St. Patrick s University Hospital

Transcription

1 St. Patrick s University Hospital ID Number: AC Approved Centre Inspection Report (Mental Health Act 2001) St. Patrick s University Hospital James s St Dublin 8. Approved Centre Type: Acute Adult Mental Health Care Psychiatry of Later Life Mental Health Rehabilitation Most Recent Registration Date: 1 March 2017 Conditions Attached: None Registered Proprietor: Mr Paul Gilligan, CEO Registered Proprietor Nominee: N/A Inspection Team: Dr Enda Dooley MCRN004155, Lead Inspector Orla O Neill Barbara Morrissey Sandra McGrath Noeleen Byrne Siobhán Dinan The Inspector of Mental Health Services: Dr Susan Finnerty MCRN Inspection Date: 9 12 May 2017 Inspection Type: Unannounced Annual Inspection Previous Inspection Date: 8 11 November 2016 Date of Publication: 24 August 2017 COMPLIANCE RATINGS 2017 REGULATIONS 2 RULES AND PART 4 OF THE MENTAL HEALTH ACT CODES OF PRACTICE Compliant Non-compliant Not applicable

2 RATINGS SUMMARY Compliance ratings across all 41 areas of inspection are summarised in the chart below. Chart 1 Comparison of overall compliance ratings Not applicable Non-compliant Compliant 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 Low Moderate High Critical The approved centre had no areas of non-compliance in 2015 and 2017 and, therefore, no associated risk ratings for those years. AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 2 of 77

3 Contents 1.0 Introduction to the Inspection Process Inspector of Mental Health Services Summary of Findings Quality Initiatives Overview of the Approved Centre Description of approved centre Conditions to registration Reporting on the National Clinical Guidelines Governance Compliance Non-compliant areas from 2016 inspection Non-compliant areas on this inspection Areas of compliance rated Excellent on this inspection Service-user Experience Interviews with Heads of Discipline Feedback Meeting Inspection Findings Regulations Inspection Findings Rules Inspection Findings Mental Health Act Inspection Findings Codes of Practice AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 3 of 77

4 AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 4 of 77

5 1.0 Introduction 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 noncompliance 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. AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 5 of 77

6 COMPLIANCE, QUALITY AND RISK RATINGS The following ratings are assigned to areas inspected. COMPLIANCE RATINGS are given for all areas inspected. QUALITY RATINGS are given for all regulations, except for 28, 33 and 34. RISK RATINGS are given for any area that is deemed non-compliant. COMPLIANCE QUALITY RISK COMPLIANT EXCELLENT SATISFACTORY LOW NON- COMPLIANT REQUIRES IMPROVEMENT INADEQUATE MODERATE HIGH 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, realistic, achievable and time-bound (SMART). The approved centre s CAPAs are included in the published inspection report, as submitted. The Commission monitors the implementation of the CAPAs on an ongoing basis and requests further information and action as necessary. If at any point the Commission determines that the approved centre s plan to address an area of noncompliance 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. AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 6 of 77

7 2.0 Inspector of Mental Health Services Summary of Findings Inspector of Mental Health Services Dr Susan Finnerty As Inspector of Mental Health Services, I have provided a summary of inspection findings under the headings below. This summary is based on the findings of the inspection team under the regulations and associated Judgement Support Framework, rules, Part 4 of the Mental Health Act 2001, codes of practice, service user experience, staff interviews and governance structures and operations, all of which are contained in this report. Safety in the approved centre The approved centre had a written policy in relation to health and safety and also had a Corporate Safety Statement. There were risk management policies and procedures in place. There was excellent food safety and the approved centre had been awarded a Food Safety Assurance award in relation to its food safety and hygiene procedures. Two appropriate resident identifiers were used before the administration of medication, the initiation of medical investigations, and the provision of other health care services. Medication ordering, prescribing, storage, and administration was satisfactory. The administration of ECT was compliant with the relevant Rule and Code of Practice. Physical restraint was carried out in accordance with the relevant Code of Practice. AREAS REFERRED TO Regulations 4, 6, 22, 23, 24, 26, 32, Rule Governing the Use of Seclusion, Code of Practice on the Use of Physical Restraint, the Rule and Code of Practice on the Use of ECT, service user experience, and interviews with staff. Appropriate care and treatment of residents Residents expressed satisfaction with their treatment and accommodation within the approved centre and with the range of therapeutic options available. Some residents expressed the view that they did not have sufficient contact with their designated key worker. Where residents were identified as having special nutritional requirements, their needs were reviewed by the dietician. Residents had a multidisciplinary individual care plan. The range of available, evidence-based therapeutic programmes was appropriate to the assessed needs of the resident population, as outlined in individual care plans. A psychological group programme (SAGE) for older adults experiencing mental health problems had been developed and introduced. An excellent transfer process was in place for residents transferring to another facility. A primary care general practitioner service was available on-site, and a medical consultant visited weekly. Residents received appropriate general health care in line with their individual care plans, and their general health needs were monitored and assessed not less than every six months. Residents records were observed to be securely stored, up to date, and in good order. The administration of ECT was compliant with the relevant Rule and Code of Practice. The approved centre was compliant with Part 4 of The Mental Health Act (2001): Consent to Treatment. Admission and discharge of residents was in line with the relevant Code of Practice. AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 7 of 77

8 AREAS REFERRED TO Regulations 5, 14, 15, 16, 17, 18, 19, 23, 25, 27, Part 4 of the Mental Health Act 2001, Rule Governing the Use of Seclusion and Mechanical Means of Bodily Restraint, Rule Governing the Use of ECT, Code of Practice on Physical Restraint, Code of Practice on the Admission of Children, Code of Practice on the Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities, Code of Practice on Admission, Transfer and Discharge, service user experience, and interviews with staff. Respect for residents privacy and dignity Residents were supported to keep and wear their personal clothing, and each resident had an individual wardrobe and locker. Residents clothing was observed to be clean and appropriate to their needs. Provision was made for residents to secure personal property and possessions. Where the approved centre assumed responsibility for residents property, personal effects were stored securely. Searches, which were documented in the clinical files, were attended by at least two clinical staff and were implemented with due regard to the residents dignity, privacy, and gender. The approved centre s layout and furnishings were conducive to resident privacy and dignity and staff were observed to treat residents with respect. AREAS REFERRED TO Regulations 7, 8, 13, 14, 21, 25, Rule Governing the Use of Seclusion, Code of Practice on Physical Restraint, Code of Practice on the Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities, service user experience, and interviews with staff. Responsiveness to residents needs Residents were provided with a range of wholesome and nutritious food choices. Food, including modified diets, was properly prepared and presented in an attractive and appealing manner. Residents had access to an extensive range of appropriate recreational activities and had access to a multi-faith oratory and to multifaith chaplains. Residents said that staff were supportive and engaged with them. Visiting times were appropriate and reasonable and there were a number of rooms throughout the approved centre that were suitable for visits, including a family room, which had facilities suitable for visiting children. Residents had access to mail, fax, telephone, and . While residents in the special care units did not have access to their own phones, they were facilitated in using a cordless phone. Information was provided to residents and/or their representatives at admission in the form of a service user information booklet. The hospital information centre, which was accessible to all residents, contained comprehensive medical information, including details of medication risks and potential side-effects of medication. The approved centre was in a good state of repair, inside and out, and was clean and hygienic. There was a nominated complaints officer in the approved centre, and all complaints were dealt with in a consistent and standardised manner. Complaints procedures were clearly displayed. AREAS REFERRED TO Regulations 5, 9, 10, 11, 12, 20, 22, 30, 31, Code of Practice on the Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities, service user experience, and interviews with staff. AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 8 of 77

9 Governance of the approved centre St. Patrick s Hospital was part of St. Patricks Mental Health Services and came under the overall management of a board of governors established by charter. The direct operation of the hospital came within the competence of a senior management team. A detailed clinical and corporate governance structure was in place. There was an active process involving senior management and, as appropriate, members of various disciplines within the approved centre. The governance process addressed both clinical and operational issues relating to the effective functioning of the centre. Operating policies and procedures were developed with input from clinical and managerial staff and in consultation with relevant stakeholders. All operating policies and procedures required by the regulations were reviewed within the required three-year time frame. Risks were addressed or escalated as required. There was an organisational chart to identify the leadership and management structure and lines of authority and accountability within the approved centre. An appropriately qualified staff member was on duty and in charge at all times in the approved centre, as indicated by staff rotas. AREAS REFERRED TO Regulations 26 and 32, interviews with heads of discipline, and minutes of area management team meetings. AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 9 of 77

10 3.0 Quality Initiatives The following quality initiatives were identified on this inspection: 1. A new clozapine booklet had been introduced to inform residents of the nature of the medication and the oversight processes required. 2. A psychological group programme (SAGE) for older adults experiencing mental health problems had been developed and introduced. 3. The approved centre had been awarded a Food Safety Assurance award in relation to its food safety and hygiene procedures. AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 10 of 77

11 4.0 Overview of the Approved Centre 4.1 Description of approved centre The approved centre was an independent hospital and part of the St. Patrick s Mental Health Service. It was located in central Dublin. The original hospital structure was an 18 th century listed building. A variety of extensions had been developed over the years. The centre was registered for up to 241 residents. It was well maintained and decorated. Residents had access to a variety of recreational and garden facilities within the hospital grounds. The approved centre comprised eight wards: Dean Swift, including Special Care Unit (acute admissions); Stella, Grattan, Delaney, and Kilroot (general admissions); Vanessa (care of the elderly); Clara (eating disorders); and Temple (addictions service). A wide range of therapeutic services was offered and residents had access to newly developed primary care services within the approved centre. Children were not admitted. The resident profile on the first day of inspection was as follows: Resident Profile Number of registered beds 241 Total number of residents 218 Number of detained patients 4 Number of Wards of Court 0 Number of children 0 Number of residents in the approved centre for more than 6 months Conditions to registration There were no conditions attached to the registration of this approved centre at the time of inspection. 4.3 Reporting on the National Clinical Guidelines The service reported that it was cognisant of and implemented, where indicated, the National Clinical Guidelines as published by the Department of Health. 4.4 Governance St. Patrick s Hospital was part of St. Patricks Mental Health Services and came under the overall management of a board of governors established by charter. The direct operation of the hospital came within the competence of a senior management team. A detailed clinical and corporate governance structure was in place. Minutes of all governance committee meetings, which included Clinical Council meetings, senior staff meetings, Clinical Governance Committee meetings, and Risk & Safety Committee meetings, were provided to the inspectors. There was an active process involving senior management and, as appropriate, members AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 11 of 77

12 of various disciplines within the approved centre. The governance process addressed both clinical and operational issues relating to the effective functioning of the centre. Risks were addressed or escalated as required. AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 12 of 77

13 5.0 Compliance 5.1 Non-compliant areas from 2016 inspection The previous inspection of the approved centre on 8 11 November 2016 identified the following areas that were not compliant. The approved centre was requested to provide Corrective and Preventative Actions (CAPAs) for areas of non-compliance and these were published with the 2016 inspection report. Regulation/Rule/Act/Code 2017 Inspection Findings Regulation 13: Searches Compliant Regulation 15: Individual Care Plan Compliant Regulation 23: Ordering, Prescribing, Storing and Administration of Compliant Medicines Code of Practice on Admission, Transfer and Discharge to and from an Compliant Approved Centre 5.2 Non-compliant areas on this inspection No areas of non-compliance were identified on this inspection. AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 13 of 77

14 5.3 Areas of compliance rated Excellent on this inspection The following areas were rated excellent on this inspection: Regulation Regulation 4: Identification of Residents Regulation 5: Food and Nutrition Regulation 6: Food Safety Regulation 7: Clothing Regulation 8: Residents Personal Property and Possessions Regulation 9: Recreational Activities Regulation 10: Religion Regulation 11: Visits Regulation 12: Communication Regulation 14: Care of the Dying Regulation 16: Therapeutic Services and Programmes Regulation 18: Transfer of Residents Regulation 19: General Health Regulation 20: Provision of Information to Residents Regulation 21: Privacy Regulation 22: Premises Regulation 26: Staffing Regulation 27: Maintenance of Records Regulation 29: Operating Policies and Procedures Regulation 30: Mental Health Tribunals Regulation 31: Complaints Procedures Regulation 32: Risk Management Procedures AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 14 of 77

15 6.0 Service-user Experience 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. A total of ten residents met with the inspection team. A further 14 residents returned a service user experience questionnaire. Residents expressed satisfaction with their treatment and accommodation within the approved centre and with the range of therapeutic options available. They felt that staff were supportive and engaged with them. Some residents expressed the view that they did not have sufficient contact with their designated key worker. This matter was raised with management during the feedback meeting for consideration and review. AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 15 of 77

16 7.0 Interviews with Heads of Discipline The inspection team sought to meet with heads of discipline during the inspection. The inspection team met with the following individuals: Chief Executive Officer Medical Director Director of Operations Director of Nursing Head of Psychology Head of Occupational Therapy Head Social Worker These meetings clarified issues of overall service goals and strategic aims. They also provided clarity regarding risk management within the approved centre, processes for supervision and appraisal of staff, and specific operational risks affecting areas of service provision. AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 16 of 77

17 8.0 Feedback Meeting 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: Chief Executive Officer Medical Director Director of Operations Director of Nursing Acting Head of Pharmacy Senior Clinical Psychologist Head of Occupational Therapy Head Social Worker Programme Manager Nurse Practice Development Coordinator Administrator Clinical Governance Department 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. AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 17 of 77

18 9.0 Inspection Findings Regulations EVIDENCE OF COMPLIANCE WITH REGULATIONS UNDER MENTAL HEALTH ACT 2001 SECTION 52 (d) The following regulations are not applicable Regulation 1: Citation Regulation 2: Commencement and Regulation Regulation 3: Definitions AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 18 of 77

19 Regulation 4: Identification of Residents COMPLIANT Quality Rating Excellent The registered proprietor shall make arrangements to ensure that each resident is readily identifiable by staff when receiving medication, health care or other services. Processes: The approved centre had a written policy in relation to the identification of residents, which was last reviewed in September It included all of the requirements of the Judgement Support Framework. Training and Education: All relevant staff had signed a log indicating 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 of 77 clinical files and Medication Prescription and Administration Records had been undertaken to ensure the use of appropriate resident identifiers. Analysis had been completed to identify opportunities for improving the resident identification process. Evidence of Implementation: An inspection of clinical files indicated that the following person-specific resident identifiers were used on all clinical records: date of birth, medical record number, and photographic ID. Two appropriate resident identifiers were used before the administration of medication, the initiation of medical investigations, and the provision of other health care services. An appropriate resident identifier was used prior to the provision of therapeutic services and programmes. A red caution stamp was used to alert staff to the presence of residents with the same or a similar name. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all the criteria of the Judgement Support Framework. AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 19 of 77

20 Regulation 5: Food and Nutrition COMPLIANT Quality Rating Excellent (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. Processes: The approved centre had five written policies in relation to the provision of appropriate food and nutrition to residents. These related to patient meal orders (May 2016), therapeutic meal orders (July 2015), nutritional care (May 2016), safe fresh drinking water (September 2016), and catering for individual requests (May 2016). Together, these included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed a log indicating that they had read and understood the policies. Relevant staff interviewed were able to articulate the processes for food and nutrition, as set out in the policies. Monitoring: A systematic review of menus was undertaken every three weeks by the dietician to ensure that residents received wholesome and nutritious food in accordance with their needs. Analysis had been completed to ensure that residents received a nutritious and varied diet appropriate to their needs. Evidence of Implementation: Menus were analysed for nutritional adequacy every three weeks by a dietician in cooperation with the catering department. Residents were provided with a range of wholesome and nutritious food choices, and low-fat and gluten-free options were available. Food, including modified diets, was properly prepared and presented in an attractive and appealing manner. Hot meals were provided daily, including six lunchtime and four teatime options. Residents had access to hot and cold drinks throughout the day. Fresh water dispensers were available on each ward. The St. Andrew s Nutrition Screening Instrument (SANSI) nutrition assessment tool was in use in the approved centre. The clinical files of five residents were inspected. These indicated that nutritional and dietary needs were assessed and documented in individual care plans. Weight charts were implemented, monitored, and acted upon, where appropriate. Where residents were identified as having special nutritional requirements, their needs were reviewed by the dietician. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all the criteria of the Judgement Support Framework. AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 20 of 77

21 Regulation 6: Food Safety COMPLIANT Quality Rating Excellent (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 Processes: The approved centre had two written policies in relation to food safety: a policy on the catering department service plan, dated July 2016, and a waste management policy, dated September The policies combined included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed a log indicating that they had read and understood the policies. Relevant staff interviewed could articulate the processes for food safety, as set out in the policies. All staff handling food had up-to-date training in the application of Hazard Analysis and Critical Control Point (HACCP). The training was documented. Monitoring: Food safety audits had been completed on the facilities for the refrigeration, storage, preparation, cooking, and serving of food and on adherence to the relevant food safety legislative requirements. Food temperatures were recorded in line with food safety recommendations, and a temperature log sheet was maintained and monitored. Analysis had been completed to identify opportunities for improving food safety processes. Evidence of Implementation: Appropriate hand-washing areas were in place for catering services, and the catering equipment was suitable and adequate, with appropriate facilities for the refrigeration, storage, preparation, cooking, and serving of food. Hygiene was maintained to support food safety requirements. Catering areas and associated equipment were appropriately cleaned. Residents had access to a supply of suitable crockery and cutlery. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all the criteria of the Judgement Support Framework. AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 21 of 77

22 Regulation 7: Clothing COMPLIANT Quality Rating Excellent 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. Processes: The approved centre had a written policy in relation to clothing. Dated March 2017, it was entitled Service User Access to their Clothing and Personal Property and Possessions. It included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed a log indicating that they had read and understood the policy. Relevant staff interviewed could articulate the processes in relation to 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. A record of residents who were prescribed night attire during the day was maintained. Evidence of Implementation: Residents were supported to keep and wear their personal clothing, and each resident had an individual wardrobe and locker. Residents clothing was observed to be clean and appropriate to their needs. An emergency supply of clothing was stored in the laundry area of the hospital. Emergency attire took account of the residents preferences, dignity, bodily integrity, and religious and cultural practices. Residents changed out of their nightclothes during the day unless otherwise specified in their individual care plans. All residents had an adequate supply of individualised clothing. 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. AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 22 of 77

23 Regulation 8: Residents Personal Property and Possessions COMPLIANT Quality Rating Excellent (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. Processes: The approved centre had four written policies in relation to residents personal property and possessions. These related to service user property (September 2015); property storage post-discharge (September 2015); service user access to clothing, personal property, and possessions (March 2017); and processing service user property (March 2017). Together, the policies included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed a log indicating that they had read and understood the policies. Relevant staff interviewed could articulate the processes relating to residents personal property and possessions, as set out in the policies. Monitoring: Personal property logs were maintained in clinical files and monitored. Analysis had been completed to identify opportunities for improving the processes around residents personal property and possessions. The approved centre conducted audits on personal property and possessions approximately every six months. Evidence of Implementation: Residents could bring personal possessions into the approved centre and were supported to manage their own property, unless this posed a danger to them or others, as indicated in their individual care plans. Provision was made for residents to secure personal property and possessions. Where the approved centre assumed responsibility for residents property, personal effects were stored securely. Examination of 24 resident files indicated that signed property checklists were maintained. The checklists were available to residents and were kept separately to the residents individual care plans. Two members AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 23 of 77

24 of staff oversaw the process of providing residents with access to their money, and signed records of staff issuing money were maintained and, where possible, countersigned by the resident or a 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. AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 24 of 77

25 Regulation 9: Recreational Activities COMPLIANT Quality Rating Excellent The registered proprietor shall ensure that an approved centre, insofar as is practicable, provides access for residents to appropriate recreational activities. Processes: The approved centre had a written policy in relation to the provision of recreational activities, which was last reviewed in March It included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed a log indicating that they had read and understood the policy. Relevant staff interviewed could articulate the processes relating to recreational activities, as set out in the policy. Monitoring: A record was maintained of the occurrence of planned recreational activities, including a log of resident uptake/attendance. Audits were undertaken twice a year to elicit service users feedback on recreation and identify opportunities for improving the processes in relation to recreational activities. Evidence of Implementation: Residents had access to an extensive range of appropriate recreational activities. The available resources included reading materials, board games, walking groups, TV, movie nights, arts and crafts, jewellery making, bingo, Tai Chi, yoga, quizzes, and pool. A hairdresser attended the approved centre once a week. Recreational activities were scheduled in the approved centre on weekdays, and residents attended evening and weekend activities as part of the Twilight Programme. Recreational activities were developed, maintained, and implemented with resident involvement, and they were appropriately resourced. Opportunities were available for indoor and outdoor exercise and physical activity. Residents had access to a gym, a mini-golf course, and garden areas. There were suitable indoor areas for recreation, including arts and crafts, music, pottery, and computer rooms as well as a library and computer room. Residents decisions on whether or not to participate in activities were respected. Records of resident attendance at recreational activities were maintained in the clinical files. 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. AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 25 of 77

26 Regulation 10: Religion COMPLIANT Quality Rating Excellent The registered proprietor shall ensure that residents are facilitated, insofar as is reasonably practicable, in the practice of their religion. Processes: The approved centre had a written policy in relation to the facilitation of religious practice by residents, which was last reviewed in September The policy included all of the requirements of the Judgement Support Framework. Training and Education: All relevant staff had signed the policy, indicating that they had read and understood it. 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: An audit of the policy s implementation had been completed to ensure that residents identified religious needs were met. Evidence of Implementation: Residents were facilitated in the practice of their religion insofar as was practicable. They had access to a multi-faith oratory and to multi-faith chaplains. Residents could also attend religious services outside of the approved centre, if it was deemed appropriate following a risk assessment. The care and services provided within the approved centre were respectful of residents religious beliefs and values, and residents were facilitated in observing or abstaining from religious practice in line with their wishes. Particular religious requirements relating to the provision of services, care, and treatment were documented. 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. AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 26 of 77

27 Regulation 11: Visits COMPLIANT Quality Rating Excellent (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. Processes: The approved centre had two written policies in relation to visits: a service user visitor control policy, dated March 2017, and a contractors identification policy, dated September The policies combined included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed a log indicating that they had read and understood the policies. Relevant staff interviewed were able to articulate the processes relating to visits, as set out in the policies. Monitoring: Restrictions on residents rights to receive visitors were monitored and reviewed on an ongoing basis. Audits had been completed to identify opportunities for improving visiting processes, specifically in relation to visitor information signage. Evidence of Implementation: Visiting times, which were appropriate and reasonable, were displayed in the main reception of the approved centre and at the entrance to all ward areas. There were a number of rooms throughout the approved centre that were suitable for visits, including private visits: bedrooms, quiet areas, multi-functional rooms, a large restaurant and lobby area, and the Wishing Well family room, which had facilities suitable for visiting children. Appropriate steps were taken to ensure visitor safety and the safety of residents during visits. Children were welcome when accompanied at all times. At the time of the inspection, there were no restrictions on visits. The approved centre was compliant with this regulation. The quality assessment was excellent because the approved centre met all criteria of the Judgement Support Framework. AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 27 of 77

28 Regulation 12: Communication COMPLIANT Quality Rating Excellent (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, , internet, telephone or any device for the purposes of sending or receiving messages or goods. Processes: The approved centre had four written policies in relation to resident communication. These addressed service user access to communication facilities (March 2017), the accessing of interpretation and translation services (March 2017), guidelines for digital Media (March 2017), and literacy friendly practice (March 2016). Together, the policies included all the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed a log indicating that they had read and understood the policies. Relevant staff interviewed were able to articulate the processes for facilitating residents communication, as set out in the policies. Monitoring: Residents communications needs and restrictions on communication were monitored on an ongoing basis. Analysis had been completed to identify opportunities for improving communication processes in the form of an audit of the variety of communication methods available in the approved centre. Evidence of Implementation: Residents had access to mail, fax, telephone, and . Residents on Dean Swift ward could use personal mobile phones or the computer room, following a risk assessment. Residents of the special care units did not have access to their own phones, as per the approved centre s policy, but they were facilitated in using a cordless phone. A senior member of staff could examine resident communication only where there was reasonable cause to believe that the communication may result in harm to the resident or others. No resident communication had required examination since the last inspection. The approved centre was compliant with this regulation. The quality assessment was excellent because the approved centre met all the criteria of the Judgement Support Framework. AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 28 of 77

29 Regulation 13: Searches COMPLIANT Quality Rating Satisfactory (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. Processes: The approved centre had three written policies in relation to searches. These addressed service user searches (March 2017), the processing of service user property (March 2017), and the possession and use of illegal drugs and consumption of alcohol (September 2015). The policies covered all of the requirements of the Judgement Support Framework, including those relating to the following: The management and application of searches of a resident, his or her belongings, and the environment in which he or she was accommodated. The consent requirements of a resident regarding searches and the process for conducting searches in the absence of consent. The process for dealing with illicit substances uncovered during a search. Training and Education: Relevant staff had signed a log indicating that they had read and understood the policies. Staff were aware of the policy and procedures but not all staff queried could accurately outline the searching processes, as set out in the policies. Monitoring: A search log was available to the inspectors, and it indicated a process for systematically reviewing each search to ensure compliance with the requirements of the regulation. Documented analysis had been completed to identify opportunities for improvement of search processes. Evidence of Implementation: The policy and processes relating to searches were communicated to all residents in the approved centre. A written record of every search of a resident and every property search was available, which detailed the reasons for the search, the names of the staff members who undertook AC0005 St. Patrick s University Hospital Approved Centre Inspection Report 2017 Page 29 of 77