Department of Psychiatry, University Hospital Galway

Transcription

1 Department of Psychiatry, University Hospital Galway ID Number: AC Approved Centre Inspection Report (Mental Health Act 2001) Department of Psychiatry, University Hospital Galway Newcastle Road Galway Conditions Attached: Yes Approved Centre Type: Acute Adult Mental Health Care Psychiatry of Later Life Mental Health Care for People with Intellectual Disability Registered Proprietor: HSE Most Recent Registration Date: 1 March 2017 Registered Proprietor Nominee: Mr Steve Jackson, General Manager CHO2 Mental Health Services Inspection Team: Barbara Morrissey, Lead Inspector Siobhán Dinan Mary Connellan Carol Brennan-Forsyth Inspection Date: May 2017 Inspection Type: Unannounced Annual Inspection Previous Inspection Date: June 2016 The Inspector of Mental Health Services: Dr Susan Finnerty MCRN Date of Publication: 9 November REGULATIONS 1 COMPLIANCE RATINGS 2017 RULES AND PART 4 OF THE MENTAL HEALTH ACT 2001 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 AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 2 of 90

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 Appendix 1: Corrective and Preventative Action Plan Template Le Brun House and Whitethorn House, Vergemount Mental Health Facility... Error! Bookmark not defined. AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 3 of 90

4 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. AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 4 of 90

5 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. AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 5 of 90

6 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 There was a written policy in place and an associated safety statement in relation to health and safety as well as a risk management policy. Quality and safety walkabouts took place on a regular basis with the maintenance department and with unit staff. There was safe processes in place for the ordering, prescription, storage and administering medication. Resident identifiers were checked before staff administered medications, carried out medical investigations, and provided other health care services. The catering company completed food safety audits. There were proper facilities for the refrigeration, storage, preparation, cooking, and serving of food. Hygiene was maintained to support food safety requirements. Catering areas, and associated catering and food safety equipment were appropriately cleaned. Not all health care professionals were up to date with required training in fire safety, Basic Life Support, management of violence and aggression, and the Mental Health Act Physical restraint was carried out in a safe manner. 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 Four residents were in the approved centre for a period of over six months and their six-monthly physical examinations were documented. Adequate arrangements were in place for residents to access general health services and for their referral to other health services, as required. Each resident had an individual care plan (ICP). All ICPs were a composite set of documentation detailing appropriate goals, treatment, care, interventions, reviews, and resources required. The therapeutic services and programmes provided by the approved centre were evidence-based, appropriate, and met the needs of the residents, Residents were given an individual therapeutic programme adapted to their own needs and aligned with their care plan, goals, and interventions. Therapeutic services and programmes were provided in a separate dedicated room or in the occupational therapy department. Due to limited space in station C, the high observation unit, groups had to be facilitated in the dining area, however there was an appropriate quiet room where one to AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 6 of 90

7 one sessions could be facilitated. Not all clinical files were in good order. The approved centre was compliant with the rules on electro-convulsive therapy and seclusion. 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 Secure facilities were provided for the safe-keeping of the residents monies, valuables, personal property, and possessions. Each resident had a locker and a small wardrobe beside their beds and a larger locked locker in the resident property room. Residents were supported to keep and use their personal clothing, which was clean and appropriate to their needs. Searches were implemented with due regard to each resident s dignity, privacy and gender. Two CCTV cameras positioned in the internal garden areas of the approved centre were found to be recording residents images. The high observation beds near the nurses offices in Station A and B opened out on to the unit. There were no walls or partition and this did not afford privacy for the residents accommodated in these areas, as it was not feasible to have privacy curtains drawn at all times. 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 menus offering a variety of wholesome and nutritious food choices and meals were attractively presented. Residents could use mail and telephone. There was no internet available for residents in the approved centre. There was no dedicated visiting room in the approved centre, however a room was provided when required and this room was made available for children visiting. Visiting areas such as the quiet room and garden, were also available, where residents could meet visitors in private. Residents rights to practice religion were facilitated. There was a chapel in the main hospital of the approved centre and multi-faith chaplains were available. A separate quiet room was available to residents for quiet reflection and prayer. Residents were provided with an information handbook at admission, and it included all necessary information on housekeeping arrangements. Information was available on medication and diagnosis. Ligature points were not minimised despite a ligature audit having taken place. There was no programme of general maintenance or decorative maintenance. Heating was centrally controlled and could only be turned on or off. At the time of the inspection, the weather was extremely warm and radiators remained on. The approved centre was not clean, hygienic, and free from offensive odours. The inspection team requested a deep clean of the bathrooms on the first day of the inspection. The approved centre did not provide suitable furnishings to support resident independence and comfort. There was a well-advertised complaints procedure in place. AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 7 of 90

8 AREAS REFERRED TO Regulations 5, 9, 10, 11, 12, 20, 22, 30, 31, Code of Practice on the Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities, service user experience, and interviews with staff. Governance of the approved centre The approved centre was a part of the HSE Community Healthcare Organisation (CHO) 2 area. Governance of the approved centre was managed by the executive management team. Overarching clinical governance mental health teams met monthly. This was a forum for the different staff disciplines providing input to the approved centre to meet together to discuss specific governance matters. Mutual support meetings took place on the unit between residents and staff to address any items of concern and to improve quality and services. The operating policies and procedures were developed with input from nursing, clinical, and business staff and in consultation with relevant stakeholders, including service users. Operating policies and procedures were communicated to all relevant staff and were reviewed within three years. The unit had 15 consultant-led teams that could admit to the approved centre. The CHO 2 area had a quality and safety risk advisor who sat on the clinical governance mental health team and provided training once a month on risk management and incident reporting. All heads of disciplines met monthly. There was service user involvement on senior management team. AREAS REFERRED TO Regulations 26 and 32, interviews with heads of discipline, and minutes of area management team meetings. AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 8 of 90

9 3.0 Quality Initiatives The following quality initiatives were identified on this inspection: 1. Quality and safety walkabouts through the unit with the maintenance department and with unit staff. 2. Service user involvement on senior management team. 3. Medication alert aprons now worn during the administration of medication. 4. Mutual support meetings on unit. (These are quality improvement meetings between staff and residents). 5. A new 50 bedded unit has now been built in the grounds of the University Hospital Galway. This will be the new approved centre. 6. Whiteboards on display on each station to assist with the provision of information to residents. AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 9 of 90

10 4.0 Overview of the Approved Centre 4.1 Description of approved centre The Department of Psychiatry, University Hospital Galway, was a registered 45-bed unit, located on the ground floor of the university hospital, Newcastle Rd, Co. Galway. The unit was accessed through a side door at the back of the hospital, or via St. Anthony s ward in the general hospital, as the unit was connected to the main hospital by a link corridor. The unit was not well signposted within the main hospital and there was no reception or waiting area at the entrance to the approved centre. The main hospital had a shop and a café. The unit was laid out in three areas, station A, which was the male ward; station B, the female ward; and station C, the high observation unit. Station C was a six-bed area, and on the first day of the inspection there were six patients accommodated in this area. The approved centre was locked and access was via swipe card or by staff releasing the door mechanism. A gym facility was available in the approved centre, but as there was not an appropriately qualified instructor available, this was not in use at the time of the inspection. A charter of patient rights was displayed in the approved centre. Fifteen consultant-led teams admitted residents to the approved centre, including two psychiatry of later life teams, one rehabilitation and recovery team and one mental health intellectual disability team. The approved centre was the main regional centre for electro-convulsive therapy with a dedicated consultant and nursing staff. The approved centre in Roscommon University Hospital also admits to the centre if it requires further beds. The approved centre operated mostly on full capacity. It was noted that when residents went on leave from the unit, then these beds had been used as admission beds. The high observation areas in both station A and B, open out on to the unit. There was no walls or partition for this area and this was of concern in terms of resident privacy, as it was not feasible for privacy curtains to be drawn at all times. The general maintenance of the premises was not of a high standard. The resident profile on the first day of inspection was as follows: Resident Profile Number of registered beds 45 Total number of residents 44 Number of detained patients 17 Number of Wards of Court 1 Number of children 0 Number of residents in the approved centre for more than 6 months Conditions to registration There were two conditions attached to the registration of this approved centre at the time of inspection. AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 10 of 90

11 Condition 1: To ensure adherence to Regulation 15: Individual Care Plan, the approved centre shall audit their individual care plans on a monthly basis. The approved centre shall provide a report on the results of the audits to the Mental Health Commission in a form and frequency prescribed by the Commission. Condition 2: The approved centre shall submit a plan to the Mental Health Commission for the closure of the approved centre, including the transfer or discharge of all current residents. The approved centre shall provide updates on the closure plan in a form and frequency prescribed by the Commission. The updates shall include ongoing maintenance to be undertaken on the approved centre premises up until all residents have been transferred or discharged. 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 The approved centre was a part of the HSE s Community Healthcare Organisation 2 area. Governance of the approved centre was managed by the executive management team. Members of the team included the executive clinical director, the clinical director, the head of mental health services, the acting area director of nursing for Galway/Roscommon, the general manager, principal social worker, occupational therapy manager, and consultant psychiatrists from each sector and the approved centre s assistant director of nursing. Overarching clinical governance mental health teams met monthly in Ballard House in Galway. This was a forum for the different staff disciplines providing input to the approved centre to meet together to discuss specific governance matters. Copies of the minutes were provided to the inspection team, which outlined an active governance process. Issues raised in the minutes included the forthcoming opening of the new approved centre and also the creation of a smoke-free campus. Issues from the approved centre s subcommittees such as acute unit business meetings, health and safety meetings, drugs and therapeutics and policy and procedure committees escalated issues to this monthly overarching meeting. Staff training was discussed at the health and safety meeting. Bed capacity and incidents were standing items on the agenda at the acute unit business meeting. Discussion with members of senior management confirmed a current focus on risk minimisation and on addressing various areas of non-compliance with required regulations and rules, as outlined by the Mental Health Commission, (MHC). Mutual support meetings took place on the unit between residents and staff to address any items of concern and to improve quality and services. The unit had 15 consultant-led teams that could admit to the approved centre and there appeared to be limited office space to accommodate this. AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 11 of 90

12 5.0 Compliance 5.1 Non-compliant areas from 2016 inspection The previous inspection of the approved centre on June 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 7: Clothing Compliant Regulation 15: Individual Care Plan Compliant Regulation 20: Provision of Information to Residents Compliant Regulation 21: Privacy Non-Compliant Regulation 22: Premises Non-Compliant Regulation 23: Ordering, Prescribing, Storing and Administration of Compliant Medicines Regulation 25: Use of Closed Circuit Television Non-Compliant Regulation 26: Staffing Non-Compliant Regulation 27: Maintenance of Records Non-Compliant Regulation 28: Register of Residents Non-Compliant Part 4 of the Mental Health Act 2001: Consent to Treatment Compliant Code of Practice on the Use of Physical Restraint in Approved Centres Compliant Code of Practice on Admission, Transfer and Discharge to and from an Non-Compliant Approved Centre AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 12 of 90

13 5.2 Non-compliant areas on this inspection Non-compliant (X) areas on this inspection are detailed below. Also shown is whether the service was compliant ( ) or non-compliant (X) in these areas in 2016 and 2015: Regulation/Rule/Act/Code 2015 Compliance 2016 Compliance 2017 Compliance Regulation 21: Privacy X Regulation 22: Premises X X Regulation 25: Use of Closed Circuit Television X Regulation 26: Staffing X Regulation 27: Maintenance of Records X X Regulation 28: Register of Residents X Code of Practice on the Use of Physical Restraint in x x X Approved Centres Code of Practice Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities Code of Practice Guidance on Admission, Transfer, and Discharge to and from an Approved Centre X X X X X The approved centre was requested to provide Corrective and Preventative Actions (CAPAs) for areas of noncompliance. These are included in Appendix 1 of the report. 5.3 Areas of compliance rated Excellent on this inspection The following areas were rated excellent on this inspection: Regulation Regulation 7: Clothing Regulation 10: Religion Regulation 13: Searches AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 13 of 90

14 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. During the inspection the inspection team met with three residents. Residents were complimentary about the care received from staff and food provided in the approved centre. Residents reported that they would like if there was more tea and coffee available. One resident reported that they were not offered a copy of their care plan. AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 14 of 90

15 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: Executive Clinical Director Clinical Director Acting Area Director of Nursing Business Manager Occupational Therapy Manager Principal Social Worker The following was unable to meet the inspection team: Head of Psychology There was an organisational chart to identify the leadership and management structure and lines of authority and accountability. Responsibilities were allocated at management level to ensure the effective implementation of risk management. Each clinical discipline had its own governance structure with clear line management. The assistant director of nursing was located in the approved centre from Monday to Friday. Representatives from nursing, medical, social work, and occupational therapy each provided a clear overview of the governance within their respective departments. All heads of discipline identified strategic aims for their teams and discussed potential operational risks within their departments. Business plans had been put forward to enhance the therapeutic and the recreational programme. The new unit will be a 50-bed unit and will include Psychiatry of Later Life. The acting area director of nursing was the chair of the steering group for the new approved centre. The CHO 2 area also had a quality and safety risk advisor who sat on the clinical governance mental health team and provided training once a month on risk management and incident reporting. There was a mentoring system in place for all new nursing staff. All heads of disciplines met monthly. AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 15 of 90

16 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: Clinical Director Head of Service Consultant Psychiatrist Nurse Practice Development Coordinator Acting Area Director of Nursing Clinical Nurse Manager 3 x 2 Assistant Director of Nursing Occupational Therapy Manager Principal Social Worker Mental Health Act Administrator Business administrator Electro-Convulsive Therapy Nurse Principal Social Worker 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. A number of clarifications were provided regarding various issues that had arisen during the course of the inspection and these are incorporated into the report. AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 16 of 90

17 9.0 Inspection Findings Regulations EVIDENCE OF COMPLIANCE WITH REGULATIONS UNDER MENTAL HEALTH ACT 2001 SECTION 52 (d) The EVIDENCE following OF regulations COMPLIANCE are not WITH applicable REGULATIONS UNDER MENTAL HEALTH ACT 2001 SECTION 52 (d) Regulation 1: Citation Regulation 2: Commencement and Regulation Regulation 3: Definitions The following regulations are not applicable Regulation 1: Citation Regulation 2: Commencement and Regulation Regulation 3: Definitions AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 17 of 90

18 Regulation 4: Identification of Residents COMPLIANT Quality Rating Satisfactory 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 Galway Roscommon Mental Health Services generic policy in place, dated November 2016, on the identification of residents. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed a log to indicate that they had read and understood the policy on the identification of residents. Relevant staff interviewed were able to articulate the processes for identifying residents, as set out in the policy. Monitoring: An annual audit was undertaken to ensure that there were appropriate resident identifiers on clinical files. A documented analysis had been completed to identify opportunities for improving resident identification processes. Evidence of Implementation: A minimum of two resident identifiers appropriate to the resident group profile and individual resident needs were detailed within the residents clinical files. The approved centre used the name, date of birth, address, and medical record number of each resident as identifiers. The identifiers used were person-specific and appropriate to the residents communication abilities. Room number and physical location were not included on the identifiers. The identifiers within the residents clinical files were checked before staff administered medications, carried out medical investigations, and provided other health care services. An appropriate resident identifier was used prior to the provision of therapeutic services and programmes. While the policy detailed that there was an alert sticker in place to distinguish between residents with the same or a similar name, in practice a highlighter pen was used on Medication Prescription and Administration Records to distinguish between residents with the same or a similar name. In one clinical file inspected, 12 pages of progress notes failed to use two means of identification. 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 evidence of implementation pillar. AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 18 of 90

19 Regulation 5: Food and Nutrition COMPLIANT Quality Rating Satisfactory (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 did not have a policy in place in relation to the provision of appropriate food and nutrition to residents. Training and Education: There was no policy in place for staff to read, and articulate. Monitoring: A systematic and regular review of menu plans was conducted by the approved centre s contracted catering company, Aramark Catering. The aim of the review was to ensure that residents were provided with wholesome and nutritious food suitable to their needs. A documented analysis was completed to improve the food and nutrition processes. Evidence of Implementation: Food was properly prepared in the main hospital kitchen. The approved centre s menus had been reviewed and approved by both the hospital dietician and the dietician with the catering company to ensure nutritional adequacy in accordance with the resident s dietary needs. Residents were provided with menus offering a variety of wholesome and nutritious food choices. Hot meals were served daily, at breakfast, lunch, and teatime. Meals were attractively presented. Both hot and cold drinks were offered regularly. Residents had adequate supplies of safe and fresh drinking water through easily accessible water fountains located throughout the approved centre. The needs of residents identified as having special nutritional requirements were reviewed regularly. An evidence-based nutritional assessment tool was used. Nutritional and dietary needs were assessed, where necessary, and addressed and documented in the residents individual care plans. Intake and output charts were maintained for residents, where 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 processes and training and education pillars. AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 19 of 90

20 Regulation 6: Food Safety COMPLIANT Quality Rating Satisfactory (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 INSPECTION FINDINGS Processes: The approved centre had a policy in place on food safety, dated November The policy included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed a 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 the application of Hazard Analysis and Critical Control Point (HACCP), and the training was documented. Staff had up to-to-date certificates in food safety training. Monitoring: Food temperatures were recorded in line with food safety recommendations, and a log sheet was maintained and monitored. Food safety audits were completed by the catering company. A documented analysis was not completed by the approved centre. Evidence of Implementation: There was appropriate and sufficient catering equipment, crockery, and cutlery to suit the needs of residents in the approved centre. There were proper facilities for the refrigeration, storage, preparation, cooking, and serving of food. Hygiene was maintained to support food safety requirements. Catering areas and associated catering and food safety equipment were appropriately cleaned. 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. AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 20 of 90

21 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. INSPECTION FINDINGS Processes: The approved centre had a written policy, dated July 2014, in relation to residents clothing. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed a log to log indicate that they had read and understood the policy on residents clothing. Relevant staff interviewed were able to articulate the processes on residents clothing, as set out in the policy. Monitoring: The availability of an emergency supply of clothing for residents was monitored on an ongoing basis, and the record was kept in the linen room. A record of residents wearing night clothing during the day was kept and monitored. Evidence of Implementation: Residents changed out of nightclothes during daytime hours unless otherwise specified in their individual care plans. Residents were supported to keep and use their personal clothing, which was clean and appropriate to their needs. There was no laundry facilities on site, but residents could avail of a launderette service if they wished. Residents had an adequate supply of individualised clothing. All residents had storage facilities in their bedrooms. Each resident had a very small wardrobe. All residents were provided with a bedside locker. Residents were provided with emergency personal clothing that was appropriate to them and considered their preferences, dignity, bodily integrity, and religious and cultural practices. 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. AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 21 of 90

22 Regulation 8: Residents Personal Property and Possessions COMPLIANT Quality Rating Satisfactory (1) For the purpose of this regulation "personal property and possessions" means the belongings and personal effects that a resident brings into an approved centre; items purchased by or on behalf of a resident during his or her stay in an approved centre; and items and monies received by the resident during his or her stay in an approved centre. (2) The registered proprietor shall ensure that the approved centre has written operational policies and procedures relating to residents' personal property and possessions. (3) The registered proprietor shall ensure that a record is maintained of each resident's personal property and possessions and is available to the resident in accordance with the approved centre's written policy. (4) The registered proprietor shall ensure that records relating to a resident's personal property and possessions are kept separately from the resident's individual care plan. (5) The registered proprietor shall ensure that each resident retains control of his or her personal property and possessions except under circumstances where this poses a danger to the resident or others as indicated by the resident's individual care plan. (6) The registered proprietor shall ensure that provision is made for the safe-keeping of all personal property and possessions. INSPECTION FINDINGS Processes: The approved centre had a written operational policy dated October 2016 relating to residents personal property and possessions. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed a log to indicate that they had read and understood the policy on residents personal property and possessions. 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. A documented analysis was completed to identify opportunities to improve the processes for managing residents personal property and possessions. Evidence of Implementation: Secure facilities were provided for the safe-keeping of the residents monies, valuables, personal property, and possessions, as necessary. Small amounts of cash and valuables were held in the approved centre. Each resident had a locker and a small wardrobe beside their beds and a larger locked locker in the resident property room. The approved maintained a signed property checklist detailing each resident s personal property and possessions. The property checklist was kept separate to the resident s individual care plan (ICP). Residents were given a copy of their property checklist. Residents were supported to manage their own property, unless this posed a danger to the resident or others, as indicated in their ICP. 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. AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 22 of 90

23 Regulation 9: Recreational Activities COMPLIANT Quality Rating Satisfactory 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 did not have a policy in place in relation to the provision of recreational activities. Training and Education: There was no policy in place for staff to read and articulate. Monitoring: There was a record of the occurrence of planned recreational activities, including a record of resident uptake. A documented analysis had not been completed to identify opportunities to improve the processes for recreational activity. Evidence of Implementation: The approved centre provided access to recreational activities appropriate to the resident group profile, on weekdays and during the weekend. A weekly schedule of recreational activities was available to residents and displayed on the whiteboard on each ward. Occupational therapy and nursing staff provided a schedule of activities in the approved centre. Residents had access to a wide range of appropriate recreational activities such as TV, books, a pool table, arts, crafts, and cookery. Opportunities were provided for indoor and outdoor exercise and physical activity. The outdoor space available for residents in the high observation unit was small. There was a spacious internal garden for residents in the two main ward areas. Resident opinions on recreational activities were taken into account by staff on a one-to-one communication basis and through group forums, most notably the Mutual Help Meeting. The Mutual Help Meeting provided information for residents and gave residents an opportunity to make suggestions and requests. Attendance and participation in recreational activities was documented. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the processes, training and education, and monitoring pillars. AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 23 of 90

24 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. INSPECTION FINDINGS Processes: The approved centre had a policy in place, dated November 2016, on religion. It included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed a 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 reviewed and documented to ensure it reflected the identified needs of the residents. Evidence of Implementation: Residents rights to practice religion were facilitated within the approved centre insofar as was practicable, with suitable facilities available to support their religious practices. There was a chapel in the main hospital of the approved centre, and mass was offered daily to residents. A separate quiet room was available to residents for quiet reflection and prayer. Multi-faith chaplains were available. Residents could access local religious services and were supported to attend, if deemed appropriate following a risk assessment. Residents were facilitated to observe or abstain from religious practice in accordance with their own wishes. 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. AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 24 of 90

25 Regulation 11: Visits COMPLIANT Quality Rating Satisfactory (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 operational policy, dated October 2016, in relation to visits The policy included the requirements of the Judgement Support Framework, with the exception of the required visitor identification methods. Training and Education: Relevant staff had signed a log to indicate that they had read and understood the policy on visits. Relevant staff interviewed could articulate the processes for visits, as set out in the policy. Monitoring: Restrictions on residents rights to receive visitors were monitored, and reviewed on an ongoing basis. A documented analysis of the processes relating to visits had not been completed. Evidence of Implementation: Appropriate and reasonable visiting times were publicly displayed at the entrance area and in each individual ward. Visiting times were also detailed in the resident information booklet. There was no dedicated visiting room in the approved centre, however a room was provided when required and this room was made available for children visiting. Staff and residents were aware that children had to be accompanied at all times during visits. Visiting areas such as the quiet room and garden, were also available, where residents could meet visitors in private, unless there was an identified risk to the resident or others or a health and safety risk as indicated in the residents individual care plan. Appropriate steps were taken to ensure the safety of residents and visitors during visits. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the processes, monitoring and evidence of implementation pillars. AC0023 Department of Psychiatry, University Hospital Galway Approved Centre Inspection Report 2017 Page 25 of 90