2017 Approved Centre Focused Inspection Report (Mental Health Act 2001) Approved Centre Type: Acute Adult Mental Health Care. Registered Proprietor:

Transcription

1 Lois Bridges ID Number: AC Approved Centre Focused Inspection Report (Mental Health Act 2001) Lois Bridges 3 Greenfield Road Sutton Dublin 13 Approved Centre Type: Acute Adult Mental Health Care Most Recent Registration Date: 19 January 2016 Conditions Attached: None Registered Proprietor: Ms Melanie Wright Registered Proprietor Nominee: N/A Inspection Team: Dr Susan Finnerty, Lead Inspector Siobhán Dinan Advisor: Dr Frances Connan, Consultant Psychiatrist and Specialist in Eating Disorders The Inspector of Mental Health Services: Dr Susan Finnerty MCRN Inspection Date: 5 6 December 2017 Inspection Type: Focused Inspection Previous Inspection Date: August 2017 (Focused) March 2017 (Annual) Date of Publication: 7 June 2018

2 Contents 1.0 Introduction to the Inspection Process Inspector of Mental Health Services Summary of Findings Background Reason for focused inspection Focus of inspection Advisor Overview of the Approved Centre Description of approved centre Conditions to registration Governance Feedback Meeting Focused Inspection Findings Appendix 1: Lois Bridges Corrective and Preventative Action (CAPA) Plans AC0079 Lois Bridges Approved Centre Focused Inspection Report 2017 Page 2 of 22

3 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. On a focused inspection, the Inspector does not assess all regulations, rules, code of practice, and Part 4 of the 2001 Act. The focus of the inspection will be on specific legislative requirements, or parts of legislative requirements where it is determined that there may be a risk to the safety, health and well-being of residents and/or staff members. Following the focused 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 and risk ratings, 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. 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. AC0079 Lois Bridges Approved Centre Focused Inspection Report 2017 Page 3 of 22

4 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 findings from the focused inspection of Lois Bridges. Lois Bridges is an approved centre providing care and treatment for adults with an eating disorder. It is a private, for-profit facility. Following an annual inspection on March 2017 and a focused inspection on August 2017, there have been ongoing concerns about the safety of residents, risk management, and staffing in the approved centre. Despite an immediate action notice, these concerns continued and this second focused inspection, on 5 and 6 December 2017, was carried out. On this inspection, the Inspector was accompanied by a specialist in eating disorders to act as an advisor to the Inspector under section 51(2)(a) of the Mental Health Act On this second focused inspection, there were again serious concerns about staffing and risk management procedures, particularly in relation to seriously ill residents with anorexia nervosa. These concerns were again risk-rated as critical. The Inspector found that seriously ill residents continued to be admitted to Lois Bridges, which did not have sufficient medical support in place to safely treat and care for them. The Inspector found that persons were admitted with critically low body mass indexes (BMIs) and with blood and cardiac abnormalities. There were no facilities for taking daily bloods, essential in the initial treatment of a person with severe anorexia nervosa. There was a waiting time of 24 hours for blood results on weekdays, which impacted on the treatment of severely ill residents. There was no arrangement with any medical facilities, including the local Beaumont Hospital, for admission and gastroenterology input. Reports to the Inspector from Beaumont Hospital stated that seriously and critically ill residents were discharged or transferred from Lois Bridges to the emergency department where they had to wait considerable lengths of time, with inadequate referral information and no prior contact from Lois Bridges with Beaumont Hospital staff. Staffing in Lois Bridges remained at unsafe levels. There was only one consultant psychiatrist who was also the clinical director. There was no other medical input apart from the local GP. The consultant psychiatrist provided regular input two days a week and also worked in another health care facility. Sixteen hours of consultant psychiatrist input on-site per week is not sufficient psychiatric input to meet the needs of up to seven in-patients, especially if some of those patients have severe and complex eating disorders associated with high clinical risk. There was only one health care assistant and one nurse on duty for day and night. There was not always a registered psychiatric nurse on duty. Apart from one registered psychiatric nurse and the dietician, the

5 medical, nursing, and health care assistants did not have any formal training in eating disorders, despite Lois Bridges functioning as an eating disorder unit. The Inspector found that the care and treatment of seriously ill residents with anorexia nervosa admitted to Lois Bridges was inadequate and unsafe and that there had been little improvement in the provision of safe care since the annual inspection in March AC0079 Lois Bridges Approved Centre Focused Inspection Report 2017 Page 5 of 22

6 3.0 Background 3.1 Reason for focused inspection This second focused inspection on 5 and 6 December 2017, was carried out as there had been serious concerns following the annual inspection on March 2017 and a focused inspection on August 2017, regarding the safety of residents and staffing of the approved centre. Non-compliance with regulations relating to risk management procedures and staffing on both annual and focused inspections was risk-rated as critical. These reports are published on the Mental Health Commission website: During the annual inspection on March 2017 and the focused inspection on August 2017, the inspectors found that a registered psychiatric nurse was not on duty and in charge of the approved centre at all times and the skill mix of staff was not appropriate to the assessed needs of residents. The clinical director was on call for Lois Bridges 24 hours a day, 7 days a week and also worked in another fulltime post in another approved centre. There were no other medical or psychiatric doctors employed by the approved centre. Not all staff were trained in Basic Life Support, fire safety, management of aggression and violence, and the Mental Health Act During the annual inspection on March 2017 and the focused inspection on August 2017, the inspectors found the approved centre did not have input from a gastroenterologist or from a medical facility. Residents were discharged to the emergency department if they were medically unwell. There were no admission criteria to ensure that residents were not admitted to Lois Bridges if they were too physically or mentally ill to be treated there. The inspectors found that the layout of the approved centre and skills and expertise of staffing were not adequate for the care and treatment of a resident with severe mental illness. Following the annual regulatory inspection of Lois Bridges on March 2017, the Director of Standards and Quality Assurance was alerted by the Inspector to serious concerns about the operation of Lois Bridges as an in-patient mental health service. The Mental Health Commission issued an immediate action notice to the service on 29 March 2017, seeking information relating to risk management processes, admission processes, and staffing levels. The Mental Health Commission continued to monitor the service closely throughout 2017 by way of further requests for information and through the Corrective and Preventative Action Plan (CAPA) process. 3.2 Focus of inspection The focus of this inspection was Regulation 32: Risk Management Procedures and Regulation 26: Staffing. In particular, the inspection focused on the safety of residents and the staffing levels in the approved centre. AC0079 Lois Bridges Approved Centre Focused Inspection Report 2017 Page 6 of 22

7 3.3 Advisor On this inspection, the Inspector was accompanied by Dr Frances Connan, Consultant Psychiatrist and Clinical Director of Vincent Square Eating Disorder Service, London, UK, and Chair of the Quality Network for Eating Disorders, to act as an advisor to the Inspector under section 51(2)(a) of the Mental Health Act Her expert opinion about Lois Bridges has informed this report. Her recommendations, along with this report, have been provided to the Director of Quality and Standards in the Mental Health Commission for consideration as part of the regulatory function of the Mental Health Commission. AC0079 Lois Bridges Approved Centre Focused Inspection Report 2017 Page 7 of 22

8 4.0 Overview of the Approved Centre 4.1 Description of approved centre Lois Bridges was located in a residential area in Sutton village in north Dublin. It comprised a five-bedroom, two-storey house with a private garden. There was also an open-plan kitchen, dining and seating area, two rooms for groups, a sitting room, and a small office or interview room. Lois Bridges provided care and treatment for up to seven adults with eating disorders. Admissions were planned and voluntary, and detention under the Mental Health Act was not used. The approved centre was an independent, for-profit facility. Referrals for admission were made by general medical practitioners, selfreferral, consultant psychiatrists, and the HSE. Residents were funded by private health insurance, the HSE by prior arrangement, or occasionally self-funded. There were seven residents in Lois Bridges on the first day of the inspection. This decreased to six on the second day. The inspection team were not made aware of the transfer of a seriously ill resident with anorexia nervosa to Beaumont Hospital during the inspection period, despite requesting information about seriously ill residents in Lois Bridges. The director of services coordinated care and there was a consultant psychiatrist who attended Lois Bridges two days a week. There were no other medical or psychiatric doctors employed by the approved centre. The treatment programme featured group and individual therapies provided by a range of professionally qualified therapists who were contracted for services provided. There was no specialist medical input or formal arrangement with a medical facility. A GP assessed the residents and provided primary care medical assessments and interventions. 4.2 Conditions to registration There were no conditions attached to the registration of this approved centre at the time of this focused inspection. 4.3 Governance Lois Bridges approved centre was privately owned and managed. The management team comprised the registered proprietor, the clinical director and the director of services. The management team met sporadically; six meetings were held in 2017, none were held from April to July Minutes were available of these meetings. Sessional therapy staff, nursing staff, the dietician, and health care assistants reported to the director of services. Minutes of the Management and Clinical Governance Meeting showed no evidence that the risk management audit was reviewed with the senior management team at this meeting. In addition, there was no evidence in the minutes that regulatory compliance concerns of the Mental Health Commission were discussed and acted upon in this forum. For example, actions from February 2017 minutes were not all followed up in March 2017 minutes.

9 An admission criteria policy was developed in response to regulatory concerns following the previous focused inspection. However, this failed to include criteria to prevent inappropriate high risk admissions to Lois Bridges and is further evidence of poor risk identification and management at organisational level. There was little evidence that the current medical, nursing, or health care assistant staff had training in eating disorders. The clinical nurse manager had experience and training in eating disorders and demonstrated knowledge and skill. However, that staff member was not always on duty and no contingency plan was in place should this skilled staff member be unavailable. The dietician had training in eating disorders. There was a culture of informal governance structures in Lois Bridges, including ad hoc management meetings and informal discussions about clinical and organisational matters. It was apparent during interviews that some staff wanted to treat everyone, regardless of clinical risk and lack of appropriate facilities and staffing. There was a lack of awareness of the clinical implications of admitting severely ill residents to Lois Bridges without adequate medical back-up. While there was a risk register, key risks were not recorded or were minimised. Regulatory non-compliance was risk-rated too low by management, despite being risk-rated by the Inspector as critical. Clinical risks specific to eating disorders were not included and this reflected a concerning lack of awareness by senior staff of clinical risks. Action plans in the risk register were not SMART (specific, measurable, achievable, realistic, and time-bound). AC0079 Lois Bridges Approved Centre Focused Inspection Report 2017 Page 9 of 22

10 5.0 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 1 Registered Proprietor Director of Services Clinical Nurse Manager 2 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. These have been included in the body of the report. 1 A new Clinical Director had commenced employment on the day of this second focused inspection and attended the feedback meeting AC0079 Lois Bridges Approved Centre Focused Inspection Report 2017 Page 10 of 22

11 6.0 Focused Inspection Findings AC0079 Lois Bridges Approved Centre Focused Inspection Report 2017 Page 11 of 22

12 Regulation 26: Staffing NON-COMPLIANT Risk Rating (1) The registered proprietor shall ensure that the approved centre has written policies and procedures relating to the recruitment, selection and vetting of staff. (2) The registered proprietor shall ensure that the numbers of staff and skill mix of staff are appropriate to the assessed needs of residents, the size and layout of the approved centre. (3) The registered proprietor shall ensure that there is an appropriately qualified staff member on duty and in charge of the approved centre at all times and a record thereof maintained in the approved centre. (4) The registered proprietor shall ensure that staff have access to education and training to enable them to provide care and treatment in accordance with best contemporary practice. (5) The registered proprietor shall ensure that all staff members are made aware of the provisions of the Act and all regulations and rules made thereunder, commensurate with their role. (6) The registered proprietor shall ensure that a copy of the Act and any regulations and rules made thereunder are to be made available to all staff in the approved centre. INSPECTION FOCUS Part 2, 3 and 4 of the regulation were inspected against. INSPECTION FINDINGS There was no improvement in the number and skill mix of staff of the approved centre since the annual inspection in May 2017 and the focused inspection in August The approved centre had an organisational chart to identify the leadership and management structure and lines of authority and accountability of staff. A planned and actual staff rota was maintained. Staff were recruited, selected, and vetted in line with the approved centre s policy and procedures for recruitment, selection, and appointment. A nurse and health care assistant were on duty during the day and at night. The number and skill mix of staffing did not meet resident needs because an appropriately qualified staff member was not on duty and in charge at all times. According to the staff roster for the previous three months, 30% of the time a registered psychiatric nurse (RPN) was not in charge during daytime hours and for 52% of the time, an RPN was not in charge during night time hours. This issue was identified in the 2016 inspection report and had been ongoing with no improvement. At the time of this inspection, two RPN posts were vacant. The clinical director, who had just taken up post, provided 16 hours of direct input across two days and was also on call 24 hours a day, 7 days a week for Lois Bridges. The clinical director also worked in another health care facility during this time. There was no other input from a psychiatrist or non-consultant hospital doctor. There were no formal arrangements for a consultant on-call rota. There were arrangements for cover in the event of annual leave, sick leave, or unforeseen absences. It was not considered safe practice to have only one consultant psychiatrist on continuous duty with no other medical/psychiatric input. A written staffing plan for the approved centre was not available to the inspection team. Annual staff training plans had been developed for all staff, and orientation and induction training was completed. At least one staff member had Children First training. All staff had received training in fire safety. Most but AC0079 Lois Bridges Approved Centre Focused Inspection Report 2017 Page 12 of 22

13 not all staff were up to date with required training in Basic Life Support (BLS). Staff were trained in the Mental Health Act 2001, and the management of aggression and violence. Staff training records indicated that efforts had been made to achieve compliance with this part of the regulation. In an approved centre where severely ill residents with anorexia nervosa were treated, training in BLS is considered essential. One nursing staff member and dietician had received training in Master Practitioner skills for eating disorders. No other nursing, health care assistant, or medical staff had training in eating disorders, despite Lois Bridges offering a specialist eating disorder service. The Mental Health Act 2001, the associated regulation, Mental Health Commission rules and codes, and all other documentation and guidance were available to staff throughout the approved centre. The following is a table of staff assigned to the approved centre. Ward or Unit Staff Grade Day Night CNM Lois Bridges RPN or RGN 1 1 HCA 1 1 Clinical Nurse Manager (CNM), Registered Psychiatric Nurse (RPN), Registered General Nurse (RGN), Health Care Assistant (HCA) The approved centre was non-compliant with this regulation for the following reasons: a) An appropriately qualified staff member was not on duty and in charge at all times, 26(3). b) There was insufficient psychiatric input from a consultant psychiatrist, 26(2). c) Not all staff had up-to-date, mandatory training in Basic Life Support, 26(4). d) Not all clinical staff had training in eating disorders to enable them to provide a specialist eating disorder in-patient service, 26(4). AC0079 Lois Bridges Approved Centre Focused Inspection Report 2017 Page 13 of 22

14 Regulation 32: Risk Management Procedures NON-COMPLIANT Risk Rating (1) The registered proprietor shall ensure that an approved centre has a comprehensive written risk management policy in place and that it is implemented throughout the approved centre. (2) The registered proprietor shall ensure that risk management policy covers, but is not limited to, the following: (a) The identification and assessment of risks throughout the approved centre; (b) The precautions in place to control the risks identified; (c) The precautions in place to control the following specified risks: (i) resident absent without leave, (ii) suicide and self harm, (iii) assault, (iv) accidental injury to residents or staff; (d) Arrangements for the identification, recording, investigation and learning from serious or untoward incidents or adverse events involving residents; (e) Arrangements for responding to emergencies; (f) Arrangements for the protection of children and vulnerable adults from abuse. (3) The registered proprietor shall ensure that an approved centre shall maintain a record of all incidents and notify the Mental Health Commission of incidents occurring in the approved centre with due regard to any relevant codes of practice issued by the Mental Health Commission from time to time which have been notified to the approved centre. INSPECTION FOCUS Part 1 and 2 of the regulation were inspected against. INSPECTION FINDINGS There had been limited improvement in risk management procedures in the approved centre since the annual inspection in March 2017 and the focused inspection in August There was a risk management policy that was dated September 2017, authored by a health care assistant, and approved by the Clinical Director rather than the senior management team. The policy was not comprehensive. It did not cover clinical risk, in particular the clinical risks associated with severe anorexia, or outline any precautions in place to control or mitigate these risks. No arrangements were outlined in the policy for learning from adverse events. The medical emergency policy only addressed the management of an unresponsive patient. It did not address any of the medical emergencies that can arise when treating seriously ill patients with anorexia nervosa. No protocols for these emergencies were in place. This was of particular concern as most of the time no medical staff, apart from one nurse, were on-site and Lois Bridges was not close to a medical facility or emergency department. A number of ligature anchor points had been rectified since the previous inspection, namely the bannisters and showers. However, a number remained such as hand rails in the downstairs toilet. While the inspectors were assured that this door was kept locked, this was not observed to be the case during the inspection. Blinds in the bedrooms constituted a ligature risk, as did a curtain holder on the stairs. AC0079 Lois Bridges Approved Centre Focused Inspection Report 2017 Page 14 of 22

15 There was evidence that some residents had been assessed as too high a risk for the clinical setting and for admission and had not therefore been offered a bed. However, Lois Bridges continued to admit seriously ill patients with anorexia nervosa, i.e. with a body mass index (BMI) of below 15, sometimes as low as 11 (potentially life-threatening range). The admission criteria did not specify exclusion criteria for admission and did not assist in determining the safe admission of residents. There were inconsistencies in the evidence of staff in Lois Bridges as to what level of seriousness of eating disorder they could safely treat. The risk assessment tool used by service did not identify specific eating disorder risks adequately. The approved centre did not have an arrangement with a gastroenterologist to provide specialist care where necessary. The gastroenterologist in Beaumont Hospital (the nearest hospital) reported to the inspectors that no contact had been made with him at any time to discuss the referral and ongoing care of seriously ill patients with anorexia nervosa who had been admitted from Lois Bridges. Any medical input was sourced through the emergency department where there could be lengthy waiting times for a bed. Contact with the liaison psychiatrist in Beaumont Hospital was sporadic and mostly initiated by the liaison psychiatrist. Some residents had continuing weight loss, neutropenia, cardiac abnormalities, hypoglycaemia, and electrolyte abnormalities when transferred to Beaumont Hospital emergency department from Lois Bridges. The liaison psychiatrists and gastroenterologist in Beaumont Hospital described residents referred from Lois Bridges as critically ill and not having been referred in a timely manner. They stated that referral letters to the emergency department contained little information and did not always include the residents BMI, which is essential information in assessing a patient with anorexia nervosa. During the inspection period, a critically ill resident was transferred at night to the emergency department due to a deterioration in their medical condition. The approved centre did not inform the inspection team that this transfer had taken place. The inspection team were subsequently informed by Beaumont Hospital (a) of the transfer and the seriousness of this resident s condition, (b) that referral details were minimal, (c) that the resident s BMI was not included on the referral letter, and (d) that there was no prior contact by Lois Bridges to state that they were discharging this resident to Beaumont Hospital. There was no facility to obtain daily bloods at weekends in Lois Bridges and there was a waiting time of 24 hours for results of blood tests taken on weekdays. For seriously ill residents, this was not safe practice as daily blood tests may be required initially as well as same day test results. The risk assessment tool used by the service (implemented March 2017) did not identify specific eating disorder risks adequately. To obtain a full picture of clinical risk for a patient, it was necessary for the inspectors to read a variety of entries in the notes, including progress notes, dietetic notes, blood tests, and the risk assessment form. The risk assessment form should identify and record all eating disorders and associated risks and guide assessment of appropriateness for admission, management of risk during treatment, and appropriate discharge planning, but this was not the case. AC0079 Lois Bridges Approved Centre Focused Inspection Report 2017 Page 15 of 22

16 The approved centre stated that it closed during the Christmas period every year and discharged residents into the care of their GPs. This was an unsafe practice. The approved centre was advised that it should remain open and that, if clinically indicated, residents should be on leave with an option to return to the approved centre at any time. The service used a Risk Management Audit (RMA) form as its method for recording and reviewing identified risk, with risk rating and risk mitigation and management plans. The RMA was reviewed quarterly, which for some of the risks identified was not sufficiently frequent. Key risks identified by the regulator were omitted or minimised. Inappropriately high-risk admissions, discharge planning, and medicines management were absent. Lack of registered psychiatric nursing staff was recorded as an organisational risk/business continuity risk rather than a clinical risk. The potential impact of this risk was recorded as unsatisfactory client experience because of inadequate information provided to client or family, which is a strange reflection of the potential clinical impact. Risk mitigation and management entries in the RMA are statements of policy rather than action plans. Action plans to reduce risk were not SMART (specific, measureable, achievable, realistic, and time bound). Contingency plans, to mitigate risk while actions to reduce risk were undertaken, were inadequate to manage current risks. Suggested controls for non-compliance with the regulation were recorded as Still a number of minor issues requiring improvements, continue to work with MHC (Mental Health Commission). The approved centre was non-compliant with this regulation for the following reasons: a) The risk management policy was not adequately comprehensive, 32(1). b) The risk management policy was not implemented throughout the approved centre in that not all ligatures and ligature anchor points had been mitigated or removed, 32(1). c) The risk management policy did not specify the processes for learning from serious or untoward incidents or adverse events involving residents, 32(2)(d). d) The only access to specialist medical assessment and treatment was for residents to be sent in emergency circumstances to an emergency department of a general hospital, which constituted a risk to residents, 32(1). e) Individual risk assessment did not assess for specific risks associated with eating disorders, 32(1). f) Severely ill residents with anorexia nervosa were admitted to Lois Bridges, which did not provide resources and facilities for safe care and treatment, 32(1). AC0079 Lois Bridges Approved Centre Focused Inspection Report 2017 Page 16 of 22

17 Appendix 1: Lois Bridges Corrective and Preventative Action (CAPA) Plans Regulation 26: Staffing Area(s) of noncompliance 1. An appropriately qualified staff member was not on duty and in charge at all times, 26(3). Specific Measureable Achievable / Realistic Corrective Action(s): Presently there are 5 RPNs on the duty roster. A further RPN is coming into post on 22 nd June 2018 having been recruited from the UK This will give Lois Bridges its full complement of RPNs by 22 nd June Post-Holder(s) responsible: HR The CNM coming into post on 22 nd June will ensure that a full complement of 6 RPNs is available for duty at all times. This will ensure that there is an appropriate qualified staff member on duty and in charge of the approved centre at all times. Duty rosters will be maintained as per the approved centres records management policy Time-bound Achievable 22 nd June RPNs currently on the duty roster. Final RPN on roster 22 nd June to commence induction Preventative Action(s): Six monthly audit of Regulation 26 Staffing will measure compliance Audits reviewed at Management meeting to ensure actions are implemented. Achievable 12 th June 2018 Post-Holder(s) responsible: CNM Staffing will be part of the agenda at each management team meeting. 2. There was insufficient psychiatric input from a consultant psychiatrist, 26(2). Corrective Action(s): The Clinical Director is on site for a minimum of 16 hours per week. Based on clinical need this can be increased. In the case of annual leave/sickness or unforeseen circumstances and any other planned leave a formal arrangement is in place with Dr Haytham Elhassan Consultant Psychiatrist A clear record of the Clinical Director s weekly input will be maintained. In place since March 2018 Preventative Action(s): At the weekly MDT (Thursday), the CNM and the Director of Service assesses the needs of each resident to determine if additional psychiatric input from the Clinical Director is required Post-Holder(s) responsible: Director of Services, Clinical Director & CMN Minutes of MDT meeting. A clear record of the Clinical Director s weekly input is maintained. Implemented since Jan 2018 In place since March 2018

18 Area(s) of noncompliance 3. Not all staff had up-to-date, mandatory training in Basic Life Support, 26(4). Specific Measureable Achievable / Realistic Corrective Action(s): All staff now have been trained in all mandatory training including MAPA and Basic Life support Post-Holder(s: HR Jacinta Moor A Training record for each staff member is available both on soft copy and hard copy (located in each individual personal file). Time-bound In Place since April 2018 Preventative Action(s): Six monthly audits of Individual training records Action plan resulting from audits will be discussed and actions resulting from finding of audits will be implemented Achievable 12 th June 2018 Post-Holder(s) responsible: Director of Services 4. Not all clinical staff had training in eating disorders to enable them to provide a specialist eating disorder in-patient service, 26(4). Corrective Action(s. CBT-E Training has been arranged for all staff on July 12/13th. All relevant staff will attend. The following Internal Training has taken place: April 17 th 2018: Harriette Lynch Consultant Dietitian Refeeding Syndrome Records of staff training will be maintained in the Training log and in each staff member s personnel file Records of staff training are maintained in the Training log and in each staff member s personnel file Achievable July 13 th 2018 In place since April 2018 April 19 th 2018: Suzanna Gahoviec Clinical Psychologist Shame Experienced by Eating Disorder Clients A training program is being rolled out to staff by each member of the MDT in respect of their individual specialities Post-Holder(s) responsible: Director of Services Records of staff training are maintained in the Training log and in each staff member s personnel file Training programmes are currently in place twice monthly Preventative Action(s): six monthly audits of Regulation 26 Staffing. Post-Holder(s) responsible: Director of Services Regulation 32: Risk Management Procedures Audit results to be reviewed at Management Team meeting Feedback to Staff at MDT and staff meetings Achievable 12 th June 2018 AC0079 Lois Bridges Approved Centre Focused Inspection Report 2017 Page 18 of 22

19 Area(s) of non-compliance Specific Measureable Achievable / Realistic Time-bound 5. The risk management policy was not adequately comprehensive, 32(1). Corrective Action(s): The risk management policy is being reviewed and currently update in line with the requirements of the regulations and JSF. Lois Bridges has engaged the services of Sean Logue External Compliance consultant to facilities this review. Sean is a former Inspector with the Mental Health Commission Risk Management Policy currently undergoing review and updating Achievable 15 th June 2018 Post-Holder(s) responsible: Management Team: Director of Services Proprietor Clinical Director External Consultant Preventative Action(s): Following review of the updated policy a six-monthly audit of compliance with Regulation 32 Risk Management Procedures will be carried out to ensure compliance Six-monthly Audit Achievable November The risk management policy was not implemented throughout the approved centre in that not all ligatures or ligature anchor points had been mitigated or removed, 32(1) Post-Holder(s) responsible: Director of Services Corrective Action(s): Curtain Ring rail bar removed from landing: April 19 th 2018 Blinds replaced in room 3 & 1 April 16 th 2018 Downstairs bathroom is locked at all times and a key requested from nursing staff. Ligature risk audits are now carried out every quarter by Post-Holder(s) responsible: Registered Proprietor Completed 19 th April 2018 Preventative Action(s): Ligature Anchor Audit completed on April 13 th Health & Safety meeting is conducted every quarter, minutes are maintained and any issues identified are actioned. The ligature audit is available for inspection Completed 13 th April 2018 Post-Holder(s) responsible: Alisha Woods Director of Services AC0079 Lois Bridges Approved Centre Focused Inspection Report 2017 Page 19 of 22

20 Area(s) of non-compliance Specific Measureable Achievable / Realistic 7. The risk management policy did not specify the processes for learning from serious or untoward incidents or adverse events involving residents, 32(2)(d). Health & safety Officer Corrective Action(s): The risk management policy is being reviewed and currently update in line with the requirements of the regulations and JSF. Lois Bridges has engaged the services of Sean Logue External Compliance consultant to facilitate this review. Sean is a former Inspector with the Mental Health Commission. This revised policy will include the processes from learning from serious or untoward incidents or adverse events involving residents. Minutes of Health & Safety meeting are available Risk Management Policy is currently under review. Achievable Time-bound 15 th June 2018 Preventative Action(s): Currently at weekly MDT any serious or untoward incidents are now reviewed by the team and record of these meetings are maintained. The learning from any incidents are now discussed and shared among the staff team at staff meetings (held every 8 weeks). Information is also shared regularly through the internal network Post-Holder(s) responsible: Management Team: Director of Services Proprietor Clinical Director External Consultant Since 12 th April 2018 Since 12 th April 2018 AC0079 Lois Bridges Approved Centre Focused Inspection Report 2017 Page 20 of 22

21 Area(s) of non-compliance Specific Measureable Achievable / Realistic 8. The only access to specialist medical assessment and treatment was for residents to be sent in emergency circumstances to an emergency department of a general hospital, which constituted a risk to residents, 32(1). Corrective Action(s): In Medical Emergencies such as (slips, trips, falls, cardiac arrest) Residents will be sent via ambulance to the local hospital. Staff will accompany the resident and relevant patient information will be handed over. In the case of discharge or transfers all residents will be discharged/transferred to their own hospital under the care of their gastroenterologist. It is now part of the admission criteria for Lois Bridges that all residents prior to admission have been assessed by a consultant gastroenterologist. Post-Holder(s) responsible: Clinical Director Time-bound Since 22 nd December 2017 Since 22 nd December 2017 Preventative Action(s): The exclusion criteria are now part of the individual risk assessment process on admission Since 23 rd April 2018 Post-Holder(s) responsible Clinical Director & admitting Nurse 9. Individual risk assessment did not assess for specific risks associated with eating disorders, 32(1). Corrective Action(s): All current risks assessments are now specific to risks associated with eating disorders. All future admissions to Lois Bridges now have an individual risk assessment that assesses for specific risks associated with eating disorders. Since 23 rd April 2018 Post-Holder(s) responsible: Clinical Director CNM Preventative Action(s): All individual risk assessments will now be audited six monthly. Achievable Achievable November 2018 AC0079 Lois Bridges Approved Centre Focused Inspection Report 2017 Page 21 of 22

22 Area(s) of non-compliance Specific Measureable Achievable / Realistic Time-bound 10. Severely ill residents with anorexia nervosa were admitted to Lois Bridges, which did not provide resources and facilities for safe care and treatment, 32(1). Corrective Action(s): An Individual requiring admission is not admitted to Lois Bridges if their BMI is less than 13.5 An Individual must be seen by a Consultant Gastroenterologist prior to admission No Individual requiring daily bloods is admitted. An Individual requiring nasogastric tube feeding is not admitted to Lois Bridges Post-Holder(s) responsible: Clinical Director Preventative Action(s): Six monthly audits of a sample of admissions to Lois Bridges will be conducted Post-Holder(s) responsible: In place since 1 st Jan 2018 Achievable Achievable November 2018 AC0079 Lois Bridges Approved Centre Focused Inspection Report 2017 Page 22 of 22