Regulatory Compliance Report (RCR) 2014 St. Aloysius Ward, Mater Misericordiae University Hospital

Transcription

1 Regulatory Compliance Report (RCR) 2014 St. Aloysius Ward, Mater Misericordiae University Hospital Please complete this Regulatory Compliance Report by providing details of the actions you intend to take, the person(s) responsible for implementing these actions and the timeframe for completion of each individual action. Please also provide details of the measures you intend to use to assess that you are now with requirements. Evidence of performing clinical audit before and afterwards should be provided to support your report, where relevant. The final report, as agreed with the Commission, will be published on the Commission s website, The completed Plan will inform your ongoing registration as an approved centre, as detailed in Section 64 of the Mental Health Act, For Mental Health Commission use only Compliance Report Due Date: 13 th May 2014 Date of Receipt:

2 Article 15 Areas of Non Compliance identified in with the Mental Health Act 2001 (Approved Centres) Regulations 2006 A new Integrated Care Plan (ICP) is being developed by a multidisciplinary group that will allow the recording of each residents individually tailored programme of therapeutic activities and other treatments. The resident will be involved in the content of the plan and will be invited to sign the ICP and offered a copy (thus recording their involvement). Regular audit. ICP use data is collected in frequent nursing Metric collection. The new ICP will outline the Therapeutic Activities and programmes particular to that resident. Please see Article 15 Dr Molyneux (Clinical Director) Article 16 The Clinical Director will write to the Mater Misericordiae University Hospital (MMUH) CEO and the HSE OT manager requesting an increased OT allocation. Continue to request an increased OT resource at the center. Dr Molyneux (Clinical Director Six months (Before 26/11/14) Article 22 The ADON will communicate with management outlining the need for prompt filling of nursing vacancies. 1) No access to outside space / unsatisfactory smoking room Tenders for building work to allow direct access from the ward to the adjacent garden are currently being sought and this project is with the MMUH Buildings office. There will be a designated covered smoking area in this garden. Continue to request that existing psychiatric nursing posts are filled. Regular communication with MMUH buildings office by ADON Six months (Before 26/11/14) 2014 (subject to planning and other exigencies) 2) Presence of ligature anchor points A Ligature Anchor Point Audit will be completed and once ligature points are identified then action will be taken to minimise risk in collaboration with the Building dept at MMUH Completing the AUDIT cycle.

3 Article 23 Areas of Non Compliance identified in with Rules under the Mental Health Act 2001 The Approved Center already has a policy concerning medication management. The policy draws on and refers to the medication policies of the entire MMUH. One of these policies specifically concerns itself with Medication storage and ordering and is available on paper and electronically. Already Dr Guy Molyneux (Clinical Director) Completed Article 26(2) Please refer to Article 16 submission as above Article 27 The Approved Center will request an Environmental Health Officer s Report from the MMUH CEO and Catering Dept Receipt of Report

4 Areas of Non Compliance identified in with Codes of Practice under the Mental Health Act 2001 Article 29 Please refer to Article 23 submission as above Code of Practise on Admission, Transfer and Discharge. -Section 17 Breach Please refer to Article 15 submission as above

5 The completed Compliance Report must be agreed to and signed by the registered proprietor of the above-named approved centre. The final report, as agreed with the Commission, will be published on the Commission s website, If the registered proprietor is a corporate entity, the completed report may be signed by the person with delegated responsibility for the running of the above-named approved centre (e.g. the local health manager where the registered proprietor is the Health Service Executive). Signature of Registered Proprietor/ with delegated responsibility for the running of the approved centre: NOTE: Electronic Signature Acceptable Job Title: MARY DAY CEO Date: 13 TH June 2014 A scanned copy of the completed and signed Compliance Report may be sent by to simon.horne@mhcirl.ie Alternatively, the completed and signed Report can be returned by post to: Ms Rosemary Smyth, Director Standards and Quality Assurance (Interim), Mental Health Commission, St Martin s House, Waterloo Road, Dublin 4.