There was no policy for staff to read, understand, or articulate. Monitoring: The approved centre had completed a hygiene audit. No ligature audit had been completed. Documented analysis had been undertaken to identify opportunities for improving the premises. Evidence of Implementation: Residents had access to ample personal space. Only four bedrooms, three single rooms and one four-bed room, were occupied at the time of inspection. Sufficient spaces were provided for residents to move about, including an enclosed outdoor space with benches. The approved centre was comfortably heated, and heating could be safely controlled in residents’ rooms. Appropriately sized communal rooms were provided, with sufficient seating for residents. Communal areas were adequately lit to facilitate reading and other activities. The corridors of the approved centre had been newly painted and were clean and bright. Signage to support resident orientation had been removed prior to the commencement of painting and not all the signs had been replaced at the time of inspection. Hazards, including large open spaces, steps and stairs, slippery floors, hard and sharp edges, and hard or rough surfaces, had been minimised. Ligature points had not been mitigated, and numerous ligature points were observed in bathrooms and bedrooms during the inspection. The approved centre was not in a good state of repair internally. Not all rooms were adequately ventilated. In particular, the male shower room was not properly ventilated and mould was observed on the ceiling. Cracked and mouldy tiles were observed in bathrooms. There were numerous window handles missing throughout the approved centre.



There was a system of reactive maintenance but no maintenance schedule or programme of routine maintenance. A cleaning schedule was implemented in the approved centre, which was clean and hygienic. Current national infection control guidelines were followed. There was a sufficient number of toilets and showers, including accessible facilities, for residents. Toilets were not identified, however. Wheelchair accessible facilities were available in the main hospital for use by visitors who required them. Furnishings in the approved centre supported resident independence and comfort, and assistive devices and equipment were available to address resident needs. The approved centre was non-compliant with this regulation for the following reasons:

a) The premises were not maintained in good decorative condition, 22(1)(a). b) There was no programme of routine maintenance for the premises, 22(1)(c). c) Ligature points had not been mitigated, indicating that the physical structure and overall

approved centre environment was not developed and maintained with due regard to the safety and well-being of residents, staff, and visitors, 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 a written policy in relation to the ordering, storing, prescribing, and administration of medication, which was last reviewed in May 2017. It included requirements of the Judgement Support Framework, with the exception of processes for medication reconciliation and review of resident medication. Training and Education: Not all nursing, medical, and pharmacy 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 ordering, prescribing, storing, and administering medicines, as set out in the policy. Staff had access to comprehensive, up-to-date information on all aspects of medication management through the pharmacist. All clinical staff had received training on the importance of reporting medication incidents, errors, or near misses. 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 using the National Incident Management System. Analysis had been completed to identify opportunities for improving medication management processes. Evidence of Implementation: An MPAR was maintained for each resident, and all seven of these were inspected. Two appropriate resident identifiers were used on each MPAR. Names of medications were written in full, the generic names of medications were recorded, and all medications administered to residents were appropriately documented. Where there was an alteration to the medication order, the prescription was rewritten by the medical practitioner. All medicines were administered by a registered nurse or registered medical practitioner and appropriately dispensed. The expiry dates of medications were checked prior to their administration, and good hand-hygiene and cross-infection control techniques were implemented when medication was being dispensed. Where a resident refused medication, this was documented in the MPAR and clinical file and communicated to medical staff. Where medication was withheld, the justification was documented in the MPAR and clinical file. At the time of inspection, no controlled drugs were being administered in the approved centre and no resident was self-administering medications Medication arriving from the pharmacist was verified against the order to ensure that it was correct and accompanied by appropriate directions for use. Medication was appropriately stored, and medication storage areas were clean and tidy. Food was not stored in areas used for the storage of medication.



In two MPARs, directions to crush medication had not been signed by the medical practitioner. When this was highlighted by the inspectors, it was rectified by the medical practitioner, who wrote new prescriptions. Medication was stored securely in a locked trolley in a secure room. There was a separate secure cupboard for scheduled controlled drugs, but no scheduled controlled drugs were being administered at the time of inspection. A system of stock rotation was implemented by the pharmacy assistant, who also completed an inventory of medications on a monthly basis. The approved centre was non-compliant with this regulation because directions to crush medications had not been signed by the medical practitioner in two MPARs, which is an unsuitable prescribing practice, 23(1).


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, which was last reviewed in August 2017. It also had a safety statement, which was dated 2017. The policy and safety statement addressed requirements of the Judgement Support Framework, with the following exceptions:

The allocation and documentation of safety representative roles.

Vehicle controls. Training and Education: Not all staff had signed the signature log to indicate that they had read and understood the policy. Staff interviewed were able to articulate the processes relating to health and safety, as set out in the policy. 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 As CCTV was not in use in the approved centre, this regulation was not applicable.

NOT APPLICABLE


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 the recruitment, selection, and vetting of staff, which was last reviewed in August 2017. It addressed requirements of the Judgement Support Framework, with the exception of the staff performance and evaluation requirements and the required qualifications of training personnel.

Training and Education: Not all 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 had been reviewed annually, and this was documented. The numbers and skill mix of staff were assessed against the levels recorded in the approved centre’s registration. Analysis had been completed to identify opportunities for improving staffing processes and responding to the changing needs and circumstances of residents. Evidence of Implementation: There was an organisational chart in the staffing policy to identify the leadership and management structure and lines of authority and accountability of staff in the approved centre. A planned and actual staff rota was in place. Staff were appropriately qualified for their roles, and an appropriately qualified staff member was on duty and in charge at all times. The numbers and skill mix of staff were sufficient to address resident needs. The approved centre did not have a written staffing plan that addressed the following:

The skill mix, competencies, number, and qualifications of staff.

The assessed needs of the resident group profile.

The process for reassigning staff in response to changing resident needs or staff shortages.

Annual staff training plans were implemented for staff to identify required training and skills development in line with the assessed needs of the resident group profile. Orientation and induction training had been completed by staff. The inspection team was not provided with training records from all disciplines, but training logs reviewed indicated that not all health care professionals had up-to-date mandatory training



in fire safety, Basic Life Support (BLS), the management of aggression and violence, and the Mental Health Act 2001. At least one staff member was trained in Children First. Staff were trained in accordance with the assessed needs of residents, with training completed in infection control and prevention, care for residents with an intellectual disability, end of life care, risk management, residents’ rights, and incident reporting. Staff had not been trained in manual handling, dementia care, recovery-centred approaches to mental health care and treatment or training with regard to vulnerable adults. Staff training was documented, and staff training logs were maintained. The Mental Health Act 2001, the associated regulation, Mental Health Commission rules and codes, and all other relevant Mental Health Commission documentation and guidance were available throughout the approved centre. The following is a table of clinical staff assigned to the approved centre:

The approved centre was non-compliant with this regulation because not all health care professionals had up-to-date mandatory training in fire safety, BLS, the management of aggression and violence, and the Mental Health Act 2001, 26(4) and 26(5).

Ward or Unit Staff Grade Day Night

Rehab and Recovery Mental Health Unit

CNM2 RPN MTA Occupational Therapist Social Worker Psychologist

1 (Monday – Friday) 2 2 3 hours/week On referral 0

2 0

Clinical Nurse Manager (CNM), Registered Psychiatric Nurse (RPN), Multi Task Attendant (MTA)


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 in relation to the maintenance of records, which was last reviewed in February 2017. It addressed all of the 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. Training and Education: Not all clinical staff and other relevant staff had signed the signature log to indicate that they had read and understood the policy. Clinical staff and other relevant staff interviewed were able to articulate the processes around creating, accessing, retaining, and destroying records, as set out in the policy. All clinical staff had received training in best-practice record keeping. Monitoring: Resident records had been audited to ensure their completeness, accuracy, and ease of retrieval, and this was documented. Analysis had been completed to identify opportunities for improving processes relating to the maintenance of records. Evidence of Implementation: Residents’ records were secure, up to date, and constructed, maintained, and used in accordance with the Data Protection Act 1988 and 2003, the Freedom of Information Act 1997 and 2003, and national guidelines and legislative requirements. Resident records were stored together and were appropriately secured from loss or destruction, tampering, and unauthorised access or use. A record had been initiated for every resident in the approved centre, and these were reflective of residents’ current status and the care and treatment being provided. Resident records were maintained through the use of a person-specific identifier. Resident records were developed and maintained in a logical sequence and in good order. They were easy to find and navigate and contained factual, consistent, and accurate entries.



Documentation relating to health and safety, food safety, and fire inspections was maintained in the approved centre. 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 training and education pillar.


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 new register of residents, which was made available to the inspection team. It was up to date and 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 on the development and review of operating policies and procedures, which was last reviewed in August 2017. It addressed requirements of the Judgement Support Framework, with the exception of 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. Relevant staff had received training on approved operational policies and procedures. Relevant staff interviewed were able to 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 not been completed to identify opportunities for improving the processes for developing and reviewing policies. Evidence of Implementation: Operating policies and procedures were developed with input from clinical and managerial staff and in consultation with all relevant stakeholders. The policies and procedures incorporated relevant legislation, evidence-based best practice, and clinical guidelines and were appropriately approved before being implemented. All of the operating policies and procedures required by the regulations had been reviewed within three years. Generic policies in use were appropriate to the approved centre and the resident group profile. Where generic policies were used, the approved centre had a written statement to this effect. 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 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 As no resident had been detained in the approved centre since its registration, this regulation was not applicable.

NOT APPLICABLE


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 policy in relation to making, handling, and investigating complaints, which was last reviewed in October 2017. The policy referenced the HSE’s Your Service, Your Say complaints procedure. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had not received training in complaints management processes. Not all staff had signed the signature log to indicate that they had read and understood the policy. 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. Complaints data had been analysed and details of the analysis had been considered by senior management. Required actions were identified to ensure continuous improvement of the complaints management process. Evidence of Implementation: There was a nominated complaints officer in the approved centre who was responsible for dealing with all complaints. The ways in which residents and their representatives could lodge verbal or written complaints were detailed in the complaints policy. Insofar as was practicable, the registered proprietor ensured that the quality of the service, care, and treatment of a resident was not adversely affected by reason of a complaint being lodged. The approved centre’s management of complaints processes was well publicised and accessible to residents and their representatives.



Complaints, whether oral or written, were investigated promptly and handled appropriately and sensitively. All complaints were addressed in a consistent and standardised manner. Minor complaints were addressed at weekly resident meetings and documented. Where minor complaints could not be addressed locally, they were dealt with by the nominated person. All complaints that were not minor were addressed by the nominated person and recorded in the complaints log. Where complaints could not be addressed by the nominated person, they were escalated in line with the approved centre’s policy and documented. Details of complaints, subsequent investigations, and outcomes were recorded and kept separately from residents’ individual care plans. There had only been one serious complaint in the last seven years, and it had been closed. 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 training and education pillar.


Regulation 32: Risk Management Procedures

(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 three written policies in relation to risk management: a clinical risk management policy dated June 2017, the HSE’s risk management policy, and an incident management reporting policy, which was last reviewed in May 2017. Together, the policies addressed requirements of the Judgement Support Framework, including the following:

The process of identification, assessment, treatment, reporting, and monitoring of risks, including

- Organisational risks. - Structural risks such as ligature points. - Health and safety risks to the residents, staff, and visitors. - Risks to the resident group during the provision of general care and services. - Risks to individual residents during the delivery of individualised care.

The process for rating identified risks.

The methods for controlling risks associated with resident absence without leave and suicide and self-harm.

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

The process for responding to specific emergencies.

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

The responsibilities of the registered proprietor.

The responsibilities of the multi-disciplinary team (MDT).

The person responsible for the completion of six-monthly incident summary reports.



The process of identification, assessment, treatment, reporting, and monitoring of capacity risks relating to the number of residents in the approved centre.

The methods for controlling risks associated with assault and accidental injury to residents or staff.

The process for learning from incidents. Training and Education: Relevant staff had received training in the identification, assessment, and management of risk and in health and safety risk management. Clinical staff had received training in individual risk management processes. All staff had been trained in incident reporting and documentation. Managerial staff had not been trained in organisational risk management. Not all staff had signed the signature log to indicate that they had read and understood the policy. Staff interviewed were able to articulate the risk management processes, as set out in the policies. All training was documented. Monitoring: The risk register was audited 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 person with responsibility for risk was known by all staff in the approved centre, and responsibilities were allocated at management level to ensure the effective implementation of risk management. Not all clinical, corporate, and health and safety risks were identified, assessed, reported, monitored, and documented in the risk register. The approved centre had not completed a risk assessment for one resident prior to transfer, however risk assessments had been completed for residents who had been discharged. Structural risks, including ligature points, had not been assessed or mitigated. All clinical incidents were not reviewed by the MDT at their regular meeting, and the person with responsibility for risk management had not reviewed incident reports for any trends or patterns occurring in the service. Incidents in the approved centre were recorded and risk-rated using the National Incident Management System. A six-monthly summary report of all incidents occurring in the approved centre was sent to the Mental Health Commission in accordance with the Code of Practice for Mental Health Services on Notification of Deaths and Incident Reporting. The approved centre had an emergency plan that incorporated a fire evacuation plan. The approved centre was non-compliant with this regulation because the risk management policy did not address the following:

a) The process of identification and assessment of capacity risks relating to the number of residents in the approved centre, 32(2)(a).

b) The methods for controlling risks associated with assault and accidental injury to residents or staff, 32(2)(c)(iii) and (iv).

c) Arrangements for learning from incidents, 32(2)(d).


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 insured under the auspices of 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, which was displayed prominently in the foyer. The two conditions relating to the certificate of registration were attached. The approved centre was compliant with this regulation.

COMPLIANT


10.0 Inspection Findings – Rules

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


Section 59: The Use of Electro-Convulsive Therapy

Section 59 (1) A programme of electro-convulsive therapy shall not be administered to a patient unless either – (a) the patient gives his or her consent in writing to the administration of the programme of therapy, or (b) where the patient is unable to give such consent – (i) the programme of therapy is approved (in a form specified by the Commission) by the consultant psychiatrist responsible for the care and treatment of the patient, and (ii) the programme of therapy is also 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. (2) The Commission shall make rules providing for the use of electro-convulsive therapy and a programme of electro-convulsive therapy shall not be administered to a patient except in accordance with such rules.

INSPECTION FINDINGS As the approved centre did not use Electro-Convulsive Therapy, this rule was not applicable.

NOT APPLICABLE


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 As the approved centre did not use seclusion, this rule was not applicable.

NOT APPLICABLE


Section 69: The Use of Mechanical Restraint

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 The clinical file of one resident was inspected in relation to the use of mechanical restraint. Mechanical restraint was used because of an enduring risk of harm to the resident or others and to address an identified clinical need. It was implemented when less restrictive alternatives were unsuitable. The restraint was ordered by the consultant psychiatrist responsible for the resident’s care and treatment. The clinical file contained a contemporaneous record of the following:

That there was an enduring risk of harm to self or others.

That less restrictive alternatives were implemented without success.

The type of mechanical restraint used.

The situation in which mechanical restraint was applied.

The duration of the restraint.

The duration of the order.

The review date. The approved centre was compliant with this rule.

COMPLIANT


11.0 Inspection Findings – Mental Health Act 2001

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


Part 4 Consent to Treatment

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 As there had been no involuntary admissions to the approved centre since its registration, Part 4 of the Mental Health Act 2001: Consent to Treatment was not applicable.

NOT APPLICABLE


12.0 Inspection Findings – Codes of Practice

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

Section 33(3)(e) of the Mental Health Act 2001 requires the Commission to: “prepare and review periodically, after consultation with such bodies as it considers appropriate, a code or codes of practice for the guidance of persons working in the mental health services”. The Mental Health Act, 2001 (“the Act”) does not impose a legal duty on persons working in the mental health services to comply with codes of practice, except where a legal provision from primary legislation, regulations or rules is directly referred to in the code. Best practice however requires that codes of practice be followed to ensure that the Act is implemented consistently by persons working in the mental health services. A failure to implement or follow this Code could be referred to during the course of legal proceedings. Please refer to the Mental Health Commission Codes of Practice, for further guidance for compliance in relation to each code.


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 As physical restraint had not been used in the approved centre since the last inspection, this code of practice was not applicable.

NOT APPLICABLE


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 As the approved centre did not admit children, this code of practice was not applicable.

NOT APPLICABLE


Notification of Deaths and Incident Reporting

Please refer to the Mental Health Commission Code of Practice for Mental Health Services on Notification of Deaths and Incident Reporting, for further guidance for compliance in relation to this practice.

INSPECTION FINDINGS Processes: The approved centre had two policies that covered the notification of deaths and incident reporting to the Mental Health Commission (MHC): the risk management policy, which was dated June 2017, and the end of life care policy, which was last reviewed in November 2015. The policies identified the risk manager and specified the roles and responsibilities of staff in relation to the following:

a) The reporting of deaths and incidents. b) The completion of death notification forms. c) The submission of forms to the MHC.

The policies did not address the roles and responsibilities in relation to the completion of six-monthly incident summary reports. Monitoring: Deaths and incidents had not been reviewed to identify and correct any problems as they arose and to improve quality. Evidence of Implementation: The approved centre did not comply with Regulation 32: Risk Management Procedures, which is associated with this code of practice. The approved centre used the National Incident Management System to report incidents, and the standard incident report form was available to inspectors. A six-monthly summary of all incidents was sent to the MHC. There had been one death in the approved centre since the last inspection, but it had not been notified to the MHC within the required 48-hour time frame. The approved centre was non-compliant with this code of practice for the following reasons:

a) The policies did not address the roles and responsibilities in relation to the completion of six-monthly incident summary reports.

b) It did not comply with Regulation 32: Risk Management Procedures, 3.1. c) Deaths and incidents were not reviewed to identify and correct any problems and improve the

quality of processes, 6.1.

NON-COMPLIANT Risk Rating


Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities

Please refer to the Mental Health Commission Code of Practice Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities, for further guidance for compliance in relation to this practice.

INSPECTION FINDINGS As no resident of the approved centre had a diagnosis of intellectual disability, this code of practice was not applicable.

NOT APPLICABLE


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 As Electro-Convulsive Therapy was not in use in the approved centre, this code of practice was not applicable.

NOT APPLICABLE


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 policies in relation to admission, transfer, and discharge, all of which had been reviewed in May 2017. Admission: The admission policy included a procedure for involuntary admission and protocols for planned admission, urgent referrals, self-presenting individuals, and timely communication with primary care and community mental health teams. The approved centre also had a policy on confidentiality, privacy, and consent. Transfer: The transfer policy included procedures for involuntary transfer and outlined the roles and responsibilities of staff in relation to the transfer of residents. It detailed how a transfer was arranged, addressed the safety of the resident and staff during a transfer, and contained provisions for emergency transfer and transfer abroad. Discharge: The discharge policy included procedures for the discharge of involuntary patients and the management of discharge against medical advice. It referenced prescriptions and supply of medication on discharge and contained protocols for discharging homeless people, older persons, and people with intellectual disability. The approved centre had a post-discharge follow-up policy, but it did not reference relapse prevention strategies or crisis management plans. Training and Education: There was no documentary evidence that staff had read and understood the admission, transfer, or discharge policies. Monitoring: As the approved centre was prohibited from admitting new residents, the monitoring pillar for admission was not inspected against. An audit had not been completed on the implementation of and adherence to the discharge policy. Evidence of Implementation: The approved centre was non-compliant with Regulation 32: Risk Management Procedures, which is associated with this code of practice. Admission: As the approved centre was prohibited from admitting new residents, the evidence of implementation pillar for the admission process was not inspected against. Transfer: The approved centre was compliant with Regulation 18: Transfer of Residents. The clinical file of one resident who had been transferred to hospital in an emergency was inspected. The decision to transfer was made by the registered medical practitioner (RMP) and documented, and it was agreed with the receiving facility. A pre-transfer clinical assessment, including a risk assessment, was not recorded for the resident. There was no evidence of the involvement of the resident’s family/carer/advocate in the transfer process or that an attempt was made to obtain the resident’s consent to the transfer. The clinical file did not contain a copy of the referral letter.

NON-COMPLIANT Risk Rating


Discharge: Two clinical files were inspected in relation to discharge. The decision to discharge was taken by the RMP, and a discharge plan was in place as part of the residents’ individual care plans. The residents received a comprehensive assessment prior to discharge. Efforts were made to inform primary care/community mental health teams of the discharges within 24 hours. In both cases, a preliminary discharge summary was issued within three days and a comprehensive discharge summary was issued within two weeks. Neither file evidenced appropriate multi-disciplinary team (MDT) input into discharge planning. The approved centre was non-complaint with this code of practice for the following reasons:

a) The post-discharge follow-up policy did not reference relapse prevention strategies or crisis management plans, 4.14.

b) There was no evidence that an audit had been undertaken in relation to the implementation of and adherence to the discharge policy, 4.19.

c) The approved centre was non-compliant with Regulation 32: Risk Management Procedures, which is associated with this code of practice, 7.1.

d) There was no documentary evidence that staff had read and understood the admission, transfer, or discharge policies, 9.1.

e) A pre-transfer clinical assessment, including a risk assessment, was not recorded for the resident, 27.1.

f) The clinical file inspected in relation to transfer did not contain a copy of the referral letter, 31.2. g) There was no evidence of the involvement of the resident’s family/carer/advocate in the

transfer process, 31.3. h) There was no evidence that an attempt was made to obtain the resident’s consent to the

transfer, 31.4. i) Neither file inspected in relation to discharge evidenced appropriate MDT input into discharge

planning, 36.1.

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Appendix 1: Corrective and Preventative Action Plan Template – RRMHU, St John’s Hospital Campus

Regulation 8: Residents’ Personal Property and Possessions Report reference: Page 24

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

Taken from the inspection report Reoccurring1 or

New2 area of non-

compliance

Provide corrective and preventative

action(s) to address the area of non-

compliance

Provide the method of monitoring

the implementation of the

action(s)

Provide details of any barriers to the

implementation of the action(s)

Provide the timeframe of the

completion of the action(s)

1. The approved centre did not

maintain a record of each

resident’s property and

possessions.

New

Corrective Action(s):

A personal property log will be

completed immediately with

each resident as per policy

HM48 and filed in each

residents clinical file

Post-Holder(s) responsible:

CNM2, ADON

A 6 monthly analysis, with

action plans as required, will

be completed on regulation

8 to ensure compliance

Realistic and achievable Completed December 2017

Preventative Action(s):

Personal property log will be

maintained accurately as per

policy HM48

A 6 monthly analysis with action

plans as required will be

completed on regulation 8 to

ensure compliance


CNM2, CQPS

A 6 monthly analysis with

action plans as required will

be completed on regulation

8 to ensure compliance

Realistic and achievable January 2018

July 2018

January 2019

1 Area of non-compliance reoccurring from 2016 2 Area of non-compliance new in 2017

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Regulation 14: Care of the Dying Report reference: Page 30


Taken from the inspection report Reoccurring or New

area of non-

compliance

Provide corrective and preventative

action(s) to address the area of non-

compliance



action(s)

Provide details of any barriers to the




2. The death of a resident had

not been notified to the

Mental Health Commission

within the required 48-hour

time frame.

New


Mental Health Commission to

be notified immediately of the

death of this resident


AMHMT, ECD, CQPS

A review and analysis will be

completed following the

death of any resident to

ensure the service is in

compliance with regulation

14 of the JSF

Realistic and achievable Completed October 2017



completed following the death

of any resident to ensure the

service is in compliance with

regulation 14 of the JSF


AMHMT, ECD, CQPS




ensure the service is in


14 of the JSF

Realistic and achievable As required

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Regulation 15: Individual Care Plan Report reference: Page 31-32


Taken from the inspection

report

Reoccurring or

New area of non-

compliance

Provide corrective and preventative action(s) to address the

area of non-compliance

Provide the method of

monitoring the implementation

of the action(s)

Provide details of any barriers

to the implementation of the

action(s)



3. The ICPs were not

developed by the

MDT.

Reoccurring


Full MDT input in development of each residents ICP

Each ICP to be developed and reviewed at weekly

MDT meeting

Post-Holder(s) responsible: All members of the MDT

3 monthly ICP audit to be

completed by members of

the MDT with support

from CQPS

Realistic and achievable 28/2/18


3 monthly ICP audit to be completed by members of

the MDT with support from CQPS


All members of the MDT, CQPS




from CQPS

Realistic and achievable November 2017

February 2018

May 2018

August 2018

November 2018

4. None of the ICPs

detailed the resources

required to provide

the care and

treatment identified.

Reoccurring


ICP template will be amended to more accurately

reflect the requirements of Regulation 15 of the JSF

Post-Holder(s) responsible: PPG group




from CQPS

Realistic and achievable Completed December

2017


3 monthly ICP audit to be completed by members of

the MDT with support from CQPS

Post-Holder(s) responsible: CQPS




from CQPS

Realistic and achievable November 2017

February 2018

May 2018

August 2018

November 2018

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Regulation 16: Therapeutic Services and Programmes Report reference: Page 33-34



report

Reoccurring or

New area of non-

compliance

Provide corrective and preventative action(s) to address the area of non-

compliance


monitoring the

implementation of the

action(s)



action(s)

Provide the

timeframe of the

completion of the

action(s)

5. Residents did not

have access to

appropriate

therapeutic

programmes in

accordance with

their ICPs.

6. Therapeutic

programmes were

not directed

towards restoring

and maintaining

optimal levels of

physical and

psychosocial

function of

residents.

Reoccurring


1. 3 Hours of Occupational Therapy will be purchased from a

preferred provider within the HSE Agency Framework., effective

from the 1st September.

2. A commitment has been provided through the Psychology

service to review and monitor each ICP as part of the wider

MDT. An Assistant Psychologist will be assigned to support the

resident’s ICP weekly.

3. The Registered Proprietor and AMHMT has agreed that funding

will be approved to purchase four hours of Speech and

Language from a private practitioner, and based on the findings

and need for review, further input and purchasing of same will

then be agreed

4. The Social Work Service has have agreed to put in place

dedicated hours towards the ICP regarding input of goals and

specific identified needs/actions as agreed with the client

and/or their family. These cannot be completed until the work

begins.

5. A Memorandum from Business Manager was issued advising

that funding is in place to access Private Clinicians in the fields of

Physiotherapy, Speech and Language Therapy, Occupational in

liaison with HSE Management in Primary Care or Mental Health

Services as required by Service Users.

A key Performance

Indicator will be put

into place monitoring

the input from each of

these professions

listed under points 1,

2, 3 and 4.

No barriers perceived as

agreement gained from

all Multidisciplinary Team

Managers on actions.

Completed

Completed

28/2/18

Complete

Complete

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report

Reoccurring or

New area of non-

compliance

Provide corrective and preventative action(s) to address the area of non-

compliance


monitoring the


action(s)



action(s)

Provide the

timeframe of the

completion of the

action(s)

Post-Holder(s) responsible: Occupational Therapy Manager. Business

Manager. Speech and Language Therapy Manager. Chief

Psychologist.


The MDT will implement a monthly audit on the implementation of

this CAPA.


All members of the Multidisciplinary Team.

These Audit findings

will be reported at the

Quality Meeting on a

Monthly basis.

No barriers perceived. Complete and

reported

monthly to

Quality and

Risk

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Regulation 19: General Health Report reference: Page 37


Taken from the inspection report Reoccurring or

New area of non-

compliance

Provide corrective and preventative action(s) to

address the area of non-compliance



action(s)



action(s)

Provide the timeframe of

the completion of the

action(s)

7. The approved centre did not

have its own operational

policy and procedures for

responding to medical

emergencies.

New


PPG group to amend policy HM58 to

accurately reflect procedures for

responding to medical emergencies.


The policy HM58 will be

reviewed as part of a 6

monthly audit of Regulation

19 of the JSF

Realistic and achievable Completed January

2018


The policy HM58 will be reviewed as part of

a 6 monthly audit of Regulation 19, JSF


The policy HM58 will be

reviewed as part of a 6

monthly audit of Regulation

19, JSF

Realistic and achievable December 2017

June 2018

December 2018

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Regulation 20: Provision of Information to Residents Report reference: Page 38-39


Taken from the inspection report Reoccurring or New

area of non-

compliance




monitoring the implementation

of the action(s)

Provide details of any barriers to


action(s)

Provide the timeframe of

the completion of the

action(s)

8. Written information was

not provided to residents

in relation to their

diagnosis.

New


Written information to be provided to all

residents in relation to their diagnosis


MDT, CNM2, ADON

6 monthly review with

analysis of the services

compliance with




6 monthly review with analysis of the services

compliance with regulation 20 of the JSF




compliance with


Realistic and achievable February 2018

August 2018

February 2019

9. Written information on

indications for use of all

medications, including

potential side-effects,

was not available to

residents.

New


Written information on indications for use of

all medications, including potential side-

effects will be made available to all residents


All members of the MDT

CNM2, ADON, Consultant Psychiatrist



compliance with




6 monthly review with analysis of the services

compliance with regulation 20 of the JSF




compliance with


Realistic and achievable February 2018

August 2018

February 2019

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Regulation 22: Premises Report reference: Page 41-42



report

Reoccurring or New

area of non-

compliance

Provide corrective and preventative action(s) to address the area of

non-compliance


monitoring the


action(s)



action(s)

Provide the timeframe

of the completion of

the action(s)

10. The premises were

not maintained in

good decorative

condition.

Reoccurring


1. The HSE Estate Manager and the SLMHS Maintenance

Manager have completed the initial works assessment.

2. The HSE Estates Manager and SLMHS Maintenance

Manager will develop a St. John’s Project Team to action

the recommendations as identified in the MHC Draft

Report.

3. The initial focus will be on the residents living area

including bedrooms bathrooms sitting rooms.

4. On-going schedule of minor works to improve

decorative condition include-artwork hung around the

unit, signage ordered

5. New curtains throughout unit

6. Window handles replaced where broken

7. Lighting throughout unit was reviewed and replaced as

required


Maintenance Manager, Estates Manager.

A monthly audit will be

completed for first 6

months and bi monthly

thereafter to ensure work

is being completed.

No barriers perceived,

acknowledgement of

work to be done by all in

Management Team.

1.complete Nov

2017

2.CAPA

implementation

group in place

meeting monthly

3.Redecoration for

bedrooms

completed Dec

2017, bathrooms

1/4/18

4. 28/2/18

5. completed Dec

2017

6.complete Dec

2017

7. Complete Dec

2017


A Monthly audit of works will be completed against work

planned each month.

Post-Holder(s) responsible: Maintenance Manager, Estates

Manager.





is being completed.

28/2/18

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report

Reoccurring or New

area of non-

compliance

Provide corrective and preventative action(s) to address the area of

non-compliance


monitoring the


action(s)



action(s)



the action(s)

11. There was no

programme of

routine

maintenance for

the premises.

Reoccurring


Premises audit to be completed immediately

Routine maintenance for the premises to be developed

resulting from this by maintenance

Maintenance to update CQPS monthly on progress of

schedule







is being completed as

scheduled.

No barriers perceived,

acknowledgement of

work to be done by all in

Management Team.

31/1/18


Monthly audits will be implemented to ensure compliance to

work planned.







is being completed.


12. Ligature points had

not been mitigated.

New


Ligature audit to be completed

Schedule of works to be completed following ligature audit

to mitigate ligature points


ADON, Maintenance

Ligature audit findings to

be presents to Quality

and risk on completion



On-going schedule of works to be developed following

completion of ligature audit


ADON, Maintenance

Quality and Risk will

maintain oversight of

schedule of works

Realistic and achievable April 2018

of 89


Report reference: Page 43-44



New area of non-

compliance





action(s)



action(s)



13. Directions to crush

medications had not been

signed by the medical

practitioner in two MPARs,

which is an unsuitable

prescribing practice.

Reoccurring


Directions to crush medications will be

signed on all MPARS immediately


Consultant Psychiatrist, NCHD

MPARS will be audited 3

monthly by the pharmacist

and NCHD with analysis and

action plans if required

Realistic and achievable Completed October

2017


MPARS will be audited 3 monthly by the

pharmacist and NCHD with analysis and



Consultant Psychiatrist

MPARS will be audited 3

monthly by the pharmacist

and NCHD with analysis and


Realistic and achievable October 2017

Jan 2018

April 2018

July 2018

October 2018

of 89

Regulation 26: Staffing Report reference: Page 47-48



report

Reoccurring or New

area of non-

compliance

Provide corrective and preventative action(s) to address the

area of non-compliance



action(s)



action(s)



the action(s)

14. Not all health care

professionals had up-

to-date mandatory

training in fire safety,

BLS, the management

of aggression and

violence, and the

Mental Health Act

2001.

Reoccurring

Corrective action(s):

1. Service to provide comprehensive timetable of

training for staff and staff to be facilitated to attend

same.

2.All staff training records (mandatory and

otherwise) for nursing staff and all members of the

MDT, to be available on site

3. Each Head of discipline to monitor staff

compliance with mandatory training

Post-holder(s):All Heads of Service, ADON, CNM2

Include MHC Inspection

Report as Quality Item on

Agenda of monthly Quality

and Risk Group and Area

Management Team

Realistic & Achievable 1.Complete-

Timetable available

for all disciplines

2.31/1/18

3. Nov 2017-All

members of the

MDT have been

requested by

Quality and Risk to

maintain records of

staff training on site

Preventative action(s):

Ensure implementation of monthly compliance of

training records on all sites

Ensure Training schedules are made available to all

heads of service for dissemination to all staff.

Post-holder(s):All Heads of Service, ADON,CNM2

Realistic and achievable Completed and

Ongoing

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Regulation 32: Risk Management Procedures (and Code of Practice: Notification of Deaths and Incident Reporting) Report reference: Page 56-57 and 69



New area of

non-

compliance





action(s)

Provide details of any

barriers to the


action(s)



The risk management policy did not

address the following:

15. The process of identification and

assessment of capacity risks relating

to the number of residents in the

approved centre

16. The methods for controlling risks

associated with assault and

accidental injury to residents or staff

17. Arrangements for learning from

incidents.

18. The policies did not address the roles

and responsibilities in relation to the

completion of six-monthly incident

summary reports.

New


Policy HM7 & HM52 to be amended to

include all requirements of regulation 32

of the JSF


PPG group

Policy HM7 & HM52 Will be

audited 6 monthly to ensure


32 of the JSF

Realistic and

achievable

28/2/18


Policy HM7 & HM52 Will be audited 6

monthly to ensure compliance with



CQPS

Policy HM7 & HM52 Will be



32 of the JSF

Realistic and

achievable

Completed

of 89



New area of

non-

compliance





action(s)

Provide details of any

barriers to the


action(s)



19. Deaths and incidents were not

reviewed to identify and correct any

problems and improve the quality of

processes.

New


A review and analysis will be completed

following the death of any resident to

ensure SLMHS has acted in compliance

with all requirements of the JSF

Incident analysis reports will be printed 3

monthly and presented at the monthly

Quality and Risk meeting to identify and

correct any problems and improve the

quality of processes


CQPS, Business manager




ensure SLMHS has acted in

compliance with all

requirements of the JSF

Incident trend analysis to be

a standing agenda item for

Quality and Risk Committee

Realistic and

achievable

Review of this policy

was completed and all

teams were engaged

regarding adherence to

the Policy for

SLAMHMT. This policy

will be enacted as and

when is required.

Quarterly reporting


Regulation 32 will be audited 6 monthly

to ensure compliance with the JSF

Incident trend analysis will be discussed

3 monthly at Quality and Risk

A review and analysis will be completed

following the death of any resident to

ensure SLMHS has acted in compliance

with all requirements of the JSF


CQPS, Business manager, Quality and

Risk Committee

Regulation 32 will be


compliance with the JSF

Incident trend analysis will

be a standing agenda item

for all Quality and Risk

Committee meetings




ensure SLMHS has acted in

compliance with all

requirements of the JSF

Realistic and

achievable

November 2017

May 2018

November 2018

3 monthly reporting-

March 2018

June 2018

Sept 2018

Dec 2018

As required

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Code of Practice: Admission, Transfer and Discharge Report reference: Page 72-73



New area of non-

compliance



Provide the method of monitoring the




action(s)


of the completion of the

action(s)

20. The post-discharge follow-up

policy did not reference

relapse prevention strategies

or crisis management plans.

New


Policy HM2 to be amended to include all

aspects of the JSF requirements


Policy HM2 will be audited as

part of a 6 monthly audit to

ensure compliance with all

aspects of the JSF



Policy HM2 will be audited as part of a 6

monthly audit to ensure compliance with all

aspects of the JSF


Policy HM2 will be audited as

part of a 6 monthly audit to

ensure compliance with all

aspects of the JSF


June 2018

January 2019

21. There was no evidence that

an audit had been

undertaken in relation to the

implementation of and

adherence to the discharge

policy.

New


Audit to be completed in relation to the

implementation of and adherence to the

discharge policy HM2 to ensure compliance

with all requirements


6 monthly audit to be

completed to ensure

compliance with the Code of

Practice on admission,

discharge and transfer as well

as policy HM2


June 2018

January 2019


6 monthly audit to be completed to ensure

compliance with the Code of Practice on

admission, discharge and transfer as well as

policy HM2


6 monthly audit to be

completed to ensure

compliance with the Code of

Practice on admission,

discharge and transfer as well

as policy HM2


June 2018

January 2019

of 89



New area of non-

compliance







action(s)



action(s)

22. There was no documentary

evidence that staff had read

and understood the

admission, transfer, or

discharge policies.

New


Staff to read and sign as evidence they have

read and understood policies

HM2

Post-Holder(s) responsible: All MDT members

Staff signatures to be audited as

part of a 6 monthly audit on the

admission, discharge and

transfer policies



Staff signatures to be audited as part of a 6

monthly audit on the admission, discharge

and transfer policies


Staff signatures to be audited as

part of a 6 monthly audit on the

admission, discharge and

transfer policies


June 2018

January 2019

23. A pre-transfer clinical

assessment, including a risk

assessment, was not

recorded for the resident.

24. The clinical file inspected in

relation to transfer did not

contain a copy of the referral

letter.

25. There was no evidence of

the involvement of the

resident’s

family/carer/advocate in the

transfer process.

26. There was no evidence that

an attempt was made to

obtain the resident’s consent

to the transfer.

New


All transfers to be compliant with all

requirements of the JSF .

Memo from the ECD and DON reminding all

staff of correct process and procedures to be

carried out for transfers.


ECD, DON, MDT

Transfer procedures to be

audited as part of a 6 monthly

audit on admission, discharge

and transfer processes

Realistic and achievable Immediate

31/1/18


Transfer procedures to be audited as part of a

6 monthly audit on admission, discharge and

transfer processes


Transfer procedures to be

audited as part of a 6 monthly

audit on admission, discharge

and transfer processes


June 2018

January 2019

of 89



New area of non-

compliance







action(s)



action(s)

27. Neither file inspected in

relation to discharge

evidenced appropriate MDT

input into discharge

planning.

New


ICP template to be amended to include

discharge planning

Discharge planning to be discussed as part of

weekly MDT review and documented

Post-Holder(s) responsible: All members of

MDT

6 monthly audit on admission,

discharge and transfer

processes will monitor

compliance with discharge

planning

Realistic and achievable Complete December

2017

Completed

December 2017


6 monthly audit on admission, discharge and

transfer processes will monitor compliance

with discharge planning


6 monthly audit on admission,

discharge and transfer

processes will monitor

compliance with discharge

planning


June 2018

January 2019

rehab and recovery mental health unit · 4 inspection team: carol brennan-forsyth, lead inspector...

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