jonathan swift clinic - mentalhealthcommission · 2020-01-03 · the jonathan swift linic was...

2019 COMPLIANCE RATINGS

22

7

2 1

3

1

1

2

Inspection Team:

Susan O’Neill, Lead Inspector

Carol Brennan-Forsyth

Noeleen Byrne

Marianne Griffiths

Inspection Date: 20 – 23 August 2019

Inspection Type: Unannounced Annual Inspection

Previous Inspection Date: 11 – 14 September 2018

The Inspector of Mental Health Services:

Dr Susan Finnerty MCRN009711

Date of Publication: Monday 06 January 2020

RULES AND PART 4 OF THE MENTAL HEALTH

ACT 2001

Compliant

Jonathan Swift Clinic

ID Number: AC0009

2019 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 Other

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 2019 of 89

RATINGS SUMMARY 2017 – 2019

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

Chart 1 – Comparison of overall compliance ratings 2017 – 2019

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 2017 – 2019

8 6 7

16

10 8

17

23 24

0

5

10

15

20

25

30

35

40

45

2017 2018 2019

Not applicable Non-compliant Compliant

3 2

7

6

3

3

2

4

3

1

0

2

4

6

8

10

12

14

16

18

2017 2018 2019

Low Moderate High Critical


Contents 1.0 Inspector of Mental Health Services – Review of Findings .............................................................. 5

2.0 Quality Initiatives ............................................................................................................................. 8

3.0 Overview of the Approved Centre ................................................................................................. 10

3.1 Description of approved centre ............................................................................................. 10

3.2 Governance ............................................................................................................................ 10

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

4.0 Compliance ..................................................................................................................................... 13

4.1 Non-compliant areas on this inspection ................................................................................ 13

4.2 Areas of compliance rated “excellent” on this inspection ..................................................... 13

4.3 Areas that were not applicable on this inspection ................................................................ 14

5.0 Service-user Experience ................................................................................................................. 15

6.0 Feedback Meeting .......................................................................................................................... 16

7.0 Inspection Findings – Regulations .................................................................................................. 17

8.0 Inspection Findings – Rules ............................................................................................................ 59

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

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

Appendix 1: Corrective and preventative action plan……………………………………………………………………… 67

Appendix 2: Background to the inspection process…………………………………………………………………………. 88

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Inspector of Mental Health Services Dr Susan Finnerty

In brief

The Jonathan Swift Clinic was located within the St. James’s Hospital campus, connected to the main hospital

building. The unit consisted of three wards, with a total bed capacity of 47: Connolly Norman, a 9-bedded

acute admissions unit for the care of older persons; Beckett Ward, a 16-bedded step down, pre-discharge

unit; and William Fownes Ward, with 22 acute admission beds, on the first floor. All three wards shared a

small internal garden on the ground floor; however, only residents in Beckett Ward had unrestricted access

to this garden.

The approved centre had seven multi-disciplinary teams specialising in general adult, psychiatry of later life,

and rehabilitation and recovery.

Due to the cramped environment and lack of access to outside space, the approved centre was unsuitable

as an inpatient mental health unit; however, the service had worked hard to improve the existing conditions

and service offered to residents, insofar as the structure allowed. This is evidenced by the year on year

increase in compliance with regulations, rules and codes of practice: 52% compliance in 2017; 70%

compliance in 2018; and 75% compliance in 2019. Five compliances with regulations were rated as excellent.

Conditions to registration

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

Condition 1: 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.

Finding on this inspection: Although the approved centre provided a progress report on the programme of

maintenance, it was in breach of Condition 1. The approved centre was non-compliant with Regulation 22:

Premises at the time of inspection.

Safety in the approved centre

1.0 Inspector of Mental Health Services – Review of Findings


Safewards was an ongoing programme in the approved centre. This encouraged staff and residents

to work together to make the inpatient unit safer for everyone.

Ligature anchor points and other hazards had been minimised.

The approved centre adhered to food safety requirements.

The nursing office had been moved to a more central position in William Fownes Ward to improve

observation of both corridors.

However:

The problem of smoking was evidenced by the numerous incident reports of smoking since

September 2018, verbal reports from residents to the inspection team, and a distinct smell of

cigarette smoke on certain wards throughout the inspection. While a risk assessment for fire risk due

to cigarette smoking had been completed and included in the safety statement, indoor smoking

continued in spite of the various control measures in place. This risk assessment was reviewed on an

annual basis only and was, therefore, not being regularly reviewed or monitored by the local

management team to a degree which the problem indicated.

Not all health care professionals were trained in fire safety, Basic Life Support, management of

violence and aggression, The Mental Health Act 2001, and Children First. Staff were not trained in

line with the assessed needs of the resident group profile and of individual residents.

Appropriate care and treatment of residents

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

and met the assessed needs of the residents as documented in their individual care plans. The group

programme included pottery, art, music, wellness, psychology, and discharge planning groups and

were provided in a separate, dedicated room that contained facilities and space for individual and

group therapies.

Residents’ general health needs were monitored and assessed at least every six months in line with

best practice. Adequate arrangements were in place for residents to access general health services

and referral to other health services.

A Physical Restraint Pathway had been introduced in the Electronic Patient Record (EPR) system to

support improved documentation of processes.

However:

Although each resident had an individual care plan (ICP), a number of the ICPs inspected were not

acceptable as person centred recovery focused care plans and did not comply with Regulation 15:

Individual Care Plan.

As there was no designated dietitian in the centre, the needs of residents identified as having special

nutritional requirements were not regularly reviewed. An evidence-based nutritional tool was not

used.


Respect for residents’ privacy, dignity and autonomy

Residents’ consent was sought prior to all searches. At least two clinical staff were in attendance at

all times when searches were conducted. Searches were implemented with due regard to the

resident’s dignity, privacy, and gender.

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

was an identified risk to a resident. All observation panels on doors of treatment rooms and

bedrooms had blinds, curtains or opaque glass.

Seclusion was not used in the approved centre and physical restraint was carried out in full

accordance with the relevant code of practice.

However:

The premises lacked outdoor space on Fownes Ward, which was located on the first floor of the

approved centre. Residents requiring supervision when accessing the downstairs courtyard area

were dependent on the availability of a nurse to accompany them. Both residents and staff stated

that planned time outside of the unit was often cancelled if something urgent arose. Residents

expressed their frustration to the inspection team concerning the resulting limitation in outdoor

access. While measures had been implemented to facilitate access, this was not monitored, resulting

in access that was limited and not guaranteed for certain residents. This presented a serious risk to a

resident’s quality of life and the therapeutic environment.

The four-bedded rooms on Fownes Ward and the six-bedded dormitory on Beckett Ward were

cramped and did not allow for resident privacy.

The approved centre was not kept in a good state of repair externally and internally and was not

clean, hygienic and free from offensive odours. Two sinks were blocked, two showers had cigarette

burns, the floors of the dining rooms were marked, a ceiling tile had become dislodged in a dormitory,

the ceiling in one of the shower rooms was dirty and discoloured, cigarette ash was found on the

windowsill of the family room, and there was a consistent pervasive smell of cigarette smoke on

Fownes Ward through each day of the inspection. While there was a programme of general

maintenance and cleaning, there was no programme of decorative maintenance.

Responsiveness to residents’ needs

Residents were provided with a variety of wholesome and nutritious food that was presented in an

attractive and appealing manner and for which the residents provided positive feedback. Residents

had at least two meal choices, including daily hot meals.

The Occupational Therapy department and The Dementia Services Information and Development

Centre collaborated on the redesign and decoration of the Connolly Norman Ward sitting room to

ensure a user friendly and homely environment for residents.

Good information was provided about the approved centre, residents’ diagnoses and medication.

There was a robust complaints system in place.


The approved centre provided access to recreational activities throughout the seven-day week. The

recreational activities were appropriately resourced and included walking groups, yoga, film groups,

exercise groups and a gym in the garden area.

Communal areas were suitable for recreational activities. The approved centre had an Occupational

Therapy department which was used for some recreational activities. The approved centre had a

recreational and therapeutic programme schedule in an accessible format which was easily available

to residents and included the types and frequency of activities available.

Governance of the approved centre

The Jonathan Swift Clinic was governed by St. James’s Hospital and Community Healthcare

Organisation (CHO) Dublin South, Kildare, and West Wicklow. The St. James’s Hospital and HSE

Oversight Committee, with membership comprising of senior management from both organisations,

convened on a quarterly basis to discuss relevant operational issues. All committees consisted of

multi-disciplinary representation.

All medical and health and social care professionals were employed by CHO Dublin South, Kildare and

West Wicklow, while both organisations supplied the approved centre’s complement of nursing staff.

Opportunities for further education were made available to staff. Training completion rates for all

disciplines were monitored at the QPS meeting and required training was identified.

The service had a local risk register and this was kept up-to-date by management and reviewed as

part of their governance systems.

A cycle of audit was implemented within the approved centre and results were communicated to the

multi-disciplinary team at the Quality and Patient Safety (QPS) meetings. The majority of audits were

completed by the nursing team with minimal involvement of the wider multi-disciplinary team. A

multi-disciplinary audit committee was established earlier this year.

The area lead for mental health engagement was invited to attend the CHO Area Management team

meeting on a monthly basis. At a local level, regular resident community meetings, suggestion boxes,

and engagement with the complaints process (both formal and informal) were the principal

mechanisms evident for resident and carer engagement. All formal complaints were reviewed at the

QPS committee meetings and relevant actions identified.

However:

The risk register did not contain the risk of fire due to resident smoking within the approved centre.

In spite of analysis and planning, training records indicated that not all health professionals had up-

to-date mandatory training.

2.0 Quality Initiatives


1. Introduction of a discharge messages board as part of the ongoing implementation of the Safewards

project. Safewards is a programme that encourages staff and residents to work together to make the

inpatient unit safer for everyone.

2. Collaboration between the Occupational Therapy department and The Dementia Services

Information and Development Centre on the redesign and decoration of the Connolly Norman Ward

sitting room to ensure a user friendly and homely environment for residents.

3. Implementation of a new personal alarm system to improve safety of both staff and residents.

4. Introduction of new printed menus for residents which include additional information on food

choices.

5. Implementation of an Electronic Patient Record system in all wards within the approved centre.

6. Introduction of a Physical Restraint Pathway into the Electronic Patient Record (EPR) system to

support improved documentation of processes.

7. Delivery of a Crime Prevention and Safety Talk to residents by local Gardaí to provide information on

how to be more safety aware.

8. Implementation of evening and weekend recreational groups within the approved centre.

9. Implementation of a music therapy group on Connolly Norman Unit.


3.1 Description of approved centre The Jonathan Swift Clinic was located within the St. James’s Hospital campus. The unit consisted of three

wards, with a total bed capacity of 47. Connolly Norman and Beckett Wards were located on the ground

floor of the main hospital building, while the William Fownes Ward was on the first floor.

The approved centre had seven multi-disciplinary teams specialising in general adult, psychiatry of later life,

and rehabilitation and recovery. Connolly Norman Ward was a nine-bedded acute admissions unit for the

care of older persons, Beckett Ward consisted of 16 step down/pre-discharge beds, and the William Fownes

Ward had 22 acute admission beds. All three wards shared a small internal garden on the ground floor;

however, only residents in Beckett Ward had unrestricted access to this garden.

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

Resident Profile

Number of registered beds 47

Total number of residents 43

Number of detained patients 9

Number of wards of court 1

Number of children 0

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

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

3.2 Governance

The Jonathan Swift Clinic was governed by two systems of governance; St. James’s Hospital and Community

Healthcare Organisation (CHO) Dublin South, Kildare, and West Wicklow. The St James’s Hospital and HSE

Oversight Committee, with membership comprising of senior management from both organisations,

convened on a quarterly basis to discuss relevant operational issues. The CHO Area Management team for

Dublin South Central met on a monthly basis. Locally, the Quality and Patient Safety (QPS) Committee and

the Operation and Communications committee both convened on a monthly basis also. All committees

consisted of multi-disciplinary representation. An organisation chart to identify the leadership and

management structure and the lines of authority and accountability of the approved centre’s staff was

available.

All medical and health and social care professionals were employed by CHO Dublin South, Kildare and West

Wicklow, while both organisations supplied the approved centre’s complement of nursing staff. At the time

of inspection, there were two nursing staff vacancies, however, staffing levels across all units were effectively

managed through the use of agency personnel. Plans were in place for recruitment to these posts. Staffing

levels for all disciplines were reviewed at both the monthly QPS and Operation and Communications

3.0 Overview of the Approved Centre


committee meetings. Staff performance management was achieved through a process of staff appraisal and

supervision across the majority of disciplines.

A local orientation programme was undertaken for all new staff commencing employment within the

approved centre. There was no consistent in-service training programme for nursing staff in operation.

Opportunities for further education were made available to staff and at the time of inspection, three staff

members were expected to commence postgraduate courses this year. Training completion rates for all

disciplines were monitored at the QPS meeting and required training was identified. In spite of this analysis

and planning, however, training records indicated that not all health professionals had up-to-date mandatory

training.

The service had a local risk register and this was kept up-to-date by management and reviewed as part of

their governance systems; however, the register did not feature the risk of fire due to resident smoking

within the approved centre. The problem of smoking was evidenced by the numerous and consistent number

of incident reports of smoking since September 2018, verbal reports from residents to the inspection team,

and a distinct smell of cigarette smoke on certain wards throughout the inspection. While a risk assessment

for fire risk due to cigarette smoking had been completed and included in the safety statement, it was clear

that indoor smoking continued in spite of the various control measures in place. This risk assessment was

reviewed on an annual basis only and was therefore not being regularly reviewed or monitored by the local

management team to a degree which the problem indicated.

One of the principal issues concerning the premises was the lack of outdoor space on Fownes Ward, which

was located on the first floor of the approved centre. Residents requiring supervision when accessing the

downstairs courtyard area were dependent on the availability of a nurse to accompany them. Both residents

and staff stated that planned time outside of the unit was often cancelled if something urgent arose.

Residents expressed their frustration to the inspection team concerning the resulting limitation in outdoor

access. Therefore, while measures had been implemented to facilitate access, this was not monitored,

resulting in access that was limited and not guaranteed for certain residents. This presented a serious risk to

a resident’s quality of life and the therapeutic environment.

A cycle of audit was implemented within the approved centre and results were communicated to the multi-

disciplinary team at the QPS meetings. The majority of audits were completed by the nursing team with

minimal involvement of the wider multi-disciplinary team. Management recognised the requirement for

multi-disciplinary integration within the audit process and a multi-disciplinary audit committee was

established earlier this year.

The area lead for mental health engagement was invited to attend the CHO Area Management team meeting

on a monthly basis. At a local level, regular resident community meetings, suggestion boxes, and

engagement with the complaints process (both formal and informal) were the principal mechanisms evident

for resident and carer engagement. All formal complaints were reviewed at the QPS committee meetings

and relevant actions identified.

3.3 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.


4.1 Non-compliant areas on this inspection

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

compliant () or non-compliant (X) in these areas in 2018 and 2017 and the relevant risk rating when the

service was non-compliant:

Regulation/Rule/Act/Code Compliance/Risk Rating 2017

Compliance/Risk Rating 2018

Compliance/Risk Rating 2019

Regulation 5: Food and Nutrition X Moderate

Regulation 15: Individual Care Plan X Moderate X High

Regulation 21: Privacy X Moderate X Moderate X High

Regulation 22: Premises X Critical X High X Critical

Regulation 23: Ordering, Prescribing, Administration of Medicines

X High X Moderate X High

Regulation 26: Staffing X Critical X Moderate X Moderate

Regulation 32: Risk Management Procedures

X High X High

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

X Moderate X Low X Moderate

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

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

4.2 Areas of compliance rated “excellent” on this inspection

The following areas were rated excellent on this inspection:

Regulation

Regulation 4: Identification of Residents

Regulation 6: Food Safety

Regulation 7: Clothing

Regulation 8: Residents’ Personal Property and Possessions

Regulation 11: Visits

Regulation 13: Searches

Regulation 29: Operating Policies and Procedures

4.0 Compliance


4.3 Areas that were not applicable on this inspection

Regulation/Rule/Code of Practice Details

Regulation 17: Children’s Education As the approved centre had not admitted any children since the last inspection, this regulation was not applicable.

Regulation 25: Use of Closed Circuit Television As CCTV was not in use in the approved centre, this regulation was not applicable.

Rules Governing the Use of Electro-Convulsive Therapy

As the approved centre did not provide an ECT service, this rule was not applicable.

Rules Governing the Use of Seclusion As the approved centre did not use seclusion, this rule was not applicable.

Rules Governing the Use of Mechanical Means of Bodily Restraint

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

Code of Practice Relating to Admission of Children Under the Mental Health Act 2001

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

Code of Practice on the Use of Electro-Convulsive Therapy for Voluntary Patients

As the approved centre did not provide an ECT service, this code of practice was not applicable.


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

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

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

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

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

residents to talk to the inspection team.

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

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

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

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

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

the approved centre.

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

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

below.

The inspection team met with nine residents during the inspection. All residents expressed satisfaction with

the choice and quality of food; however, one resident stated that food options become repetitive with time.

The majority of residents were familiar with their individual care plan and multi-disciplinary team members.

Two residents expressed frustration with the degree of resident smoking within the approved centre and

the lack of effective enforcement of no smoking rules. Two residents on Fownes Ward highlighted the limited

access to outdoor areas. All residents engaged with activities to varying degrees, while one resident reported

that there were few activities on Fownes Ward. One resident reported difficulty watching TV due to the level

of noise on Fownes Ward.

Six resident questionnaires were completed and returned to the inspection team. All questionnaires

indicated that a staff member explained what was happening when they arrived on the unit. All respondents

understood their individual care plan and five respondents indicated that they knew the multi-disciplinary

team members. Two questionnaires indicated there was not enough activities within the approved centre.

All respondents indicated their privacy and dignity were respected. On a scale of 1-10, with one being poor

and 10 being excellent, the residents rated their overall experience of care and treatment ranging from seven

to nine.

5.0 Service-user Experience


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

inspection team and the following representatives of the service:

Clinical Director

Area Director of Nursing

Two Assistant Directors of Nursing

Clinical Nurse Manager 2

Two Consultant Psychiatrists

Principal Psychology Manager

Occupational Therapy Manager

Operations Manager

Social work Team Leader

Mental Health Act Administrator

Head of Mental Health Community Healthcare Dublin, South Kildare, and West Wicklow

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.

6.0 Feedback Meeting


7.0 Inspection Findings – Regulations

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

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


Regulation 4: Identification of Residents

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

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the identification of residents, which was last reviewed in June 2019. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for identifying residents, as set out in the policy. Monitoring: An annual audit had been undertaken to ensure that there were appropriate resident identifiers on clinical files. Documented analysis had been completed to identify opportunities for improving the resident identification process. Evidence of Implementation: The approved centre used a minimum of two person specific resident identifiers that were appropriate for the resident’s communication abilities. Identifiers used included a name, date of birth and medical registration number, and were recorded in the approved centre’s electronic files and on resident bracelets. Two resident identifiers were used before administering medications, undertaking medical investigations, and providing other health care services. The approved centre’s electronic records operated a red alert system to inform staff of the presence of residents with the same or similar names. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.

Regulation 5: Food and Nutrition

COMPLIANT Quality Rating Excellent

NON-COMPLIANT Quality Rating Requires Improvement Risk Rating


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

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

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to food and nutrition, which was last reviewed in May 2018. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for food and nutrition, as set out in the policy. Monitoring: A systematic review of menu plans had been undertaken to ensure that residents were provided with wholesome and nutritious food in line with their needs. Documented analysis had been completed to identify opportunities for improving the processes for food and nutrition. Evidence of Implementation: A dietitian had approved menus to ensure nutritional adequacy in accordance with residents’ needs. Residents were provided with a variety of wholesome and nutritious food that was presented in an attractive and appealing manner and for which the residents provided positive feedback. Residents had at least two meal choices, including daily hot meals. Hot and cold drinks were offered to residents regularly and a source of safe, fresh drinking water was available to residents at all times in easily accessible locations. For residents with special dietary needs, nutritional and dietary needs were not assessed where necessary and addressed in residents’ individual care plans. Weight charts were implemented, monitored and acted upon for residents, where appropriate. Residents and their representatives were educated about resident diets and their interaction with medication. As there was no designated dietitian in the centre, the needs of residents identified as having special nutritional requirements were not regularly reviewed. An evidence-based nutritional tool was not used. Intake and output charts were maintained, where appropriate. The approved centre was non-compliant with this regulation because residents with special dietary requirements were not reviewed by a dietitian and their special dietary requirements were not documented in their individual care plan or clinical notes, 5(2).


Regulation 6: Food Safety

(1) The registered proprietor shall ensure:

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

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

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

(2) This regulation is without prejudice to:

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

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

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

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to food safety, which was last reviewed in June 2019. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for food safety, as set out in the policy. All staff handling food had up-to-date training in food safety commensurate with their role. This training was documented, and evidence of certification was available. Monitoring: Food safety audits had been completed periodically. Food temperatures were recorded in line with food safety recommendations and a food temperature log sheet was maintained and monitored. Documented analysis had been completed to identify opportunities to improve food safety processes. Evidence of Implementation: Appropriate hand-washing areas were provided for catering services. There was suitable and sufficient catering equipment and appropriate protective equipment was used during the catering process. Hygiene was maintained to support food safety requirements and catering areas and associated catering and food safety equipment were appropriately cleaned. There were proper facilities for the refrigeration, storage, preparation, and servicing of food. Food was prepared in a manner that reduces the risk of contamination, spoilage, and infection. Residents were provided with crockery and cutlery that addressed their specific needs. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.



Regulation 7: Clothing

The registered proprietor shall ensure that:

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

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

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to residents’ clothing, which was last reviewed in April 2018. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for residents’ 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. No residents were wearing nightclothes at the time of inspection. Evidence of Implementation: Residents were supported to keep and use personal clothing. Residents had an adequate supply of individualised clothing, which was clean and appropriate to their needs. There was emergency clothing available which was appropriate and took account of resident preferences, dignity, bodily integrity, religious, and cultural practices. Residents changed out of nightclothes during daytime hours. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.



Regulation 8: Residents’ Personal Property and Possessions

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

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

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

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

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

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

INSPECTION FINDINGS Processes: The approved centre had a written operational policy in relation to residents’ personal property and possessions, which was last reviewed in May 2018. The policy included all of the requirements of the Judgement Support Framework.

Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for residents’ personal property and possessions, as set out in the policy. Monitoring: Personal property logs were monitored in the approved centre. Documented analysis had been completed to identify opportunities for improving the processes relating to residents’ personal property and possessions. Evidence of Implementation: Residents were entitled to bring personal possessions to the approved centre. A resident property checklist was compiled on admission and updated as needed, with valuable items added as required. The checklist was kept separately to the resident’s individual care plan (ICP) and was available to the resident. Where the approved centre assumed responsibility for a resident’s personal property and possessions, they were safeguarded appropriately. Secure facilities were provided for the safe-keeping of the residents’ personal property. Each resident had a personal safe beside their bed with an individual private access code. Residents were supported to manage their own property, unless this posed a danger to the resident or others, as indicated in their ICP. Items assessed as posing a risk to the resident were stored in the property room. Access to and use of resident monies was overseen by two members of staff and the resident or their representative. Where money belonging to the resident was handled or issued by staff, signed records of two staff members were retained and where possible counter-signed by the resident or their representative.



The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.


Regulation 9: Recreational Activities

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

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the provision of recreational activities, which was last reviewed in August 2019. The policy addressed all requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for recreational activities, as set out in the policy. Monitoring: A record was maintained of the occurrence of planned recreational activities, including a log of resident uptake and attendance. Documented analysis had not been completed to identify opportunities for improving the processes relating to recreational activities. Evidence of Implementation: The approved centre provided access to recreational activities appropriate to the resident group profile. Activities were provided throughout the 7-day week, with indoor and outdoor exercise opportunities available to residents. Individual risk assessments were completed for residents, where deemed appropriate, in relation to the selection of appropriate activities. The recreational activities were appropriately resourced and included walking groups, yoga, film groups, exercise groups and a gym in the garden area. Residents had some access to the garden area, which was located on the ground floor, and when possible, staff accompanied residents of Fownes Ward to the garden. Communal areas were suitable for recreational activities. The approved centre had an Occupational Therapy department which was used for some recreational activities. Fownes Ward had a bright and spacious recreational room and a TV room. The Connolly Norman Ward had access to a day room and the Beckett Ward had a day room for recreational activities. The approved centre had a recreational and therapeutic programme schedule in an accessible format which was easily available to residents and included the types and frequency of activities available. Recreational activities programmes were developed, implemented, and maintained for residents, with regular feedback sought from residents. Residents were free to choose whether to participate in activities and their decisions were respected and documented. Logs of participation were maintained for recreational activities in the residents’ clinical files, as appropriate. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the monitoring pillars.

COMPLIANT Quality Rating Satisfactory


Regulation 10: Religion

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

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

Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for facilitating residents in the practice of their religion, as set out in the policy. Monitoring: The implementation of the policy to support residents’ religious practices was not reviewed to ensure that it reflected the identified needs of residents. Evidence of Implementation: Residents’ rights to practice religion were facilitated within the approved centre insofar as was practicable. Multi-faith facilities were available in the hospital and residents had access to multi-faith chaplains. Residents could attend weekly masses in the hospital campus and were risk assessed prior to attending any religious services outside of the approved centre. Care and services were respectful of the residents’ religious beliefs and values. Any specific religious requirements relating to the provision of services, care, and treatment were assessed at admission and clearly documented. Residents were facilitated to observe or abstain from religious practice in accordance with their wishes. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the monitoring pillar.



Regulation 11: Visits

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

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

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

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

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

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

INSPECTION FINDINGS Processes: The approved centre had a written policy and procedures in relation to visits. The policy was last reviewed in June 2019. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for visits, as set out in the policy. Monitoring: At the time of inspection, there were no restrictions on residents’ rights to receive visitors, therefore monitoring in this context applicable. Documented analysis had been completed to identify opportunities for improving visiting processes. Evidence of Implementation: Visiting times were appropriate and reasonable, and were publicly displayed at the entrance of the approved centre. At the time of inspection there were no residents with visitor restrictions. Appropriate steps were taken to ensure the safety of residents and visitors during visits. Visiting children were accompanied to ensure their safety, and this was communicated publicly. A separate, private visiting room was available to residents and was suitable for children. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.



Regulation 12: Communication

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

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

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

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

INSPECTION FINDINGS Processes: The approved centre had a written operational policy and procedures in relation to resident communication. The policy was last reviewed in June 2019. The policy and procedures included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for communication, as set out in the policy. Monitoring: Resident communication needs and restrictions on communication were not monitored on an ongoing basis. Documented analysis had been completed to identify ways of improving communication processes. Evidence of Implementation: Residents had access to mail, fax, e-mail, internet, and telephone, unless otherwise risk-assessed. Each unit had a cordless phone for residents use. There was no Wi-Fi access, however residents were supervised to use computers in the nurse’s station office if internet access was needed. At the time of inspection no resident had any restrictions on external communication and no outgoing communication had been examined by the clinical director or relevant senior staff member since the last inspection. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education and monitoring pillars.



Regulation 13: Searches

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

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

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

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

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

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

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

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

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

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

INSPECTION FINDINGS Processes: The approved centre had a written operational policy and procedures in relation to the implementation of resident searches. The policy was last reviewed in January 2019. The policy and procedures addressed all of the requirements of the Judgement Support Framework, including the following:

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

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

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



substances were found as a result of a search. There were no environmental searches conducted. Instead, every morning residents were reminded to hand in risk items. At least two clinical staff were in attendance at all times when searches were conducted. Searches were implemented with due regard to the resident’s dignity, privacy, and gender; at least one of the staff members conducting the search was the same gender as the resident being searched. A written record of every search of a resident or property was available, which included the reason for the search, the names of both staff members who undertook the search, and details of who was in attendance for the search. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.


Regulation 14: Care of the Dying

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

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

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

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

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

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

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

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

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

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

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

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

INSPECTION FINDINGS Processes: The approved centre had a written operational policy and protocols in relation to care of the dying. The policy was last reviewed in May 2019. The policy and protocols included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for end of life care, as set out in the policy. Monitoring: End of life care provided to residents was systematically reviewed to ensure section 2 of the regulation had been complied with. Documented analysis had not been completed to identify opportunities for improving the processes relating to care of the dying. Evidence of Implementation: One clinical file of a resident who had died outside the approved centre was inspected. This death was reported to the Mental Health Commission within the 48-hour timeframe. The approved centre was compliant with this regulation.

COMPLIANT


Regulation 15: Individual Care Plan

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

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

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the development, use, and review of individual care plans (ICPs), which was last reviewed in September 2017. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Not all clinical staff had signed the signature log to indicate that they had read and understood the policy. All clinical staff interviewed were able to articulate the processes relating to individual care planning, as set out in the policy. All multi-disciplinary team (MDT) members had not received training in individual care planning. Monitoring: Residents’ ICPs were audited on a quarterly basis to determine compliance with the regulation. Documented analysis had been completed to identify ways of improving the individual care planning process. Evidence of Implementation: Ten ICPs were reviewed on inspection. Each resident was initially assessed at admission and an ICP was completed by the admitting clinician to address the immediate needs of the resident, though admission assessments were not easily found on inspection. ICPs were developed by the MDT following a comprehensive assessment, within seven days of admission. The assessment included; medical, psychiatric and psychosocial history; medication history and current medications; current physical health assessment; detailed risk assessment; social, interpersonal, and physical environment-related issues, including resilience and strengths; communication abilities, and; educational, occupational, and vocational history. In one case, the ICP was not a composite set of documents. This ICP was interrupted by old care plans and amalgamated with progress notes. Evidence based assessments were used where possible and the ICPs were discussed, agreed where practicable, and drawn up with the participation of the resident and their representative, family, and next of kin, as appropriate. The ICPs did not identify the residents’ assessed needs and five of ten ICPs inspected did not document appropriate goals. Four of ten ICPs inspected did not document care and treatment required to meet the goals identified, including the frequency and responsibilities for implementing the care and treatment. Half of the ICPs reviewed did not document the resources required to provide care and treatment. A key worker was identified to ensure continuity in the implementation of a resident’s ICP. The ICPs examined included an individual risk management plan as well as a preliminary discharge plan, where deemed appropriate. Residents had access to their ICP, were kept informed of any changes and were offered a copy of their ICP, including any reviews. Where a resident declined or refused a copy of their ICP, this was recorded, including the reason, if given. The ICPs were reviewed by the MDT in consultation with the resident. However, several ICPs were not updated following review by the MDT and had goals



that were written months before the inspection and that did not reflect the residents’ changing needs, condition and circumstances. The approved centre was non-compliant with this regulation for the following reasons:

a) One ICP was not a composite set of documents. b) Five of ten ICPs inspected did not specify appropriate goals. c) Four of ten ICPs did not specify the treatment and care required. d) Five of ten ICPs did not identify necessary resources.


Regulation 16: Therapeutic Services and Programmes

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

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

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the provision of therapeutic services and programmes, which was last reviewed in December 2016. The policy included all of the requirements of the Judgement Support Framework.

Training and Education: Not all clinical staff had signed the signature log to indicate that they had read and understood the policy. All clinical staff interviewed were able to articulate the processes relating to therapeutic activities and programmes, as set out in the policy. Monitoring: The range of services and programmes provided in the approved centre was monitored on an ongoing basis to ensure that the assessed needs of residents were met. Documented analysis had been completed to identify opportunities for improving the processes relating to therapeutic services and programmes. Evidence of Implementation: The therapeutic services and programmes provided by the approved centre were evidence-based, appropriate, and met the assessed needs of the residents as documented in their individual care plans (ICPs). The therapeutic services and programmes were directed towards restoring and maintaining optimal levels of physical and psychosocial functioning of residents. The group programme included pottery, art, music, wellness, psychology, and discharge planning groups. These therapeutic services were adequately and appropriately resourced and provided in a separate, dedicated room that contained facilities and space for individual and group therapies. A list of all therapeutic services and programmes was available to residents. Where a resident required a therapeutic service or programme that was not provided internally, the approved centre arranged for the service to be provided by an approved, qualified health professional in an appropriate location. A record was maintained of participation and engagement in and outcomes achieved in therapeutic services or programmes in residents’ ICPs or clinical files. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education pillar.



Regulation 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 written policies and procedures in relation to the transfer of residents both internally and externally, which were last reviewed in May 2018 and November 2017 respectively. The policies included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed the signature log to indicate that they had read and understood the policies. Relevant staff interviewed were able to articulate the processes for the transfer of residents, as set out in the policies. Monitoring: A log of transfers was maintained. Each transfer record had been systematically reviewed to ensure all relevant information was provided to the receiving facility. Documented analysis had not been completed to identify opportunities for improving the provision of information during transfers. Evidence of Implementation: The clinical file of one resident transferred internally to a medical ward of St. James’s Hospital was inspected. An assessment was completed and documented prior to the transfer, which included an individual risk assessment. This assessment was available to staff on the receiving ward via the electronic patient record system. Verbal communication and liaison took place between the approved centre and the receiving hospital ward prior to the transfer, which included a discussion of the reasons for transfer, care and treatment plans, and the resident’s accompaniment requirements. Full and complete written information was available through the hospital’s internal electronic patient record system. Information included a letter of referral, medication requirements, and a transfer form. A checklist was completed by the approved centre to ensure comprehensive resident records were transferred. This was included on the transfer letter. Copies of all records relevant to the resident’s transfer were retained in the resident’s electronic healthcare record. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education and monitoring pillars.



Regulation 19: General Health

(1) The registered proprietor shall ensure that:

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

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

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

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

INSPECTION FINDINGS Processes: The approved centre had written operational policies and procedures in relation to the provision of general health services and the response to medical emergencies. The general health policy was last reviewed in December 2016. The medical emergencies policy was last reviewed in July 2019. The policies and procedures included all of the requirements of the Judgement Support Framework. Training and Education: All clinical staff had signed the signature log to indicate that they had read and understood the policies. All clinical staff interviewed were able to articulate the processes relating to the provision of general health services and the response to medical emergencies, as set out in the policies. Monitoring: Residents’ take-up of national screening programmes was recorded and monitored, where applicable. A systematic review had been undertaken to ensure that six-monthly general health assessments of residents occurred. Analysis had not been completed to identify opportunities for improving general health processes. Evidence of Implementation: The approved centre had an emergency trolley and staff had access at all times to an Automated External Defibrillator. These were checked weekly. Records were available of any medical emergency within the approved centre and the care provided. In the provision of general health services, registered medical practitioners assessed residents’ general health needs at admission and on an ongoing basis. All five clinical files inspected showed that residents’ general health needs were monitored and assessed as indicated by the residents’ specific needs, but at least every six months, and included: a physical examination; family and personal history; Body Mass Index, weight and waist circumference; blood pressure; smoking status; nutritional status; a medication review, and; dental health assessment. Residents received appropriate general health care interventions in line with their individual care plans (ICPs). For residents on antipsychotic medication, an annual assessment considered their glucose regulation, blood lipids, and prolactin, and included and an electrocardiogram (ECG). Residents’ completed general health checks and associated results were recorded. Adequate arrangements were in place for residents to access general health services and referral to other health services. Residents had information on and could access appropriate national screening programmes, including breast checks, retina checks, and bowel screening. The hospital campus was a smoke-free campus and there was a smoking cessation committee in the approved centre. Two nurses were trained in smoking cessation and planned to run groups on smoking cessation.



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


Regulation 20: Provision of Information to Residents

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

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

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

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

(d) details of relevant advocacy and voluntary agencies;

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

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

INSPECTION FINDINGS Processes: The approved centre had a written policy and procedures in relation to the provision of information to residents. The policy was last reviewed in January 2018. The policy and procedures addressed all requirements of the Judgement Support Framework.

Training and Education: Not all staff had signed the signature log to indicate that they had read and understood the policy. All staff interviewed were able to articulate the processes relating to the provision of information to residents, as set out in the policy. Monitoring: The provision of information to residents was not monitored on an ongoing basis to ensure it was appropriate and accurate. Documented analysis had been completed to identify opportunities for improving the processes relating to the provision of information to residents. Evidence of Implementation: An information booklet was provided to residents and their representatives at admission in the required format. The booklet was clearly and simply written and outlined the required information on the complaints procedure, visiting times and arrangements, and the housekeeping arrangements, including arrangements for personal property and mealtimes. Residents were provided with details of their multi-disciplinary team. Information on relevant advocacy and voluntary agencies, as well as residents’ rights, were displayed throughout the approved centre. Residents were provided with written and verbal information on diagnosis unless, in the treating psychiatrist’s view, the provision of such information was prejudicial to the resident’s physical or mental-health, wellbeing, or emotional condition. The justification for restricting information regarding a resident’s diagnosis was documented in their clinical file. A variety of diagnosis and medication-related information, including risks and potential side effects, was available and provided to residents, as appropriate. The information in the documents provided by or within the approved centre was evidence-based. Residents had access to interpretation and translation services as required.



The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education 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 written policy in relation to resident privacy, which was last reviewed in August 2017. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Not all staff had signed the signature log to indicate that they had read and understood the policy. All staff interviewed could articulate the processes for ensuring resident privacy and dignity, as set out in the policy. Monitoring: A documented annual review had been undertaken to ensure that the policy was being implemented and that the premises and facilities in the approved centre were conducive to resident privacy. Analysis had not been completed to identify opportunities for improving the processes relating to residents’ privacy and dignity. Evidence of Implementation: The general demeanour of staff, their appearance and dress, and the manner in which they addressed and communicated with residents, including calling them by their preferred names, demonstrated dignity and respect. Staff discretion was observed when discussing a resident’s condition or treatment needs. The permission of residents was sought by staff before entering their rooms. All residents were wearing clothing that respected their privacy and dignity. Residents were facilitated to make private phone calls. All bathrooms, showers, toilets, and single bedrooms had locks on the inside of the door, unless there was an identified risk to a resident. The four bedded rooms on Fownes Ward and the six bedded dorm on Beckett Ward were cramped and did not allow for resident privacy. In the cases of two beds, hooks were missing from the beds’ privacy screening curtain rail, potentially compromising privacy. All observation panels on doors of treatment rooms and bedrooms have blinds, curtains or opaque glass. There was no blind or opaque glass on the window of Connolly Norman Ward’s sitting room, which could potentially be seen into by members of the public from a separate garden on the St. James’s Hospital site. Noticeboards detailing resident information located in both Beckett and Connolly Norman Ward offices were visible from corridors through door observation panels. The noticeboard in Beckett Ward office was moved during the inspection and was no longer visible through the observation panel. However, the noticeboard in Connolly Norman Ward office could still be viewed as it was observed that the door to the room was not consistently closed. The approved centre was non-compliant with this regulation for the following reasons:

a) The bedrooms in the four and six bedded dormitories were cramped and did not allow for resident privacy.

b) Noticeboards on Beckett and Connolly Norman Ward contained resident names and were visible to the public from the corridors.

c) Two curtains around the beds in Fownes Ward were missing hooks at the end; thus potentially compromising resident privacy.

d) There was a blind missing from the sitting room window in Connolly Norman Ward.



Regulation 22: Premises

(1) The registered proprietor shall ensure that:

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

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

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

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

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

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

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

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

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to its premises, which was last reviewed in December 2018. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed could articulate the processes relating to the maintenance of the premises, as set out in the policy. Monitoring: The approved centre had completed a hygiene audit. The approved centre had completed a ligature audit using a validated audit tool. Documented analysis had been completed to identify opportunities for improving the premises. Evidence of Implementation: Sufficient outdoor space was not provided for residents to move about as the approved centre had one small shared garden for residents within all three units. Fownes Ward was located on the first floor of the approved centre and, therefore, residents did not have direct access to an outdoor area. Residents did not have access to adequate personal space on Fownes Ward and Beckett Ward as some of the dormitories were small in size for the number of beds resulting in cramped areas. Appropriately sized communal rooms were provided and private and communal areas were suitably sized and furnished to remove excessive noise. The lighting in communal rooms suited the needs of residents and staff, though there was limited natural light in Fownes Ward. Hazards and ligature points were minimised in the approved centre to the lowest practicable level, based on risk assessment. The approved centre was not kept in a good state of repair externally and internally and was not clean, hygienic and free from offensive odours. Two sinks on Fownes Ward were blocked, two showers on the ward had cigarette burns, the floors of the dining rooms on Fownes and Beckett Ward were marked, a ceiling tile had become dislodged in a dormitory on Fownes Ward, the ceiling in one of the shower rooms on Fownes Ward was dirty and discoloured, cigarette ash was found on the windowsill of the family room



and there was a consistent smell of cigarette smoke on Fownes Ward through each day of the inspection. While there was a programme of general maintenance and cleaning, there was no programme of decorative maintenance. Where faults or problems were identified in relation to the premises, this was communicated through the appropriate maintenance reporting process Rooms were centrally heated however the heating could not be controlled in the residents’ own rooms. Current national infection control guidelines were followed and back-up power was available to the approved centre. There was a sufficient number of toilets and showers for residents in the approved centre and toilets were accessible, clearly marked and close to day and dining areas. Wheelchair accessible toilet facilities were identified for use by visitors who required such facilities and there was at least one assisted toilet per floor. The approved centre had a designated sluice room and cleaning room, but not a laundry room. It also had designated therapy rooms and appropriately sized lifts. Suitable furnishings were provided to support resident independence and comfort, as were assisted devices and equipment to address resident needs. Remote or isolated areas of the approved centre were monitored. The approved centre was non-compliant with this regulation for the following reasons:

a) The registered proprietor did not ensure that Fownes Ward was appropriately clean; two sinks on were dirty and blocked, a shower room ceiling on was dirty, and cigarette ash was observed on a windowsill, 22(1)(a).

b) The registered proprietor did not ensure that the approved centre was free from malodour as there was consistent smell of cigarette smoke on Fownes Ward, 22(1)(a).

c) The premises were not maintained in good decorative condition; two shower units on Fownes Ward contained cigarette burn marks and the dining room floor in both Fownes and Beckett Wards was marked, 22(1)(a).

d) A programme of decorative maintenance was not developed or implemented within the approved centre, 22(1)(c).

e) The registered proprietor did not ensure that the overall approved centre environment was developed with due regard for the specific needs of the residents, as there was very limited access to outdoor space provided to the residents of Fownes Ward, 22(3).

f) The registered proprietor did not ensure that the overall approved centre environment was developed with due regard for the specific needs of the residents, as there was not sufficient space for residents within Fownes and Beckett Wards, which were cramped, 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 policy in relation to the ordering, storing, prescribing, and administration of medication. The policy was last reviewed in January 2018. The policy addressed requirements of the Judgement Support Framework with the exception of the process for withholding medication.

Training and Education: Not all nursing, medical and pharmacy staff had signed the signature log to indicate that they had read and understood the policy. All nursing, medical and pharmacy staff interviewed could articulate the processes relating to the ordering, prescribing, storing, and administering of medicines, as set out in the policy. Staff had access to comprehensive, up-to-date information on all aspects of medication management. All nursing, medical and pharmacy staff had received training on the importance of reporting medication incidents, errors, or near misses. The training was documented. Monitoring: Quarterly audits of Medication Prescription and Administration Records (MPARs) had been undertaken to determine compliance with the policies and procedures and the applicable legislation and guidelines. Incident reports were recorded for medication incidents, errors, and near misses. Analysis had been completed to identify opportunities for improving medication management processes. Evidence of Implementation: Ten MPARs were reviewed on inspection. All entries were legible, written in black, indelible ink, and used two appropriate identifiers. MPARs had dedicated space for routine, once-off, and “as-required” medications. A record of all medications administered to residents was kept, as well as all allergies or sensitivities, the medication dose/amount, frequency, administration route, date of initiation and discontinuation, the generic and full name, and micrograms was written in full. MPARs included the Medical Council Registration Number of every medical practitioner prescribing medication, and MPARs were signed by the medical practitioner for each entry. All medicines were administered by a registered nurse or medical practitioner. Medicinal products were administered in accordance with the directions of the prescriber and pharmacist’s advice. The expiration date of medication was checked prior to administration; expired medications were not administered. Good hand-hygiene techniques were implemented during the dispensing of medications. When a resident’s medication was withheld, the justification was noted in the MPAR and documented in a clinical file. Schedule 2 controlled drugs were checked by two staff members, including one registered nurse, against the delivery form. Details were entered on the controlled drug book and signed by both staff members. The controlled drug balance corresponded with the balance recorded in the controlled drug book, and the book was checked morning and evening by two staff nurses. Medication was reviewed and rewritten at least six-monthly. Medical practitioners rewrote prescriptions where an alteration was required. The pharmacist technician implemented a system of stock rotation and completed a monthly inventory of medications which checked the name and dose of medication, quantity



of medication and expiry date. Medications that were no longer required, which were past their expiry date, or had been dispensed to a resident but were no longer required, were stored in a secure manner, segregated from other medication, and returned to the pharmacy for disposal. The MPAR of a resident who was receiving crushed medication was inspected. The resident received medication covertly and this was documented in the resident’s individual care plan (ICP) within the multi-disciplinary team (MDT) review section. There were no directions to crush medication on the MPAR. A medical practitioner did not document in the MPAR that the medication was to be crushed and a documented reason why the medication was to be crushed was not provided. The pharmacist was not consulted about the type of preparation to be used and was not aware that the resident was receiving crushed medication. Medication storage areas were clean and free from damp, mould, litter, dust, pests, spillage or breakage. Food and drink was not stored in areas used for medication storage. Medication storage areas were incorporated in the cleaning and housekeeping schedules. Where medication required refrigeration, a log of the temperature of the refrigeration storage unit was taken daily. Medication dispensed or supplied to a resident was stored securely in a locked trolleys in secure clinical rooms. The approved centre was non-compliant with this regulation because one resident was in receipt of crushed medication. There were no directions to crush medication on the resident’s MPAR, 23(1).


Regulation 24: Health and Safety

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

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

INSPECTION FINDINGS Processes: The approved centre had a written operational policy and procedures in relation to the health and safety of residents, staff, and visitors, dated June 2019, as well as a site-specific ancillary safety statement. The policy and safety statement addressed requirements of the Judgement Support Framework, with the following exceptions:

Management of spillages.

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

Linen handling.

Covering of cuts and abrasions.

Support provided to staff following exposure to infectious diseases.

First aid response requirements.

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

COMPLIANT


Regulation 26: Staffing

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

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

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

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

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

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

INSPECTION FINDINGS Processes: The approved centre had a written policy and procedures in relation to its staffing requirements. The policy was last reviewed in June 2019. The policy and procedures addressed all of the requirements of the Judgement Support Framework, including the following:

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

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

Training and Education: Not all relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes relating to staffing, as set out in the policy. Monitoring: The implementation and effectiveness of the staff training plan was reviewed on an annual basis. This was documented. The numbers and skill mix of staff had been reviewed against the levels recorded in the approved centre’s registration. Analysis had been completed to identify opportunities to improve staffing processes and respond to the changing needs and circumstances of residents. Evidence of Implementation: The numbers and skill mix of staff were sufficient to meet resident needs and staff had appropriate qualifications to do their jobs. Staff were recruited, selected and vetted in accordance with the approved centre’s policy and procedures for recruitment, selection, and appointment. Information from referees was sought and documented. There was an organisational chart to identify the leadership and management structure and the lines of authority and accountability of the centre’s staff. A planned and actual staff rota, showing staff on duty at any one time during the day or night, was maintained in the approved centre and an appropriately qualified staff member was on duty and in charge at all times. This was documented. There was a written staffing plan for the approved centre which addressed the skill mix, competencies, number and qualifications of staff, as well as the required number of staff on duty at night to ensure safety of residents in the event of a fire or other emergency. It also took into consideration the assessed needs of the resident group profile through the size and layout of the centre, number of beds available, level of



acuity of psychiatric illness, and the age profile, length of stay, physical care needs and level of dependency of residents, as well as challenging behaviour exhibited by residents. Where agency staff were used, there was a comprehensive contract between the approved centre and a registered or licensed staffing agency used that set out the agency’s responsibilities, including vetting of staff, confirmation of identity and staff training. Annual staff training plans were completed for all staff to identify required training and skills development in line with the assessed needs of the resident group profile. However, staff training plans only detailed mandatory training; additional assessed needs and associated trainings were not documented. Orientation and induction training was completed for staff. Each new staff member received approximately one week’s orientation on the ward and a week of corporate induction provided by St. James’s Hospital. Not all health care professionals were trained in fire safety, Basic Life Support, management of violence and aggression, The Mental Health Act 2001, and Children First. Staff were not trained in line with the assessed needs of the resident group profile and of individual residents. Not all health care staff were trained in care for residents with intellectual disability, resident rights, incident reporting, protection of children and vulnerable adults, and recovery centred approaches to mental health care and treatment. Opportunities were made available to staff for further education, and three staff members were due to undertake postgraduate course this year. Facilities and equipment was available for staff in-service education and training. Regular briefings for staff on subjects relating to policy and regulation was reported during inspection to have not occurred for some time due to staffing and scheduling issues. The Mental Health Act 2001, the associated regulation (S.I. No.551 of 2006) and Mental Health Commission Rules and Codes, and all other relevant Mental Health Commission documentation and guidance were available to staff throughout the approved centre.

Profession Basic Life

Support

Fire Safety Management

Of Violence

and

Aggression

Mental

Health Act

2001

Children First

Nursing (37) 33 89% 36 97% 28 75% 35 94% 36 97%

Consultant

Psychiatrist (10) 10 100% 7 70% 5 50% 9 90% 9 90%

Medical (15) 15 100% 12 80% 8 53% 11 73% 13 86%

Occupational

Therapist (14) 14 100% 14 100% 14 100% 14 100% 14 100%

Social Worker (7) 6 85% 7 100% 6 85% 7 100% 7 100%

Psychologist (8) 8 100% 8 100% 8 100% 8 100% 8 100%

Pharmacist (1) 1 100% 1 100% 1 100% 1 100% 1 100%

Healthcare

assistant (7) 6 85% 7 100% 7 100% N/A N/A 7 100%

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


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

a) Not all staff had up-to-date mandatory training in Basic Life Support, fire safety, management of violence and aggression, and Children First, 26(4).

b) Not all staff had up-to-date mandatory training in the Mental Health Act 2001, 26(5).

Ward or Unit Staff Grade Day Night

William Fownes

CNM RPN HCA

1 (+1 supernumerary CNM) 4 1

1 3 1


Beckett

CNM RPN HCA

1 1 0

0 1 0


Connolly Norman

CNM RPN HCA

1 2 1

0 1 1

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

Psychology, Social Work and Occupational Therapy Services available on referral


Regulation 27: Maintenance of Records

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

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

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

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

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

INSPECTION FINDINGS Processes: The approved centre had a written policy and procedures in relation to the maintenance of records. The policy was last reviewed in June 2019. The policy and procedures addressed all of the requirements of the Judgement Support Framework, including the following:

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

The required resident record creation and content.

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

Record retention periods.

The destruction of records. Training and Education: Not all clinical staff and other relevant staff had signed the signature log to indicate that they had read and understood the policy. All clinical staff and other relevant staff interviewed were able to articulate the processes relating to the creation of, access to, retention of, and destruction of records, as set out in the policy. All clinical staff had been trained in best-practice record keeping. Monitoring: Resident records were not audited to ensure their completeness, accuracy, and ease of retrieval. Analysis had not been completed to identify opportunities to improve the processes relating to the maintenance of records. Evidence of Implementation: The approved centre utilised an electronic patient record system. A record was maintained for every resident who was assessed or provided with care. All records were developed and maintained in a logical sequence. Resident records were stored together, where appropriate, and were reflective of the residents’ current status and the care and treatment being provided. Resident records were maintained using a unique identifier and were secure, up to date, in good order, and maintained in line with national guidelines and legislative requirements. Only authorised staff could access resident data and make new entries, and residents could access records in accordance with relevant legislation. Staff had access to the information needed to carry out their job. Records were maintained appropriately, including being factual, consistent and written legibly in indelible black ink, using date and time in the 24-hour clock format, and signed appropriately. The approved centre also maintained a record of signatures used in the resident record.



No entries were made by student nurses in the clinical files examined. Two appropriate resident identifiers were recorded on all documentation. Where a member of staff made a referral, or consulted with a colleague, this person was clearly identified by their full name and title. Information or advice given over the phone was documented. Records were appropriately secured throughout the approved centre. Documentation of food safety, health and safety, and fire inspections was maintained. Records were retained or destroyed in accordance with legislative requirements. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education and monitoring pillars.


Regulation 28: Register of Residents

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

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

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

COMPLIANT


Regulation 29: Operating Policies and Procedures

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

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the development and review of operating policies and procedures required by the regulations, which was last reviewed in May 2018. It included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff had been trained on approved operational policies and procedures. Relevant staff interviewed could articulate the processes for developing and reviewing operational policies, as set out in the policy. Monitoring: An annual audit had been undertaken to determine compliance with review time frames. Analysis had been completed to identify opportunities for improving the processes of developing and reviewing policies. Evidence of Implementation: The operating policies and procedures were developed with input from clinical and managerial staff and in consultation with relevant stakeholders, including service users. The policies incorporated relevant legislation, evidence-based best practice, and clinical guidelines. The policies were appropriately formatted, approved, and communicated to all relevant staff. Relevant policies had been reviewed within the past three years. Obsolete versions of operating policies and procedures were retained but removed from access by staff. Generic policies were appropriate to the approved centre and the resident group profile, and were reviewed at least every three years. Where generic policies were used, the approved centre had a written statement to this effect, adopting the generic policy. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.

Regulation 30: Mental Health Tribunals

COMPLIANT

Quality Rating Satisfactory



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

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

INSPECTION FINDINGS Processes: The approved centre had a written policy and procedures in relation to the facilitation of Mental Health Tribunals. The policy was last reviewed in March 2019. The policy and procedures included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed could articulate the processes for facilitating Mental Health Tribunals, as set out in the policy. Monitoring: Analysis had not been completed to identify opportunities for improving the processes for facilitating Mental Health Tribunals. Evidence of Implementation: The approved centre provided private facilities and adequate resources to support the Mental Health Tribunal process. Staff attended Mental Health Tribunals and provided assistance, as necessary, when a patient required assistance to attend or participate in the process. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the monitoring pillar.

Regulation 31: Complaints Procedures

COMPLIANT

Quality Rating Satisfactory


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

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

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

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

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

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

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

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

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

INSPECTION FINDINGS Processes: The approved centre had a written operational policy and procedures in relation to the management of complaints. The policy was last reviewed in August 2017. The policy included reference to Your Service, Your Say. The policy and procedures addressed all of the requirements of the Judgement Support Framework, including the process for managing complaints, including the raising, handling, and investigation of complaints from any person regarding any aspect of the services, care, and treatment provided in or on behalf of the approved centre. Training and Education: Relevant staff had been trained on the complaints management process. Not all staff had signed the signature log to indicate that they had read and understood the policy. All staff interviewed were able to articulate the processes for making, handling, and investigating complaints, as set out in the policy. Monitoring: Audits of the complaints log and related records had been completed. Audits were documented and the findings acted upon. Complaints data was analysed. Details of the analysis had been considered by senior management. Required actions had been identified and implemented 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 clearly identified. Residents and their representatives were provided with information about the complaints procedure at admission, or soon thereafter, and were facilitated to make complaints using appropriate methods, including: verbal, written, electronic (e-mail), and telephone communication, and through complaint, feedback or suggestion forms. The complaints procedure and how to contact the nominated person was publicly displayed, and representatives, family, and next of kin were informed of all methods by which a complaint could be made. An advocate attended the approved centre every week and was ensured access to facilitate the participation of the resident and advocate in the complaints procedure. All complaints, whether oral or written, were investigated promptly and handled appropriately and sensitively. The registered proprietor ensured that the quality of the service, care, and treatment of a resident was not adversely affected because of the complaint being made. There was a consistent and standardised approach for the management of all complaints. A method for addressing minor complaints within the approved centre was provided and minor complaints were documented and a log was


maintained. The complaints officer dealt with minor complaints that could not be addressed locally and maintained a log of all complaints that were not minor. Details of complaints, as well as subsequent investigations and outcomes, were fully recorded and kept distinct from the resident’s individual care plan. Where complaints could not be addressed by the nominated person, they were escalated in accordance with the approved centre’s policy. This was documented. A complainant’s satisfaction or dissatisfaction with an investigation’s findings was not documented. None of the complaints logged were made against any services, care, or treatment provided on behalf of the approved centre by an external party. All information obtained in the complaints process was treated confidentially, consistent with all relevant legislation.

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



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

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

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

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

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

(i) resident absent without leave,

(ii) suicide and self harm,

(iii) assault,

(iv) accidental injury to residents or staff;

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

(e) Arrangements for responding to emergencies;

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

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

INSPECTION FINDINGS Processes: The approved centre had the following relevant written policies:

Integrated Risk Management, last reviewed in August 2017.

Safety Incident Reporting and Management Policy, last reviewed in October 2018.

Safety Statement, last reviewed in January 2019. The policy addressed most of the requirements of the Judgement Support Framework, including the following:

The process for rating identified risks.

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

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

The process for responding to emergencies.

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

The person responsible for overall risk management.

The process of identification, assessment, treatment, reporting, and monitoring of organisational risks.

Training and Education: Not all relevant staff had received training in the identification, assessment, and management of risk and in health and safety risk management. All clinical staff were trained in individual risk management processes. Management were trained in organisational risk management. Not all staff



had been trained in incident reporting and documentation. Not all staff had signed the signature log to indicate that they had read and understood the policies. All staff interviewed were able to articulate the risk management processes, as set out in the policies. All training was documented. Monitoring: The risk register was reviewed at least quarterly to determine compliance with the approved centre’s risk management policy. The audit did not measure actions taken to address risks identified against the time frames identified in the register. Analysis of incident reports had been completed to identify opportunities for improving risk management processes. Evidence of Implementation: Responsibilities were allocated at management level and throughout the approved centre to ensure the effective implementation of the risk management policy and the person responsible for risk was identified and known by all staff. Clinical and corporate risks were identified, assessed, treated, reported, monitored, and were documented in the local risk register as appropriate. Structural risks, including ligature points, were removed or effectively mitigated. The risk of fire due to cigarette smoking on the wards was not documented within the local risk register, however it was included as a risk assessment within the safety statement. Various control measures were outlined to minimise this risk, however the problem of smoking continued on some of the wards. This was evidenced in 82 incident reports documenting smoking on the wards since the last inspection, interviews with residents, the continuous smell of cigarette smoke throughout the inspection, and the finding of ash in sinks and stub marks on windowsills. This risk assessment was reviewed on an annual basis only and was therefore not being regularly reviewed or monitored by the local management team to a degree which the problem indicated. Individual risk assessments were completed prior to and during: physical restraint; resident transfer; resident discharge; in conjunction with medication requirements or administration, and; at admission to identify individual risk factors, including general health risk, risk of absconding and risk of self-harm. Multi-disciplinary teams (MDT), along with residents and/or their representatives, were involved in the development, implementation, and review of individual risk management processes. 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 and reviewed for trends or patterns occurring in the services by the risk management department. All clinical incidents were not reviewed by the MDT. The approved centre provided a six-monthly summary report of all incidents to the Mental Health Commission. All information provided was anonymous at resident level. There was an emergency plan that specified responses by staff to possible emergencies and which incorporates evacuation procedures. The approved centre was non-compliant with this regulation because the risk of fire due to cigarette smoking was not documented in the risk register and was not adequately monitored by the local management team, 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’s insurance certificate was provided to the inspection team. It confirmed that the approved centre was covered by the State Claims Agency for public liability, employer’s liability, clinical indemnity, and property. The approved centre was compliant with this regulation.

COMPLIANT


Regulation 34: Certificate of Registration

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

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

COMPLIANT


None of the rules under Mental Health Act 2001 Section 52(d) were applicable to this approved centre.

Please see Section 4.3 Areas of compliance that were not applicable on this inspection for details.

8.0 Inspection Findings – Rules

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


9.0 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 file of one patient was inspected in relation to Part 4 of the Mental Health Act 2001: Consent to Treatment. The patient 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 the clinical file contained the following information:

The names of the medication prescribed.

Confirmation of the assessment of the patient’s 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 medication(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.

10.0 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. The policy had been reviewed annually and was dated August 2019. It addressed the following:

The provision of information to the resident.

Who can initiate and who may implement physical restraint.

Child protection process where a child is physically restrained.

Training and Education: There was a written record to indicate that staff involved in the use of physical restraint had read and understood the policy. Monitoring: An annual report on the use of physical restraint in the approved centre had been completed. Evidence of Implementation: Three episodes of physical restraint were inspected. In all cases, physical restraint was used in rare, exceptional circumstances and in the best interests of the resident. Physical restraint was only exercised where a resident posed immediate threat of serious harm to self or others, after all alternative interventions had been considered, and based on a risk assessment. Physical restraint was initiated by an appropriate health professional in line with the physical restraint policy. A designated staff member was responsible for leading the physical restraint and monitoring the head and airway of the resident. The consultant psychiatrist or duty consultant psychiatrist was notified as soon as was practicable. This was documented. Cultural awareness and gender sensitivity was demonstrated. A same-sex staff member was present during all episodes of physical restraint. Staff were aware of relevant considerations in the individual care plans. Registered medical professionals completed a medical examination within three hours of the end of the episodes. The residents’ representatives were informed of the use of physical restraint in two cases. In one case this was not done; however, this was justified and recorded. Each episode of physical restraint was documented in the clinical file. A clinical practice form was completed by the initiator of physical restraint within three hours. That form was signed by a consultant psychiatrist within 24 hours in all cases. The forms were placed into the resident’s clinical file. Two episodes were reviewed by members of the multi-disciplinary team (MDT) and documented within two working days, and the residents had the opportunity to speak with the MDT about the episodes. One of the episodes inspected had only taken place the night before the inspection and had not yet been reviewed. The approved centre was compliant with this code of practice.

COMPLIANT


Admission, Transfer and Discharge

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

INSPECTION FINDINGS Processes: The approved centre had separate written policies in relation to admission, transfer, and discharge, which were last reviewed in October 2018, November 2017, and December 2018 respectively. The policies combined addressed all of the policy-related criteria for this code of practice. Training and Education: There was no documentary evidence that relevant staff had read and understood the admission, transfer, and discharge policies. Monitoring: Audits had been completed on the implementation of and adherence to the admission, transfer and discharge policies. Evidence of Implementation: Admission: The admission process within one clinical file was inspected. The admission was on the basis of mental illness or mental disorder. An admission assessment was completed and included an appropriate range of assessments. A full physical examination was performed the day after admission as the resident was documented to be too drowsy on day of admission. The resident’s representative(s) were involved in the admission process, with the resident’s consent. There was evidence of a key worker system in place. Transfer: The approved centre complied with Regulation 18: Transfer of Residents. Discharge: The discharge process within one clinical file was inspected. The approved centre maintained a discharge plan, which included estimated date of discharge, documented communication with the relevant health professionals, a follow-up plan, and a reference to early warning signs of relapse and risks. A discharge meeting attended by the resident, key worker, relevant members of the MDT and family, carer or chosen advocate, where appropriate, was not held. The discharge was coordinated by a key worker and a preliminary discharge summary was sent to relevant health professionals within three days of discharge. A comprehensive discharge summary was issued within 14 days of discharge and included details of diagnosis, prognosis, medication, mental state at discharge, outstanding health or social issues, follow-up arrangements, the names and contact details of key people for follow-up, and risk issues such as signs of relapse. A family member, carer or advocate was involved in the discharge process, where appropriate, and there was a timely follow-up appointment made. This was documented. The approved centre was non-compliant with this code of practice for the following reasons:

a) There was no documentary evidence that relevant staff had read and understood the admission policy, transfer policy or discharge policy, 9(1).

b) A discharge meeting attended by the resident, key worker, relevant members of the MDT and family, carer or chosen advocate, where appropriate, was not held, 34(4).

NON-COMPLIANT Risk Rating

Appendix 1: Corrective and Preventative Action Plan


Reason ID : 10000582 The risk of fire due to cigarette smoking was not documented in the risk register and was not adequately monitored by the local management team, 32(1).

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action The risk of fire due to

cigarette smoking was added to the local risk register in September 2019. Safety measures/controls are reviewed & updated on a regular basis.

Reviewed on a quarterly basis at the local QPS Committee.This includes a review of the risk rating, existing controls &/or additional controls/actions required to minimise the risk.

Achieved. 12/09/2019 Quality & Pateint Safety (QPS) Committee .

Preventative Action As above. The tobacco free campus (TFC) committee membership was reviewed following the inspection - a representative from each discipline now sits on the committee, this includes a Pharmacist, Smoking cessation officer, ANP in Physical Health, a Health promotion officer. The aim of the committee is to implement a

Reviewed on a quarterly basis at the local QPS Committee.This includes a review of the risk rating, existing controls &/or additional controls/actions required to minimise the risk.

Achievable, however, this will require a targeted approach from all staff to minimise the liklihood of breaches in tobacco use on site. Furthermore, the approved centre will require the assistance from external experts (Health Promotion Officers etc.) to assist with this process.

27/01/2020 All staff. Quality & Pateint Safety (QPS) Committee . Tobacco Free Campus Committee


successful tobacco free campus. The plans include, psycho education for Residents, promotion of NRT, staff education and the methods of engaging with all relevant stakeholders. The TFC committee is currently exploring ways of implementing a tobacco free campus. The local policy will be amended to outline the measures to be taken to support staff in implementing a tobacco free campus.


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

Reason ID : 10000589 One resident was in receipt of crushed medication. There were no directions to crush medication on the resident's MPAR, 23(1).

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action A dedicated unit

pharmacist commenced in March 2019 following a period of no pharmacy cover. Following the MHC feedback, the directions were added to the MPAR to guide the administration of the medication to be crushed.

The unit pharmacist attends weekly MDT meetings & will monitor the use & suitability of crushing medication on an ongoing basis. This will be documented in the residents ICP & clinical notes.

Achieved 23/08/2019 Treating Team. Darren Carthy (Senior Pharmacist)

Preventative Action The Jonathan Swift Clinic Medication Management policy outlines the process of crushing medication & recording the order for crushing on the MPAR & the residents ICP. In order to increase relevant staff members awareness of this process, educational sessions will be facilitated by the unit pharmacist. Furthermore, relevant staff will read & sign

The unit pharmacist attends MDT meetings & will be involved in any decision regarding the process of crushing medications. They will monitor the use & suitability of crushing medication on an ongoing basis. This will be

Achievable following increased educational sessions & the involvement of the unit pharmacist in any decision regarding the crushing of medications.

28/02/2020 Medical staff. Darren Carthy (Senior Pharmacist)


the policy to indicate that they understand the process. Additionally, the area of medication management will be included in the NCHD induction which is facilitated on a bi-annual basis.

documented in the residents ICP & clinical notes.


Regulation 26: Staffing

Reason ID : 10000590 Not all staff had up-to-date mandatory training in Basic Life Support, fire safety, management of violence and aggression, and Children First, 26(4). Not all staff had up-to-date mandatory training in the Mental Health Act 2001, 26(5).

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action The issue of training is a standing

item at the monthly Operational and Communication (O&C) meeting and the Quality and Patient Safety (QPS) meeting. Every effort will be made by each Head of Discipline to ensure all staff of the approved centre are in date with mandatory training and that a training log is kept and maintained.

Training will remain a standing item at the monthly O&C and QPS meeting. Training records are reviewed at the monthly QPS meeting.

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

31/03/2020 QPS Group and each Head of Discipline.

Preventative Action Training statistics are reviewed and monitored on a monthly basis at the Quality and patient safety committee meetings and the Operational and Communication committee meetings. The approved centre has organised facilitators to facilitate aforementioned mandatory training (BLS, manual handling, hand hygiene) to staff members on site, with the aim of increasing accessability to training. The service is in the process of exploring the feasibility of replicating this process in order to facilitate TMVA on site. Mandatory training is kept as a

Training will remain a standing item at the monthly O&C and QPS meeting. Training records are reviewed at the monthly QPS meetings.

This will be achievable by a targeted approach by reviewing mandatory training statistics on a monthly basis.

31/03/2020 QPS Group and each Head of Discipline.


standing item at the daily safety pause which takes place on the unit.


Regulation 15: Individual Care Plan

Reason ID : 10000592 One ICP was not a composite set of documents. Specific Measurable Achievable/Realistic Time-bound Post-Holder(s)

Corrective Action Following the training provided on September 10th by an external expert facilitator, a mechanisim was developed to ensure that 'live/current goals' are transferred onto a new ICP booklet when the previous booklet has been completed. This is to ensure that all 'live/current goals' are maintained within a composite set of documents.

Weekly ICP audit to recommence once the ICP document has been introduced. This will include a check of any resident who has more than one care plan document, to assess if all 'live/current goals' have been transferred to the new ICP document.

Achievable with planned education to all relevant staff members on the introduction and use of the new ICP document

31/03/2020 Care Plan Committee

Preventative Action Following the training provided on September 10th by an external expert facilitator, a mechanisim was developed to ensure that 'live/current goals' are transferred onto a new ICP booklet when the previous booklet has been completed. This is to ensure that all 'live/current goals' are maintained within a composite set

Weekly ICP audit to recommence once the ICP document has been introduced. This will include a check of any

This is acheivable through weekly ICP audits and feedback to individual teams. Also planned training to be facilitated on a bi annual basis. ICP committee will continue to meet every 6 months to review the process.



of documents. The care plan committee reconvened in September 2019 to review the process taking into consideration the MHC inpsection feedback. The committee updated the ICP template in response to this feedback. This will be launched in February 2020.

resident who has more than one care plan document, to assess if all 'live/current goals' have been transferred to the new ICP document.

Reason ID : 10000593 Five of ten ICPs inspected did not specify appropriate goals. Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action A Care Plan training day was held

on September 10th for all 'champions'/key stakeholders.This was facilitated by an external expert in this field. Taking guidance from the expert training facilitator and the feedback from the MHC inspection team, a new Individual Care Plan (ICP) document was developed. As part of the implementation plan, for this document ICP 'champions' have been identified & will be involved in educating teams on the process. This includes the importance of MDT members specifying appropriate goals & documening these in the residents ICP.

Weekly care plan audits to recommence once the new care plan document is introduced. Monthly care plan audits to continue.

Achievable with the appropriate staff education, weekly audits & feedback of the results to all key stakeholders.


Preventative Action The approved centre is currently in the process of implementing a new Individual Care Plan (ICP)

Weekly & monthly ICP audits.

Achievable. 31/03/2020 Care Plan Committee.


document. As part of the implementation plan, ICP 'champions' have been identified & will be involved in educating teams on the process. This includes the importance of MDT members specifying appropriate goals & documening these in the residents ICP. In order for care planning to become more embedded within the approved centre, this will require ongoing education for MDT members, education for all residents, a mechanism to feedback weekly & monthly audit results that are undertaken on the area of care planning & ongoing review of the ICP template.

Reason ID : 10000594 Four of ten ICPs did not specify the treatment and care required. Five of ten ICPs did not identify necessary resources.

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action A Care Plan training day was held

on September 10th for all ICP 'champions'/key stakeholders. This was facilitated by an external expert in this field Taking guidance from the expert training facilitator and the feedback from the MHC inspection team, a new Individual Care Plan (ICP) document was developed. As part of the implementation plan for this document, ICP 'champions' have been identified & will be

Weekly ICP audits to recommence once the new ICP document has been introduced. Monthly ICP audits to continue

This will be achievable with the education provided and reestablishment of ICP audits and feedback of audit results to all relevant stakeholders



involved in educating teams on the process. This includes the importance of MDT members specifying treatment and care required and identifing necessary resources

Preventative Action The approved centre is currently in the process of implementing a new Individual Care Plan (ICP) document. As part of the implementation plan, ICP 'champions' have been identified & will be involved in educating teams on the process. This includes the importance of MDT members specifying the treatment and care required and necessary resources required. In order for care planning to become more embedded within the approved centre, this will require ongoing education for MDT members, education for all residents, a mechanism to feedback weekly & monthly audit results that are undertaken on the area of care planning & ongoing review of the ICP template

Weekly ICP audits to recommence once the new ICP document has been introduced. Monthly ICP audits to continue.

The care plan committee plan to meet bi annually to review audit results and feedback from Multidisciplinary team members regarding the efficacy of the ICP document. This will inform subesequent education sessions for staff on the ICP principles. Next review meeting will be held in June 2020

31/03/2020 Care plan committee


Regulation 21: Privacy

Reason ID : 10000596 The bedrooms in the four and six bedded dormitories were cramped and did not allow for resident privacy.

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action As the approved centre is

currently subject to a condition on Regulation 22 'Premises', the Mental Health Commission have been made aware of the medium to long term plans to address these concerns. The Mental Health Commission are updated on a three monthly basis of any progress in this area. The next Premises Condition update is due in January 2020. The approved centre has ordered new furnishings which will enhance the environment & maximise space/minimise clutter in dormitory rooms. Expected date of delivery: Febuary 2020.

An annual privacy audit is undertaken to examine the layout & furnishings & if any updates can be made to the environment to enhance the privacy of residents. Furthermore, a daily environmental checklist is undertaken to examine the bed screens in dormitory rooms & follow-up on any damaged bed screens that may compromise resident privacy. The approved

The service is fully aware of shortcomings with regards to the conditions on the premises. Extensive refurbishments have been undertaken over the past 2 years which has involved a reduction in the capacity of beds, however, issues with the environment & it's impact on resident privacy persist. A number of meetings with the hospital planning department, HSE estates and senior management to discuss longer-term options have taken place over the past 2 years and progress documented in the aforementioned mandatory quarterly reports to the MHC. In the interim, the approved centre will make every effort to maintain & continously improve on resident privacy within the remit of it's current resources.

01/07/2020 Aiden Corvin (Clinical Director) Ollie Mernagh (Director of Nursing)


centre strives to escalate any issues involving bed screens to the relevant department so that they can be resolved in an efficient manner.

Preventative Action As the approved centre is currently subject to a condition on regulation 22 'Premises', the Mental Health Commission have been made aware of the medium to long term plans to address these concerns. The Mental Health Commission are updated on a three monthly basis of any progress in this area. The next Premises Condition update is due in January 2020. The approved centre has ordered new furnishings which will enhance the environment & maximise space/minimise clutter in dormitory rooms. Expected date of delivery: Febuary 2020.

An annual privacy audit is undertaken to examine the layout & furnishings & if any updates can be made to the environment to enhance the privacy of residents. Furthermore, a daily environmental checklist is undertaken to examine the bed screens in dormitory rooms & follow-up on any damaged

The service is fully aware of shortcomings with regards to the conditions on the premises. Extensive refurbishments have been undertaken over the past 2 years which has involved a reduction in the capacity of beds, however, issues with the environment & it's impact on resident privacy persist. A number of meetings with the hospital planning department, HSE estates and senior management to discuss longer-term options have taken place over the past 2 years and progress documented in the aforementioned mandatory quarterly reports to the MHC. In the interim, the approved

01/07/2020 Aiden Corvin (Clinical Director) Ollie Mernagh (Director of Nursing)


bed screens that may compromise resident privacy. The approved centre strives to escalate any issues involving bed screens to the relevant department so that they can be resolved in an efficient manner.

centre will make every effort to maintain & continously improve on resident privacy within the remit of it's current resources.

Reason ID : 10000597 Noticeboards on Beckett and Connolly Norman Ward contained resident names and were visible to the public from the corridors.

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action A new enhanced notice board

containing resident names was obtained for Conolly Norman Ward. This includes a privacy screen which maintains patient privacy. The notice board on Beckett ward was relocated to a different section of the office to maintain patient privacy.

Monthly privacy audit for Conolly Norman ward and annual privacy audit for all wards within the unit.

Achieved 09/09/2019 Mairead Kelly

Preventative Action Continue to undertake monthly audits of privacy in relation to the visibility of the noticeboard on Conolly Norman Unit. Continue to undertake annual audits of privacy

Continue to undertake monthly audits of privacy in relation to the visibility of the

This is achievable if above audits are completed & acted upon in a timely manner.

03/02/2020 Mairead Kelly


in relation to the visibility of the noticeboard on Beckett Ward.

noticeboard on Conolly Norman Unit. Continue to undertake annual audits of privacy in relation to the visibility of the noticeboard on Beckett Ward.

Reason ID : 10000598 Two curtains around the beds in Fownes Ward were missing hooks at the end; thus potentially compromising resident privacy. There was a blind missing from the sitting room window in Connolly Norman Ward

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action The blind in the sitting room in

Conolly Norman Ward has since been replaced. The two bed curtains in Fownes Ward

Each ward completes a daily environmental checklist which includes an assessment of all curtain rails and blinds.

Achieved 02/09/2019 Breda O'Connor CNM 2 Daren Hurry CNM 2

Preventative Action In the event of any blinds or curtain rails becoming damaged or removed, the CNM in charge of the ward will commence the process to repair or replace the blind/curtain. In order to maintain patient privacy, alternative bed arrangements will be sought within the remit of the ward. Daily environmental checklist will

Daily environmental checklist Annual privacy audit

Achievable if daily environmental checklist completed & acted upon in a prompt manner.

04/12/2019 Breda O'Connor CNM 2 Daren Hurry CNM 2


be undertaken with an emphasis on whether bed curtains & blinds are present & functioning. Annual privacy audit undertaken on all three wards within the unit. This includes a check if all bed screens & curtains/blinds are present & functioning.


Regulation 05 Food and Nutrition

Reason ID : 10000600 Residents with special dietary requirements were not reviewed by a dietitian and their special dietary requirements were not documented in their individual care plan or clinical notes, 5(2).

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action At the time of the inspection,

there was no dedicated dietician employed by the service, however, a dietician commenced in the approved centre on 14/10/19. They currently provide dietician cover for one day per week. Any resident who has been identified as having a special dietary requirement has been referred to the dietician for review. A new Individual Care Plan (ICP) document has been developed. As part of the roll out for this document, education has been planned for the multi disciplinary teams, this will include the recording of specific care needs and goals/interventions in the ICP.

On a monthly basis, the dietician & the CNM3 will review the dietician referrals received & undertake a check of residents ICP's & clinical notes to ensure that the dietary requirements are clearly outlined & that an action plan is devised to address the residents needs.

Achievable 24/11/2019 Brendan Harold (Dietitics Manager) Mairead Kelly (ADON) & Gary Timmons (CNM 3)

Preventative Action Ongoing dietician input to continue to residents receiving care in the approved centre. As part of the ICP implementation plan staff will be educated on the correct use of the ICP and the

On a monthly basis, the dietician & the CNM3 will review the dietician

Achievable. 01/03/2020 Brendan Harold (Dietitics Manager) Mairead Kelly ADoN, Gary Timmons CNM 3


importance of documenting any special dietary requiremants in the ICP. Dietician manager will undertake staff training commencing in Quater 1 2020.

referrals received & undertake a check of residents ICP's & clinical notes to ensure that the dietary requirements are clearly outlined & that an action plan is devised to address the residents needs.


Code of Practice on Admission, Transfer and Discharge to and from an approved centre

Reason ID : 10000580 There was no documentary evidence that relevant staff had read and understood the admission policy, transfer policy or discharge policy, 9(1).

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action The issue was discussed with

each head of discipline (HOD)/relevant stakeholders at the most recent Operation & Communication (O&C), Quality & Patient Safety (QPS) and compliance meetings. It was agreed that each HOD will take responsibility to ensure that staff within their discipline are up-to-date with the relevant policies/procedures/guidelines (PPG's). The QPS agenda schedule has been updated to include 'New/Updated PPG's' as a standing item. PPG's will be kept as a standing item at each department meeting. Approved Centre ADON forwards any policies that have been ratified to all staff members to follow-up.

The ADON & CNM3 undertake a bi-annual audit of the policies to monitor that (1) all policies are up-to-date, (2) that all updated policies are present in each folder & (3) that signature sheets are available with each policy. This audit will be updated to include a check that all relevant staff have signed the sheet to indicate that they have read & understood each policy. Results will then be fed-back to each HOD who will action same.

Achievable if PPG's are kept as a standing item at each HOD & department meeting and if the audit is undertaken and results fedback to all relevant stakeholders.

03/12/2019 Each HOD

Preventative Action The issue was discussed with each head of discipline (HOD)/relevant stakeholders at the most recent Operation & Communication (O&C), Quality & Patient Safety (QPS)

The ADON & CNM3 undertake a bi-annual audit of the policies to monitor that (1) all policies are up-to-date, (2)

Achievable if PPG's are kept as a standing item at each HOD & department meeting and if the audit is undertaken and results

03/12/2019 Each HOD


and compliance meetings. It was agreed that each HOD will take responsibility to ensure that staff within their discipline are up-to-date with the relevant policies/procedures/guidelines (PPG's). There is a 'Policy of the day' system in place for all disciplines, whereby all staff read and sign an allocated policy per day. Once policies are ratified they are disseminated to all staff who are requested to read and sign these policies. The QPS agenda schedule has been updated to include 'New/Updated PPG's' as a standing item. PPG's will be kept as a standing item at each department meeting.

that all updated policies are present in each folder & (3) that signature sheets are available with each policy. This audit will be updated to include a check that all relevant staff have signed the sheet to indicate that they have read & understood each policy. Results will then be fed-back to each HOD who will action same. This audit is next due to be undertaken in January 2020.

fedback to all relevant stakeholders.

Reason ID : 10000581 A discharge meeting attended by the resident, key worker, relevant members of the MDT and family, carer or chosen advocate, where appropriate, was not held, 34(4).

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action A Care Plan training day

(which included discharge planning) was held for all key stakeholders on September 10th. This was facilitated by an external expert in this field. Taking guidance from the expert training facilitator and the feedback from the MHC inspection team a new

As part of the weekly ICP audit, auditors will examine if discharge planning is being considered throughout the residents admission. Findings will be fedback to all

This is achievable once the planned education sessions are delivered to key stakeholders & audits are undertaken & acted upon.

31/03/2020 Care Plan Committee All relevant MDT members.


Individual Care Plan (ICP) document was developed with an enhanced focus on continous and final discharge planning. As part of the implementation plan, for this document ICP 'champions' have been identified & will be involved in educating teams on the process. This includes (1) the importance of considering & recording discharge planning from the point of admission & throughout & (2) in the event that a discharge planning meeting cannot be facilitated, the reasons for this are clearly outlined in the residents ICP.

relevant MDT members on a weekly basis.

Preventative Action Taking guidance from the expert training facilitator and the feedback from the MHC inspection team a new Individual Care Plan (ICP) document was developed with an enhanced focus on continous and final discharge planning. As part of the implementation plan, for this document ICP 'champions' have been identified & will be involved in educating teams on the process. This includes (1) the importance of considering & recording

As part of the weekly ICP audit, auditors will examine if discharge planning is being considered throughout the residents admission. Findings will be fedback to all relevant MDT members on a weekly basis.

This is achievable once the planned education sessions are delivered to key stakeholders & audits are undertaken & acted upon.

31/03/2020 Care Plan Committee All relevant MDT members.


discharge planning from the point of admission & throughout & (2) in the event that a discharge planning meeting cannot be facilitated, the reasons for this are clearly outlined in the residents ICP.

Appendix 2: Background to the inspection process

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.


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

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

amend the report as appropriate.

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

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

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

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

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

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

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

compliance is unacceptable, enforcement action may be taken.

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

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

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

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

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

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

COMPLIANCE RATING

COMPLIANT

EXCELLENT

LOW

QUALITY RATING

RISK RATING

NON-COMPLIANT

SATISFACTORY

MODERATE REQUIRES IMPROVEMENT

INADEQUATE HIGH

CRITICAL

jonathan swift clinic - mentalhealthcommission · 2020-01-03 · the jonathan swift linic was...

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