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St. Finbarr’s Hospital approved centre inspection report, 22September 2010

Item type Report

Authors Mental Health Commission (MHC)

Citation Mental Health Commission.

Publisher Mental Health Commission (MHC)

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Link to item http://hdl.handle.net/10147/323210

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http://hdl.handle.net/10147/323210

Inspectorate of Mental Health Services

Report of the Inspector of Mental Health Services 2010

EXECUTIVE CATCHMENT AREA South Lee, West Cork, Kerry

HSE AREA HSE South

CATCHMENT AREA South Lee

MENTAL HEALTH SERVICE South Lee

APPROVED CENTRE St. Finbarr’s Hospital

NUMBER OF WARDS

2

NAMES OF UNITS OR WARDS INSPECTED

St. Catherine’s Ward

St. Monica’s Ward

TOTAL NUMBER OF BEDS 34

CONDITIONS ATTACHED TO REGISTRATION

No

TYPE OF INSPECTION

Announced

DATE OF INSPECTION 22 September 2010

Page 1 of 46


PART ONE: QUALITY OF CARE AND TREATMENT SECTION 51 (1) (b) (i) MENTAL HEALTH ACT 2001

INTRODUCTION

In 2010, the Inspectorate paid particular attention to Articles 15 to 22 and 26 of the Mental Health Act 2001 (Approved Centres) Regulations 2006 and all areas of non-compliance with the Regulations in 2009 and any other Article where applicable. The Inspectorate was keen to highlight improvements and initiatives carried out in the past year and track progress on the implementation of recommendations made in 2009. Information was gathered from self-assessments, service user interviews, staff interviews and photographic evidence collected on the day of the inspection.

DESCRIPTION

The approved centre at St. Finbarr’s Hospital comprised St. Monica’s ward which provided a continuing care unit for long-stay residents and St. Catherine’s ward, a rehabilitation ward. Many of the residents had been long-stay residents of Our Lady’s Hospital prior to their transfer to St. Finbarr’s Hospital. The most recent admission to St. Monica’s ward (apart from a re-admission of one resident from the South Lee Acute Mental Health Unit), was in 2007. The wards were housed in two separate old buildings on the hospital campus. Both wards were under the care of a general adult sector team. Residents from both wards were able to access community resources as needs allowed. St. Catherine’s ward provided day activities which were also attended by a small number of residents from St. Monica’s ward.

DETAILS OF WARDS IN THE APPROVED CENTRE

WARD NUMBER OF BEDS NUMBER OF RESIDENTS TEAM RESPONSIBLE


21 19 General Adult

St. Monica’s Ward 13 13 General Adult

QUALITY INITIATIVES

• A wheelchair accessible toilet and shower had been installed recently in St.Catherine’s ward.

• Staff had commenced a gardening programme with residents to produce vegetables for their own use in the St. Catherine’s ward garden.

• A Bar-B-Q was held in the garden of St. Catherine’s ward for all residents, family and friends during the summer.

• New individual care plans were introduced in 2009.

• In St. Monica’s ward, self-medication programmes had been introduced for a small number of residents.

• Re-wiring of the approved centre had commenced in St. Monica’s ward.

Page 2 of 46


PROGRESS ON RECOMMENDATIONS IN THE 2009 APPROVED CENTRE REPORT

1. A rehabilitation team should be appointed.

Outcome: There was no progress made in appointing a rehabilitation team.

2. Policies should be reviewed in accordance with the review dates on them.

Outcome: Policies had been reviewed and were up-to-date.

3. The individual care plans must specify the goals for the resident and therapeutic activities must be linked clearly to the care plans.

Outcome: There were individual care plan templates in individual clinical files. The individual care plans were not always completed and individual goals and the required interventions were not clearly identified.

4. Clinical files must be kept in line with the Health Service Executive policy on records and should be structured in such a way as to facilitate the easy retrieval of information.

Outcome: Clinical files were in order and information was accessible.

5. The policy on searches should reflect local practice, which was that searches were not conducted.

Outcome: The approved centre had a policy on searches. Staff informed the Inspectorate that searches were occasionally carried out.

6. Routine physical reviews must be carried out at least every six months. The schedule in place for physical and psychiatric reviews should be adhered to.

Outcome: General physical reviews and psychiatric reviews had been completed.

Page 3 of 46


PART TWO: EVIDENCE OF COMPLIANCE WITH REGULATIONS, RULES AND CODES OF PRACTICE, AND SECTION 60, MHA 2001

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

Article 4: Identification of Residents

LEVEL OF COMPLIANCE DESCRIPTION 2009 2010

Fully compliant Evidence of full compliance with this Regulation.

X X

Substantial compliance

Evidence of substantial compliance but improvement needed.

Compliance initiated

An attempt has been made to achieve compliance but significant progress is still needed.

Not compliant Service is unable to demonstrate structures or processes to be compliant with this Regulation.

Page 4 of 46


Article 5: Food and Nutrition



X X






Page 5 of 46


Article 6 (1-2): Food Safety



X X






Page 6 of 46


Article 7: Clothing

DESCRIPTION 2009 2010


X X






Page 7 of 46


Article 8: Residents’ Personal Property and Possessions



X X






Page 8 of 46


Article 9: Recreational Activities



X X






Page 9 of 46


Article 10: Religion



X X






Page 10 of 46


Article 11 (1-6): Visits



X X






Page 11 of 46


Article 12 (1-4): Communication



X X






Page 12 of 46


Article 13: Searches



X X






Page 13 of 46


Article 14 (1-5): Care of the Dying



X X






Page 14 of 46


Article 15: Individual Care Plan





X X




Justification for this rating:

There were separate medical and nursing clinical files and these were kept in separate offices. Staff informed the Inspectorate that there were plans to introduce integrated clinical files. There was a multidisciplinary care plan in individual clinical files. The individual care plans were not consistently completed. There were monthly care planning meetings and each resident’s individual care plan was reviewed every six months. Some residents had signed care plans.

Breach: 15

Page 15 of 46


Article 16: Therapeutic Services and Programmes





X X





Many of the residents in both wards attended outside activities in various day centres and community resource centres. A small number of residents participated in mainstream extra-mural courses. The remaining residents had activities in the ward organised by the nursing staff. There was an activities therapy nurse on St. Catherine’s ward and there appeared to be good uptake and participation in the programme by residents. Activities provided included relaxation, art class, word games, cooking and gardening. An art teacher ran a weekly class. At least one resident in St. Monica’s ward went out to work daily, and another resident spent six days per week at home. Four residents in St. Catherine’s ward were on leave. There was little recorded information on the focus and progress of those individuals who were participating in community based programmes.

There was no occupational therapy in the approved centre. Occupational therapy functional assessment might have supported residents in pursuing a rehabilitation and recovery pathway. Social work and clinical psychology input was available on request.

Overall, there was insufficient evidence recorded to show that the therapeutic services and programmes provided and the daily activities engaged in by residents were based on individually assessed need and a planned care pathway.

Breach: 16 (1) (2)

Page 16 of 46


Article 17: Children’s Education



X NOT APPLICABLE







No children were admitted to the hospital. The approved centre had a policy to this effect.

Page 17 of 46


Article 18: Transfer of Residents



X X







There was a written policy on the transfer of residents to other hospitals.

Page 18 of 46


Article 19 (1-2): General Health



X





X



Six monthly general physical health examinations were up-to-date and were carried out by a general practitioner. These were recorded in the clinical files. In some clinical files inspected the role and signature of the general practitioner was not clearly recorded.

Page 19 of 46


Article 20 (1-2): Provision of Information to Residents



X X







There was written information available to residents detailing housekeeping arrangements, multidisciplinary team, diagnosis and medications.

Page 20 of 46


Article 21: Privacy



X X







All beds had surround curtains and there were window curtains in all rooms. Bathrooms and lavatories were lockable.

Page 21 of 46


Article 22: Premises





X



X



Both wards were in old buildings on the St. Finbarr’s Hospital campus.

St. Catherine’s ward was bright and clean. Décor and painting were good, with minor repainting work to be done. There were plans to refurbish a suite of lavatories and showers. The décor reflected the residents’ interests and activities, with paintings, crafts, plants and photographs throughout. Two fireside sitting rooms had been refurbished and contributed to the homely atmosphere in the ward. Staff endeavoured to provide an attractive and welcoming unit and maintained the garden also.

St. Monica’s ward was in poor decorative order, cluttered and in need of cleaning. Staff stored toilet rolls and incontinence pads in a heap in a residents’ sitting room. This sitting room had two couches which were worn, stained and dirty. There was a wall mirror on the floor and a television set. Staff also stored supplies, such as latex gloves and tissue paper, in the residents’ main sitting room. This sitting room contained a brown leather three piece suite. There was insufficient comfortable seating for the number of residents.

Staff reported that insufficient storage space was an issue in St. Monica’s ward. A number of items were impeding access at the top of the stairs, including, a vacuum cleaner, a polishing machine, an emergency stretcher, a suction machine and a loose cylinder of oxygen. There was a linen cupboard and the shelves were almost empty and bags were stored on the floor.

Despite the age profile of residents, there was no lift in St. Monica’s ward.

The small garden area adjoining St. Monica’s was in need of maintenance and garden furniture was neglected.

Breach: 22 (1) (a), (b); 22 (2), 22 (3)

Page 22 of 46


Article 23 (1-2): Ordering, Prescribing, Storing and Administration of Medicines



X X






Page 23 of 46


Article 24 (1-2): Health and Safety



X X






Page 24 of 46


Article 25: Use of Closed Circuit Television (CCTV)

CCTV was not used in the approved centre.

Page 25 of 46


Article 26: Staffing

WARD OR UNIT STAFF TYPE DAY NIGHT


CNM 2

Staff nurse

Activities Therapy Nurse

1

2-3

1

0

2

0

St. Monica’s Ward CNM 2

Staff nurse

1

1

0

2

St. Monica’s and St. Catherine’s Wards

Consultant Psychiatrist

Non consultant hospital doctor (NCHD)

Clinical psychologist

Social Worker

Occupational Therapist

Sessional

Sessional

On request

On request

0

0

0

0

0

0







X X


Page 26 of 46



Staff reported that there had been a reduction of 18% in nursing staff over the previous calendar year. This was largely due to retirements and the Health Service Executive moratorium on recruitment meant that these posts had not been filled. The units were not self-staffing. Staff reported that in the twelve months from September 2009 to September 2010, nursing staff had been re-deployed from St. Catherine’s ward on 60 occasions because of staff shortages in other centres. Staff told the Inspectorate that this had left one nurse on duty in St. Catherine’s 21-bedded ward, augmented by the activities therapy nurse. One non consultant hospital doctor post which was a 0.5 whole-time-equivalent had been vacant since July 2010.

The sector team did not have a full complement of multidisciplinary staff. There was no occupational therapist.

Breach: 26

Page 27 of 46


Article 27: Maintenance of Records



X



X





There were separate nursing and medical clinical files. Records were in order.

Page 28 of 46


Article 28: Register of Residents



X X






Page 29 of 46


Article 29: Operating policies and procedures



X X






Page 30 of 46


Article 30: Mental Health Tribunals



X X






Page 31 of 46


Article 31: Complaint Procedures



X X






Page 32 of 46


Article 32: Risk Management Procedures



X X






Page 33 of 46


Article 33: Insurance



X X






Page 34 of 46


Article 34: Certificate of Registration



X X






Page 35 of 46


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

SECLUSION

Use: Seclusion was not used in the approved centre.

ECT (DETAINED PATIENTS)

Use: The approved centre did not administer ECT. On the day of Inspection there were no residents in receipt of ECT in another hospital.

MECHANICAL RESTRAINT

Use: The approved centre did not use mechanical restraint. There was a policy to this effect.

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

PHYSICAL RESTRAINT

Use: Physical restraint was not used in the approved centre.

ADMISSION OF CHILDREN

Description: Children were not admitted to the approved centre.

Page 36 of 46


NOTIFICATION OF DEATHS AND INCIDENT REPORTING

Descripton: There had been no deaths in the approved centre in 2010 up to the time of inspecrion.

SECTION DESCRIPTION FULLY

COMPLIANT

SUBSTANTIALLY

COMPLIANT

COMPLIANCE

INITIATED

NOT

COMPLIANT

2 Notification of deaths X

3 Incident reporting X

4 Clinical governance X


There was a policy on risk management. Incidents and deaths were reported to the Mental Health Commission.

Page 37 of 46


ECT FOR VOLUNTARY PATIENTS

Use: ECT was not administered in the approved centre. There were no residents in receipt of ECT in another hospital on the day of Inspection.

Page 38 of 46


ADMISSION, TRANSFER AND DISCHARGE

Description: The approved centre primarily provided continuing care and admissions, discharges and transfers were few in number.

Part 2 Enabling Good Practice through Effective Governance

The following aspects were considered: 4. policies and protocols, 5.privacy confidentiality and consent, 6. staff roles and responsibility, 7.risk management, 8. information transfer, 9. staff information and training.

Level of compliance:

FULLY COMPLIANT SUBSTANTIALLY COMPLIANT COMPLIANCE INITIATED NOT COMPLIANT

X


The approved centre had policies in place and these were implemented by staff.

Page 39 of 46


Part 3 Admission Process

The following aspects were considered: 10. pre-admission process, 11. unplanned referral to an Approved Centre, 12. admission criteria, 13. decision to admit, 14. decision not to admit, 15. assessment following admission, 16. rights and information,17. individual care and treatment plan, 18. resident and family/carer/advocate involvement, 19. multidisciplinary team involvement, 20. key-worker, 21. collaboration with primary health care community mental health services, relevant outside agencies and information transfer, 22. record-keeping and documentation, 23. day of admission, 24. specific groups.



X


Admissions to the approved centre were planned and there were policies in place. St. Monica’s ward staff reported that the last new admission to the ward was in 2007. The approved centre was not fully compliant with the Regulation on Individual Care Plans.

Breach: 17

Page 40 of 46


Part 4 Transfer Process

The following aspects were considered: 25. Transfer criteria, 26. decision to transfer, 27. assessment before transfer, 28. resident involvement, 29. multi-disciplinary team involvement, 30. communication between Approved Centre and receiving facility and information transfer, 31. record-keeping and documentation, 32. day of transfer.



X


One voluntary resident had been transferred to an approved centre. There was a policy and clear procedures were in place. Written information was provided when a resident was transferred to another approved centre.

Page 41 of 46


Part 5 Discharge Process

The following aspects were considered: 33. Decision to discharge, 34. discharge planning, 35. pre-discharge assessment, 36. multi-disciplinary team involvement, 37. key-worker, 38. collaboration with primary health care, community mental health services, relevant outside agencies and information transfer, 39. resident and family/carer/advocate involvement and information provision, 40. notice of discharge, 41. follow-up and aftercare, 42. record-keeping and documentation, 43. day of discharge, 44. specific groups.



X


Two residents had been discharged from St. Catherine’s ward in 2010, one to independent living, and one to home. In both cases, staff had worked with the residents to ensure a smooth transition from the approved centre. Staff reported that the most recent discharge from St. Monica’s ward had occurred in 2008, but it was planned that three residents would be discharged from there to a supervised community residence when places became available. This was being planned in conjunction with the residents.

Page 42 of 46


HOW MENTAL HEALTH SERVICES SHOULD WORK WITH PEOPLE WITH AN INTELLECTUAL DISABILITY AND MENTAL ILLNESS

Description: On the day of Inspection there was no resident with an intellectual disability and mental illness.

The following aspects were considered: 5. policies, 6. education and training, 7. inter-agency collaboration, 8. individual care and treatment plan, 9.communication issues, 10. environmental considerations, 11. considering the use of restrictive practices, 12. main recommendations, 13. assessing capacity



X


The approved centre did not have a policy on admission of people with intellectual disability and mental illness. Staff reported that they did not have training in working with individuals with an intellectual disability and mental illness.

Breach: 5, 6

Page 43 of 46


2.5 EVIDENCE OF COMPLIANCE WITH SECTIONS 60/61 MENTAL HEALTH ACT (MEDICATION)

SECTION 60 – ADMINISTRATION OF MEDICINE

Description: There was no one detained in the approved centre on the day of Inspection. Section 60 did not apply.

SECTION 61 – TREATMENT OF CHILDREN WITH SECTION 25 ORDER IN FORCE

Description: Children were not admitted to the approved centre.

Page 44 of 46


SECTION THREE: OTHER ASPECTS OF THE APPROVED CENTRE

SERVICE USER INTERVIEWS

The Inspectorate greeted residents in St. Catherine’s and St. Monica’s wards. One resident wished to meet with the Inspectorate and expressed satisfaction with the care provided and commented very positively on the relationship with nursing staff.

MEDICATION

The medication sheets were in booklet format. A photograph was included as well as printed name, date of birth, responsible consultant, ward and patient identification numbers and as such was excellent. PRN (as required) medication was separate from regular medication and there was space to document indications for PRN medication. Most signatures were legible as were the prescriptions.

All residents in the two units were prescribed regular antipsychotic medication. Forty five per cent of residents were on more than one antipsychotic medication and 23% were on high dose antipsychotic medication.

MEDICATION LONG STAY

NUMBER OF PRESCRIPTIONS: 31

Number on benzodiazepines 16 (52%)

Number on more than one benzodiazepine 5 (16%)

Number on regular benzodiazepines 13 (42%)

Number on PRN benzodiazepines 9 (29%)

Number on hypnotics 13 (42%)

Number on Non benzodiazepine hypnotics 7 (23%)

Number on antipsychotic medication 31 (100%)

Number on high dose antipsychotic medication 7 (23%)

Number on more than one antipsychotic medication 14 (45%)

Number on PRN antipsychotic medication 13 (42%)

Page 45 of 46


Page 46 of 46

Number on antidepressant medication 16 (52%)

Number on more than one antidepressant 4 (13%)

Number on antiepileptic medication 12 (39%)

Number on Lithium 4 (13%)

OVERALL CONCLUSIONS

St. Finbarr’s Hospital provided continuing care for 32 residents with an age profile ranging from 40 to 90 years of age. The last new admission to the St. Monica’s ward had been in 2007 and many residents originally came from the old Our Lady’s Hospital. Most individuals had been resident in St. Finbarr’s Hospital for a significant length of time, for example, one individual was resident for ten years. The accommodation provided was not suited to long-term living as individuals were generally housed in dormitories. Staff on St. Catherine’s ward had made particular efforts to create a warm, attractive and homely environment and this was also reflected in their interaction with residents. Nonetheless, the institutional accommodation and the fabric of old buildings were not appropriate and the approved centre should be closed.

The dearth of community based rehabilitation resources, including the lack of a rehabilitation team and sufficient community residences, was evident in the poorly developed recovery pathways. Several residents were on leave and it was unclear to the Inspectorate why some of them continued to be resident in an approved centre. Several residents attended community based activities. There appeared to be limited individualised progressive rehabilitation.

RECOMMENDATIONS 2010

1. A fully staffed rehabilitation team should be appointed.

2. Community based residences should be developed to provide a rehabilitation and recovery pathway to community living.

3. St. Monica’s ward should be closed.

4. Plans for the closure of St. Catherine’s ward should be initiated in accordance with A Vision for Change policy.

5. Therapeutic services and programmes should be robustly linked to individual care plans.

6. All residents should be provided with the opportunity to sign their individual care plan and where they so decline, this should be recorded.

7. There should be integrated clinical case files.

8. A review of medication should take place with a view to reducing polypharmacy.

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