Jonathan Swift Clinic - mhcirl.ie · AC0009 Jonathan Swift Clinic Approved Centre Inspection Report 2017 Page 4 of 112 The principal functions of the Mental Health Commission are

COMPLIANCE RATINGS 2017

16

13

2 1

3

3

3

Inspection Team:

Leon Donovan, Lead Inspector

Marianne Griffiths

Noeleen Byrne

Donal O’Gorman

Inspection Date: 28 – 31 March 2017 Inspection Type: Unannounced Annual Inspection

Previous Inspection Date: 3 – 5 May 2016

The Inspector of Mental Health Services:

Dr Susan Finnerty MCRN009711

Date of Publication: 31 August 2017

RULES AND PART 4 OF THE MENTAL HEALTH ACT 2001

Compliant

Jonathan Swift Clinic

ID Number: AC0009

2017 Approved Centre Inspection Report (Mental Health Act 2001) Jonathan Swift Clinic

St. James’s Hospital

James’s Street

Dublin 8

Approved Centre Type:

Acute Adult Mental Health Care Continuing Mental Health Care/Long Stay Psychiatry of Later Life

Most Recent Registration Date:

1 March 2017

Conditions Attached: Yes

Registered Proprietor:

HSE

Registered Proprietor Nominee:

Mr Kevin Brady, Head of Service,

Mental Health, CHO7

REGULATIONS

CODES OF PRACTICE

Non-compliant

Not applicable

AC0009 Jonathan Swift Clinic Approved Centre Inspection Report 2017 Page 2 of 112

RATINGS SUMMARY 2015 – 2017

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

Chart 1 – Comparison of overall compliance ratings 2015 – 2017

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

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

Chart 2 – Comparison of overall risk ratings 2015 – 2017

7 7 8

3

1216

31

2217

0

5

10

15

20

25

30

35

40

45

2015 2016 2017

Not applicable Non-compliant Compliant

2

7

31

2

7

33

3

0

2

4

6

8

10

12

14

16

18

2015 2016 2017

Low Moderate High Critical


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

2.0 Inspector of Mental Health Services – Summary of Findings .......................................................... 5

3.0 Quality Initiatives ............................................................................................................................. 9

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

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

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

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

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

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

5.1 Non-compliant areas from 2016 inspection .......................................................................... 12

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

5.3 Areas of compliance rated Excellent on this inspection ........................................................ 13

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

7.0 Interviews with Heads of Discipline ............................................................................................... 15

8.0 Feedback Meeting .......................................................................................................................... 16

9.0 Inspection Findings – Regulations .................................................................................................. 17

10.0 Inspection Findings – Rules .......................................................................................................... 66

11.0 Inspection Findings – Mental Health Act 2001 ............................................................................ 70

12.0 Inspection Findings – Codes of Practice ....................................................................................... 73

Appendix 1 – Corrective and Preventative Action Plan ......................................................................... 83


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

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

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

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

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

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

and standardised.

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

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

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

are being provided as he or she thinks appropriate”.

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

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

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

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

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

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

thereunder.

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

and the provision of Part 4 are being complied with.

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

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

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

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

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

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

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

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

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

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

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

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

high or critical.

1.0 Introduction to the Inspection Process


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

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

amend the report as appropriate.

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

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

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

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

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

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

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

compliance is unacceptable, enforcement action may be taken.

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

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

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

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

2.0 Inspector of Mental Health Services – Summary of Findings

COMPLIANCE, QUALITY AND RISK RATINGS

The following ratings are assigned to areas inspected. COMPLIANCE RATINGS are given for all areas inspected. QUALITY RATINGS are given for all regulations, except for 28, 33 and 34. RISK RATINGS

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

COMPLIANCE

COMPLIANT

EXCELLENT

LOW

QUALITY RISK

NON-COMPLIANT

SATISFACTORY

MODERATE REQUIRES IMPROVEMENT

INADEQUATE HIGH

CRITICAL


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

below.

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

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

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

report.

Safety in the approved centre There was a written policy in place and associated safety statement in relation to health and safety. The

approved centre did not have a comprehensive risk management policy. The risk management policy in place

had not been implemented throughout the approved centre, did not address the process surrounding the

identification and assessment of all categories of risk and did not identify the precautions in place to control

accidental injury to residents and staff.

A minimum of two resident identifiers appropriate to the resident group profile and individual residents’

needs were used. In one ward, the facilities for the refrigeration and storage of food were not suitable.

Attempts to keep the approved centre clean resulted in regular floor washing, with wet and slippery floors

observed without signage in place. Ligature points were not minimised, and a number of potential ligature

points were observed on Fownes ward. The medication trolley on Connolly Norman ward was observed to

be left open and unattended in the dining room. There were unsafe practices in the carrying out of physical

restraint in one instance.

There was no written staffing plan for the approved centre. The number and skill mix of staffing were not

sufficient to meet resident needs. Not all health care staff were trained in the following: fire safety, Basic

Life Support (BLS), management of violence and aggression or the Mental Health Act (2001). All staff training

was not documented and staff training logs were not maintained.

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

Appropriate care and treatment of residents All residents had an individual care plan, although three did not identify resources needed for therapeutic

interventions. The therapeutic services and programmes provided by the approved centre were evidence-

based, appropriate and met the needs of the residents, as documented in the residents’ individual care plans.

However, a number of residents from Fownes ward could only attend therapeutic services downstairs if

accompanied by staff and this was not always possible due to staff shortages. This meant that adequate and

appropriate resources were not available to provide therapeutic services and programmes. Full and


complete written information regarding each resident was transferred when they moved from the approved

centre to the receiving facility. Residents’ general health needs were monitored and assessed as indicated

by the resident’s specific needs, but not less than every six months. Not all clinical files were kept in good

order, as some files had loose pages. The approved centre was compliant with Part 4 of the Mental Health

Act 2001: Consent to Treatment. There were deficits in the admission, transfer and discharge policies.

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

Respect for residents’ privacy and dignity Two residents were observed to be wearing theatre gowns during the course of the inspection as a form of

emergency personal clothing. Theatre gowns did not provide adequate coverage and one resident may have

been visible to workmen working in close proximity. Both residents were accommodated on a mixed ward

of male and female residents. This was unacceptable.

Residents were supported to manage their own property, and possessions were safeguarded when the

approved centre assumed responsibility for them. With regard to searching residents, the consent of the

resident to a search was not sought in one of the three searches examined, during one search a minimum of

two appropriately qualified staff were not in attendance when the search was being conducted, and during

three searches, the resident being searched was not informed of what was happening and why. Bed

screening did not protect the privacy of residents sharing a room on Fownes ward. The small size of the four-

and six-bed units meant that these bedrooms were not conducive to resident privacy as the beds were

located too close together. There was no dedicated examination room, and there was no room for

examination of residents on the Beckett ward. In two episodes of physical restraint cultural awareness and

gender sensitivity were not demonstrated.

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

Responsiveness to residents’ needs Residents, through the Irish Advocacy Network representative, reported some issues with the premises,

including cramped accommodation, blocked showers, and lights not working. The representative also

described how involuntary patients in Fownes ward had no access to an outside area unless escorted. The

condition of the physical environment was unacceptable: areas were small and cramped, noise levels were

high, there were deficits in signage, and there was inadequate outdoor space that was not fully accessible

to residents upstairs. The approved centre was not kept in a good state of repair, externally and internally.

There were holes in the wall which had been reported as a problem but had not been repaired. The approved

centre was not clean and there were offensive odours as the smell of cigarette smoke was pervasive

throughout. Litter, dirt, cigarette butts and cut hair was observed on the floors. Some toilets required deep

cleaning. There was no documented evidence of a cleaning schedule having been implemented within the


approved centre. There was insufficient number of toilets and showers for residents in the approved centre,

there was no laundry room, there was no dedicated therapy/examination room and, due to inadequate

space, there were just two 3-seater couches in the sitting room, serving 26 residents.

Menus had been approved by a dietitian, chefs, and a speech and language therapist to ensure nutritional

adequacy in accordance with the residents’ needs. Residents were provided with a variety of wholesome

and nutritious food choices. The approved centre provided access to recreational activities appropriate to

the resident group profile and the activities occurred during the week and at the weekends. However, staff

shortages led to the cancellation of recreational activities. Communal areas provided were not suitable for

recreational activities. Multi-faith chaplains were available to residents where necessary, and residents had

access to the main chapel in St. James’s Hospital. Visiting times were appropriate, reasonable, and flexible.

A separate visitors’ room or visiting area was located on each of the three wards where residents could meet

visitors in private. The visiting room on one ward had a strong tobacco odour as a result of residents smoking

out of the window. Residents were free to receive and send communication. Residents were provided with

an information booklet and were also provided with written and verbal information regarding their diagnosis

and medication. The procedure of dealing with residents’ complaints was deficient in the areas of recording

complaints and their investigation.

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

Governance of the approved centre Jonathan Swift Clinic was part of the Community Healthcare Organisation (CHO) 7 area. There was joint

governance of the approved centre between St. James’s Hospital and the HSE with both organisations

supplying nursing staff. The two authorities held regular joint meetings. There was an organisational chart

in place for St. James’s Hospital but no equivalent for the approved centre to identify the leadership and

management structure and the lines of authority and accountability of staff. The approved centre’s operating

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

with relevant stakeholders, including service users, as appropriate.

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


The following quality initiatives were identified on this inspection:

A twice-weekly exercise group had been established to provide the in-patients on Fownes and

Beckett wards with an opportunity for engaging in meaningful physical activity.

A Policy of the Day initiative was set up, whereby a policy was pinned to the noticeboard in the

nurses’ station to encourage staff to read a policy every day.

3.0 Quality Initiatives


4.1 Description of approved centre

The approved centre was located within St. James’s Hospital campus. It was comprised of three wards:

William Fownes, Beckett, and Connolly Norman. William Fownes ward (Fownes) was the secure acute adult

psychiatry ward and was located on the first floor of the building. There were a total of 26 beds on this ward,

spread over six single rooms, two 6-bed dorms, and two 4-bed dorms. Twenty-five beds were occupied in

Fownes on the first day of the inspection, of which six were involuntary admissions. Beckett ward was

located on the ground floor and provided a step-down and pre-discharge service. This ward contained 16

beds, which were spread over two 6-bed dorms and one 4-bed dorm. There were 14 beds occupied in

Beckett on the first day of the inspection. Connolly Norman ward, a Psychiatry of Later Life unit located on

the ground floor, contained nine beds, consisting of one 6-bed dorm and three single rooms. Six beds were

occupied in Connolly Norman on the first day of the inspection.

Residents in Beckett and Connolly Norman wards had direct access to the garden, but residents of Fownes

ward did not. There was little potential for the approved centre to expand due to its tight geographical

location within the larger hospital campus. In addition, the relatively recent addition of the seven-storey

Mercer’s Institute for Successful Ageing (MISA) building adjacent the Jonathan Swift Clinic had lessened the

amount of sunlight entering the southern aspect of the approved centre. St. James’s Hospital was a no-

smoking campus and residents in the approved centre were not permitted to smoke.

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

Resident Profile

Number of registered beds 51

Total number of residents 45

Number of detained patients 6

Number of Wards of Court 0

Number of children 0

Number of residents in the approved centre for more than 6 months 14

4.2 Conditions to registration

The following condition was attached to the registration of this approved centre at the time of inspection:

To ensure adherence to Regulation 22: Premises, the approved centre shall implement a programme of

maintenance to ensure the premises are safe and meet the needs, privacy and dignity of the resident group.

The approved centre shall provide a progress update on the programme of maintenance to the Mental Health

Commission in a form and frequency prescribed by the Commission.

During the inspection, some maintenance was being carried out, but as this condition was attached to the

registration three weeks prior to the inspection, it was not possible to assess compliance.

4.0 Overview of the Approved Centre


4.3 Reporting on the National Clinical Guidelines

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

Guidelines as published by the Department of Health.

4.4 Governance

Jonathan Swift Clinic was part of the Community Healthcare Organisation (CHO) 7 area. There was joint

governance of the approved centre between St. James’s Hospital and the HSE with both organisations

supplying nursing staff. The two authorities held regular joint meetings. The minutes of the Mental Health

Area Management Team meeting were provided and documented the attendance by heads of discipline of

the service. These meetings discussed matters concerning the entire CHO7 area, but issues regarding the

Jonathan Swift Clinic were also discussed, including the backfilling of key positions and structural works.

The Operational and Communication Group meetings were also scheduled on a monthly basis and minutes

were provided. These meetings were attended by a mix of local managers from each discipline as well as

senior clinical staff. Issues such as care planning, staffing, training, policies, and the risk register were

discussed at this meeting. The minutes for the Clinical Governance meetings, which were attended by senior

clinical staff, were also provided. These meetings were scheduled monthly, and serious incidents, near

misses, as well as audits were reviewed. Minutes of the capital planning meeting were provided. This was

attended by a mix of administrative and clinical staff. This meeting discussed the short-, medium-, and long-

term options to address a number of concerns about the approved centre’s premises.


5.1 Non-compliant areas from 2016 inspection

The previous inspection of the approved centre on 3 – 5 May 2016 identified the following areas that were

non-compliant. The approved centre was requested to provide Corrective and Preventative Actions (CAPAs)

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

Regulation/Rule/Act/Code 2017 Inspection Findings

Regulation 6: Food Safety Non-Compliant

Regulation 9: Recreational Activities Compliant

Regulation 14: Care of the Dying Compliant

Regulation 15: Individual Care Plan Non-Compliant

Regulation 19: General Health Compliant

Regulation 22: Premises Non-Compliant

Regulation 26: Staffing Non-Compliant

Regulation 27: Maintenance of Records Non-Compliant

Mental Health Act 2001: Part 4 Consent to Treatment Compliant

Code of Practice on the Use of Physical Restraint in Approved Centres Non-Compliant

Code of Practice on the Notification of Deaths and Incident Reporting Non-Compliant

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

Non-Compliant

5.2 Non-compliant areas on this inspection

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

compliant () or non-compliant (X) in these areas in 2016 and 2015:

Regulation/Rule/Act/Code 2015 Compliance

2016 Compliance

2017 Compliance

Regulation 6: Food Safety X X

Regulation 7: Clothing X

Regulation 8: Residents’ Personal Property and Possessions

X

Regulation 13: Searches X

Regulation 15: Individual Care Plan X X

Regulation 21: Privacy X

Regulation 22: Premises X X X

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

X X

Regulation 26: Staffing X X

Regulation 27: Maintenance of Records X X

Regulation 28: Register of Residents X

Regulation 31: Complaints Procedure X

5.0 Compliance


Regulation 32: Risk Management Procedures X

Code of Practice on the Use of Physical Restraint in Approved Centres

X X

Code of Practice on the Notification of Deaths and Incident Reporting

X X

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

X X

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

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

5.3 Areas of compliance rated Excellent on this inspection

No areas of compliance were rated excellent on this inspection.


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

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

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

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

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

residents to talk to the inspection team.

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

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

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

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

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

the approved centre.

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

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

below.

The inspection team met with three residents, one from Beckett ward and two from Fownes. Residents

reported that the food was good and nursing staff were kind.

The IAN representative reported some issues with the premises, including cramped accommodation,

blocked showers, and lights not working. The representative also described how involuntary patients in

Fownes ward had no access to an outside area unless escorted.

Three questionnaires were completed by residents and returned to the inspection team. One resident

expressed a desire to have a smoking room for residents.

6.0 Service-user Experience


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

with the following individuals:

Clinical Director

Director of Nursing

Senior Clinical Psychologist

Occupational Therapy Manager

The principal social worker was unable to meet with the inspection team but was interviewed by phone.

Most of the heads of discipline had offices located within or close to the approved centre on the St. James’s

Hospital campus. The principal social worker was not based on-site but visited the approved centre when

required, for challenging cases and the supervision of senior social workers. There was evidence of clear lines

of responsibility and reporting in each discipline.

Some heads of discipline identified the premises as a current operational risk. There were short-term plans

in place to improve the premises, but medium-and long-term plans had yet to be approved. Staffing

shortages were also cited as an organisational risk, with a number of staff currently on extended leave.

Two heads of discipline had clear strategic aims for the approved centre and two heads of discipline had

identified key performance indicators (KPIs) for the staff in their departments. Formal performance

appraisals were not undertaken; however, supervision and peer review was available in most disciplines.

7.0 Interviews with Heads of Discipline


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

inspection team and the following representatives of the service:

Registered Proprietor Nominee

Clinical Director

Mental Health Act Administrator

Director of Nursing

Acting Assistant Director of Nursing x 2

Consultant Psychiatrist

Clinical Psychologist

Senior Pharmacist

Occupational Therapy Manager

Social Work Team Leader

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

the service to offer any corrections or clarifications deemed appropriate.

8.0 Feedback Meeting


9.0 Inspection Findings – Regulations

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

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


Regulation 4: Identification of Residents

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

INSPECTION FINDINGS

Processes: The approved centre had a policy in place on the identification of residents, which was dated

2015. The policy included the requirements of the Judgement Support Framework, with the exception of

the process of identification applied for residents with the same or a similar name.

Training and Education: Relevant staff had signed a document to indicate that they had read and

understood the policy on the identification of residents. Relevant staff interviewed were able to articulate

the processes for identifying residents, as set out in the policy.

Monitoring: An annual audit was undertaken to ensure that there were appropriate resident identifiers

on clinical files. A documented analysis had been completed to identify opportunities for improving

resident identification processes.

Evidence of Implementation: A minimum of two resident identifiers appropriate to the resident group

profile and individual residents’ needs were used. The identifiers were detailed within each resident’s

clinical file. Two appropriate resident identifiers were used before administering medications, undertaking

medical investigations, and providing other health care services. An appropriate resident identifier was

used prior to the provision of therapeutic services and programmes.

The approved centre used the following person-specific identifiers: a photograph on Medication

Prescription Administration Records as well as name, unique medical record number, gender, and date of

birth. The identifiers did not include the residents’ room numbers or physical location. There was an alert

system in place for residents with the same or a similar name.

The approved centre was compliant with this regulation. The quality assessment was satisfactory and

not rated excellent because the approved centre did not meet all criteria of the Judgement Support

Framework under the processes pillar.

COMPLIANT Quality Rating Satisfactory


Regulation 5: Food and Nutrition

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

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

INSPECTION FINDINGS

Processes: The approved centre had a policy on food and nutrition dated June 2015. The policy included

the requirements of the Judgement Support Framework except the following:

The roles and responsibilities for food and nutrition.

The management of food and nutrition for each resident.


understood the policy on food and nutrition. Relevant staff were able to articulate the processes relating

to food and nutrition, as described in the policy.

Monitoring: A systematic review of menu plans was conducted to ensure residents received wholesome

and nutritious food in line with their needs. A documented analysis was completed to enhance the food

and nutrition processes.

Evidence of Implementation: The approved centre’s menus had been approved by a dietitian, chefs, and

a speech and language therapist to ensure nutritional adequacy in accordance with the residents’ needs.

Residents were provided with a variety of wholesome and nutritious food choices, and they were provided

with hot meals daily at teatime.

Hot and cold drinks were offered regularly to residents. However, there was limited access to drinking

water on Fownes ward on day one of the inspection as the water dispenser was functioning with a reduced

flow rate for the previous six weeks. The issue was resolved while the inspectors were on-site.

Nutritional and dietary needs were assessed, where necessary, and addressed and documented in each

resident’s individual care plan.



Framework under the processes and evidence of implementation pillars.



Regulation 6: Food Safety

(1) The registered proprietor shall ensure:

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

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

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

(2) This regulation is without prejudice to:

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

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

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

INSPECTION FINDINGS

Processes: The approved centre had a policy in place on food safety dated June 2016. The policy included

requirements of the Judgement Support Framework, with the exception of the following:

Food preparation, handling, storage, distribution, and disposal controls.

The management of catering and food safety equipment.


understood the policy on food safety. Relevant staff were able to articulate the processes for food safety,

as set out in the policy. All staff had up-to-date training in the application of Hazard Analysis and Critical

Control Point (HACCP). The training was documented and evidence of certification was available, where

appropriate.

Monitoring: Food safety audits were not periodically conducted. Food temperatures were recorded in

line with food safety recommendations. A log sheet of temperatures was maintained and monitored. A

documented analysis was not completed to identify opportunities to improve food safety processes.

Evidence of Implementation: There was appropriate and sufficient catering equipment, crockery, and

cutlery to suit the needs of residents. There were proper facilities for the refrigeration, preparation,

cooking, and serving of food.

Kitchen surfaces were clean and hygiene was maintained to support food safety requirements, however,

the floor within the servery on the Fownes unit was observed to be dirty. On the first day of the inspection,

on Beckett ward, food was found in the same storage unit as incontinence pads, dishwasher liquid,

dishwasher salt, and other non-food items. This was not a suitable facility for the storage of food.

NON-COMPLIANT Quality Rating Requires Improvement Risk Rating


The approved centre was non-compliant with this regulation as the facilities for the storage of food

were not appropriate in Beckett ward, 6(1)(b).


Regulation 7: Clothing

The registered proprietor shall ensure that:

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

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

INSPECTION FINDINGS

Processes: The approved centre had a written policy, dated April 2016, in relation to residents’ clothing.

The policy included all of the requirements of the Judgement Support Framework.

Training and Education: Not all relevant staff had signed a document to indicate that they had read and

understood the policy on residents’ clothing. Relevant staff were able to articulate the processes on

residents’ clothing, as set out in the policy.

Monitoring: The availability of an emergency supply of clothing for residents was monitored on an

ongoing basis. This was documented. A record of residents wearing nightclothes during the day was kept

and monitored.

Evidence of Implementation: Two residents were observed to be wearing theatre gowns during the

course of the inspection as a form of emergency personal clothing. Theatre gowns did not provide

adequate coverage and one resident may have been visible to workmen working in close proximity. Both

residents were accommodated on a mixed ward of male and female residents. This meant that emergency

clothing provided to both residents did not ensure their dignity and bodily integrity was respected at all

times.

Residents changed out of nightclothes during day time hours unless otherwise specified in their individual

care plans, and they were supported to keep and use personal clothing.

The approved centre was non-compliant with this regulation as two residents were not supplied with

individualised clothing to ensure their dignity was respected, 7(1).



Regulation 8: Residents’ Personal Property and Possessions

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

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

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

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

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

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

INSPECTION FINDINGS

Processes: The approved centre had a written operational policy dated May 2016 in relation to residents’

personal property and possessions. The policy included all of the requirements of the Judgement Support

Framework.


understood the policy. Relevant staff were able to articulate the processes for residents’ personal

property and possessions, as set out in the policy.

Monitoring: Personal property logs were monitored A documented analysis was completed to identify

opportunities to improve the processes for managing residents’ personal property and possessions.

Evidence of Implementation: Residents were supported to manage their own property, unless this posed

a danger to the resident or others, as indicated in their individual care plan. Each resident had a locker

and a wardrobe. Residents’ personal property and possessions were safeguarded when the approved

centre assumed responsibility for them.

The approved centre had a property book containing a checklist. One property checklist inspected did not

detail the name of the resident, the date, and contained no staff or resident signature, and was not

adequately maintained. The property checklist was kept separate to each resident’s individual care plan

(ICP). The property book was kept on Fownes ward and the resident was given a copy of it.

The approved centre was non-compliant with this regulation because a record of one resident’s

property was not maintained contrary to 8(3).

NON-COMPLIANT Quality Rating Requires Improvement Risk Rating LOW


Regulation 9: Recreational Activities

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

INSPECTION FINDINGS

Processes: The approved centre had a written policy dated January 2017 in relation to the provision of

recreational activities. The policy included all of the requirements of the Judgement Support Framework,

with the exception of:

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

approved centre.

The process applied for the development of recreational activity programmes.

Training and Education: Not any relevant staff had signed a document to indicate that they had read and

understood the policy on recreational activities. Relevant staff were able to articulate the processes for

residents’ recreational activities, as set out in the policy.

Monitoring: There was a record of the occurrence of planned recreational activities, including a record of

resident uptake and attendance. A documented analysis had been completed to identify opportunities to

improve the processes for recreational activity.

Evidence of Implementation: The approved centre provided access to recreational activities appropriate

to the resident group profile such as yoga, aromatherapy, an exercise group, and a walking group which

took place twice daily. The activities occurred during the week and at the weekends. A new television had

been installed in the sitting room of the approved centre. Board games were available but the inspection

team did not witness them being used over the course of the inspection.

However, the following was evident on inspection:

Staff shortages led to the cancellation of recreational activities.

Recreational activities programmes were not developed, implemented and maintained for

residents, with resident involvement.

Individual risk assessments were not completed for residents, where deemed appropriate, in

relation to the selection of appropriate activities.

Resident decisions to participate or not in activities were not respected or documented, as

appropriate.

Communal areas provided were not suitable for recreational activities; the communal area within

Fownes ward was small.



Documented records of attendance were not retained for recreational activities in group records

or within the residents’ clinical file.



Framework under the processes, training and education, and evidence of implementation pillars.


Regulation 10: Religion

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

INSPECTION FINDINGS

Processes: The approved centre had a policy on the facilitation of religious practices. The policy included

requirements of the Judgement Support Framework, with the exception of resident choice regarding their

involvement in religious practice.


understood the policy on religion. Relevant staff interviewed could articulate the processes for facilitating

residents in the practice of their religion, as set out in the policy.

Monitoring: The implementation of the policy to support residents’ religious practices had not been

reviewed to ensure that it reflected the identified needs of the residents.

Evidence of Implementation: Residents’ rights to practice religion were facilitated within the approved

centre insofar as was practicable. Pastoral care staff visited the approved centre regularly. Multi-faith

chaplains were available to residents where necessary, and residents had access to the main chapel in St.

James’s Hospital.

Residents were facilitated to observe or abstain from religious practice in accordance with their wishes.

The care and services that were provided within the approved centre were respectful of the residents’

religious beliefs and values.



Framework under the processes and monitoring pillars.



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 written operational policy, last reviewed in 2016, in relation to visits. It included

all of the requirements of the Judgement Support Framework.


understood the policy on visits. Relevant staff could articulate the processes for visits, as set out in the

policy.

Monitoring: Restrictions on residents’ rights to receive visitors were monitored and reviewed on an

ongoing basis. There was no documented analysis completed to identify opportunities to improve visiting

processes.

Evidence of Implementation: Visiting times were publicly displayed at the entrance to the approved

centre, and on the residents’ information board. Visiting times were appropriate, reasonable, and flexible.

A separate visitors’ room or visiting area was located on each of the three wards where residents could

meet visitors in private, unless there was an identified risk to the resident, an identified risk to others, or

a health and safety risk. Appropriate steps were taken to ensure the safety of residents and visitors during

visits.

Children could visit, if accompanied by an adult and supervised at all times. The visiting room on Fownes

had a strong tobacco odour as a result of residents smoking out the window. It contained no child-friendly

material and was unsuitable for visiting children. However, there were other rooms available on the

Fownes unit that were appropriate for residents, visitors and children, if required.

The approved centre was compliant with this regulation. The quality assessment was rated satisfactory

because the approved centre did not meet all criteria of the Judgement Support Framework under the

monitoring and evidence of implementation pillars.



Regulation 12: Communication

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

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

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

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

INSPECTION FINDINGS

Processes: The approved centre had a written operational policy and procedures dated August 2016 in

relation to communication. The policy included the requirements of the Judgement Support Framework,

with the exception of the following:

The communication services available to the resident.

The assessment of resident communication needs.

The individual risk assessment requirements in relation to limiting resident communication

activities.


understood the policy on communication. Relevant staff were able to articulate the processes for

communication, as described in the policy.

Monitoring: Resident communication needs and restrictions on communication were not monitored on

an ongoing basis. Analysis had not been undertaken to identify opportunities to improve the

communication processes by the approved centre.

Evidence of Implementation: The approved centre completed individual resident risk assessments, when

necessary, in relation to any risks associated with their external communications. These were documented

in each resident’s individual care plan.

Residents could use mail, fax, e-mail, internet, telephone or any device for the purposes of sending or

receiving messages or goods unless otherwise risk assessed with due regard to the residents’ well-being,

safety, and health.

Relevant senior staff only examined incoming and outgoing resident communication if there was cause to

believe the resident or others may be harmed.




not rated excellent as the approved centre did not meet all criteria of the Judgement Support

Framework under the processes, staff training and education, and monitoring pillars.


Regulation 13: Searches

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

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

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

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

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

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

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

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

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

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

INSPECTION FINDINGS Processes: There was a written policy, dated June 2016, available in relation to the implementation of

resident searches by the approved centre. The policy included the requirements of the regulation and the

Judgement Support Framework, with the exception of the processes for communicating the approved

centre’s search policies and procedures to residents and staff.

Training and Education: Relevant staff had signed a document to indicate that they had read the policy

on searches. Relevant staff were able to articulate the searching processes, as set out in the policy.

Monitoring: A log of searches was maintained. Each search record was systematically reviewed to ensure

the requirements of the regulation had been complied with. Analysis had not been completed to identify

opportunities for improvement of search processes.

Evidence of Implementation: Three clinical files which recorded three resident searches, were inspected

against in respect of the searches processes, and the following was found on inspection:

There was no risk assessment documented, prior to the resident being searched in two out of

three searches.

Resident consent was not documented in two out of three searches.

Searches were implemented with due regard to the resident’s dignity, privacy and gender.

General written consent was not sought for routine environmental searches.

The resident search policy and procedure was not communicated to all residents and not

contained within the resident information booklet.



There was no documentation that residents were informed by those implementing the search

of what was happening during a search and why, in three searches.

There was not a minimum of two clinical staff in attendance during one search of a resident’s

property.

A full written record of every search including property searches was not available. Two

searches examined were documented in the clinical files and on search logs. In one case an

environmental search was noted in the clinical file but was not documented on a search log.

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

a) The consent of the resident to a search was not sought in one of the three searches examined,

13(4).

b) During one search, a minimum of two appropriately qualified staff were not in attendance when

the search was being conducted, 13(6).

c) During three searches, the resident being searched was not informed of what was happening

and why, 13(8).


Regulation 14: Care of the Dying

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

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

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

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

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

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

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

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

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

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

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

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

INSPECTION FINDINGS

Processes: The approved centre had a written operational policy, dated June 2016, in relation to care of

the dying. The policy included requirements of the Judgement Support Framework, with the exception of

the process for ensuring that the approved centre was informed in the event of the death of a resident

who had been transferred elsewhere.


understood the policy and protocols on care of the dying. Relevant staff interviewed could articulate the

processes for end of life care, as set out in the policy.

As no deaths had occurred since the last inspection and no current resident was receiving end of life care,

this regulation was assessed under the processes and training and education pillars of this regulation only.

It was not assessed under monitoring and evidence of implementation.


not rated excellent as the approved centre did not meet all criteria of the Judgement Support

Framework under the processes, and training and education pillars.



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 policy on individual care plans (ICPs) dated April 2015. The policy included all of

the requirements of the Judgement Support Framework.

Training and Education: Not all clinical staff had signed a document to indicate that they had read and

understood the policy on individual care planning. All clinical staff interviewed could articulate the

processes relating to individual care planning, as set out in the policy. All multi-disciplinary team (MDT)

members were trained in individual care planning during their induction training.

Monitoring: ICP audits were carried out to assess compliance with the regulation. ICPs were audited on a

weekly basis to ensure that residents had a care plan, care-coordinator and discharge plan. Quarterly

audits assessed risk factors and the appropriate resident involvement. A documented analysis was

completed to identify opportunities to improve the individual care planning process.

Evidence of Implementation: Each resident had an ICP, and 19 of these were inspected. These indicated

that the residents had been assessed at admission by the admitting clinician and an initial ICP was

established. The ICPs were then developed by the MDT within seven days of admission, following a

comprehensive assessment. The ICP was discussed, agreed where practicable, and drawn up with the

participation of the resident and their representative, family and next of kin, as appropriate. In all 19 ICPs

reviewed, the appropriate goals, care, and treatment for each of the 19 residents were identified.

The following discrepancies were found on inspection:

The ICP was not contained in one composite set of documentation. Instead, the ICP was on a

card located at the ICP section of the clinical file and the weekly MDT ICP review notes were

pasted into the progress notes section of the file.

In three ICPs, the resources required to provide the care and treatment identified were not

identified.

Four of the ICPs did not include a preliminary discharge plan, where deemed appropriate.

Discharge planning was documented in the progress notes.



Due to the continued practice of pasting the weekly review into the clinical notes on each day

of the MDT meeting instead of the ICP, this meant that the ICP itself was not updated following

review.

There was no documented evidence to show that the resident had access to their ICP or was

kept informed of any changes. In 14 of the 19 ICPs inspected, there was no documented

evidence that the resident was offered a copy of their ICP or reasons as to why not.


a) The ICP was not recorded in one composite set of documentation.

b) In three of the ICPs inspected, the necessary resources were not identified. e set of documentation

The individual care plan shall be recorded


Regulation 16: Therapeutic Services and Programmes

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

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

INSPECTION FINDINGS

Processes: The approved centre had a policy in place, dated December 2016, in relation to the provision

of therapeutic services and programmes, which included all of the requirements of the Judgement Support

Framework.

Training and Education: Not all clinical staff had signed a document to indicate that they had read and

understood the policy on therapeutic services and programmes. All clinical staff could articulate the

processes for therapeutic activities and programmes, as set out in the policy.

Monitoring: There was no evidence of ongoing monitoring of the range of services and programmes

provided to ensure that they met the assessed needs of residents. Analysis had not been completed to

improve the processes relating to therapeutic services and programmes.

Evidence of Implementation: The therapeutic services and programmes provided by the approved centre

were evidence-based, appropriate and met the needs of the residents, as documented in the residents’

individual care plans (ICPs).

However, a number of residents from Fownes ward could only attend therapeutic services downstairs if

accompanied by staff and this was not always possible due to staff shortages. This meant that adequate

and appropriate resources were not available to provide therapeutic services and programmes.

The therapeutic services and programmes provided by the approved centre were directed towards

restoring and maintaining optimal levels of physical and psychosocial functioning of a resident.


and not excellent because the approved centre did not meet all criteria of the Judgement Support

Framework under the training and education, monitoring, and evidence of implementation pillars.



Regulation 17: Children’s Education

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

INSPECTION FINDINGS

As there were no children in the approved centre during the inspection and no child had been admitted

to the approved since last year’s inspection, this regulation was not applicable.

NOT APPLICABLE


Regulation 18: Transfer of Residents

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

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

INSPECTION FINDINGS

Processes: The approved centre had a written operational policy dated 2016 in relation to the transfer of

residents. The policy detailed the requirements of the Judgement Support Framework, with the exception

of:

The process for managing resident medications during transfer from the approved centre.

The process for ensuring resident privacy and confidentiality during a transfer, specifically in

relation to the transfer of personal information.

The processes for ensuring the safety of the resident and staff during a resident transfer.


understood the policy on transfers. Relevant staff interviewed could articulate the processes for the

transfer of residents, as set out in the policy.

Monitoring: A log of transfers was maintained. Each transfer record was systematically reviewed to

ensure all relevant information was provided to the receiving facility. A documented analysis was

completed to identify opportunities to improve information provision during transfers.

Evidence of Implementation: The clinical files of two residents who had been transferred from the

approved centre to another facility were inspected.

Each resident consented to the transfer and their next-of-kin was notified of the transfer. Prior to transfer,

each resident was assessed, which included an individual risk assessment relating to the transfer and an

assessment of the resident’s needs. This was documented and forwarded to the receiving facility in the

form of a referral letter.

Full and complete written information regarding each resident was transferred when they moved from

the approved centre to the receiving facility. The clinical files recorded the documentation released to the

receiving facility as part of the transfer, including the letter of referral, a list of current medications, the

resident transfer form, and the required medication for the resident during the transfer process.

The approved centre completed checks on an electronic transfer record (PAS) system to ensure

comprehensive resident records were transferred to the receiving facility.





Framework under the processes pillar.


Regulation 19: General Health

(1) The registered proprietor shall ensure that:

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

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

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

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

INSPECTION FINDINGS

Processes: There were separate general health and responding to medical emergency policies available,

dated October 2015. The policies included requirements of the Judgement Support Framework, with the

exception of the following:

The medical emergency policy did not reference the management of emergency response

equipment, including the resuscitation trolley and Automated External Defibrillator (AED).

The provision of general health services policy did not detail:

- Resident access to a registered medical practitioner.

- The resource requirements for general health services, including equipment needs.

- The incorporation of general health needs into the resident individual care plan.

- The referral process for general health needs of residents.

Training and Education: Not all clinical staff had signed a document to indicate that they had read the

policies on the provision of general health services and for responding to medical emergencies. All clinical

staff interviewed were able to articulate the processes as described in the medical emergency policy and

the general health care policy.

Monitoring: Resident take-up of national screening programmes was recorded and monitored, where

applicable. A systematic appraisal was undertaken to ensure six-monthly reviews of general health needs

took place. Analysis was completed to identify opportunities to improve general health processes.

Evidence of Implementation: In relation to responding to medical emergencies, the approved centre had

an emergency trolley and staff had access at all times to an AED. In relation to the provision of general

health services, registered medical practitioners assessed residents’ general health needs at admission

and on an ongoing basis as part of the approved centre’s provision of care. Residents’ general health needs

were monitored and assessed as indicated by the resident’s specific needs, but not less than every six

months.



Adequate arrangements were in place for residents to access general health services and for their referral

to other health services, as required. Residents had access to national screening programmes that were

available according to age and gender. Information was not provided to residents regarding the national

screening programmes available through the approved centre.



Framework under the processes, training and education, and evidence of implementation pillars.


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 written policy dated December 2016 available in relation to the provision of

information to residents. The policy included requirements of the Judgement Support Framework, with

the exception of the methods for providing information to residents with specific communication needs.

Training and Education: Not all staff had signed a document to indicate that they had read and understood

the policy on the provision of information to residents. Staff interviewed were able to articulate the

processes for providing information to residents, as set out in the policy.

Monitoring: The provision of information to residents was not monitored on an ongoing basis to ensure

the information was appropriate and accurate, particularly where information changed such as

information on medication and housekeeping practices. A documented analysis was not completed to

identify opportunities to improve the processes for providing information to residents.

Evidence of Implementation: Residents were provided with an information booklet detailing

housekeeping practices, including arrangements for personal property and mealtimes, the complaints

procedure, visiting times and arrangements, advocacy and voluntary agencies, and residents’ rights.

Residents were also provided with the details of their multi-disciplinary team.

Residents received written and verbal information regarding their diagnosis unless, in the treating

psychiatrist’s view, the provision of such information might be prejudicial to the resident’s physical or

mental health, well-being, or emotional condition. This was documented where appropriate.

Medication information sheets as well as verbal information were provided in a format that was

appropriate to the resident’s needs. The content of medication information sheets included details of

indications for use of all medications to be administered to the resident, including any possible side-

effects.





Framework under the processes, training and education, and monitoring pillars.


Regulation 21: Privacy

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

INSPECTION FINDINGS

Processes: The approved centre had a policy available in relation to privacy, dated 2016. The policy

included requirements of the Judgement Support Framework, with the exception of the method for

identifying and ensuring, where possible, the resident’s privacy and dignity expectations and preferences.

Training and Education: All staff had signed a document to indicate that they had read and understood

the policy relating to resident privacy. All staff interviewed were able to articulate the processes for

ensuring resident privacy and dignity, as set out in the policy.

Monitoring: An annual review, to check that the policy was being implemented, was undertaken in the

approved centre. Analysis was not completed to identify opportunities to improve the processes relating

to residents’ privacy and dignity.

Evidence of Implementation: The general demeanour of staff and the way in which staff addressed and

communicated with residents demonstrated dignity and respect.

Not all residents were dressed appropriately to ensure their privacy and dignity, with two residents

observed wearing an inappropriate type of emergency clothing, in the form of theatre gowns. Theatre

gowns did not provide adequate coverage and one resident may have been visible to workmen working

in close proximity. Both residents were accommodated on a mixed ward of male and female residents.

All bathrooms, showers, toilets, and single bedrooms had locks on the inside of the doors, unless there

was an identified risk to a resident. Locks had an override function. Bed screening did not protect the

privacy of residents sharing a room on Fownes ward as two curtains were falling down. The small size of

the four- and six-bed units meant it was not possible to have a private conversation behind curtains. These

bedrooms were not conducive to resident privacy as the beds were located close together.

The sitting room in Beckett ward was used as an access route to the garden, which was a barrier to resident

privacy in the sitting room. There was no dedicated examination room, and there was no room for

examination of residents on the Beckett ward.

The approved centre was non-compliant with this regulation because

(a) Bed screening did not protect the privacy of residents sharing a room on Fownes ward.

(b) The small size of the four- and six-bed rooms were not conducive to resident privacy as the beds

were located too close together.



(c) There was no dedicated examination room, and there was no room for examination of residents

on the Beckett ward.

(d) The sitting room in Beckett ward was used as an access route to the garden, which was a barrier

to resident privacy in the sitting room.

(e) Two residents were wearing theatre gowns which did not provide adequate coverage and one

resident may have been visible to workmen working in close proximity. Therefore these

residents’ privacy and dignity were compromised.


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 was a policy on premises, dated July 2016, in place. The policy included all of the

requirements of the Judgement Support Framework.


understood the premises policy. Relevant staff were able to articulate the processes relating to the

maintenance of the premises, as set out in the policy.

Monitoring: There was documented evidence of a hygiene audit and a ligature audit. Analysis had been

completed that identified opportunities for improving the premises. This included a short, medium and

long term plan to improve the premises. Short term plans included increasing the cleaning hours,

upgrading of Fownes pantry and upgrade of lighting in Fownes corridor which was underway at the time

of the inspection. A decision on the medium and long term plans had not been made.

Evidence of Implementation: Lighting, temperature, and ventilation was suitable and sufficient within the

approved centre. Heating was centrally controlled with adequate surface temperatures not exceeding 43

degrees C.

In relation to the physical environment, the following was found on inspection:

The approved centre did not provide accommodation for each resident to assure comfort and

privacy. The four-and six-bed units were very cramped and as a result residents did not have

access to personal space.



Communal rooms were quite small and smelled of cigarette smoke.

In relation to noise levels/acoustics, the private and communal areas were not suitably sized

and furnished to remove excessive noise/acoustics. Due to the cramped conditions, Fownes

ward was loud at all times.

Appropriate signage and sensory aids were not provided to support resident orientation needs.

On Fownes ward, the rooms were not always identified as bathrooms/bedrooms.

Sufficient spaces were not provided for residents to move about, including outdoor spaces.

Hazards were not minimised at all times in the approved centre. Attempts to keep the

approved centre clean resulted in regular floor washing, with wet and slippery floors observed

without signage in place.

Ligature points were not minimised, and a number of potential ligature points were observed

on Fownes ward.

In relation to maintenance, the following was found on inspection:

The approved centre was not kept in a good state of repair, externally and internally. There were

holes in the wall which had been reported as a problem but had not been repaired.

The approved centre was not clean, hygienic, and free from offensive odours as the smell of

cigarette smoke was pervasive throughout. Litter was visible on floors and numerous cigarette

butts were observed on the window ledges of Fownes, and on the ground of the internal courtyard.

Cut hair was also observed on the floor of one bathroom, and dirt was observed on the floor of

another. Some toilets required deep cleaning.

There was no documented evidence of a cleaning schedule having been implemented within the

approved centre.

In relation to facilities and furnishings, the following was found on inspection:

There was not a sufficient number of toilets and showers for residents in the approved centre,

The approved centre did not have a designated laundry room.

The approved centre did not have dedicated therapy/examination rooms, and there was no

space for the examination of residents on Beckett ward.

The approved centre did not provide suitable furnishings to support resident independence

and comfort. Due to inadequate space, there were just two 3-seater couches in the sitting

room, serving 26 residents.


a) The registered proprietor did not ensure that the approved centre was cleaned and maintained

in good structural and decorative condition, 22(1)(a).

b) The sitting room did not have adequate and suitable furnishings for the number and mix of

residents in the approved centre, with just two 3-seater couches for 26 residents, 22(2).


c) Due to the identification of ligature points, residents’ lack of access to personal space the

registered proprietor did not ensure that the condition of the physical structure and the overall

approved centre environment was 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,

22(3).


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: The approved centre had a written operational policy dated 2016 on the ordering, prescribing,

storing and administration of medicines. The policy detailed requirements of the Judgement Support

Framework, with the exception of the following:

The process for self-administration of medication.

The process for withholding medication.

The process for medication management at admission, transfer, and discharge.

The process for medication reconciliation.

The process to review resident medication.

Training and Education: Not all nursing, medical, and pharmacy staff had signed a document to indicate

that they had read and understood the policy on ordering, prescribing, storing, and administering

medicines. Staff interviewed were able to articulate the processes relating to ordering, prescribing,

storing, and administering medicines, as set out in the policy. Staff had access to comprehensive, up-to-

date information on all aspects of medication. All nursing, medical, and pharmacy staff, where applicable,

had received training on the importance of reporting medication incidents, errors, or near misses and this

was documented.

Monitoring: Quarterly audits had been conducted on residents’ Medication Prescription and

Administration Records (MPARs). Incident reports were recorded for medication errors and near misses,

which were then issued to the risk manager. Analysis had been completed to identify opportunities for

improving medication management processes.

Evidence of Implementation: Each resident had an MPAR, and 25 of these were inspected. Each MPAR

contained at least two appropriate resident identifiers. All medications administered were recorded and

the Medical Council Registration Number (MCRN) of the prescribing medical practitioner was recorded

within each resident’s MPAR. Scheduled controlled drugs were locked in a separate cupboard from other

medicinal products to ensure further security.


Micrograms and nanograms were not written in full within each MPAR.



The medication trolley was left open and unattended in the dining room area within the Connolly

Norman ward during the first day of the inspection.

The approved centre was non-compliant with this regulation because the medication trolley on

Connolly Norman ward was left open and unattended in the dining room, 23(1).


Regulation 24: Health and Safety

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

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

INSPECTION FINDINGS

Processes: There was a written policy in place dated February 2016 and an associated safety statement

dated January 2017 in relation to health and safety. The policy included requirements of the Judgement

Support Framework, with the exception of the following:

Vehicle controls.

The staff training requirements in relation to health and safety.

First aid response requirements.

The following infection control measures:

Safe handling and disposal of health care risk waste.

Management of spillages.

Raising awareness of residents and their visitors to infection control measures.

Linen handling.

Covering of cuts and abrasions.

Availability of staff vaccinations and immunisations.

Management and reporting of an infection outbreak.

Support provided to staff following exposure to infectious diseases.


the health and safety policy. Staff could articulate the processes relating to health and safety, as set out

in the policy and safety statement.

Monitoring: The health and safety policy was monitored pursuant to Regulation 29: Operational Policies

and Procedures.

Evidence of Implementation: Regulation 24 was only assessed against the approved centre’s written

policies and procedures. Health and safety practices within the approved centre were not assessed.



Framework under the processes and training and education pillars.



Regulation 25: Use of Closed Circuit Television

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

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

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

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

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

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

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

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

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

INSPECTION FINDINGS

As the approved centre did not use CCTV, this regulation was not applicable.

NOT APPLICABLE


Regulation 26: Staffing

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

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

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

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

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

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

INSPECTION FINDINGS

Processes: There was a policy dated January 2016 in relation to the approved centre’s staffing

requirements. The policy met the requirements of the Judgement Support Framework, in relation to the

recruitment, selection and vetting of staff with the exception of the following:

The organisational structure of the approved centre, including lines of responsibility.

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

The ongoing staff training requirements and frequency of training needed to provide safe and

effective care and treatment in accordance with best contemporary practice.

The required qualifications of training personnel.

The evaluation of training programmes.


understood the staffing policy. Relevant staff interviewed were able to articulate the processes relating

to staffing, as set out in the policy.

Monitoring: The implementation and effectiveness of the staff training plan was reviewed on an annual

basis, and this was documented. The number and skill mix of staff was not reviewed against the levels

recorded in the approved centre’s registration. Analysis was completed to identify opportunities to

improve staffing processes and to respond to the changing needs and circumstances of residents.

Evidence of Implementation: There was an organisational chart in place for St. James’s Hospital but no

equivalent for the approved centre, to identify the leadership and management structure and the lines of

authority and accountability of staff.

Staff were recruited and selected in accordance with the approved centre’s policy and procedures for

recruitment, selection, and appointment. There was no written staffing plan for the approved centre. The

number and skill mix of staffing were not sufficient to meet resident needs. During the inspection, Fownes



ward had four nurses on duty rather than five nurses required by their registration, even though the ward

was at full capacity, with 26 residents.

Staff were trained in accordance with the assessed needs of the resident group profile and assessed needs

of individual residents, as detailed in the staff training plan. Training included manual handling, infection

control, incident reporting training, online training on persons with an intellectual disability, end of life

care, and Wellness Recovery Action Plan (WRAP) training was given if required. At least one staff member

was trained in Children First.

However, not all staff had up-to-date training. Not all health care staff were trained in the following:

Fire safety.

Basic Life Support (BLS).

Management of violence and aggression {e.g. Therapeutic Crisis Intervention/Professional

Management of Aggression and Violence (PMAV)}

The Mental Health Act (2001).

All staff training was not documented and staff training logs were not maintained. The Mental Health Act

2001 and Mental Health Commission rules and codes and all other Mental Health Commission

documentation and guidance were made available to staff throughout the approved centre.

The approved centre was not compliant with this regulation for the following reasons:

(a) Not all health care professionals were up-to-date with the required training in fire safety, BLS, PMAV or equivalent, and the Mental Health Act 2001, 26(4).

(b) The number and skill mix of staffing were not sufficient to meet resident needs, 26(2).

The following is a table of staff assigned to the approved centre.

Ward or Unit Staff Grade Day Night

Fownes Ward

CNM1 or CNM2 RPN HCA

1 4

CNM2 x1 2 1


Beckett Ward

CNM1 RPN

1 1

1


Connolly Norman Ward

CNM2 RPN HCA

1 2 1

1 1

Clinical Nurse Manager (CNM), Registered Psychiatric Nurse (RPN), Health Care Assistant (HCA)


Regulation 27: Maintenance of Records

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

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

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

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

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

INSPECTION FINDINGS

Processes: The approved centre had a written operational policy and procedures in relation to the

maintenance of records, dated December 2015. The policy did not include all the requirements of the

regulation. Specifically, it did not outline the procedure relating to the access to records. The policy did

not include the following elements of the Judgement Support Framework:

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

Record review requirements.

Privacy and confidentiality of resident record and content.

Residents’ access to their records.

How entries in the residents’ records were made, corrected and overwritten.

The process for making a retrospective entry in residents’ records.

Retention of inspection reports relating to food safety, health and safety, and fire inspections.

Training and Education: Not all medical staff within the clinical staff cohort had signed a document to

indicate that they had read and understood the policies relating to maintenance of records. All clinical

staff and other relevant staff could articulate the processes for the creation of, access to, retention of and

destruction of records, as set out in the policies. There was documented evidence of clinical staff being

trained in best-practice record keeping.

Monitoring: Resident records were audited to ensure their completeness, accuracy and ease of retrieval.

Analysis was not completed to identify opportunities to improve the maintenance of records process.

Evidence of Implementation: All records were secure, up to date, and constructed, maintained, and used

in accordance to the Data Protection Act 1988 and 2003, the Freedom of Information Act 1997 and 2003,

and national guidelines and legislative requirements. Resident records were reflective of the residents’

current status as well as the care and treatment being provided and were developed and maintained in a

logical sequence so as to ensure ease of retrieval.



Of the clinical files inspected, not all resident records were maintained in good order as some resident

records contained loose pages. There was evidence of good documentation practice with entries made in

black and followed by a signature.

Records were appropriately secured throughout the approved centre from loss or destruction and

tampering and unauthorised access or use. Documentation relating to food safety, health and safety, and

fire inspections was maintained in the approved centre.


a) The policy did not detail the procedure relating to the access to records, 27(2).

b) Not all clinical files were kept in good order, as some files had loose pages, 27(1).


Regulation 28: Register of Residents

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

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

INSPECTION FINDINGS

The approved centre had a documented and up-to-date register of residents. It was available to the

Mental Health Commission on inspection. The register included the information specified in Schedule 1

to the Mental Health Act 2001, with one exception. Residents’ diagnosis on discharge was not detailed in

the register.

The approved centre was non-compliant with this regulation as the resident’s diagnosis on discharge

was not detailed in the register, 28(2).

NON-COMPLIANT Quality Rating Requires Improvement Risk Rating LOW


Regulation 29: Operating Policies and Procedures

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

INSPECTION FINDINGS

Processes: The approved centre had a policy dated July 2016 in relation to the development and review

of operating policies and procedures. The policy included requirements of the Judgement Support

Framework, with the exception of the standardised operating policy and procedure layout used by the

approved centre.


understood the policy on developing and reviewing operating policies. Relevant staff were trained on

approved operational policies and procedures. Relevant staff could articulate the processes for developing

and reviewing operational policies, as set out in the policy.

Monitoring: An annual audit had not been undertaken to determine compliance with review time frames.

Analysis had not been completed to identify opportunities to improve the processes of developing and

reviewing policies.

Evidence of Implementation: The approved centre’s operating policies and procedures were developed

with input from clinical and managerial staff and in consultation with relevant stakeholders, including

service users, as appropriate. All policies used were specific to the approved centre and were not generic.

The operating policies and procedures were appropriately approved and incorporated relevant legislation,

evidence-based best practice, and clinical guidelines. All operating policies and procedures required by

the regulations were reviewed within three years.



Framework under the processes, training and education, and monitoring pillars.



Regulation 30: Mental Health Tribunals

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

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

INSPECTION FINDINGS

Processes: The approved centre had a policy on Mental Health Tribunals dated 2016. The policy included

all of the requirements of the Judgement Support Framework.


understood the policy on Mental Health Tribunals. Relevant staff were able to articulate the processes for

facilitating Mental Health Tribunals, as described in the policy.

Monitoring: There was no documented evidence of analysis completed to identify opportunities to

improve the processes for facilitating Mental Health Tribunals.

Evidence of Implementation: The approved centre provided facilities and resources to support the Mental

Health Tribunals process. There were private facilities on the Fownes ward to support the process. Staff

accompanied and assisted patients to attend a tribunal, as necessary.



Framework under the training and education, and monitoring pillar.



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 had a written operational policy dated July 2015 in relation to the

management of complaints. It included the requirements of the regulation and incorporated the elements

of the Judgement Support Framework, with the exception of the following:

The communication of the complaints policy and procedure with residents, their representatives,

family, and next of kin, as well as visitors.

The confidentiality requirements in relation to complaints, including the applicable legislative

requirements regarding data protection.

The appeal process available where the complainant is dissatisfied with the outcome of the

complaint investigation.

While the verbal and written methods available to all persons to make complaints regarding the

service, care or treatment by the approved centre were included, the following complaints

methods were not included in the policy: electronic e-mail, telephone, and through complaint,

feedback or suggestion forms.

Training and Education: There was no documented evidence to show that relevant staff were trained in

the complaints management process. Not all staff had signed a document to indicate that they had read

and understood the policy. All staff interviewed could articulate the processes for making, handling and

investigating complaints, as set out in the policy.



Monitoring: There was no documented evidence of an audit of the complaints log and related records.

Complaints data were analysed, discussed, and considered by senior management to ensure continuous

improvement of the complaints management process.

Evidence of Implementation: There was a nominated person responsible for dealing with all complaints

who was available to the approved centre. The complaints procedure was displayed on the wall within

the approved centre and residents were made aware of the procedure when given information about the

unit in the booklet. The methods for the resident and their representatives to make a complaint were

detailed within the complaints policy and procedure, and the methods were verbal and written methods

only. E-mail, telephone, compliant feedback, and complaint suggestion forms were not in the approved

centres policy as methods for the resident or representatives to make a complaint. The approved centre

ensured that residents who made a complaint were not adversely affected on foot of the complaint being

made.


A consistent and standardised approach was not implemented for the management of all

complaints.

All complaints, whether oral or written, were not certain to have been investigated promptly

and handled appropriately and sensitively. Documentation on this was variable.

A method for addressing and documenting minor complaints within the approved centre was

not provided. No complaints had been logged in 2017, even though a complaint was

documented in the clinical notes of one service user.

All non-minor complaints were not dealt with by the nominated person and not recorded in

the complaints log.

Details of complaints, as well as subsequent investigations and outcomes, were not fully

recorded.

There was no documented evidence in the complaints log that the complainant was informed

promptly of the outcome of the complaint investigation and that details of the appeals process

were made available to them.

The complainant’s satisfaction or dissatisfaction with the investigation findings was not

documented.

All information obtained through the course of the management of the complaint and the associated

investigation process was treated in a confidential manner and met the requirements of the Data

Protection Acts 1988 and 2003 and the Freedom of Information Act 1997 and 2003.


a) The registered proprietor did not ensure that the nominated person maintained a record of all

complaints relating to the approved centre as one complaint was not documented, 31(6).


b) The registered proprietor did not ensure that all complaints were investigated promptly as full

investigations for complaints were not documented in the complaints log, 31(5).

c) The registered proprietor did not ensure that all complaints and the results of any investigations

into the matters complained and any actions taken on foot of a complaint were fully and

properly recorded, 31(7).


Regulation 32: Risk Management Procedures

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

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

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

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

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

(i) resident absent without leave,

(ii) suicide and self harm,

(iii) assault,

(iv) accidental injury to residents or staff;

(d) Arrangements for the identification, recording, investigation and learning from

serious or untoward incidents or adverse events involving residents;

(e) Arrangements for responding to emergencies;

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

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

INSPECTION FINDINGS

Processes: There was a risk management policy in place dated April 2016. The policy did not include the

following requirements of the Regulation:

The process surrounding the identification and assessment of all categories of risk throughout the

approved centre.

The precautions in place to control accidental injury to residents and staff.

The policy included requirements of the Judgement Support Framework with the exception of the

following:

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

organisational risks throughout the approved centre.

Structural risks, including ligature points.

Capacity risks relating to the number of residents in the approved centre.

Health and safety risks to the residents, staff and visitors.

The record keeping requirement for risk management.

The process for notifying the Mental Health Commission about incidents involving residents of

the approved centre.

Training and Education: Relevant staff were trained in the identification, assessment, and management

of risk. Staff were trained in health and safety risk management. Clinical staff were trained in individual

risk management processes. Management staff were trained in organisational risk management. All staff



were trained in incident reporting and documentation. All staff interviewed could articulate the risk

management processes as set out in the policy. Not all staff, specifically multi-disciplinary team staff, had

signed a document to indicate that they had read and understood the risk management policy, as

evidenced by the incomplete signature log. All training was not documented.

Monitoring: The risk register was audited at least quarterly to determine compliance with the approved

centre’s risk management policy. All incidents in the approved centre were recorded and risk-rated.

Evidence of Implementation: Responsibilities were allocated at management level and throughout the

approved centre to ensure their effective implementation. The person with responsibility for risk was

identified and known by all staff. The risk management procedures actively sought to reduce identified

risks to the lowest level of risk, as was reasonably practicable. Clinical risks were identified, assessed,

treated, reported and monitored. Clinical risks were documented in the risk register as appropriate.

Whereas corporate risks were identified, they were not assessed, treated, reported, and monitored by

the approved centre. Not all corporate risks were documented in the risk register. Low staffing levels were

not identified as a risk within the risk register. During the inspection, a resident was observed to be denied

an escort to the ground floor for fresh air, with staff shortages cited as the reason.

Not all health and safety risks were treated, reported, and monitored by the approved centre in

accordance with relevant legislation. There was no-smoking policy in the hospital campus which included

the approved centre. While smoking was listed as a component of fire risk (safety) in the risk register,

passive smoking health risk to residents, staff, and visitors as a result of persistent smoking in bedrooms

and visitors’ room on Fownes ward was not detailed in the risk register or being adequately controlled.

Individual risk assessments were not completed prior to and during one episode of physical restraint. An

untrained security guard was involved in the use of physical restraint and no individual risk assessment

had been completed. There were insufficient numbers of staff on the ward at the time of the incident to

accompany the resident and this organisational risk of insufficient staffing numbers was not being

adequately controlled at the time of the inspection.

The requirements for the protection of children and vulnerable adults within the approved centre were

appropriate and implemented as required. Incidents were recorded and risk-rated in a standardised

format. The approved centre provided a six-monthly summary report of all incidents to the Mental Health

Commission, in line with the Code of Practice on the Notification of Deaths and Incident Reporting.


a) The risk management policy had not been implemented throughout the approved centre, 32(1). b) The risk management policy did not address the process surrounding the identification and

assessment of all categories of risk throughout the approved centre, 32(2)(a). c) The risk management policy did not identify the precautions in place to control accidental injury

to residents and staff, 32(2)(c)(iv). d) The approved centre did not have a comprehensive risk management policy, 32(1).


Regulation 33: Insurance

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

INSPECTION FINDINGS

The approved centre had up-to-date insurance. Public liability, employer’s liability, clinical indemnity, and

property were covered by the insurance.

The approved centre was compliant with this regulation.

COMPLIANT


Regulation 34: Certificate of Registration

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

INSPECTION FINDINGS

There was an up-to-date certificate of registration prominently displayed in the approved centre. There

was one condition attached.

Condition: To ensure adherence to Regulation 22: Premises, the approved centre shall implement a

programme of maintenance to ensure the premises are safe and meet the needs, privacy and dignity of

the resident group. The approved centre shall provide a progress update on the programme of

maintenance to the Mental Health Commission in a form and frequency prescribed by the Commission.

The approved centre was compliant with this regulation.

COMPLIANT


10.0 Inspection Findings – Rules

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


Section 59: The Use of Electro-Convulsive Therapy

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

INSPECTION FINDINGS

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

NOT APPLICABLE


Section 69: The Use of Seclusion

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

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

INSPECTION FINDINGS

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

NOT APPLICABLE


Section 69: The Use of Mechanical Restraint

Mental Health Act 2001 Bodily restraint and seclusion Section 69 (1) “A person shall not place a patient in seclusion or apply mechanical means of bodily restraint to the patient unless such seclusion or restraint is determined, in accordance with the rules made under subsection (2), to be necessary for the purposes of treatment or to prevent the patient from injuring himself or herself or others and unless the seclusion or restraint complies with such rules. (2) The Commission shall make rules providing for the use of seclusion and mechanical means of bodily restraint on a patient. (3) A person who contravenes this section or a rule made under this section shall be guilty of an offence and shall be liable on summary conviction to a fine not exceeding £1500. (4) In this section “patient” includes – (a) a child in respect of whom an order under section 25 is in force, and (b) a voluntary patient.

INSPECTION FINDINGS

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

NOT APPLICABLE


11.0 Inspection Findings – Mental Health Act 2001

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


Part 4 Consent to Treatment

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

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

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

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

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

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

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

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

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

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

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

INSPECTION FINDINGS

The files of two patients were inspected in relation to Part 4 of the Mental Health Act 2001: Consent to

Treatment. The two patients did not have capacity to consent to treatment. The Form 17: Administration

of Medicine for more than 3 months involuntary patient (adult) – unable to consent, within both clinical

files contained the following information:

The names of the medication prescribed.

Confirmation of the assessment of the patients’ ability to understand the nature, purpose and

likely effects of the medication(s).

Details of any discussion with the patient, including

- The nature and purpose of the medication(s).

- The effects of the medications(s), including any risks and benefits.

- Any views expressed by the patient.

- Any supports provided to the patient in relation to the discussion and their decision-making.

- Authorisation by a second consultant psychiatrist.

COMPLIANT


The approved centre was compliant with Part 4 of the Mental Health Act 2001: Consent to Treatment.


12.0 Inspection Findings – Codes of Practice

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

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


Use of Physical Restraint

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

INSPECTION FINDINGS

Processes: The approved centre had a written policy on the use of physical restraint dated December

2016. The policy was reviewed annually, and it included the requirements of this code practice with the

exception of the requirement for the provision of information to a resident. In addition, child protection

processes where a child was restrained were not detailed within the policy.

Training and Education: The approved centre had a separate policy in relation to training requirements,

which detailed who receives training and the frequency of training. However, the training policy did not

include the following:

The areas to be addressed during training or alternatives to physical restraint.

The identification of appropriately qualified persons to deliver training.

The mandatory nature of the training.

The stipulation that a record of attendance at training should be maintained.

Not all staff had signed a document to indicate that they had read and understood the policy on physical

restraint.

Monitoring: The approved centre completed an annual report on the use of physical restraint.

Evidence of Implementation: Three clinical files of residents who had been physically restrained were

inspected and the following discrepancies were found on inspection:

In one physical restraint episode witnessed by the inspection team, a lone security guard, who had

not been appropriately trained, was observed physically restraining a resident in an attempt to

prevent a violent confrontation with another resident. This was due to the lack of staff available

to escort the resident onto the ward having just being transferred from the general hospital where

they were on a one to one special observation, and many of the following issues were borne out

of this:

In one physical restraint episode, restraint was not implemented in the resident’s best interests

and in rare and exceptional circumstances where the resident posed an immediate threat of

serious harm to self or others.

Staff had not considered all other interventions to manage the patient’s unsafe behaviour.

The security staff member involved in the episode of physical restraint had not read the risk

assessment.

NON-COMPLIANT Risk Rating


In two episodes of physical restraint cultural awareness and gender sensitivity were not

demonstrated.

In one episode, physical restraint was not initiated by a registered medical practitioner, registered

nurse, or other members of the multi-disciplinary team (MDT) in accordance with the policy.

In one episode of physical restraint, a designated staff member was not the lead.

In one episode of physical restraint, there was no documented evidence that the resident was

informed of the reasons, likely duration, and circumstances leading to discontinuation of physical

restraint and the reasons for not informing the resident were not recorded.

In two episodes of physical restraint, there was no documented evidence that the resident’s next

of kin or representative was informed. There was no documented evidence of the reasons why

they were not informed or of the resident’s consent to notify their next of kin.

The approved centre was non-compliant with this code of practice for the following reasons:

a) In one episode,

- Restraint was not implemented in the resident’s best interests and in rare and exceptional

circumstances where the resident posed an immediate threat of serious harm to self or

others, 1.1.

- Staff had not considered all other interventions to manage the patient’s unsafe behaviour,

1.2.

- The security staff member involved in the episode of physical restraint had not read the risk

assessment, 1.7.

b) In two episodes of physical restraint, cultural awareness and gender sensitivity were not

demonstrated, 1.9.

c) In one episode, physical restraint was not initiated by a registered medical practitioner,

registered nurse, or other members of the multi-disciplinary team (MDT) in accordance with the

policy, 5.1.

d) In one episode of physical restraint, a designated staff member was not the lead, 5.2.

e) In one episode of physical restraint, there was no documented evidence that the resident was

informed of the reasons, likely duration, and circumstances leading to discontinuation of

physical restraint and the reasons for not informing the resident were not recorded, 5.8.

f) In two episodes of physical restraint, there was no documented evidence that the resident’s next

of kin or representative was informed. There was no documented evidence of the reasons why

they were not informed or of the resident’s consent to notify their next of kin, 5.9(a).

g) The training policy did not include the following:

- The areas to be addressed during training or alternatives to physical restraint training in the

form of prevention and management of violence such as breakaway techniques, 10.1(a).

- The identification of appropriately qualified persons to deliver training, 10.1(d).

- The mandatory nature of the training, 10.2.

- The stipulation that a record of attendance at training should be maintained, 10.2.

h) Not all staff had signed a log to indicate that they had read and understood the policy on physical

restraint, 9.2(b) and (c).


Admission of Children

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

INSPECTION FINDINGS

As the approved centre did not have any children registered as residents at the time of inspection, this

regulation was not applicable.

NOT APPLICABLE


Notification of Deaths and Incident Reporting

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

INSPECTION FINDINGS

Processes: The approved centre had a risk management policy, a safety incident policy, an unexpected

deaths policy, and a care of the dying policy. Combined, the policies included the requirements of this

code of practice with the exception of the staff roles and responsibilities in terms of completing six-

monthly incident summary reports.

Training and Education: Not all staff had signed a document to indicate their awareness and

understanding of the policies. Staff interviewed were able to articulate the processes relating to the

notification of deaths and incidents, as set out in the policies.

Monitoring: Deaths and incidents were reviewed to identify and correct any problems as they arose and

to improve quality.

Evidence of Implementation: There had been no deaths in the approved centre since the last inspection.

There was an incident report system in place. All incidents were reported using an electronic incident

report, and this information was then transcribed by the risk manager onto the National Incident

Management System. A standardised incident report form was used. A six-monthly summary of all

incidents was provided to the Mental Health Commission by the risk manager.

The approved centre was non-compliant with Article 32 of the Regulations.


a) The risk management policy did not outline the staff roles and responsibilities in relation to

completing six-monthly incident summary reports, 4.3.

b) It failed to comply with Article 32 of the Regulations, 3.1.

NON-COMPLIANT Risk Rating LOW


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 the approved centre did not have any resident with an intellectual disability at the time of the

inspection, this code of practice was not applicable.

NOT APPLICABLE


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

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

INSPECTION FINDINGS

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

NOT APPLICABLE


Admission, Transfer and Discharge

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

INSPECTION FINDINGS

Processes: There were written discharge, transfer, and admission policies in place.

Admission: The policy on admissions included the requirements of the code of practice, with the

exception of the following:

The protocol for planned admission with reference to pre-admission assessments, eligibility for

admission and referral letters.

The protocol for urgent referrals.

The protocol for individuals who self-present.

Transfer: The transfer policy included the requirements of the code of practice, with the exception of the

processes and procedures for the following:

How a transfer is arranged.

Provisions for emergency transfer.

Transfer abroad.

The safety of the resident and staff during a transfer.

Discharge: The policy on discharge included the requirements of the code of practice, with the exception

of the following:

Reference to crisis management plans in relation to following up residents who were discharged.

The protocol for discharge of people with an intellectual disability.

The protocol for the discharge of older persons.


the policies on admissions, transfer, and discharge in the approved centre.

Monitoring: The audits purpose is to ensure that the admission and discharge processes were being fully

and effectively implemented and adhered to in clinical practice. An audit was undertaken to monitor the

admission processes. There was no audit of the discharge processes.

Evidence of Implementation:

NON-COMPLIANT Risk Rating


Admission: The approved centre complied with Regulation 20: Provision of Information to Residents. It

did not comply with the following regulations: Regulation 7: Clothing, Regulation 8: Personal Property and

Possessions, Regulation 15: Individual Care Plan, Regulation 27: Maintenance of Records, and Regulation

32: Risk Management Procedures.

The clinical files of two residents were inspected in relation to the admission process. A comprehensive

psychiatric assessment and full physical examination were conducted. A key worker was assigned to the

resident. There was evidence of family/advocate/carer involvement in the admission process (with the

residents’ consent). All assessments were fully documented in the clinical file.

Transfer: The approved centre was compliant with Regulation 18: Transfer of Residents. The clinical files

of two residents who were in need of specialised treatment in another hospital were inspected in relation

to the transfer process. The decision to transfer was made by the registered medical practitioner and

documented. The assessment, including the risk assessment, was carried out prior to transfer. In both

cases, effort was made to respect the residents’ wishes and obtain consent to transfer and this was

documented. The residents’ family/carer/advocate were involved in the transfer process and this was

documented. Copies of the referral letters were retained in both residents’ clinical files.

Discharge: The clinical files of two residents were inspected in relation to the discharge process. The

decision to discharge was made by the registered medical practitioner. A discharge plan was in place as

part of the residents’ individual care plans. The discharge plan was documented and contained the

following information: estimated date of discharge, communication with the primary care and/or

community mental health team, a follow-up plan, and early warning signs of relapse and risk. Family

members/carers/advocates were involved in the discharge process, where applicable.


(a) The policy on admissions did not include:

- The protocol for planned admission with reference to pre-admission assessments, eligibility

for admission, and referral letters, 4.3.

- The protocol for urgent referrals, 4.4.

- The protocol for individuals who self-present, 4.5.

(b) The policy on transfer did not include procedures and processes for how a transfer is arranged

or provisions for an emergency transfer, transfer abroad, and the safety of residents and staff

during a transfer, 4.13.

(c) The policy on discharge did not include:

- Reference to crisis management plans on following up with residents who were discharged,

4.14.

- The protocol for discharge of people with an intellectual disability, 4.16.

- The protocol for the discharge of older persons, 4.17.

(d) There was no documented evidence that all staff had read and understood the policies on

admissions, transfer, and discharge, 9.1.


(e) The audits purpose is to ensure that the admission and discharge processes were being fully and

effectively implemented and adhered to in clinical practice. An audit was undertaken to monitor

the admission processes. There was no audit undertaken to monitor the discharge processes,

4.19.

(f) The approved centre’s admission process did not comply with the following regulations:

Regulation 7: Clothing, Regulation 8: Personal Property and Possessions, Regulation 15:

Individual Care Plan, Regulation 27: Maintenance of Records, and Regulation 32: Risk

Management Procedures.

Appendix 1 – Corrective and Preventative Action Plan

Regulation 6: Food Safety Report reference: Page 20

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

Taken from the inspection report Reoccurring1 or

New2 area of non-

compliance

Provide corrective and preventative

action(s) to address the area of non-

compliance

Provide the method of monitoring

the implementation of the

action(s)

Provide details of any barriers to the

implementation of the action(s)

Provide the timeframe of the

completion of the action(s)

1. The facilities for the

refrigeration and storage

of food were not

appropriate in Beckett

ward.

New Corrective Action(s):

Food and non food goods to be

stored appropriately and in

separate locations.

Post-Holder(s) responsible:

CNM 2

Weekly checklist of food

storage and non food storage

areas to be carried out to

ensure compliance.

No barriers Immediately actioned at time

of inspection 28/03/2017.

Preventative Action(s):

Weekly check

Catering governance meeting

brought forward to 21/07/17 to

explain the above action to

catering staff.


CNM 2 and catering supervisor

Weekly checklist of food

storage and non food storage

areas to be carried out to

ensure compliance.

Achievable Actioned from week

commencing 17/07/17

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

Regulation 8: Residents’ Personal Property and Possessions Report reference: Page 22

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

Realistic

Time-bound

Taken from the

inspection report

Reoccurring or New area

of non-

compliance

Provide corrective and preventative action(s) to

address the area of non-compliance


the implementation of the action(s)

Provide details of any

barriers to the

implementation of the

action(s)

Provide the timeframe of the completion of the

action(s)

2. A record of one

resident’s

property was

not maintained.


Ensure current procedure for management of

personal property will be adhered to by staff

and that they have read and understood the

policy in line with JSF and HSE best practice

guidance. In relation to all the regulations, the

CNMs have been given a specific number to

deliver training and education to staff on. The

relevant policy with each regulation will be

read as part of this process.


Designated CNM 2s

QPS Group

Training records of staff

attendees will be maintained

by the CNMs and monthly

updates sent to the local

Quality and Patient Safety

Group (QPS) for oversight and

analysis.

Feasible A meeting was held on 20/07/17 with

CD, DON and ADON to formalise the

process with the previously monthly

clinical governance meeting changing

title to QPS and scheduled on a

fortnightly basis.

The training on this regulation will be

delivered to all staff by 28/02/2018. All

staff will have signed off this policy by

28/02/2017.

A meeting with the CNMs is scheduled

for Wednesday 26th July 2017.



Property Audits will continue monthly to

check the process is adhered to. Feedback will

continue to the relevant staff. Results of the

audit will be sent to the QPS group.

Continue with monthly audits

with feedback to staff and

report on audit to QPS Group.

Feasible To commence August 2017

Regulation 13: Searches Report reference: Page 28-29


Taken from the inspection report Reoccurring or

New area of

non-compliance

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

non-compliance

Provide the method of

monitoring the


action(s)

Provide details of any barriers

to the implementation of the

action(s)

Provide the timeframe

of the completion of the

action(s)

3. The consent of the

resident to a search

was not sought in one

of the three searches

examined.


Training will be delivered to all staff about regulation 13

as part of a bespoke training programme for PR (Under

no 28) to ensure search procedure is adhered to and that

staff have read and understood the policy in line with JSF

and HSE best practice guidance


CNMs

Training records for the

bespoke programme will

be maintained and sent to

the QPS group for review,

Realistic 3 months (end of

October 2017


The search process is will be monitored and audited after

every search episode. In the event the check shows up

any shortcoming in the process, the staff members will

be informed immediately. The audit tool will be

redesigned to incorporate all necessary aspects of

regulation 13.

Training on regulation 13 as part of the training

programme (No 28)


CNM 111/11s

NPDU/ADON (Delivery of Program)

QPS Group (Review)

A monthly report of the

audit process will be sent

to the QPS group for

review

Feasible To commence

August 2017


4. During one search, a

minimum of two

appropriately qualified

staff were not in

attendance when the

search was being

conducted.


As above with emphasis to staff to clearly record and

document who was present at the search

As above

Post-Holder(s) responsible: CNMs

Training records to be

maintained.

Feasible 3 months (end of

October 2017

Rolling Regulations

training sessions so

ongoing in nature

Preventative Action(s): As above in 3

Post-Holder(s) responsible: CNM 111/11s

5. During three searches,

the resident being

searched was not

informed of what was

happening and why.


Education to staff will be delivered to staff as part of the

bespoke training programme to ensure residents are

informed of what is to happen and reasons why. In

addition Regulation training will be delivered by CNMs as

in No 2 (Above)

An emergency policy meeting is scheduled for

Wednesday 26th July with a plan to review all policies

over the next 6 months by policy sub committees

starting with the more critical policies with deficits

highlighted in the recent inspection. The search policy

has been identified as needing urgent review and in

particular the need for all staff to have read and

understood the policy. The policy update will reflect the

method of communicating the search process to

residents and staff. The search process will be outlined

in the patient information booklet.

As above in 3


Training records to be

maintained.


October 2017.

Rolling Regulations

training sessions so

ongoing in nature.

Search Policy will be

updated by 31st

august 2017.

Preventative Action(s): As above in



October)


Policy sub committee

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


Taken from the inspection report Reoccurring or New

area of non-

compliance



Provide the method of monitoring the




action(s)



action(s)

6. The ICP was not

recorded in one

composite set of

documentation.

Reoccurring from

2016

Corrective Action(s):

Use of the new document will commence

week of 14th August 2017.


MDT Care Plan Working Group

Monthly audit using MHC audit tool Any new change process

will take time to bed in

with possible

improvements and

updates during the

process.

14th August 2017


3 month review


MDT Care Plan Working Group

Formal review of new plan 3 months

from introduction

Realistic plan 22nd November

2017

7. In three of the ICPs

inspected, the

necessary resources

were not identified.


Rolling education sessions by CNMs on

regulation 15 to include MDT staff, with

an emphasis to ensure resources are

identified and documented in the care

plan.


CNMs

Training records to be maintained

for staff attending education session

and on induction.

Feasible On-going monthly

audit, next due 18th

August.



Change of audit tool3 to the MHC care

plan audit tool template (Form 024) to

highlight when resources are not

identified.

This will be completed monthly.


CNMs

Care planning continues to be a

standing item at all operational and

MDT management team meetings

and at the monthly policy and QPS

groups.

The Care plan audit, which is

circulated to all relevant staff on a

monthly basis, will be reviewed at

the QPS meeting and any issue

arising will be addressed and

actioned as appropriate

On-going monthly

training record

check

3 The Current audit process does not check for identification of necessary resource

Regulation 21: Privacy (and Regulation 7: Clothing) Report reference: Pages 21 and 41-42


Taken from the inspection report Reoccurring or New

area of non-

compliance





action(s)

Provide details of any barriers to


action(s)

Provide the timeframe of

the completion of the

action(s)

8. Bed screening did not

protect the privacy of

residents sharing a

room on Fownes ward.


Plan required to ensure bed screens are

maintained in proper order.

Immediate review of bed screens to identify

any faults. Curtains and curtain fittings were

repaired within one week of the inspection.

Post-Holder(s) responsible: Nursing Staff

A monthly audit of the daily

process of checks will be

completed.

Analysis of results will allow

for possible improvements

to the process.

Achievable Immediate action


As part of the daily environmental audit the

bed screens will be checked on a daily basis


As above Feasible Ongoing on a monthly

basis.

9. The small size of the

four- and six-bed

rooms were not

conducive to resident

privacy as the beds

were located too close

together.


Following area management operational

meeting 17th August 2017, a phased plan to

improve the space and privacy for residents

was agreed.

Phase 1:

Reduction of the two 6 bed wards on the

acute admission unit to 4 beds on a phased

basis (i.e. closure of a 6 bed and renovation

followed by closure of the second 6 bed and

renovation)

Progress will be monitored

by operational management

team at weekly meetings.

The closure of the 6 bedded

ward to allow for works will

create risk of reduced bed

capacity for Dublin South

City MHS.

Completion date 31st of

Decemebr 2017 with

funding now secured

for the planned works


Phase 2

Restructuring of the nursing station on

Fownes ward to enable better observation

and sight lines. (construction of an

observation area on the ward area coming

out from the nursing office).

Phase 3

Creation of recreational/communal space for

residents at the entrance to Fownes ward

through conversion of a nursing office and

changing room to a recreation/sitting room


Operational Management Team


This CAPA is linked to the current condition

attached to the approved centre in terms of

Regulation 22.


Operational Management Team

10. There was no

dedicated examination

room, and there was

no room for

examination of

residents on the

Beckett ward.


Provision of new room to allow for

examination of patients in Becket ward. (

conversion of a tea room).


MDT CAPA working group.

Monitor progress and

timescale of development at

operational and

communication meeting.

Feasible Completion by 31st

December 2017.


11. The sitting room in

Beckett ward was used

as an access route to

the garden, which was

a barrier to resident

privacy in the sitting

room.


The privacy of residents in the sitting room

will be maintained by restricting that

particular access to the garden

Residents will access the garden from the

main corridor

Post-Holder(s) responsible: CNM in becket

ward.

Nursing staff to monitor as

part of daily environmental

check for Becket ward

Achievable Commenced week of

24th July 2017


New locks on the sitting room and TV room

doors to prevent staff opening the doors as

access to garden.

Post-Holder(s) responsible: ADON/ Technical

service department

Monitor progress and

timescale of installation by

the MDT CAPA Monitoring

Group.

Achievable

12. Two residents were

wearing theatre gowns

which did not provide

adequate coverage

and one resident may

have been visible to

workmen working in

close proximity.

Therefore these

residents’ privacy and

dignity were

compromised.


Plan required to ensure that the current

system of provision of appropriate clothing is

always adhered to for resident dignity.

Prompt added to admission checklist for

nursing staff to remind them to ensure

residents are appropriately clothed.

The Privacy Policy will be updated to ensure

that the resident’s privacy and dignity

expectations and preferences are

considered.


CNMs


Monthly review at Policy

Committee. Next meeting

Wednesday 30th August

Achievable Review progress at

Policy Meeting 30th

August 2017.



Training on the regulation of clothing will be

delivered to all staff by the CNMs.

Daily check to ensure no residents are

wearing theatre gowns by nursing staff.


CNMs on all 3 wards

Nursing staff

The QPS group will monitor

to ensure all relevant staff

receive this training.

This will be recorded daily in

ward diaries.

Achievable Review progress end of

September 2017.

Regulation 22: Premises Report reference: Page 43-45

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


New area of non-

compliance

New plan; plan carried over

from 2016; or monitored as per

Condition

Provide corrective and

preventative action(s)

to address the area of

non-compliance

Provide the method

of monitoring the

implementation of

the action(s)


barriers to the


action(s)

Provide the

timeframe of the

completion of the

action(s)

13. The registered proprietor did not ensure

that the approved centre was cleaned and

maintained in good structural and

decorative condition.

Reoccurring

from 2015

Monitored as per the

Condition4 attached to the

registration of the

approved centre

14. The sitting room did not have adequate and

suitable furnishings for the number and mix

of residents in the approved centre, with just

two 3-seater couches for 26 residents.

Reoccurring

from 2016

As above

15. Due to the identification of ligature points,

residents’ lack of access to personal space

the registered proprietor did not ensure that

the condition of the physical structure and

the overall approved centre environment

was 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.

Reoccurring

from 2015

As above

4 To ensure adherence to Regulation 22: Premises, the approved centre shall implement a programme of maintenance to ensure the premises are safe and meet the needs, privacy and dignity of the resident group. The approved centre

shall provide a progress update on the programme of maintenance to the Mental Health Commission in a form and frequency prescribed by the Commission

Regulation 23: Ordering, Prescribing, Storing and Administration of Medicines Report reference: Page 46-47



New area of non-

compliance

Provide corrective and preventative action(s) to address the

area of non-compliance


monitoring the


action(s)



action(s)



action(s)

16. The medication trolley on

Connolly Norman ward

was left open and

unattended in the dining

room.


Training on the regulation on Ordering, Prescribing,

Storing and Administration of Medicines will be

delivered to all staff by the clinical pharmacist


Clinical Pharmacist

Training record to be

maintained.

Achievable A training session

has been organised

on Regulation 23

and the associated

policy for all

relevant staff on

13th September .


Notice on all medication trolleys to indicate that it

should be locked at all times and not left

unattended.


CNMs

This will be included in

the quarterly medication

round audit by the ADON

and reviewed by the QPS

group.

Achievable Quarterly, next

audit due Oct 2017.

Regulation 26: Staffing Report reference: Page 50-51



New area of non-

compliance

Provide corrective and preventative action(s) to address

the area of non-compliance


monitoring the implementation

of the action(s)

Provide details of any barriers to the




action(s)

17. Not all health care

professionals were up-

to-date with the

required training in fire

safety, BLS, PMAV or

equivalent, and the

Mental Health Act 2001.

Reoccurring

from 2016

Corrective action(s):

The issue of training was considered by the

heads of disciplines at the monthly operational

and communication meetings on 24/06/16 and

05/08/16. Every effort will be made by Head of

Discipline to ensure all staff on the approved

centre are in date with mandatory training and

that a training log is kept and maintained. THE

MHAA will assist with this process (see above)

Responsible Head of Discipline

Update

A memo emphasising the mandatory

requirement to complete fire safety, BLS, PMAV

or equivalent, and the Mental Health Act 2001

was sent to all staff by the management team

260717.

This critical issue will be emphasised at the

operational and communication meeting on

28/07/17


QPS Group

Each Head of Discipline

Training will remain a

standing item on the

monthly operational and

communication meeting

Update: Feedback from

the QPS meeting to

operational group

monthly.

The service recognises the

importance of mandatory

training but also acknowledges

the difficulty of releasing staff

and providing training

resources in a busy service.

Every effort will be made

within the boundaries of finite

resources.

Reviewed monthly.



The stats on the mandatory training needs of all

staff will be reviewed on a monthly basis at the

QPS meeting


All heads of discipline are responsible for

monitoring and keeping up to date data on their

staff. They will send the data to the MHAA who

will coordinate the provide monthly updates to

QPS.

Monthly review of

mandatory training stats

at QPS meeting.

This will be achievable by a

targeted approach by

reviewing mandatory training

stats monthly.

Reviewed monthly

and expected date of

completion is

January 31st 2018.

18. The number and skill

mix of staffing were not

sufficient to meet

resident needs.


A restructuring of nurse staffing levels on day

duty in Fownes ward was completed to ensure

that there are sufficient numbers of staff to

meet resident needs.

(i.e. CNM2 supernumerary to current staff

numbers, i.e. 1 cnm11, 1 cnm1, 4 staff nurses.

A record of the daily staffing numbers and skill

mix will be maintained by the ADON to monitor

staffing levels and reviewed monthly at QPS

monthly

Post-Holder(s) responsible: ADON

Staffing level review

monthly at QPS

Achievable To commence 31st

July 2017


A monthly report on nursing and HCA staffing

levels will be provided to the QPS Group to

ensure appropriate staffing levels

Post-Holder(s) responsible: ADON

Staffing level review

monthly at QPS

Achievable Review at QPS

meeting 17th August

2017

Regulation 27: Maintenance of Records Report reference: Page 52-53


Taken from the inspection

report

Reoccurring or New

area of non-

compliance





of the action(s)



action(s)



action(s)

19. The policy did not

detail the

procedure relating

to the access to

records.


Policy update

The policy will be amended to reflect all the

requirements of regulation 27 and the Judgement

Support Framework.

Post-Holder(s) responsible: Policy sub committee

All policies are reviewed

every 3 years unless

otherwise indicated.

Achievable 31st October 2017

20. Not all clinical files

were kept in good

order, as some files

had loose pages.


The policy amendment will include a section on the

upkeep and maintenance of clinical files.

Following policy update, the relevant changes will be

highlighted in an email from the ECD to all medical,

nursing and AHP staff.

A bi- weekly check will be completed by the ward

clerk and nursing staff to ensure that all files are kept

in good order and follow the established indexing

process already in place. Ward clerk to check Mon-

Fri, nursing staff at weekends.

Post-Holder(s) responsible: Nursing staff, Ward Clerk

Feedback to all staff in

relation to loose pages or

untidy recording of files.

Staff induction and training

records to record staff

attendance at training on

regulation 27 .



Weekly checks

Yearly audit


Current yearly audit of

medical records to be

expanded to include

condition of the clinical file.

Achievable Next audit due 10th

January 2018.

Regulation 28: Register of Residents Report reference: Page 56


Taken from the inspection

report

Reoccurring or New

area of non-

compliance





of the action(s)



action(s)



action(s)

21. The resident’s diagnosis on

discharge was not

detailed in the

register.


The CD will communicate with the consultant

teams to ensure that the discharge diagnosis and

ICD code are included in the immediate discharge

summary. This will allow the input of the

resident’s diagnosis on discharge into the

register.Administration staff will record the

discharge diagnosis.


Administrative staff

Quarterly audit Lack of access to the

diagnosis from the clinical

file

Immediate action

(Email sent to

consultant teams 24th

July 2017)


Audit of the patient registrar quarterly


The Mental Health Act Administrator

Quarterly audit. The MHAA

will give quarterly reports

to the QPS group.

Achievable Quarterly from

August 2017

Regulation 31: Complaints Procedure Report reference: Page 57-58


Taken from the inspection report Reoccurring

or New area

of non-

compliance

Provide corrective and preventative action(s)

to address the area of non-compliance


monitoring the


action(s)

Provide details of any barriers to the implementation

of the action(s)



action(s)

22. The registered proprietor did

not ensure that the

nominated person

maintained a record of all

complaints relating to the

approved centre as one

complaint was not

documented.


A record of all complaints (formal and

informal) is now being maintained by

the CHO7 Complaints Manager. The

complaints officer met the

operational management team on

Monday 31st July 2017 to outline the

workings of complaints management

in the service.

The complaints policy and patient

information booklet will be updated

to give clarification to all staff and

patients of the complaints process.


CHO 7 Complaints Officer

Complaints are a

standing item on the

QPS Group agenda

and reviewed

monthly.

Multiple recipients of complaints (Approved

Centre, Community, DON, CD, ECD, St

James’s Hospital). A number of meetings

have been held between the CD/DON and

the Director of Quality and Safety

improvement ,St James’s Hospital last being

21st July 2017 to ensure a system of

governance and oversight is in place. This

included clarification of the complaints

process, that all complaints are managed

through single point of contact (CHO 7

Complaints Officer). The CHO 7 complaints

officer will meet with the complaints office

of St James’s Hospital on Tuesday 29th

August to further enhance and communicate

this process and ensure a clear pathway for

all complaints.

August 2017

Policy will be

updated by 31st

August 2017.


A monthly report of the status and

outcome of all complaints, will sent to

the QPS Group


Complaints Officer

Review by QPS Group

monthly

Achievable August 2017

QPS Group


not ensure that all complaints

were investigated promptly as

full investigations for

complaints were not

documented in the

complaints log.


1. The complaints officer for CHO 7

will ensure that all complaints are

investigated promptly and

documented in the complaints log.

2. Staff will attend education sessions

on the complaints process in Cherry

Orchard Hospital on October 17th and

October 25th delivered by the CHO 7

Consumer Affairs Officer.

3. The CNMs will deliver training on

regulation 31 to include reading and

sign off of the complaints policy.


Complaints Officer CHO 7

CNMs

Training records of

staff attendees will be

maintained by the

CNMs and monthly

updates sent to the

local Quality and

Patient Safety Group

(QPS) for oversight

and analysis.

Achievable 1. August 2017

2. Dates as

outlined

3. Rolling sessions

delivered by

CNMs to be

completed by

28th February

2018. (Policy

needs to be

updated in the

first instance

(31st August

2017))


A monthly report of the status and

outcome of all complaints, will sent to

the QPS Group


Complaints Officer CHO 7

Review by QPS Group

monthly

Achievable August 2017


not ensure that all complaints

and the results of any

investigations into the

matters complained and any

actions taken on foot of a


As above in no 22 and 23


complaint were fully and

properly recorded.

Regulation 32: Risk Management Procedures (and Code of Practice: Notification of Deaths and Incident Reporting) Report reference: Page 59-60 and 74



New area of

non-compliance





of the action(s)



action(s)



action(s)

25. The risk management policy

did not meet all the

requirements of the

regulation and the code of

practice.


The Risk Management Policy will be reviewed

and updated in line with Regulation 32 and the

JSF to ensure all requirements are met.

Policy update and amendment


Policy Sub Committee

All policies requiring

updating are monitored 6

monthly by the chair of the

policy group. As a result of

many policy deficiencies in

the draft report, the

policies will be monitored

monthly until all are

updated.

Feasible 31st August 2017

For updating of the

risk management

policy


Education and information session to

multidisciplinary staff on assessment and

management of all risks under the policy,

monitoring of risks on risk register and

escalation processes. Staff will be required to

have read and state they have understood the

policy and process.


Quality and Patient Safety Manager, CHO 7

All training records in

relation to risk assessment

and management will be

maintained by the

appropriate head of

discipline and monitored by

the QPS group.

Feasible 3 months to

complete.

Education sessions

are scheduled for

06/09/17 and

27/09/17.

Plan for further

sessions every 6

months thereafter.


26. The risk management policy

had not been implemented

throughout the approved

centre.


A number of initial steps have been taken or

planned

1. The risk policy will be updated.

2. Information and education session to all

staff to include reading and understanding

of policy and process in the service.

3. Following discussion with the Quality,

Standards & Compliance Officer, National

Mental Health Division, the clinical

governance group has been re constituted

with terms of reference to provide

oversight of risk management, clinical

audit, complaints, health and safety,

clinical incidents and serious incidents.


CD/ DON

QPS group to monitor

processes.

Quarterly review of risk

register at QPS meeting to

ensure all risks, strategic

and operational are

addressed, actioned and

escalated if necessary.

Achievable Corrective actions

Commenced 20th

July 2017.

Risk Management

Policy updated by

31st August 2017.

Education session

as above.

Reconstitution of

clinical governance

group commenced

20th July 2017.


The clinical risk management system will

continue to be monitored using the weekly

admission audit.

The risk register is monitored 3 monthly to

ensure all risks are identified, managed and

escalated if necessary.


CNMs

QPS Group

As above Achievable On-going

Code of Practice: The Use of Physical Restraint Report reference: Page 71-72



New area of non-

compliance




monitoring the


action(s)


barriers to the


action(s)


of the completion of

the action(s)

27. In one episode,

Restraint was not implemented in the

resident’s best interests and in rare and

exceptional circumstances where the

resident posed an immediate threat of

serious harm to self or others, 1.1.

Staff had not considered all other

interventions to manage the patient’s

unsafe behaviour, 1.2.

The security staff member involved in

the episode of PR had not read the risk

assessment, 1.7.


A bespoke teaching programme will be

devised, implemented and delivered to

all staff over 6-8 weeks. This will cover all

aspects of the code of practice (COP)on

the use of physical restraint and all

deficits outlined in this report. It will

encompass a presentation and short

discussion groups.

Security staff will never be responsible for

initiating or supervising PR on the acute

mental health unit. In circumstances

where security are required, this will

always be under the direction of nursing

staff. In the event of security staff asked

to be involved in a PR, briefing of the

situation and risk assessment will be

shared with the security by the lead staff

member (designated person as per the

approved centre policy). A meeting with

Head of Security was held 21st July 2017

to highlight the concerns from the

inspection and set up process of

Staff training records for

PR, PMVA, BLS and MHA

training will be

monitored by heads of

discipline with monthly

reports to the QPS

Group Staff Induction

records to be kept up to

date.

Audit of every restraint

using a checklist.

This CAPA will be

monitored by the QPS

Group and the MDT

CAPA Monitoring Group.

Staff availability over

peak holiday period.

New staff commencing

duty

Updating of physical

restraint policy in the

first instance (by 14th

August 2017)

The training

programme will

commence week of

28th August and will

be completed by

week ending 22nd

October 2017.

The five core

members of the

security staff will be

trained in PMVA by

31st December

2017.


communication between security and

nurse management. It was agreed that 5

core members of the security team would

be trained in PMVA . The would mean

that if in a situation where security may

be required, those trained members

would attend under the direction of the

lead nursing staff member.

It was also agreed that a member of the

security team would attend the daily

safety pause meeting at 11.00 to have

awareness of possible risk situations.


CNM2s/ADON/DON/CD/ NPDU

Head of Security, St James’s Hospital


Nursing staff will always take the lead in

PR situations and adhere to all aspects of

the COP with due regard to the best

interest of the resident and considering

all other interventions to manage the

situation.

Post-Holder(s) responsible: CNM2s


using a checklist.

Feasible Actioned at CNM

meeting 26th July

2017

28. In two episodes of PR, cultural

awareness and gender sensitivity were

not demonstrated.


As part of the training plan, there will be

emphasis on correct documentation of

each episode of PR (both during and after

the episode). Staff will be made aware of

having a same sex member of staff

Staff Induction and

training records to be

kept up to date.


using a checklist.

Staff availability over

peak holiday period.

New staff commencing

duty

The training

programme will

commence week of


be completed by

week ending 22nd

October 2017.


present during a PR episode (where

practicable) and to culturally sensitive

Post-Holder(s) responsible:CNMs/NPDU


Audit of each episode to ensure

compliance with policy and COP


Actioned at CNM

meeting 26th July

2017

29. In one episode, PR was not initiated by a

registered medical practitioner,

registered nurse, or other members of

the multi-disciplinary team (MDT) in

accordance with the policy.


PR will only be initiated by appropriately

trained staff under 5.1 of the COP on PR.

This will be covered in the training plan

and in the updated policy. The training

plan will clearly outline responsibilities of

staff in PR.

5 core members of the security team will

receive PMVA training and security team

members will attend the bespoke training

programme.


CNMs/ NPDU

Head of Security

Staff Induction and

training records to be

kept up to date.


using a checklist.

Feasible. The training

programme will

commence week of


be completed by

week ending 22nd

October 2017.


Audit of each episode to ensure

compliance with policy and COP


As above Feasible Actioned at CNM

meeting 26th July

2017

30. In one episode of PR, a designated staff

member was not the lead. New Corrective Action(s):

Security staff will never be responsible for

initiating or supervising PR on the acute

mental health unit. Only appropriately


using a checklist.

Feasible The training

programme will

commence week of



qualified staff will take the lead. The

training plan will clearly outline

responsibilities of staff in PR.

Post-Holder(s) responsible: As above in

28

be completed by

week ending 22nd

October 2017.


All episodes of PR will be audited.


As above Feasible Actioned at CNM

meeting 26th July

2017

31. In one episode of PR, there was no

documented evidence that the resident

was informed of the reasons, likely

duration, and circumstances leading to

discontinuation of PR and the reasons

for not informing the resident were not

recorded.


Training plan to be implemented as in 28.


28


using a checklist.

Feasible



28

As above

32. In two episodes of PR, there was no

documented evidence that the

resident’s next of kin or representative

was informed. There was no

documented evidence of the reasons

why they were not informed or of the

resident’s consent to notify their next of

kin.


Training plan to be implemented as in 28.


28


using a checklist.

Feasible



28

As above

33. The policy did not meet all the

requirements of the code of practice. New Corrective Action(s):

The policy will be updated to reflect the

requirements for the provision of

information to a resident and to outline

The policy will be

updated and monitored

yearly.

Feasible Policy will be

updated by 14th

August 2017


the child protection processes, should a

child need restraint.

The policy will be updated to reflect the

current delivery of PMVA training for

staff in the approved centre. Specifically

the policy will include requirements of

the COP under section 10.1, i.e.

Breakaway techniques and

alternatives to PR

The identification of appropriately

qualified persons to deliver training

The mandatory nature of the training

The maintenance of records of

attendance




Post-Holder(s) responsible: Policy sub

committee

As above Feasible

34. Not all staff had signed a log to indicate

that they had read and understood the

policy on physical restraint.


All staff who attend the training will sign

off on the policy and otherwise staff will

sign off on induction or using the “policy

of the day” method


Responsible heads of discipline

Feasible 22nd October 2017



Responsible heads of discipline

Code of Practice: Admission, Transfer and Discharge Report reference: Page 80 – 82



New area of non-

compliance





action(s)



action(s)



action(s)

35. The admission, transfer

and discharge policies did

not meet all the

requirements of the code

of practice.


The polices on admission, transfer and

discharge will be updated and amended to

ensure full compliance with the requirement

of the Code of practice.

Post-Holder(s) responsible: Policy Sub

Committee

All policies are reviewed

every 3 years unless

otherwise indicated.



The current process of auditing admission and

transfers will continue.


Audit report will be sent

monthly to the QPS group for

analysis

Achievable On-going

36. There was no documented

evidence that all staff had

read and understood the

policies on admissions,

transfer, and discharge.


All staff will sign off on reading the policy after

training, on induction or after “Policy of the

Day” sessions

Training on the COP on admission, transfer

and discharge will be delivered by the CNMs.


The process for delivering the

training by CNMs will be

reviewed by the MDT CAPA

Monitoring Group.

28th February 2018



It will be incumbent of Heads of disciplines to

ensure all their staff read and understand the

policies on admission, transfer and discharge

Post-Holder(s) responsible: Heads of

Disciplines

Will be reviewed at QPS

group to ensure that all staff

are adhering to requirements

of reading and understanding

policy.


Heads of Disciplines

37. There was no audit

undertaken to monitor the

discharge processes.


An audit of the discharge process will

commence


Medical team members (NCHD)

This action will be monitored

by the QPS Group

Achievable 31st August 2017


An audit will be developed and implemented

to audit the discharge process


Medical team members (NCHD)

Results of the audits will be

sent to the QPS Group on a

monthly basis and

communicated to all staff.

Achievable Monthly from

September 2017

Jonathan Swift Clinic - mhcirl.ie · AC0009 Jonathan Swift Clinic Approved Centre Inspection Report 2017 Page 4 of 112 The principal functions of the Mental Health Commission are

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