mental health commission approved centre inspection report ... · previous inspection date: 15, 16...

Mental Health Commission

Approved Centre Inspection Report

(Mental Health Act 2001)

APPROVED CENTRE NAME: Acute Psychiatric Unit 5B, University Hospital Limerick

IDENTIFICATION NUMBER: AC0002

APPROVED CENTRE TYPE: Acute Unit

REGISTERED PROPRIETOR: HSE

REGISTERED PROPRIETOR NOMINEE: Ms Teresa Bulfin

MOST RECENT REGISTRATION DATE: 1 March 2015

NUMBER OF RESIDENTS REGISTERED FOR:

50

INSPECTION TYPE:

Unannounced

INSPECTION DATE: 5, 6, 7 August 2015

PREVIOUS INSPECTION DATE: 15, 16 April 2014

CONDITIONS ATTACHED: Yes

LEAD INSPECTOR: Dr. Fionnuala O’Loughlin MCN 008108

INSPECTION TEAM: Dr. Susan Finnerty MCN 009711

Ms. Orla O’Neill

THE INSPECTOR OF MENTAL HEALTH SERVICES:

Dr Fionnuala O’Loughlin MCN 008108 (Acting)

Ref MHC – FRM – 001- Rev 1 of 79

Contents 1.0 Mental Health Commission Inspection Process ........................................................................ 4

2.0 Approved Centre Inspection - Overview ..................................................................................... 6

2.1 Overview of the Approved Centre ................................................................................................ 6

2.2 Governance ................................................................................................................................... 6

2.3 Inspection scope ............................................................................................................................ 7

2.4 Outstanding issues from previous inspection ............................................................................... 7

2.5 Non-compliant areas on this inspection ....................................................................................... 7

2.6 Areas of compliance rated Excellent on this inspection ............................................................... 8

2.7 Reporting on the National Clinical Guidelines............................................................................... 8

2.8 Areas of good practice identified on this inspection..................................................................... 8

2.9 Resident Interviews ....................................................................................................................... 9

2.10 Feedback Meeting ....................................................................................................................... 9

3.0 Inspection Findings and Required Actions - Regulations ...................................................... 10

3.1 Regulation 1: Citation .................................................................................................................. 10

3.2 Regulation 2: Commencement .................................................................................................... 10

3.3 Regulation 3: Definitions ............................................................................................................. 10

3.4 Regulation 4: Identification of Residents .................................................................................... 11

3.5 Regulation 5: Food and Nutrition ................................................................................................ 12

3.6 Regulation 6: Food Safety............................................................................................................ 13

3.7 Regulation 7: Clothing ................................................................................................................. 14

3.8 Regulation 8: Residents’ Personal Property and Possessions ..................................................... 15

3.9 Regulation 9: Recreational Activities ........................................................................................... 16

3.10 Regulation 10: Religion .............................................................................................................. 17

3.11 Regulation 11: Visits .................................................................................................................. 18

3.12 Regulation 12: Communication ................................................................................................. 19

3.13 Regulation 13: Searches ............................................................................................................ 20

3.14 Regulation 14: Care of the Dying ............................................................................................... 24

3.15 Regulation 15: Individual Care Plan ........................................................................................... 26

3.16 Regulation 16: Therapeutic Services and Programmes............................................................. 28

3.17 Regulation 17: Children’s Education ......................................................................................... 29

3.18 Regulation 18: Transfer of Residents ........................................................................................ 30

3.19 Regulation 19: General Health .................................................................................................. 31

3.20 Regulation 20: Provision of Information to Residents .............................................................. 32


3.21 Regulation 21: Privacy ............................................................................................................... 34

3.22 Regulation 22: Premises ............................................................................................................ 38

3.23 Regulation 23: Ordering, Prescribing, Storing and Administration of Medicines ..................... 40

3.24 Regulation 24: Health and Safety .............................................................................................. 42

3.25 Regulation 25: Use of Close Circuit Television (CCTV) .............................................................. 44

3.26 Regulation 26: Staffing .............................................................................................................. 45

3.27 Regulation 27: Maintenance of Records ................................................................................... 47

3.28 Regulation 28: Register of Residents......................................................................................... 48

3.29 Regulation 29: Operating Policies and Procedures ................................................................... 49

3.30 Regulation 30: Mental Health Tribunals ................................................................................... 50

3.31 Regulation 31: Complaints Procedure ....................................................................................... 51

3.32 Regulation 32: Risk Management Procedure ............................................................................ 53

3.33 Regulation 33: Insurance ........................................................................................................... 55

3.34 Regulation 34: Certificate of Registration ................................................................................. 56

4.0 Inspection Findings and Required Actions - Rules ................................................................. 57

4.1 Section 59: The use of Electro Convulsive Therapy ..................................................................... 57

4.2 Section 69: The use of Seclusion ................................................................................................. 58

4.3 Section 69: The use of Mechanical Restraint .............................................................................. 59

5.0 Inspection Findings and Required Actions - The Mental Health Act 2001 .......................... 60

5.1 Part 4: Consent to Treatment ...................................................................................................... 60

6.0 Inspection Findings and Required Actions – Codes of Practice ........................................... 65

6.1 The Use of Physical Restraint ...................................................................................................... 65

6.2 Admission of Children ................................................................................................................. 67

6.3 Notification of Deaths and Incident Reporting ........................................................................... 72

6.4 Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities ......................................................................................................................................... 73

6.5 The Use of Electro-Convulsive Therapy (ECT) for Voluntary Patients ......................................... 74

6.6 Admissions, Transfer and Discharge ........................................................................................... 78


1.0 Mental Health Commission Inspection Process

The principal functions of the 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 under this Act. The Mental Health Commission strives to ensure its principal legislative functions are achieved through the registration 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). 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 Mental Health Act (2001), 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, and

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 shall be assessed against all regulations, rules, codes of practice and Section 4 of the Mental Health Act 2001 at least once on an annual basis. Inspectors shall use the triangulation process of documentation review, observation and interview to assess compliance with the requirements. Where non-compliance is determined the individual regulation, or rule, shall also be risk assessed. The Approved Centre is required to act on all aspects identified as non-compliant or with a high / critical risk rating. Demonstration of immediate corrective rectifications, and ongoing preventative actions must be clearly identified. These actions are required to be specific, measurable, achievable and time-bound. All actions must have identified timeframes and responsibilities. A copy of the draft report was forwarded to the service and comments and review on the report were invited from the Registered Proprietor. These comments were reviewed by the lead inspector and incorporated into the report, where relevant. In circumstances where the Registered Proprietor fails to comply with the requirements of the Mental Health Act 2001 (Approved Centres) Regulations 2006 and Rules, the Mental Health Commission has the authority to initiate escalating enforcement actions up to, and including, Ref MHC – FRM – 001- Rev 1 of 79

removal of an Approved Centre from the Register and the prosecution of the Registered Proprietor.


2.0 Approved Centre Inspection - Overview

2.1 Overview of the Approved Centre Unit 5B was the approved centre for the Limerick Mental Health Services. It was located within the University Hospital Limerick in Dooradoyle, Limerick and was situated on the ground floor of the hospital. There was access to the approved centre through the main hospital and also by its own dedicated entrance. The unit had undergone a major refurbishment in the past two years, and was still not fully completed. The refurbished unit provided a more spacious environment with five garden areas. It also included the development of a high observation area of the unit, including a seclusion room. The approved centre was registered for 50 beds but the service was utilising 40 beds routinely until the work was completed. At the time of inspection however, there were 42 beds in use. There were 43 residents in the approved centre, six of whom were detained patients; two of the residents were on leave. There were no child residents in the unit at the time of inspection. There was a seclusion room in the newly built approved centre. The room was not in use as the service had agreed that it would not be utilised until the complete redevelopment project in the approved centre was complete. The room was large and would allow a resident significant space to move around. There were blind spots which needed to be addressed in terms of the need for continuous observation of a resident being secluded. On 1 March 2014, the Mental Health Commission (MHC) attached a condition to the registration of the approved centre. This condition required full compliance with Article 15 (Individual Care Plan) of S.I. No 551 of 2006, Mental Health Act 2001 (Approved Centres) Regulations 2006. The same condition also required ongoing audits to monitor compliance with Article 15 (Individual Care Plan) of S.I. No 551 of 2006. Following the inspection, the approved centre was deemed to be compliant with the condition attached to its registration.

2.2 Governance

Meetings of the Mid-West Mental Health Management Team were held fortnightly and minutes of meetings were provided to the inspection team. There was regular attendance at these meetings by the senior operations manager, the Executive Clinical Director (ECD), Area Director of Nursing, business manager, principal clinical psychologist, principal social worker and occupational therapy manager. There was no representation by a service user or representative, but there was evidence in the minutes provided that this matter was under discussion. The minutes showed regular reviews of issues such as provision of Child and Adolescent Mental Health Services (CAMHS), developing additional therapies for service users, the establishment of a tobacco free campus for the whole hospital and difficulties with some aspects of the newly refurbished approved centre.


2.3 Inspection scope This was an unannounced annual inspection. All aspects of the Regulations, Rules and Codes of Practice were inspected against. The following were Not Applicable: Regulation 25 (CCTV), Use of Mechanical Restraint, Seclusion, Code of Practice on Working with People with an Intellectual Disability. The inspection was undertaken onsite in the approved centre from: 5 August 2015 from 0900h to 1700h 6 August 2015 from 0900h to 1700h 7 August 2015 from 0900h to 1500h.

2.4 Outstanding issues from previous inspection Five Regulations were identified as having outstanding issues arising from the previous onsite inspection carried out on 15 and 16 April 2014. These issues included:

• Residents remaining in night clothes until assessed by the consultant psychiatrist, despite this not being stated in individual care plans

• Lack of surround curtain around one bed • Refurbishment works not being completed • Lack of up-to-date training in Prevention and Management of Aggression and Violence

(PMAV) • Lack of documented risk assessment in residents admitted to the approved centre.

These were considered in the evaluation of the related Regulations and Rules, and the findings are documented within part 3 of this report.

2.5 Non-compliant areas on this inspection

Regulation/Rule/Act/Code Risk Rating Regulation 13: Searches Low Regulation 21: Privacy High Consent to Treatment High Code of Practice on Admission of Children

Moderate

Code of Practice on the Use of ECT for Voluntary Patients

Moderate


The approved centre was requested to provide CAPAs for areas of non-compliance and these are included in the report, in the relevant areas.

2.6 Areas of compliance rated Excellent on this inspection Regulation/Rule/Act/Code Regulation 7: Clothing Regulation 15: Individual Care Plan Regulation 19: General Health Regulation 24: Health and Safety Regulation 28: Register of Residents Regulation 29: Operating Policies and Procedures Regulation 33: Insurance Regulation 34: Certificate of Registration

2.7 Reporting on the National Clinical Guidelines The approved centre had access to a specifically trained Infection Control nurse; this nurse had also undertaken training with other members of staff of the approved centre.

The approved centre maintained a record of instances where notifiable infections occurred in the approved centre.

One resident had contracted MRSA and was barrier nursed within the approved centre.

In two instances, low levels of Legionella were detected within the system, but not affecting residents. This had resulted in episodes of chlorination being required in two separate areas of the approved centre.

One resident had been in contact with an area of the main hospital which proved positive for another infectious disease. As a result, this resident required barrier nursing and limited isolation, with weekly testing for a period of four weeks.

2.8 Areas of good practice identified on this inspection The refurbishment of the unit in general, had resulted in a more spacious, comfortable environment for residents and staff alike. On completion, it would provide the unit with a separate area for high observation of residents and a separate designated area for accommodating elderly residents in the approved centre. The approved centre had paid significant attention to the area of individual care planning, and the result was apparent in the individual care plans (ICPs). This had included regular audit and training for staff. As a result, the service was compliant with the condition attached to its registration.


2.9 Resident Interviews Residents were greeted by inspectors during the course of the inspection, and were invited to meet with the inspectors if they wished. One resident met with the inspectors and highlighted a number of issues which could improve the patient experience of being in the approved centre. These included holding regular community meetings between staff and residents and more readily visible name badge identification for staff.

2.10 Feedback Meeting

Before the conclusion of the inspection, a feedback meeting was held between the inspection team and the senior management team of the approved centre. The feedback meeting was part of the inspection process and enabled issues of clarification to be dealt with. Senior managers form the approved centre who attended the feedback meeting included the Executive Clinical Director, the Director of Nursing, Business Manager, a representative from the Area Manager’s office, two Assistant Directors of Nursing, principal psychologist, occupational therapy manager and the social work manager. The inspection team provided feedback on the inspection findings and welcomed discussion about areas requiring improvement.


3.0 Inspection Findings and Required Actions - Regulations

PART TWO: EVIDENCE OF COMPLIANCE WITH REGULATIONS, RULES AND CODES OF PRACTICE, AND PART 4 OF THE MENTAL HEALTH ACT 2001

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

3.1 Regulation 1: Citation Not Applicable

3.2 Regulation 2: Commencement Not Applicable

3.3 Regulation 3: Definitions Not Applicable


3.4 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: There was a policy in place regarding the identification of residents, which was implemented in March 2013. The policy identified the persons responsible but did not include the use of two identifiers of a resident. The policy did not identify the issue of training of staff in identifying residents but addressed the issue of monitoring.

Training: There was no specific training but staff were aware of the process involved in identifying a resident which consisted in asking a resident’s name and date of birth in the case of two residents with the same name.

Monitoring of Compliance: There was no evidence of monitoring having been carried out.

Evidence of Implementation: Residents did not wear identity wristbands or have photographic identification on their medication kardexes. Staff reported that residents were asked to identify themselves to a nurse administering medication, giving their address as a second identifier. A date of birth was requested if there were two residents with the same name.

Compliance Rating:

Non – Compliant – Negligible

Achievement (1)

Non – Compliant – Poor

Achievement (2)

Compliant – Good

Achievement (3)

Compliant – Excellent

Achievement (4)

Not-

Applicable

X


3.5 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: There was a policy in place regarding food and nutrition, which had been reviewed in 2014. The policy identified the roles and responsibilities of staff. The policy identified the necessity to manage and review an individual’s needs in terms of nutrition.

Training: Staff were aware of the process regarding the identification of the requirements of individual residents.

Monitoring of Compliance: There was no evidence of monitoring or audits carried out in relation to the processes.

Evidence of Implementation: Meals were provided from the kitchen in the general hospital. The food came in heated containers and was plated individually in the approved centre. A menu was not displayed in the dining room, but there was a choice of meals daily and special diets were catered for. Water coolers were observed throughout the unit. Between meals, snacks and hot drinks were provided, the final snack at 2100h.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.6 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: There was a process in place to ensure the provision of adequate kitchen equipment and catering facilities.

Training: The relevant staff had received training and the catering staff interviewed confirmed that they had received training in Hazard Analysis and Critical Control Points (HACCP) procedures.

Monitoring of Compliance: Monitoring was conducted by means of the Environmental Health Officers (EHO) inspections and reports. There was no evidence of internal audits or monitoring.

Evidence of Implementation: The kitchen and dining area were in a temporary location, pending completion of the refurbishment works in the approved centre. However, the dining area was spacious and there were adequate tables and chairs for residents. The kitchen was clean and there were hand washing facilities available. Staff in the kitchen were observed to wear suitable protective clothing and wore gloves when handling food. Staff in the kitchen reported there was sufficient crockery and cutlery, but the crockery was of the disposable variety, which was not suitable. Food refuse was disposed of twice or three times daily. Food was stored in a fridge which was observed to contain foodstuffs only. The most recent EHO report was dated February 2015 and was seen by the inspector.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.7 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: There were processes in place for ensuring a resident had suitable and sufficient clothing. There was a process for providing a resident with additional clothes if required, but this was primarily night clothes. The process included a resident wearing day clothing, unless specified in their individual care plan.

Training: There was no training but staff were aware of the processes involved in ensuring adequate clothing for residents.

Monitoring of Compliance: The monitoring of residents’ clothing was carried out informally by staff in the approved centre. No formal audits in relation to this were carried out.

Evidence of Implementation: Residents were observed to be dressed in day clothes during the course of the inspection and all residents were dressed in clothing appropriate to them. The only spare clothing available on the unit were night clothes. Most residents had their own wardrobe and locker, but those residents accommodated in extra beds did not. Clothes were not labelled as this was primarily an acute unit.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.8 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: There was a policy in place in relation to residents’ personal property and possessions, dated February 2014. The policy addressed the residents’ entitlement to bring their possessions with them on admission. The policy also addressed the necessity to document a resident’s property on admission and on discharge. It also addressed the issue of the management of a resident’s money in their possession whilst in the unit.

Training: Staff were aware of the requirements to safeguard a resident’s property.

Monitoring of Compliance: Audits or monitoring were not carried out.

Evidence of Implementation: The unit had a property book, in which a resident’s property was recorded on admission and was inspected by the inspector. However, in several clinical files inspected, there was no evidence that a copy of this record had been placed in the relevant clinical files. There was a safe in the unit and residents could ask for property to be placed in the safe. There was no restriction, within reason, on possessions being brought in by a resident, but residents were requested to hand over items which could be hazardous. Where a resident asked staff to hold money, this was recorded in individual envelopes and signed for by two staff and the resident.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.9 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: There was a policy on provision of recreational facilities in the approved centre, which was implemented in 2013. The policy identified roles and responsibilities. The policy addressed the development of individual activities for residents and suitable areas for recreation. The policy also addressed the need for a specific activities team to be in place.

Training: The Assistant Director of Nursing (ADON) had received training on the operation of the gym equipment, and staff had also received some training in the safe operation of this equipment. The activities nurse had also received training.

Monitoring of Compliance: There was no evidence of audit or incident reporting of non-compliance with the processes.

Evidence of Implementation: A weekly programme of recreational activities was displayed on the noticeboard in the unit. This identified group activities in which a resident could participate, if they wished. These activities included current affairs, newspaper reading, personal care and access to gym equipment. The group room contained three PCs but access to the internet was not provided. Staff reported that access could be provided in the nursing office, if necessary.

There was no structure in place for an assessment to be carried out prior to participating in activities, but staff would ensure a medical assessment if indicated; for example, for use of the gym equipment. The use of gym equipment was supervised by a member of staff. A record of attendance at these activities was recorded in the individual resident’s clinical file.

The refurbished unit contained five enclosed garden areas, but at the time of inspection, only one of these was accessible to residents. This limited the area available for outdoor recreation.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.10 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: There was a policy with regard to religion. Roles and responsibilities of staff were outlined in the policy. The policy included the right of a resident to practice his or her religion within the approved centre, that religious beliefs were respected and supports put in place for residents to observe religious practices. Staff training processes in relation to support of religious practices were not in the policy. There was a list of contact details for ministers of different faiths as an appendix to the policy. The Health Service Intercultural Guide was in use in the approved centre.

Training: Staff were aware of the policy with regard to religion and were able to articulate the processes. They had signed to state that they had read and understood the policy.

Monitoring of Compliance: There was no documented monitoring of the processes implemented to support residents’ religious practices.

Evidence of Implementation: There was a list of contact details for Ministers of different religions and residents were facilitated to observe or refrain from religious practice. Mass was held in the approved centre once every two weeks. Communion was distributed daily. If the practice of religion was identified as a need, this was documented in the resident’s individual care plan.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.11 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: There was a policy with regard to visiting in the approved centre. The roles and responsibilities of staff were outlined. The policy included the process for restricting visitors and the arrangements for children visiting. It did not include the location for resident visits.

Training: Staff were aware of the policy with regard to visiting and were able to articulate the processes. They had signed to state that they had read and understood the policy. There was a training pack for staff which contained a section on visiting. Staff had trained in Children First and there was documentation of this.

Monitoring of Compliance: There was no documented monitoring of the processes of residents’ visits.

Evidence of Implementation: Due to ongoing construction work in the approved centre, there was no current visitor’s room or specified area. In order to provide privacy and facilitate children visiting a consulting room was used. On completion of the construction works, a dedicated visitor’s room will be available, which will be child friendly.

Visiting times were from 1400h to 1600h and from 1830h to 2000h, but could be flexible if there was a need. The visiting times were displayed and in the residents’ information booklet. Children were accompanied at all times by a responsible adult while in the approved centre. Refusal of visitors by a resident was documented in the individual care plan. Visitor safety procedure was not displayed but was in the Health and Safety Statement.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.12 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: There was a policy with regard to communication. It outlined the staff’s roles and responsibilities. Different means of communication were included. The policy did not include the requirement for risk assessment in relation to residents’ communication activities, staff awareness requirements in relation to communication or the accessibility of interpretation services. However, there was a list of interpretation services and the staff were able to articulate how to access these services. The core management committee was responsible for evaluation and audit of the communication processes and this was documented in the policy.

Training: Staff were aware of the policy with regard to communication and were able to articulate the processes. They had signed to state that they had read and understood the policy.

Monitoring of Compliance: Audits of the communication process were carried out by the core management team as outlined in the policy, but there was no documentation of this. Staff did not fill incident forms if there was non-compliance with the process. There was no documentation of any analysis to identify opportunities for improvement to the process.

Evidence of Implementation: There was no resident whose communication was restricted due to risk. Incoming and outgoing mail was not opened by staff. All residents were allowed their own mobile phone. Internet access was available on request but it was limited to HSE sites.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.13 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: There was a policy on searches. The policy clearly addressed the procedures for the carrying out of searches with and without consent. Roles in relation to making the decision to search and who could carry out a search were clearly stated. The criteria for initiating a search and when not to carry out a search were also clearly stated. For example, where there was concern that a resident might be in possession of a weapon or dangerous implement then the Gardaí were called. Searches were only carried out in the interests of residents, staff and visitor safety. The issue of consent in relation to searches was included in the policy. The procedure for handling illicit substances and notifying the Gardaí were addressed. The policy required that the reason and procedure in relation to any search be communicated to the resident. The policy charged the senior management team with responsibility for monitoring and quality improvement.

Training: The policy required heads of department to inform staff. The induction programme for nursing staff included searches.

Monitoring of Compliance: The Mental Health Act administrator produced an annual record of searches. There was no evidence of auditing or monitoring of compliance in relation to searches. Incident reports were completed as appropriate.


Evidence of Implementation: The inspection team read the record of searches, the incident report forms, the clinical indemnity scheme incident entries (STARSWeb), individual clinical files and spoke with nursing staff.

The searches recorded in the searches record and the incident records did not match. In two instances rooms were searched in response to complaints of monies or property going missing. The STARSWeb record stated in one instance that money was found in possession of another resident. In another room search the STARSWeb entry stated that property was recovered. Neither of these incidents were recorded in the “patient searches” record. The language used in the STARSWeb entries implied that residents’ property had been searched during the room searches. The records did not provide a clear account of how the reason and the procedure for the search was communicated to the residents concerned, who carried out the searches, an account of what was searched and whether consent was given. In one instance the STARSWeb record stated that an illicit substance was “retrieved” from a resident. The entry in the clinical file in relation to this incident stated that the resident “refused to hand over” and assistance was sought from another staff member and the resident was “eventually convinced to hand over” the illicit substance. The clinical file contained a completed form in relation to the substance being handed over to the Gardaí.

The approved centre was not compliant with this Regulation because the records examined on searches did not provide an account of the searches described in the incident reports. The issue of adequately recording searches and how this might be achieved was discussed with the nurse in charge.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X

Risk Rating

Low Moderate High Critical Not - Applicable

X


3.13 Regulation 13: Searches The following Corrective and Preventative Actions (CAPAs) were provided by the Registered Proprietor or nominee and are subject to ongoing review by the Mental Health Commission. All actions should be Specific, Measurable, Achievable, Realistic and Time-bound with defined responsibilities for implementation: Date submitted

21/9/2015

CAPAs Specific Measureable Achievable & Realistic

Time-bound

Define the action and state if it is corrective or preventative and state post-holder(s) responsible

Define the area of non-compliance addressed by this CAPA

State method of evaluation and monitoring of outcome

State feasibility of action

State time-frame for completion of action

1. Corrective:

• Search Policy being reviewed. Will be completed and will include searches of the environment.

Post-Holder(s): Executive Clinical Director, Chair of the CPPPG group.

Regulation 13: Searches

Quarterly Agenda item on the Limerick Management Team to monitor implementation of CAPA. Agenda item on the Mid West Mental Health Quality and Patient Safety Committee Chair of Mid West Mental Health Quality and Patient Safety Committee to provide assurance to Mid West Mental Health Management Team

It is realistic to achieve the implementation of this CAPA

Mid November 2015


that CAPA’s are being implemented.

2. Corrective:

• Nursing management will provide in-service training for staff of the unit on the reviewed Search policy. Names will be recorded

Post-Holder(s): James Harrington, A/DoN, Unit 5B.

Regulation 13: Searches

Audits will be completed following 3 months of implementation of the reviewed policy Quarterly Agenda item on the Limerick Management Team to monitor implementation of CAPA. Agenda item on the Mid West Mental Health Quality and Patient Safety Committee Chair of Mid West Mental Health Quality and Patient Safety Committee to provide assurance to Mid West Mental Health Management Team that CAPA’s are being implemented.


Mid November 2015


3.14 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: There was a policy on the care of residents who were dying. The policy stated that the admission assessment should include an assessment of a resident’s religious and cultural needs. The policy required that staff record a resident’s wishes and choices regarding end of life care and the extent to which family were involved in the decision making process. A named nurse was assigned to a resident who was dying. Staff reported that a resident who was dying would routinely be transferred to the main hospital. The roles and procedures in relation to a sudden unexpected death were outlined in the policy. Roles and responsibilities in the notification of deaths to the Mental Health Commission (MHC) were also outlined in this policy.

Training: Heads of Discipline were charged with ensuring staff were made aware of the policy and procedures. The induction programme for medical and nursing staff included responding to emergencies and sudden unexpected deaths.

Monitoring of Compliance: Incident report forms were completed as appropriate. Deaths were notified to the Mental Health Commission.

Evidence of Implementation: The deaths of two residents of the approved centre had occurred since the inspection of 2014. One resident had been transferred and the death occurred in another facility. The death of the second resident had also occurred outside of the approved centre. The deaths of both these residents had been notified to the MHC within the required timeframe.


Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.15 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: There was a process in place for ensuring each resident had an individual care plan (ICP). This process included the inclusion of an initial care plan in the admission document completed by a doctor on the admission of each resident. Regular multidisciplinary team (MDT) meetings were scheduled weekly at which ICPs were reviewed.

Training: Staff had received training in ICPs and this was ongoing. There was documented evidence in the training record to indicate which members of staff had attended.

Monitoring of Compliance: As a result of a condition attached to the registration of the approved centre by the Mental Health Commission (MHC), monthly audits on ICPs were conducted and the results of those audits were available to inspectors.

Evidence of Implementation: The clinical files of all residents in the approved centre were inspected and there was evidence that all residents had an ICP. A number of ICPs were inspected to assess compliance with the Regulations. Each resident had an initial care plan completed on admission by the admitting doctor. Assessment on admission included a mental state examination, a history, collateral history and a physical examination, conducted by the admitting doctor. Nursing staff completed a bio psychosocial history on admission. The ICPs included identification of a resident’s needs, goals, interventions and person responsible. In most cases, there was evidence that the resident had the opportunity to contribute to their care plan and this was documented in the ICP documentation by the key worker.

Whilst the ICPs recorded issues of risk, they did not include a risk management plan.

Attendance at the ICP review meetings, which were held weekly, was documented and there was evidence that all disciplines, including occupational therapy, social work and psychology, contributed to the review of the ICP.

In a small number of cases, there was no evidence that the resident had been offered or accepted a copy of their ICP.


Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.16 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: There was a policy in place on therapeutic services which had been reviewed in October 2014. The policy identified the roles and responsibilities and the process for planning a therapeutic programme. The policy addressed the need for training for staff in relation to therapeutic services and the need to review services at three monthly intervals.

However, the policy did not address the resource requirements for this process or the provision of facilities.

Training: Training had been addressed by the provision of a specific activities therapist in the approved centre.

Monitoring of Compliance: Audits on therapeutic activities were not conducted and incident reports were not completed for non-compliance.

Evidence of Implementation: The activities therapist worked full-time in the approved centre, a post which had been increased from part-time. Facilities included a therapy room and an art room. The activities planned for the day were displayed on a large noticeboard in the unit and the therapist recorded details of attendance in each individual’s clinical file.

A social worker provided therapy in the approved centre on a 0.75 Whole Time Equivalent (WTE) basis. There was no occupational therapist based in the unit but two occupational therapists from the sector teams provided group sessions in the unit three times a week. Similarly, psychologists from the sector teams provided regular therapeutic sessions in the approved centre.

There was evidence on inspection of the clinical files that residents were receiving a range of therapeutic services, relevant to their needs.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)

Complaint – Excellent

Achievement (4)

Not-

Applicable

X


3.17 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

Processes: The policy and procedures in relation to the provision of appropriate educational services to a child resident were included in the policy on the admission of children to the approved centre. The policy clearly outlined who was responsible for assessing educational need, overseeing educational input as part of the individual care plan and the range of choices and resources available within the approved centre. The role of the Children’s Ark School and the child and adolescent mental health service (CAMHS) team were clearly outlined.

Training: Heads of discipline were charged with ensuring staff were informed about the policy and procedures in relation to children’s education. Training in Children First principles and child protection had not been provided to all staff.

Monitoring of Compliance: The policy and procedures were reviewed by the senior management team and amended as appropriate to ensure compliance. Incident reports were made as appropriate.

Evidence of Implementation: There had been three children admitted to the approved centre in 2015 up to the time of inspection. Educational input had not been required as the residents were in-patient for less than four days.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.18 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: There was a policy on the transfer of residents. The policy identified the roles and responsibilities of staff in relation to transfers. The process for transfer was described in the policy but it did not address the issue of training for staff or address the issue of emergency transfers.

Training: Staff were aware of the process of transferring residents, but there was no evidence of specific training.

Monitoring of Compliance: There was no evidence of audit or completion of incident reports for non-compliance.

Evidence of Implementation: The clinical file of one resident who had been transferred was inspected. The reason for the transfer was documented in the clinical file along with evidence of communication with the relevant clinical personnel taking over care of the resident on transfer. The next of kin was informed of the transfer but there was no evidence that the resident had been informed of the impending transfer. There was no liaison with members of the MDT but as the reason was for medical needs, this was not required.

There was no evidence of what information was transferred with the resident on transfer and no copy of a nurse transfer form or doctor’s letter was retained in the clinical file.

Non – Compliant – Negligible Achievement (1)

Non – Compliant – Poor Achievement (2)

Compliant – Good Achievement (3)

Compliant – Excellent Achievement (4)

Not-

Applicable

X


3.19 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: There was a policy in place covering the provision of general healthcare, including access to recommended national screening programmes. This policy included procedures for responding to medical emergencies.

Training: Staff interviewed outlined an awareness of the requirements of this regulation in relation to both the provision of routine and emergency health care to residents. Relevant training was ongoing and this was documented in the staff training log.

Monitoring of Compliance: There was no evidence presented of formal audit of compliance with processes. Regular weekly checks were maintained on all emergency equipment within the centre and these were documented.

Evidence of Implementation: All residents had access to regular medical and nursing intervention in relation to general health issues. Appropriate facilities were available to safeguard the privacy and dignity of residents receiving general healthcare. Interventions were in line with the requirements of the resident’s ICP. Three residents had been over six months continuously in the centre and in all cases there was evidence on file of a six-monthly physical review. Residents were encouraged to partake in recommended national screening programmes.

Compliance Rating





Not-

Applicable

X


3.20 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: There was a policy in place in relation to the provision of information to residents, which outlined the roles and responsibilities of staff. The process for provision of information to residents and their relatives was outlined in the policy. The policy included interpretation services, visiting arrangements, the content of the information given, the monitoring of the provision of information and the process for giving information about medication. The advocacy arrangements and the process for staff training were not in the policy.

Training: Staff were aware of the policy with regard to the provision of information to residents and were able to articulate the processes. They had signed to state that they had read and understood the policy. There was no formal training with relation to provision of information to residents.

Monitoring of Compliance: No audits or analysis were completed and incident forms were not completed if there was non-compliance with the process.

Evidence of Implementation: There was an information booklet, in understandable form, which had housekeeping arrangements, the complaints procedure, residents’ rights and the details of the multidisciplinary team. There was also an information booklet about discharge. There was no documentation as to whether the resident had read and understood the information. Royal College of Psychiatrists information sheets were given to residents if information was required about diagnosis or medication. There was a list of interpretation services in the nursing office. Details of the advocacy service were posted in the approved centre.


Compliance Rating


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.21 Regulation 21: Privacy The registered proprietor shall ensure that the resident's privacy and dignity is appropriately respected at all times. Inspection Findings

Processes: There were no defined processes in place in respect of privacy. The layout of the approved centre supported the privacy of residents except in cases where an additional bed had been put into shared rooms.

Training: Training in provision of privacy was not implemented but staff were aware of the requirements to provide residents with privacy and confidentiality.

Monitoring of Compliance: Audits in relation to privacy were not carried out but issues such as the addition of extra beds in bedrooms was monitored on a daily basis. There was no evidence that incident reports were carried out in respect of these issues.

Evidence of Implementation: During the course of the inspection, staff were observed speaking to residents in a respectful way and staff were dressed appropriately. Where a resident required assistance with bathing or toileting, the key worker would provide assistance; this applied in the case of one resident in the approved centre at the time of inspection.

A separate clinical room was available for carrying out medical examinations.

All toilets and showers could be locked from inside. Inspectors observed that a number of toilets were locked from outside, which meant that residents had to request staff to open them in order to use these facilities. On speaking with the accompanying staff, they were unsure as to why this was the case. Restricting free access to toilets in this way was not conducive to privacy.

Two extra beds had been moved into two shared bedrooms; these extra beds did not have surround curtains for privacy and did not have assigned wardrobes or lockers. A third bed did not have a surround curtain. Following the inspection, the inspection team was informed that curtains had been installed.

The approved centre was not overlooked by any other facility and the enclosed gardens will provide a private area for outdoor use, once operational.

There was no designated visitors’ room at the time of inspection, but staff reported that an office space could be provided for private meetings, if required.

Clinical files were stored safely and confidentially in a locked nursing office.

The service was not compliant with this Regulation because of the absence of privacy for the three residents whose beds had no surround curtains and because two of these beds did not have individual wardrobes or lockers.


Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X

Risk Rating


X


3.21 Regulation 21: Privacy The following Corrective and Preventative Actions (CAPAs) were provided by the Registered Proprietor or nominee and are subject to ongoing review by the Mental Health Commission. All actions should be Specific, Measurable, Achievable, Realistic and Time-bound with defined responsibilities for implementation: Date submitted 21/9/2015

CAPAs

Specific Measureable Achievable & Realistic

Time-bound






1.Corrective:

• Curtains were installed on day of inspection

Post-Holder(s): Maura Cahalan, SEO, Limerick Mental Health Service

Regulation 21: Privacy

Quarterly Agenda item on the Limerick Management Team to monitor implementation of CAPA. Agenda item on the Mid West Mental Health Quality and Patient Safety Committee Chair of Mid West Mental Health Quality and Patient Safety Committee to provide assurance to Mid West Mental Health Management Team that CAPA’s are being implemented.


Complete


2. Preventative:

• Management has agreed the purchase of wardrobes and lockers which will be stored on the unit in the event of the necessity to put up extra beds in order to ensure privacy.

Post-Holder(s): Maura Cahalan, SEO, Limerick Mental Health Service

Regulation 21: Privacy



End of November 2015


3.22 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: There were processes in place for the maintenance of the approved centre. The building was specifically designed for use as a mental health facility. Rooms were allocated to specific purposes but at the time of inspection, this allocation was not always in use. The process included recording of requests for maintenance, and this was managed electronically. The ADON was the person responsible for addressing maintenance issues.

Training: Staff were aware of the process in addressing maintenance issues and understood the procedure for reporting this.

Monitoring of Compliance: Audits were not carried out on the process and there was no evidence of incident reports completed in respect of non-compliance with this.

Evidence of Implementation: The premises had undergone major refurbishment in the past two years and this was accomplished whilst still functioning as an approved centre. Staff reported that this had proved difficult and there was considerable disruption with high noise levels at times.

The layout of the unit was spacious and included a High Observation area, seclusion room, therapy rooms, and a large sitting room. At the time of inspection, parts of the unit were not fully functional.


The temperature of the unit could be regulated and was zoned for different temperatures and most of the heating was underfloor heating. This was regulated by maintenance staff when requested by the ADON. Lighting was not adaptable but there was specific lighting for night time. Water was distributed through mixers and the temperature was controlled.

There were five garden areas in the approved centre, only one of which was in use at the time of inspection.

Toilets and shower rooms had anti-ligature fittings and were lockable by the person using them; bedroom doors could also be locked from inside and these locks could be overridden by staff.

The two nurses’ stations were located centrally, and each nursing office had an open counter on either side; these open spaces were unused and non-functional.

The seclusion room which was newly constructed, was an L-shaped room, but was unsuitable as it contained blind spots for a person directly observing a resident in the room.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.23 Regulation 23: Ordering, Prescribing, Storing and Administration of Medicines (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: There was a policy with regard to ordering, prescribing, storing and administration of medication. There was no process outlined for administering controlled medication. The reconciliation of medication, the management of medication errors, review of medication and staff training in medication management were not in the policy. Crushing of medication, monitoring of medication and withholding of medication were outlined in the policy.

Training: Management of medication was only done by trained medical and nursing staff, who had received training in medication as part of their professional training.

Monitoring of Compliance: An audit of medication documentation had been completed in July 2015, which had been disseminated to relevant staff and the Risk Management Steering Group. The pharmacy department also audited and analysed medication processes. Incident forms were completed for medication errors and omissions.

Evidence of Implementation: Staff were aware of relevant legislation and codes of professional conduct with regard to medication. Near misses and medication errors were recorded in the incident log.

The prescription and administration of medication was satisfactorily documented and Medical Council registration numbers were used consistently. Medication was stored in a locked cupboard in the locked pharmacy room. However, in the clinical room (which was locked) there was an open cupboard with psychotropic and other medication. This was brought to the attention of the staff and the medication was moved to the pharmacy room immediately and locked in the medication cupboard there.

There was no expired medication in the pharmacy room and there was a system of reconciliation and inventory of medication. Controlled drugs were double locked in a cupboard and the quantities were balanced with the Controlled Drug Book entries. The fridge was only used for medication and there was a temperature log.


Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.24 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: There was a comprehensive health and safety statement. The statement clearly identified the persons responsible for both overall responsibility for health and safety and those with responsibility for specific aspects. Identified hazards were risk rated and controls put in place. There was an emergency plan in place. There was a designated health and safety officer and health and safety representatives for the approved centre. There was an occupational health and employee assistance programme in place. The approved centre had a number of committees whose responsibility was to oversee: risk and patient safety; health and safety; infection prevention and control; environmental health; and the risk register.

Training: Staff were appropriately trained commensurate with their roles in relation to health and safety. The training record for staff training showed that training was provided in manual handling, handwashing, infection control, fire safety, the management of sharps, the use of personal alarms and the prevention of slips, trips and falls. The staff induction programme included the use of personal alarms and emergency procedures and use of equipment. Staff were trained in reporting incidents. Staff training in the prevention and management of violence and aggression was not up to date.

Monitoring of Compliance: The committees charged with the responsibility for various aspects of health and safety supervised a number of audits and monitoring of safety. There were scheduled audits of infection control measures within the approved centre. The contract cleaning company completed audits related to health and safety.

Evidence of Implementation: The health and safety statement for the approved centre had been reviewed annually and was available within each unit office. There was no health and safety statement displayed publicly within the approved centre.

The risk register was up to date. Hazards had been risk rated and controls identified. In relation to violence and aggression, staff training had not been adequately implemented. There was no evidence of training for a significant number of staff who had been engaged in applying physical restraint.

The fire safety procedures were clearly displayed. The fire reports and staff fire training were up to date. In relation to fire evacuation drills, the record provided was dated 2014.

The infection control department in the general hospital had input to the approved centre. The training log for infection control showed that a number of staff had not attended the course. The monthly audit schedule for infection control was up to date.


Staff reported that there had been issues with the electronic door mechanism. Consequently security staff were in place to monitor entrances until the issue was satisfactorily resolved.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.25 Regulation 25: Use of Close Circuit Television (CCTV) (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 anytime on request. Inspection Findings

CCTV was not used within the approved centre. This regulation was not applicable.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.26 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 service utilised the Health Service Executive (HSE) policy on recruitment. There was a policy in place regarding staff roles and an organisational structure was detailed on an organisational chart. Job descriptions were provided in contracts and this was seen by one inspector. There was a process for issuing the staff rota and this was issued both daily and monthly to the senior managers on the unit. The requirements for staff training were contained in the training log and there was a process in place for recruiting agency staff.

Training: The relevant staff for recruitment were aware of the requirements of the process.

Monitoring of Compliance: Staffing requirements for the approved centre were reviewed and additional resources were requested if necessary. The training schedule was reviewed annually so as to identify areas in need of training. There was no evidence that audits had been carried out; one incident report had been completed by a member of staff on a reported insufficient number of staff in the approved centre.

Evidence of Implementation: There was an organisational chart in the Safety Statement, which was seen by inspectors to be available on the ward. A daily and monthly roster of nursing staff was emailed to the senior managers on the ward and was seen by one inspector. The level of staffing of 12 nursing staff by day and eight staff by night had been agreed between staff and management. All staff were Garda vetted; this included agency staff and this was confirmed by the ADON during the course of the inspection. Evidence of Garda vetting was seen on inspection of two of the staff files. An induction programme was documented for new staff and the content was seen by inspectors; the programme included allocation of a liaison staff member.

There was an identified staff member in charge of the approved centre.


Staffing levels on the day of inspection comprised one ADON, one Clinical Nurse Manager (CNM) 3, one CNM2, eight Registered Psychiatric Nurses (RPN) and four 4th Year Student nurses. At night, the staffing complement was one CNM2 and seven RPNs.

The files of two members of staff were inspected and showed evidence of job description, qualifications, Garda vetting and up-to-date registration with the relevant Regulatory bodies.

The training record of nursing staff showed evidence of regular training in several areas of practice, but not all the training was up to date. In particular, several staff members had not received training in Prevention and Management of Aggression and Violence (PMAV) for some years.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.27 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 policy in use in the approved centre was the National Hospitals’ Office Code of Practice for Healthcare Records Management which covered the creation of, access to, retention of and destruction of medical records. It did not include the retention of inspection reports such as Environmental Health Officer reports. The training of staff and the monitoring of processes were included in the policy. The legislative framework and reference to the Data Protection Act and Freedom of Information Act were also contained in the policy.

Training: Staff were not formally trained in maintenance of records but were aware of the policy and had signed that they had read and understood it.

Monitoring of Compliance: There was an audit of medication documentation completed in July 2015. The results of this were analysed and disseminated to relevant staff. There was also an audit of nursing documentation. Incident reports were not completed for non-compliance with the process.

Evidence of Implementation: Clinical files were in good order, up to date and chronological. They were securely stored in the nursing office. Medication records were satisfactory. Each clinical file and medication record had three unique identifiers. Access to clinical files was restricted to the multidisciplinary team.

The Environmental Health Officer’s report, Health and Safety report and the Fire Officer’s report were available.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.28 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

Processes: There was a process in place to record the elements specified in the Schedule 1 to the Regulations; this was maintained electronically.

Training: The relevant staff were aware of the processes involved.

Monitoring of Compliance: The data gathered incorporated the requirements of Schedule 1 to the Regulations and contained up-to-date information. There was no evidence of audit.

Evidence of Implementation: There was a staff member assigned to maintain the Register and access was controlled, but available to staff if required. The Register was retained both electronically and in hard copy and was inspected by the inspector. The Register contained all the data required by Schedule 1 to the Regulations.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.29 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: There was a policy in place on the development of policies, dated March 2011. The policy identified the roles and responsibilities in the development of these policies and included the dissemination of policies to staff. The policy also addressed the procedure for dealing with expired policies and the need for policies to follow a standardised format.

Training: The policy identified the need for staff involved in drawing up policies to be trained, but there was no evidence that this training had taken place.

Monitoring of Compliance: There was evidence that all policies relating to the operation of the approved centre were in date, with the exception of the policy on Developing Policies. There was no evidence of audit.

Evidence of Implementation: Inspection of the policies showed that the policies had been developed by the appropriate senior managers. All policies referred to the relevant legislative requirements and the format of the policies was standardised. The policies were available to all staff, in folders in the unit.

Compliance Rating:





Not-

Applicable

X


3.30 Regulation 30: Mental Health Tribunals (1) The registered proprietor shall ensure that an approved centre will co-operate fully with Mental Health Tribunals. (2) In circumstances where a patient's condition is such that he or she requires assistance from staff of the approved centre to attend, or during, a sitting of a mental health tribunal of which he or she is the subject, the registered proprietor shall ensure that appropriate assistance is provided by the staff of the approved centre

Inspection Findings

Processes: There was a policy in place on the holding of Mental Health Tribunals. The process identified the roles and responsibilities of staff in facilitating tribunals and identified the resources, including staff to assist the patient at tribunals. It did not address the issue of provision of information to the patient about tribunals or training for staff.

Training: Staff were aware of the requirements in respect of mental health tribunals but there was no evidence of training in this.

Monitoring of Compliance: There was no evidence of monitoring of the process.

Evidence of Implementation: The approved centre provided a room for holding tribunals; at the time of inspection, this was a temporary room. There was also a room available for a patient to meet with their legal representative. There was information available for patients on tribunals and the service used the MHC information booklet.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.31 Regulation 31: Complaints Procedure (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 used the HSE policy Your Service Your Say as its complaints policy and this was clearly stated in the notices about making a complaint. This policy outlined roles and responsibilities of staff, the process of managing complaints, confidentiality, the processes regarding verbal and written complaints, appealing decisions of the complaints officer, support for complainants, staff training and monitoring of complaints.

Training: Induction training for staff included handling of complaints. There was no documented evidence of training in managing complaints or the complaints procedure. Staff had signed that they had read and understood the policy.

Monitoring of Compliance: The complaints officer recorded and analysed complaints and this was disseminated to staff. There was no record of an annual audit of complaints.

Evidence of Implementation: There were a number of notices clearly outlining the complaints procedure and stating the name of the staff member nominated to receive complaints. The complaints procedure was included in the information booklet and was on an information CD. Complaints were recorded in a complaints log, which included the outcome of the complaint. There was no specified timeline with regard to processing complaints but scrutiny of the complaints log showed that each complaint was dealt with in a prompt manner. The complainant’s satisfaction or dissatisfaction with the outcome of their complaint was not documented. Records of complaints were maintained in a secure location.


Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.32 Regulation 32: Risk Management Procedure (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: There was a policy on risk. This policy addressed the identification, reporting and management of incidents. The roles and responsibilities in relation to incidents was clearly stated, including notification and provision of summary reports to the Mental Health Commission. There was a policy on a resident being absent without leave. No policies were provided which addressed suicide and self-harm, assault, or accidental injury to residents or staff. There was a policy on responding to emergencies. The national Health Service Executive policies on the protection of vulnerable adults and the protection of children were in place. There was a defined procedure in relation to clinical risk assessment whereby the admitting doctor completed an assessment of risk at the time of admission. Risk was reviewed at each MDT review of ICPs.

Training: Training addressed the risk and incident management procedures. No information was provided in relation to staff training in clinical risk assessment. The staff induction programme addressed risk management and personal safety.

Monitoring of Compliance: There was a risk register maintained for the approved centre. There was a quality, risk and patient safety committee who reviewed and audited risk related issues.

Evidence of Implementation: Six individual clinical files were inspected. Risk assessment had been completed at the time of admission and an initial care plan developed which included specification of the level of observation required for each resident. The service did not use a standardised risk assessment tool to inform structured clinical judgment. The


recording of risk assessment in the clinical files used broad terms such as “risk of self-harm”, “suicidal ideation”, “strong history of overdose”. The records did not provide a clear elucidation of these risk items either in historical terms or in relation to current status. Nonetheless, it was evident that there had been MDT discussion and review of risk at each team review of the ICPs because the care and treatment delivered targeted relevant stressors, vulnerabilities and safety issues. The clinical files showed that, where applicable, suicidality was assessed at each clinical contact and recorded in the medical and nursing entries. The records showed an individualised approach to risk management rather than a blanket approach.

One patient was absent without leave (AWOL) having failed to return from approved leave. The patient had been medically reviewed on the day leave was approved. The clinical record did not provide a statement of updated risk assessment in relation to leave. Nor did the clinical record provide a precise account of the patient going on leave and the immediate response when AWOL status was identified.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.33 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

Processes: There was a process in place to ensure that the approved centre was appropriately covered by insurance.

Training: The relevant staff were aware of the necessity to ensure that the approved centre was insured.

Monitoring of Compliance: The requirements for insurance was reviewed annually.

Evidence of Implementation: The approved centre was insured under the State Claims Agency (SCA) and a Confirmation Statement was available to inspectors. As the State indemnity was enshrined in legislation, the Confirmation Statement issued by the SCA operated in lieu of a certificate of insurance.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


3.34 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

Processes: There was a process in place to ensure the Certificate of Registration was displayed.

Training: The relevant staff were aware of the necessity to display the certificate.

Monitoring of Compliance: The Certificate was up to date.

Evidence of Implementation: The Certificate of Registration was displayed in a prominent place in the approved centre. The certificate detailed the name of the approved centre and the date of registration and included the details of the condition attached to the registration.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


4.0 Inspection Findings and Required Actions - Rules

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

4.1 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 or unwilling 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 no detained patient had received ECT, this Rule was deemed Not Applicable.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


4.2 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

Seclusion was not in use in the approved centre.

Compliance





Not-

Applicable

X


4.3 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 approved centre did not use mechanical restraint of any type.

This rule was not applicable.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


5.0 Inspection Findings and Required Actions - The Mental Health Act 2001

5.1 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 or unwilling 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

Processes: There was no policy on place for the provision of consent to treatment by detained patients but staff were aware of the process involved.

Training: Staff were aware of the necessity to obtain consent for administering medication but this had not been implemented in the case of two patients in the approved centre.

Monitoring of Compliance: There was no evidence that audits had been carried out and no incident reports had been completed on non-compliance.

Evidence of Implementation: Two detained patients had been receiving medication for a period longer than three months.

In the case of one of these patients, there was no evidence that the patient had provided written consent for this continued administration. In the absence of this, neither had a statutory form - Form 17 - been completed by a consultant psychiatrist. Staff on duty who were assigned to administer medication were aware of the detained status of this patient and indicated that a Form 17 had been completed, but this form could not be located by either the inspector another member of staff. The absence of clear consent was a breach of this patient’s rights.

A second patient had also been receiving medication for longer than three months, and there was evidence that a Form 17 had been completed in respect of the continued administration of medication.

Another patient was currently detained but this period of detention was not longer than three months. However, prior to this period of detention this patient had been detained for longer than three months and was receiving medication. There was no evidence of a Form 17 or written consent provided for that period of detention.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X

Risk Rating


X


5.1 Part 4: Consent to Treatment

The following Corrective and Preventative Actions (CAPAs) were provided by the Registered Proprietor or nominee and are subject to ongoing review by the Mental Health Commission. All actions should be Specific, Measurable, Achievable, Realistic and Time-bound with defined responsibilities for implementation: Date submitted 21/9/2015

CAPAs


Time-bound






1.Preventative:

• Senior Operations Manager to write to Mental Health Act Administrator to request that the Epex system be used to issue reminders to medical staff in the week preceding the requirement to adhere to the protocols laid down in the act in relation to the Administration of Medicine.

Post-Holder(s): Ms. Teresa Bulfin, Senior Operations Manager

Part 4: Consent to Treatment –



Complete


2.Preventative:

• MHA Administrator will use the Epex system to issue reminders to medical staff in the week preceding the requirement to adhere to the protocols laid down in the act in relation to the Administration of Medicine.

Post-Holder(s): Elaine McInerney, Mental Health Act Administrator




Immediate

3. Preventative:

• Senior Operations Manager to write to the Executive Clinical Director to request him to write to each consultant psychiatrist to ensure they document patient consent for the administration of medication pursuant to section 60 MHA

Post-Holder(s): Ms. Teresa Bulfin, Senior Operations Manager




Complete


4. Preventative: • Executive Clinical Director to write to each consultant

psychiatrist to ensure they document patient consent for the administration of medication pursuant to section 60 MHA

Post-Holder(s): Dr. John O’Mahoney, Executive Clinical Director




End September 2015


6.0 Inspection Findings and Required Actions – 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.

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

Inspection Findings

Processes: The service had an up-to-date policy on the use of physical restraint which was reviewed annually. This policy identified the need for all staff to be trained in the use of physical restraint and those who may initiate restraint. The policy stated that, where security personnel were involved in restraint, this was under the direction of the nurse in charge. The training specified in respect of physical restraint did not make reference to the use of physical restraint of children who may be resident.

Training: The service employed the Prevention and Management of Violence and Aggression approach (PMVA). Staff training in PMVA was not up to date. Refresher courses were outstanding for a number of staff. There was no record of any training in relation to a significant number of nursing staff who had been involved in applying physical restraint. Security personnel were trained in physical restraint as a generic security skill. The mental health service provided security staff with training in relation to physical restraint applied in a mental health setting.

Monitoring of Compliance: There was no evidence of audit or analysis of the use of physical restraint. Incident forms were completed, where appropriate.

Evidence of Implementation: Two Clinical Practice Form Books for Physical Restraint were inspected. Overall, the standard of recording was accurate and met the standard required by this Code of Practice. In two instances the orders for physical restraint had not been


signed by the consultant psychiatrist and the order remained in the physical restraint book and had not been placed in the resident’s clinical file. The records showed that de-escalation techniques had been attempted where applicable. Security personnel had been involved in two instances of physical restraint. The code of practice at 6.1 requires that all staff involved in physical restraint have knowledge of the individual’s ICP. The practice in the approved centre did not adhere with this requirement because security staff did not have such knowledge.

The clinical files of two residents who had been physically restrained were inspected. The episodes of physical restraint were recorded in the clinical file. Each resident was medically assessed following the use of restraint. One resident’s next of kin had been informed and this was recorded in the file of the episode of restraint. There was no record to indicate if the second resident’s next of kin had been informed or not. The records showed that staff considered providing the residents with an opportunity to discuss the episodes of restraint. An account of discussion was recorded for one resident. The second resident was acutely ill and discussion was not appropriate. The MDTs had reviewed the use of restraint.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


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

Inspection Findings

Processes: There was a policy in place on the admission of children to the approved centre, dated October 2014. The policy addressed the issue of voluntary and involuntary admission of children, issues relating to provision of education, accommodation and notification to the MHC. The policy addressed the issue of provision of consent to the admission and treatment by the child’s parent or guardian.

Training: Staff were aware of the process involved in the admission of children to this adult approved centre. The policy stipulated that staff of the approved centre shall have completed Children First training. However, there was evidence that some members of nursing staff involved in the care of children admitted had not received this training.

Monitoring of Compliance: There was no evidence that audits of the process relating to the admission of children had been completed or that incident reports on non-compliance with the process had been completed.

Evidence of Implementation: Seven children had been admitted to the approved centre since the date of the inspection in April 2014. Three of these children had been admitted in 2015 to date. The clinical files of two of these children were inspected. The approved centre was not child appropriate and there was no evidence that four of the staff involved in the care of the child residents had training in Children First policy. The issue of education was not applicable in the case of these two residents due to the short period of admission.

Neither child had access to Child Advocacy, as this was not available in the approved centre.

The clinical files did not record the accommodation occupied by either child. At the request of the inspector, staff provided a plan of the layout and occupants of the various rooms in the unit for the periods concerned. It was evident from these charts that each child had been accommodated in a single room. The clinical files recorded assessment by the Child and Adolescent Mental Health Service (CAMHS) psychiatrist.

Visiting by relatives was facilitated and there was a record of a parent visiting with the child in the clinical file.

In the case of one of these children, there was no evidence that a parent or guardian had provided written consent for the admission or treatment of the child to the approved centre.

The admission and subsequent discharge of these children was notified, as is required, to the MHC.


Although the service was compliant with some of the requirements of the JSF, due to the absence of consent for admission and treatment and the lack of training for some members of staff, the service was deemed non-compliant with this Code of Practice.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X

Risk Rating


X


6.2 Admission of Children


CAPAs


Time-bound






1.Corrective:

• Principal Social Worker will provide Children First training for nursing staff.

Post-Holder(s): Michael Jennings, Principal Social Worker

Admission of Children



Mid December


2.Corrective:

• Senior Operations Manager to write to the Irish Advocacy Network to request information in relation to any possible advocacy service that might be available nationally for children.

Post-Holder(s): Teresa Bulfin, Senior Operations Manager




Complete

3.Preventative:

• The Senior Operations Manager to write to the ECD to ask him to write to each Consultant Psychiatrist and all NCHDs asking that they ensure that consent from either a parent or guardian is documented for the admission and treatment of a child.

Post-Holder(s): Dr John O’Mahoney, Executive Clinical Director




Complete


4.Preventative:

• The Executive Clinical Director to write to each Consultant Psychiatrist and all NCHDs asking that they ensure that consent from either a parent or guardian is documented for the admission and treatment of a child.

Post-Holder(s): Dr John O’Mahoney, Executive Clinical Director




End of September, 2015


6.3 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 service had a policy on risk management. There was a process in place for notifying the death of a resident to the MHC. The risk manager was not identified in the risk management policy but included a process for the role of the person to notify the MHC with a six-monthly summary of incidents.

Training: The relevant staff were aware of the requirements for making the notifications.

Monitoring of Compliance: There was no evidence that the processes involved were monitored.

Evidence of Implementation: The deaths of two residents had occurred since the inspection of 2014. These deaths were notified to the MHC within the required timeframe of 48 hours, and the documentation in relation to this was seen by the inspector.

Staff members carried personal alarms which, when activated, alerted other staff to an incident. Child residents were accommodated in a single room and were accompanied by a member of staff on a 1:1 special nurse, so as to minimise risk to the child.

There were systems in place to minimise risk; for example, the anti-ligature fittings in toilet and showers, the use of security personnel to guide residents back to the main area of the approved centre from isolated areas for the duration of the refurbishment works, use of personal alarms and routine checks of residents by staff, was observed by the inspector.

A record of incidents was maintained in the approved centre and the Incident Report forms for the year prior to the inspection were available for inspection. The service used a localised incident report form which was suitable for inclusion in the national incident reporting system.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


6.4 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 in the approved centre had an intellectual disability, this Code of Practice was not inspected.

Compliance Rating:





Not-

Applicable

X


6.5 The 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

Process: There was a policy regarding ECT in the approved centre. The policy identified roles and responsibilities. It addressed the issues of provision of information to the patient, capacity of the patient to provide consent and the process to be used where the patient was unable or unwilling to provide consent. The policy also addressed issues relating to medication, medical examination and protocols, recording documentation, the ECT suite and the requirement to identify a consultant psychiatrist with overall responsibility. It did not identify the necessity for regular maintenance of equipment.

Training: The training records did not show evidence that the nurse assigned to work as the ECT nurse at the time of inspection had received up-to-date training in cardio pulmonary resuscitation (CPR) or specific training in ECT. The nurse who was routinely assigned to work as the ECT nurse had training in these areas but was on extended leave.

Monitoring of Compliance: Records of the application of ECT were maintained and were available for review. However, there was no evidence of audit having been carried out.

Evidence of Implementation: One resident of the approved centre had undergone a programme of ECT. The resident’s clinical file, the Register for ECT and the record of ECT given were inspected. In addition, the ECT nurse and senior nurse manager were interviewed. A signed consent to ECT and anaesthetic form was completed by the resident and was placed in the clinical file. The resident was capable of providing consent and this was confirmed by the consultant psychiatrist in the documentation on ECT. However, there was no record in the clinical file what assessments had been carried out by the consultant to establish capacity.

A record of consent for each session of ECT was documented and there was a record in the clinical file that the resident had been given information about ECT prior to the treatment. In addition, there was a record indicating that the resident had been advised of alternative treatments and had been given 24 hours to consider ECT. However, there was no record in the clinical file that the consultant discussed ECT with the resident.

The dose of ECT to be given was documented, and the same machine was used on each occasion.

There was evidence of a cognitive assessment after each treatment.

There was a record of a pre-anaesthetic assessment. There was a named consultant psychiatrist with responsibility for ECT and a named consultant anaesthetist. There was a designated nurse for ECT but this nurse had not yet received training in ECT.

The ECT register was maintained and was inspected by the inspector and the record of administration of ECT for this resident had been documented.


The service was not compliant with this Code of Practice because the designated nurse for ECT had not received training in ECT, there was no evidence that the consultant psychiatrist had discussed ECT with the resident or recorded assessment of capacity to provide consent.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X

Risk Rating


X


6.5 Electroconvulsive Therapy (ECT) for voluntary patients


CAPAs


Time-bound






1.Preventative:

• The Senior Operations Manager and Executive Clinical Director to discuss the best was to proceed to record in the clinical notes conversations held with patients, by Consultants, prior to the administration of ECT and the best was of recording clinical judgements made that a resident had capacity to provide consent

Post-Holder(s):Dr. John O’Mahoney, executive clinical Director. Ms. Teresa Bulfin, Senior Operations Manager

Electroconvulsive Therapy (ECT) for voluntary patients



End September 2015


2.Corrective:

• The service has approved 2 nurses to undertake training in the National ECT Training Programme in St. Vincent’s Dublin. Accredited by UCD, on the 21st September 2015. The 2 nursing staff will attend this training for one week followed by two weeks in theatre recovery, UHL. This will bring the number of staff to 3 that have completed this training.

Post-Holder(s): Catherine Adams, Area Director of Nursing

Electroconvulsive Therapy (ECT) for voluntary patients



End October 2015


6.6 Admissions, 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: There was a policy on the admission, transfer and discharge of residents. The policy outlined the roles and responsibilities and the process for admitting, transferring and discharging residents. The policy did not address issues relating to training of staff in this regard or emergency transfers.

Training: Staff were aware of the processes involved in the admission, transfer and discharge of residents, but there was no evidence of specific training.

Monitoring of Compliance: There was no evidence of audit being carried out on residents transferred or incident reports on non-compliance.

Evidence of Implementation: Six individual clinical files were inspected in respect of admission. The admission process was supported through the use of admission pro forma templates. Admission assessment was completed by a doctor and a nurse. The admission documents contained a good account of the assessment process, case formulation and initial diagnosis and initial care plan. The admission assessments included a physical examination and a mental state examination. The physical, medical, psychosocial, educational and occupational histories were all adequately completed. There was evidence of family involvement and consultation, where appropriate. Each resident was provided with adequate and appropriate information about their admission process and planned care and treatment. An admission checklist was used to ensure a resident was appropriately supported and settled in to the unit.

The clinical file of one resident who had been transferred was inspected. The reason for the transfer was documented in the clinical file along with evidence of communication with the relevant clinical personnel taking over care of the resident on transfer. The next of kin was informed of the transfer but there was no evidence that the resident had been informed of the impending transfer. There was no liaison with members of the MDT but, as the reason was for medical needs, this was not required.

There was no evidence of what information was transferred with the resident on transfer and no copy of a nurse transfer form or doctor’s letter was retained in the clinical file.

The clinical file of a resident being discharged on the day of inspection was inspected. The resident was assessed by the consultant psychiatrist prior to discharge. The discharge plan was addressed in the individual’s ICP and reviewed by the MDT. There was evidence of discussion with the resident and family about the discharge, and a discharge summary was sent promptly to the GP. This documented details of the resident’s condition, medications and follow-up plans by the treating team. The resident had been provided with a follow up appointment before being discharged from hospital. There was a plan and timetable for the


input of occupational therapy and social work on discharge to support the individual’s daily living. The plans for discharge were documented in the resident’s clinical file.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not-

Applicable

X


mental health commission approved centre inspection report ... · previous inspection date: 15, 16...

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