Acute Psychiatric Unit, Tallaght Hospital

Transcription

1 Acute Psychiatric Unit, Tallaght Hospital ID Number: AC Approved Centre Inspection Report (Mental Health Act 2001) Acute Psychiatric Unit, Tallaght Hospital Tallaght Dublin 24 Approved Centre Type: Acute Adult Mental Health Care Continuing Mental Health Care/Long Stay Mental Health Rehabilitation Most Recent Registration Date: 1 March 2017 Conditions Attached: Yes Registered Proprietor: HSE Registered Proprietor Nominee: Mr Kevin Brady, Head of Service, Mental Health - CHO 7 Inspection Team: Leon Donovan, Lead Inspector Sandra McGrath Mary Connellan David McGuinness Carol Brennan-Forsyth Inspection Date: September 2017 Inspection Type: Unannounced Annual Inspection Previous Inspection Date: October 2016 The Inspector of Mental Health Services: Dr Susan Finnerty MCRN Date of Publication: 15 March COMPLIANCE RATINGS REGULATIONS RULES AND PART 4 OF THE MENTAL HEALTH ACT CODES OF PRACTICE 1 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 AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 2 of 102

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 AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 3 of 102

4 AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 4 of 102

5 1.0 Introduction to the Inspection Process The principal functions of the Mental Health Commission are to promote, encourage and foster the establishment and maintenance of high standards and good practices in the delivery of mental health services and to take all reasonable steps to protect the interests of persons detained in approved centres. The Commission strives to ensure its principal legislative functions are achieved through the registration and inspection of approved centres. The process for determination of the compliance level of approved centres against the statutory regulations, rules, Mental Health Act 2001 and codes of practice shall be transparent and standardised. Section 51(1)(a) of the Mental Health Act 2001 (the 2001 Act) states that the principal function of the Inspector shall be to visit and inspect every approved centre at least once a year in which the commencement of this section falls and to visit and inspect any other premises where mental health services are being provided as he or she thinks appropriate. Section 52 of the 2001 Act states that, when making an inspection under section 51, the Inspector shall a) See every resident (within the meaning of Part 5) whom he or she has been requested to examine by the resident himself or herself or by any other person. b) See every patient the propriety of whose detention he or she has reason to doubt. c) Ascertain whether or not due regard is being had, in the carrying on of an approved centre or other premises where mental health services are being provided, to this Act and the provisions made thereunder. d) Ascertain whether any regulations made under section 66, any rules made under section 59 and 60 and the provision of Part 4 are being complied with. Each approved centre will be assessed against all regulations, rules, codes of practice, and Part 4 of the 2001 Act as applicable, at least once on an annual basis. Inspectors will use the triangulation process of documentation review, observation and interview to assess compliance with the requirements. Where noncompliance is determined, the risk level of the non-compliance will be assessed. The Inspector will also assess the quality of services provided against the criteria of the Judgement Support Framework. As the requirements for the rules, codes of practice and Part 4 of the 2001 Act are set out exhaustively, the Inspector will not undertake a separate quality assessment. Similarly, due to the nature of Regulations 28, 33 and 34 a quality assessment is not required. Following the inspection of an approved centre, the Inspector prepares a report on the findings of the inspection. A draft of the inspection report, including provisional compliance ratings, risk ratings and quality assessments, is provided to the registered proprietor of the approved centre. Areas of inspection are deemed to be either compliant or non-compliant and where non-compliant, risk is rated as low, moderate, high or critical. AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 5 of 102

6 COMPLIANCE, QUALITY AND RISK RATINGS The following ratings are assigned to areas inspected. COMPLIANCE RATINGS are given for all areas inspected. QUALITY RATINGS are given for all regulations, except for 28, 33 and 34. RISK RATINGS are given for any area that is deemed non-compliant. COMPLIANCE QUALITY RISK COMPLIANT EXCELLENT SATISFACTORY LOW NON- COMPLIANT REQUIRES IMPROVEMENT INADEQUATE MODERATE HIGH CRITICAL The registered proprietor is given an opportunity to review the draft report and comment on any of the content or findings. The Inspector will take into account the comments by the registered proprietor and amend the report as appropriate. The registered proprietor is requested to provide a Corrective and Preventative Action (CAPA) plan for each finding of non-compliance in the draft report. Corrective actions address the specific non-compliance(s). Preventative actions mitigate the risk of the non-compliance reoccurring. CAPAs must be specific, measurable, realistic, achievable and time-bound (SMART). The approved centre s CAPAs are included in the published inspection report, as submitted. The Commission monitors the implementation of the CAPAs on an ongoing basis and requests further information and action as necessary. If at any point the Commission determines that the approved centre s plan to address an area of noncompliance is unacceptable, enforcement action may be taken. In circumstances where the registered proprietor fails to comply with the requirements of the 2001 Act, Mental Health Act 2001 (Approved Centres) Regulations 2006 and Rules made under the 2001 Act, the Commission has the authority to initiate escalating enforcement actions up to, and including, removal of an approved centre from the register and the prosecution of the registered proprietor. AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 6 of 102

7 2.0 Inspector of Mental Health Services Summary of Findings Inspector of Mental Health Services Dr Susan Finnerty As Inspector of Mental Health Services, I have provided a summary of inspection findings under the headings below. This summary is based on the findings of the inspection team under the regulations and associated Judgement Support Framework, rules, Part 4 of the Mental Health Act 2001, codes of practice, service user experience, staff interviews and governance structures and operations, all of which are contained in this report. Safety in the approved centre The approved centre had a safety statement and a series of written policies in relation to risk management, however, the risk management policy was not comprehensive. Relevant staff had received training in the identification, assessment, and management of risk. Managerial staff were not trained in organisational risk management. The risk registers were audited on a monthly basis. Health and safety risks were not identified, assessed, treated, reported, monitored, and documented. Structural risks, including ligature points, had not been removed or effectively mitigated. Numerous ligature points were observed in the approved centre, and many areas could not be actively monitored due to staff shortages. The approved centre completed risk assessments for all residents at admission to identify individual risk factors. The person with responsibility for risk management did not review incidents for any trends or patterns occurring in the services. Food safety audits were completed periodically. Hygiene was maintained to support food safety requirements. Catering areas and associated equipment were appropriately cleaned. Person-specific identifiers were used before the administration of medication, the undertaking of medical investigations, and the provision of other health care services. There were errors in the prescribing of medication practices. The numbers and skill mix of staff were not sufficient to address resident needs and there was a heavy dependency on overtime and the use of agency staff to provide cover but agency nurses were not always provided. An appropriately qualified staff member was on duty and in charge at all times. Not all health care professionals had up-to-date, mandatory training in fire safety, Basic Life Support, the management of aggression and violence, and the Mental Health Act 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 The approved centre has been non-compliant with Regulation 15 Individual Care Plans for three consecutive years. It had a condition to its registration that individual care plans must be audited monthly and a report AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 7 of 102

8 sent to the Mental Health Commission. Despite this, the approved centre was non-compliant again in 2017 with a number of serious deficits, including lack of multidisciplinary input and lack of resident involvement in their own individual care plan. The range of available therapeutic services and programmes was appropriate and met the assessed needs of the residents. Adequate and appropriate resources and facilities were available to provide therapeutic services and programmes. Two residents had not received a physical examination within the required six-month time frame. Where relevant, residents had access to appropriate national screening programmes. Not all of the clinical records were in good order. The approved centre was non-compliant with Part 4 of the Mental Health Act 2001: Consent to Treatment because the consent form was not fully completed and did not specify the following: the name of the medications prescribed, details of discussion with the patient as to the nature and purpose of the medication, the provision of information to the resident on the effects of the medications and the supports provided to the patient in relation to the discussion and their decision-making, rendering the consent invalid. The approved centre was non-compliant with nine requirements of the Rule Governing the Use of Seclusion and was non-compliant with the Code of Practice on Physical Restraint. It was non-compliant with 14 of the elements of the Code of Practice on Admission, Transfer and Discharge. The provision of ECT was compliant with the relevant rule and code of practice. AREAS REFERRED TO Regulations 5, 14, 15, 16, 17, 18, 19, 23, 25, 27, Part 4 of the Mental Health Act 2001, Rule Governing the Use of Seclusion and Mechanical Means of Bodily Restraint, Rule Governing the Use of ECT, Code of Practice on Physical Restraint, Code of Practice on the Admission of Children, Code of Practice on the Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities, Code of Practice on Admission, Transfer and Discharge, service user experience, and interviews with staff. Respect for residents privacy and dignity Residents were able wear their personal clothing and all residents had an adequate supply of individualised clothing. Residents clothing was observed to be clean and appropriate to their needs. Residents could bring personal possessions into the approved centre and were supported to manage their own property. Secure facilities were provided for the safe-keeping of residents monies, property, and valuables. Residents consent was sought in advance of a search and residents were informed by those implementing the search of what was happening and why. Two to three nursing staff were in attendance at all times when searches were conducted. Bathrooms, showers, toilets, and single bedrooms had locks on the inside of the doors. Where residents shared a room, appropriate bed screening was in place to ensure that privacy was not compromised. All windows had been fitted with reflective film, which meant that residents could see out but passers-by could not see in. AREAS REFERRED TO Regulations 7, 8, 13, 14, 21, 25, Rule Governing the Use of Seclusion, Code of Practice on Physical Restraint, Code of Practice on the Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities, service user experience, and interviews with staff. Responsiveness to residents needs Residents were provided with a variety of wholesome and nutritious food choices within the approved centre s menus, with three or four options daily for lunch and tea. Food, including modified consistency AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 8 of 102

9 diets, was presented in an appealing manner. The approved centre provided a range of recreational activities on weekdays and during the weekend appropriate to the resident group profile. A timetable of recreational activities was displayed. Residents were facilitated in the practice of their religion and there was a multifaith hospital chapel, which residents could use. Visiting times, which were appropriate and reasonable, were publicly displayed and residents could meet visitors in private in the family room. Residents had access to communications that included telephone, mail, , and fax. Required information was provided to residents and/or their representatives at admission, in an information booklet. Residents received written and verbal information about their diagnosis and indications for use of all medications administered and the risks and potential side-effects of medication. The complaints procedure was satisfactory. Residents had access to personal space, and appropriately sized communal areas were available to each ward. Sufficient spaces were provided for residents to move about, including an internal gardens. The approved centre was not in a good state of repair internally. There were plans to improve the decorative condition of the premises, but these had been in place since before the 2016 inspection and had not been acted on. A cleaning schedule was in place, but the approved centre was not clean, hygienic, and free from offensive odours. Rowan Ward was not clean and the games room was dirty, with stained walls, a smell of smoke, missing ceiling tiles, stained walls, and dirty couches. 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 Acute Psychiatric Unit, Tallaght Hospital, was part of the Community Healthcare Organisation (CHO) 7 area and provided acute admission facilities for the Dublin West and Dublin South West catchment area. The governance processes in place included a mental health area management team (Dublin South Central) meeting, a unit management meeting, and clinical nurse managers meetings. The minutes of the monthly area management team meetings provided evidence of an active governance process, which considered overall service development, policy strategy, quality and patient safety issues including incidents, health and safety strategy, staffing, training, and compliance. Minutes of the monthly unit management team meetings and clinical nurse managers team meetings covered a variety of issues pertinent to the operation of the approved centre, including risk registers, compliance, therapeutic services and activities, training, care plans, audits, and implementation of the tobacco-free campus policy. The two-monthly policy group meetings were attended by a mixture of staff, including heads of discipline, nursing, medical, and administrative staff. The most recent meeting indicated a change in strategy from a single policy group, which covered both community services and approved centres, to two distinct policy groups dealing with each. Operating policies and procedures were developed with input from clinical and managerial staff and in consultation with all relevant stakeholders. All of the operating policies and procedures required by the regulations had been reviewed within three years. AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 9 of 102

10 A Quality and Patient Safety Committee was in the process of being established, and the terms of reference had been drafted recently. Clear lines of responsibility were evident in each department; heads of discipline attended regular meetings with staff and staff supervision was facilitated by all health and social care professional heads of discipline. All heads of discipline reported having received training in clinical risk management. Clinical supervision was provided through line management in all disciplines. The HSE s key performance indicators assisted the organisation in determining how well it was performing, and service user input was facilitated by the recent appointment of the area lead for mental health engagement to the area management team. Apart from the official HSE Your Service Your Say feedback mechanism, most disciplines did not have a formal approach to garnering individual service user feedback to measure performance. Occupational therapy and social work heads of discipline used personal development plans with their staff, however no formal performance appraisals were undertaken by other disciplines. AREAS REFERRED TO Regulations 26 and 32, interviews with heads of discipline, and minutes of area management team meetings. AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 10 of 102

11 3.0 Quality Initiatives The following quality initiatives were identified on this inspection 1. Physical restraint Pathway : This document was introduced to ensure that all the recording requirements of the Code of Practice on the Use of Physical Restraint in Approved Centres were met for each episode of physical restraint. 2. Clinical supervision for staff: Clinical supervision for nursing staff was introduced. Group sessions for nursing staff and nurse managers are facilitated by a clinical psychologist on a weekly basis. 3. Going Home from Hospital booklet: The booklet was reviewed and updated in 2017, and its use was extended for patients being discharged and going on leave. It provides contact details for the ward and the community teams as well as a crisis plan, which is developed with the designated key nurse prior to leaving the ward. 4. Bleep-free zone: Following on from an audit of clinical handovers, an initiative known as a bleep-free zone was introduced. Bleep-free zones are 20-minute slots during registrar-to-registrar handovers when wards will not bleep the duty doctor (unless in an emergency situation). This is to facilitate protected time for registrars to conduct their shift handovers with minimal interruption so as to enable the transfer of accurate, up-to-date, relevant information. 5. Metrics checklist: Nursing Quality Care Metrics continued to be used to improve quality within the service. More recently a metrics checklist was created in Aspen Ward to ensure compliance with all areas included within the monthly metrics. This has since been introduced into both Rowan and Cedar Wards. 6. Transfer form: This was developed for use when residents are being transferred to another service. It was introduced to ensure that receiving facilities are provided with all relevant information, including a nursing summary of the resident s admission to the approved centre. 7. Consent to treatment form: This was developed to ensure that patients are fully facilitated in making informed decisions regarding consent to treatment. It documents all relevant information being discussed with the patient. AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 11 of 102

12 4.0 Overview of the Approved Centre 4.1 Description of approved centre The approved centre was located on the ground floor of a building within the grounds of Tallaght Hospital. Access to the unit was through the main entrance of the hospital and was signposted within. There was ample parking nearby in a multi-storey facility on the grounds of the hospital and there were a limited number of disabled parking spaces directly outside the main entrance to the hospital. The approved centre consisted of three units, Cedar (female admissions), Rowan (male admissions), and Aspen (high observation unit). There were 52 beds in the approved centre, 23 in each of Rowan and Cedar Wards and 6 in Aspen Ward. The facility was laid out around a central garden shared between Cedar and Rowan Wards, with Aspen Ward having its own separate garden area. Tallaght Hospital was a tobacco-free campus, however, residents utilised the outdoor spaces within the approved centre to engage in smoking. The resident profile on the first day of inspection was as follows: Resident Profile Number of registered beds 52 Total number of residents 51 Number of detained patients 9 Number of Wards of Court 0 Number of children 0 Number of residents in the approved centre for more than 6 months Conditions to registration There were two conditions attached to the registration of this approved centre at the time of inspection: 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: To ensure adherence to Regulation 26(4): Staffing, the approved centre shall implement a plan to ensure all healthcare professionals working in the approved centre are up-to-date in mandatory training areas. The approved centre shall provide a progress update on staff training to the Mental Health Commission in a form and frequency prescribed by the Commission. AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 12 of 102

13 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 Acute Psychiatric Unit, Tallaght Hospital, was part of the Community Healthcare Organisation (CHO) 7 area and provided acute admission facilities for the Dublin West and Dublin South West catchment area. The governance processes in place included a mental health area management team (Dublin South Central) meeting, a unit management meeting, and clinical nurse managers meetings. Minutes of the monthly area management team meetings were provided to the inspection team. These were attended by heads of discipline from across the CHO, the quality and patient safety manager, and the area lead for mental health engagement. The minutes provided evidence of an active governance process, which considered overall service development, policy strategy, quality and patient safety issues including incidents, health and safety strategy, staffing, training, and compliance. Minutes of the monthly unit management team meetings and clinical nurse managers team meetings were provided to the inspectors. These covered a variety of issues pertinent to the operation of the approved centre, including risk registers, compliance, therapeutic services and activities, training, care plans, audits, and implementation of the tobacco-free campus policy. Minutes of the two-monthly policy group meetings were provided. These meetings were attended by a mixture of staff, including heads of discipline, nursing, medical, and administrative staff. The most recent meeting indicated a change in strategy from a single policy group, which covered both community services and approved centres, to two distinct policy groups dealing with each. A Quality and Patient Safety Committee was in the process of being established, and the terms of reference had been drafted recently. AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 13 of 102

14 5.0 Compliance 5.1 Non-compliant areas from 2016 inspection The previous inspection of the approved centre on October 2016 identified the following areas that were non-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 11: Visits Compliant Regulation 15: Individual Care Plan Non-Compliant Regulation 19: General Health Non-Compliant Regulation 22: Premises Non-Compliant Regulation 23: Ordering, Prescribing, Storing and Administration of Non-Compliant Medicines Regulation 26: Staffing Non-Compliant Regulation 27: Maintenance of Records Non-Compliant Regulation 28: Register of Residents Non-Compliant Regulation 29: Operating Policies and Procedures Compliant Regulation 31: Complaints Procedures Compliant Regulation 32: Risk Management Procedures Non-Compliant Rules Governing the Use of Seclusion Non-Compliant Part 4 of the Mental Health Act 2001: Consent to Treatment Non-Compliant Code of Practice on the Use of Physical Restraint in Approved Centres Non-Compliant Code of Practice Relating to Admission of Children Under the Mental Non-Compliant Health Act 2001 Code of Practice for Mental Health Services on Notification of Deaths Non-Compliant and Incident Reporting Code of Practice Guidance for Persons working in Mental Health Not Applicable Services with People with Intellectual Disabilities Code of Practice on Admission, Transfer and Discharge to and from an Non-Compliant Approved Centre AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 14 of 102

15 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 15: Individual Care Plan X X X Regulation 19: General Health X X Regulation 22: Premises X X Regulation 23: Ordering, Prescribing, Storing and X X X Administration of Medicines Regulation 26: Staffing X X X Regulation 27: Maintenance of Records X X Regulation 28: Register of Residents X X Regulation 32: Risk Management Procedures X X Rules Governing the Use of Seclusion X X Part 4 of the Mental Health Act 2001: Consent to Treatment Code of Practice on the Use of Physical Restraint in Approved Centres Code of Practice Relating to Admission of Children Under the Mental Health Act 2001 Code of Practice for Mental Health Services on Notification of Deaths and Incident Reporting Code of Practice on Admission, Transfer and Discharge to and from an Approved Centre X X X X X X 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 4: Identification of Residents AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 15 of 102

16 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 but the advocate was not able to speak with the inspection team. 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. The inspection team met with eight residents. Residents were complimentary of the care and treatment in the approved centre and all reported that the food was good. Two of the residents were not aware of their individual care plans and one did not know who their key worker was for that day. Residents interviewed felt they had enough to do during the day and some engaged in group therapies and activities organised by occupational therapy. Residents interviewed availed of yoga sessions and cooking classes. One resident who was recently admitted was not aware of the occupational therapy services available, but those who did use the services were highly complementary. Seven questionnaires were completed by residents and returned to the inspection team; however, not all questionnaires were fully completed. Eight leaflets returned by residents indicated that they had sufficient activities during the day. All except one understood what their individual care plan (ICP) was and four were involved in setting goals for their ICP. Four residents indicated that they knew who their multi-disciplinary team were and who their key worker was. Six residents indicated that they were happy with how staff spoke to them, and five felt free to communicate with friends, family, and advocates. AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 16 of 102

17 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: Clinical Director Area Director of Nursing Principal Clinical Psychologist Occupational Therapy Manager Due to prior commitments, the principal social worker was unable to meet the inspection team but remained in contact with the inspection team throughout the inspection via and provided training records and answered questions about governance through this medium. Heads of discipline from medical, social work, occupational therapy, psychology, and nursing each provided a clear overview of the governance within their respective departments. The clinical director was based in the approved centre and was on site most days. The occupational therapy manager and principal clinical psychologist attended the unit at least once a week, and the principal social worker and area director of nursing attended every week or two. Clear lines of responsibility were evident in each department; heads of discipline attended regular meetings with staff and staff supervision was facilitated by all health and social care professionals heads of discipline. All heads of discipline reported having received training in clinical risk management, but two stated that they had not received training in corporate risk management. Most were aware of the approved centre s safety statement and their roles as heads of discipline in relation to health and safety. Two heads of discipline identified clear strategic aims for their teams and all were able to identify short and medium terms goals to be achieved. Some key operational risks cited by heads of discipline included staff shortages and retention, getting cover during extended absences, and employee fatigue Clinical supervision was provided through line management in all disciplines; however, one head of discipline did not receive clinical supervision but was actively seeking to rectify this and had written to the general manager in this regard. The HSE s key performance indicators assisted the organisation in determining how well it was performing, and service user input was facilitated by the recent appointment of the area lead for mental health engagement to the area management team. Apart from the official HSE Your Service, Your Say feedback mechanism, most disciplines did not have a formal approach to garnering individual service user feedback to measure performance. Occupational therapy and social work heads of discipline used personal development plans with their staff, however no formal performance appraisals were undertaken by other disciplines. AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 17 of 102

18 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: Head of Mental Health Services CHO 7 Area Lead for Mental Health Engagement CHO 7 Clinical Director Director of Nursing Assistant Director of Nursing Clinical Nurse Manager 3 Clinical Nurse Manager 2 x 2 Clinical Nurse Specialist for ECT Nurse Practice Development Coordinator Principal Clinical Psychologist Occupational Therapy Manager 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. AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 18 of 102

19 9.0 Inspection Findings Regulations EVIDENCE OF COMPLIANCE WITH REGULATIONS UNDER MENTAL HEALTH ACT 2001 SECTION 52 (d) The following regulations are not applicable Regulation 1: Citation Regulation 2: Commencement and Regulation Regulation 3: Definitions AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 19 of 102

20 Regulation 4: Identification of Residents COMPLIANT Quality Rating Excellent The registered proprietor shall make arrangements to ensure that each resident is readily identifiable by staff when receiving medication, health care or other services. INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the identification of residents, which was last reviewed in July It addressed all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for identifying residents, as set out in the policy. Monitoring: An annual audit had been undertaken to ensure that clinical files contained appropriate resident identifiers. Documented analysis had been completed to identify opportunities for improving the resident identification process. Evidence of Implementation: At least two person-specific resident identifiers were in use in the approved centre. During the inspection, most residents were observed to be wearing wristbands. Other forms of identification were used for residents who did not wear wristbands, and these were appropriately documented in the respective clinical files. The identifiers, which were appropriate to residents communication abilities, were used before the administration of medication, the undertaking of medical investigations, and the provision of other health care services. An appropriate resident identifier was used prior to the provision of therapeutic services and programmes. A red-sticker system was in place to alert staff to the presence of residents with the same or a similar name. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework. AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 20 of 102

21 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 unit-specific policy in relation to the provision of appropriate food and nutrition to residents. Training and Education: There was no policy for staff to read, understand, or articulate. Monitoring: A systematic review of menu plans had been undertaken to ensure that residents received wholesome and nutritious food in accordance with their needs. Documented analysis had been completed by the Nutritional Steering Committee in Tallaght Hospital to identify opportunities for improving the processes for food and nutrition. Evidence of Implementation: To ensure nutritional adequacy in line with residents needs, the approved centre s menus had been approved by a dietitian in Tallaght Hospital, where all food was prepared. Residents were provided with a variety of wholesome and nutritious food choices within the approved centre s menus, with three or four options daily for lunch and tea. Food, including modified consistency diets, was presented in an appealing manner, and hot meals were served daily. Residents were offered hot and cold drinks regularly, and they had access to a source of safe, fresh drinking water. The water fountain was broken at the time of inspection, but jugs of fresh water were available throughout the approved centre. For residents with special dietary requirements, an evidence-based nutrition assessment tool was used in the approved centre. These residents needs were regularly reviewed by staff from the nutrition and dietetics department in Tallaght Hospital. Residents, their representatives, family, and next of kin were educated about residents diets. Nutritional and dietary needs were assessed, where necessary, and addressed in the residents individual care plans. 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. AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 21 of 102

22 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 written policy in relation to food safety, which was last reviewed in June It included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed could 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). The training was documented. Monitoring: Food safety audits were completed periodically through Tallaght Hospital. Food temperatures were recorded in line with food safety recommendations, and a temperature log sheet was maintained and monitored. Documented analysis had been completed to identify opportunities for improving food safety processes. Evidence of Implementation: Appropriate hand-washing areas were provided for catering services. There was suitable and sufficient catering equipment. Food was prepared in the kitchen in Tallaght Hospital using the cook-chill food process for residents main meals and evening tea. Suitable facilities were available in the approved centre for the refrigeration, storage, preparation, cooking, and serving of food. Hygiene was maintained to support food safety requirements. Catering areas and associated equipment were appropriately cleaned. Food was prepared in a manner that reduced the risk of contamination, spoilage, and infection. Residents were provided with a supply of suitable crockery and cutlery. 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 training and education pillar. AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 22 of 102

23 Regulation 7: Clothing COMPLIANT Quality Rating Satisfactory 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 did not have a policy in relation to residents clothing. Training and Education: There was no policy for staff to read and understand. Relevant staff interviewed could articulate the processes for residents clothing in the approved centre. Monitoring: The availability of an emergency supply of resident clothing was monitored on an ongoing basis, and this was documented. A record of residents wearing nightclothes during the day was maintained and monitored. Evidence of Implementation: Residents were supported to keep and wear their personal clothing. All residents had an adequate supply of individualised clothing. Residents clothing was observed to be clean and appropriate to their needs. Each ward maintained a supply of emergency clothing that took account of residents preferences, dignity, bodily integrity, and religious and cultural practices. During the inspection, two residents were observed wearing nightclothes during the day, however this was by choice and was recorded in their progress notes as such. 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. AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 23 of 102

24 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 policy in relation to residents personal property and possessions, which was last reviewed in July It included requirements of the Judgement Support Framework, with the exception of the process for allowing residents access to and control over their personal property and possessions, unless this posed a danger to the resident or others, as indicated by a risk assessment and the resident individual care plan (ICP). Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed could articulate the processes relating to residents property and possessions, as set out in the policy. Monitoring: Personal property logs were maintained and monitored. Analysis had not been completed to identify opportunities for improving the processes relating to residents personal property and possessions. Evidence of Implementation: Residents could bring personal possessions into the approved centre and were supported to manage their own property, unless this posed a danger to themselves or others, as indicated in their ICPs. Residents personal property and possessions were safeguarded when the approved centre assumed responsibility for them. Secure facilities were provided for the safe-keeping of residents monies, property, and valuables. Residents personal property and possessions were recorded in a triplicate book. Signed property checklists were kept separately from the residents ICPs. Access to and use of resident money was overseen by two members of staff and the residents or their representatives. Where any money belonging to residents was handled by staff, signed records of the staff issuing the money were retained. Where possible, these records were countersigned by the residents or their representatives. 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 monitoring pillars. AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 24 of 102

25 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 written policy in relation to the provision of recreational activities. Training and Education: There was no policy for staff to read and understand. Relevant staff interviewed could articulate the processes relating to recreational activities in the approved centre. Monitoring: A record was maintained in the nurses station of the occurrence of planned recreational activities, including a log of resident uptake/attendance. Analysis had not been completed to identify opportunities for improving the processes relating to recreational activities. Evidence of Implementation: The approved centre provided a range of recreational activities appropriate to the resident group profile including morning stretching, music and drama, a walking group, a newspaper group, and yoga. There was a reading room and a games room with a TV, pool table, table tennis table, and large couches. There were also communal recreational areas with books, games, and a TV. Outdoor areas were accessible to all residents. Activities were provided on weekdays and during the weekend. A timetable of recreational activities was posted up on noticeboards on the wards and activities were also listed on whiteboards. Recreational activities were developed, maintained, and implemented with resident involvement. Community meetings were held weekly. Where deemed appropriate, individual risk assessments were completed for residents in relation to the selection of appropriate activities. Residents decisions on whether or not to participate in activities were respected and documented. Opportunities were available for outdoor exercise and physical activity. Records of resident attendance at events were maintained in the respective clinical files. 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. AC0012 Acute Psychiatric Unit, Tallaght Hospital Approved Centre Inspection Report 2017 Page 25 of 102