The completed Plan will inform your ongoing registration as an approved centre, as detailed in Section 64 of the Mental Health Act, 2001.

Transcription

1 Regulatory Compliance Report (RCR) 2014 Department of Psychiatry Letterkenny Please complete this Regulatory Compliance Report by providing details of the actions you intend to take, the person(s) responsible for implementing these actions and the timeframe for completion of each individual action. Please also provide details of the measures you intend to use to assess that you are now fully compliant with requirements. Evidence of performing clinical audit before and afterwards should be provided to support your report, where relevant. The final report, as agreed with the Commission, will be published on the Commission s website, The completed Plan will inform your ongoing registration as an approved centre, as detailed in Section 64 of the Mental Health Act, For Mental Health Commission use only Compliance Report Due Date: 16 th January 2015 Date of Receipt: 15 th January 2015 (Original) 31 st March 2015 (Revised)

2 Areas of Non Compliance identified in compliance with the Mental Health Act 2001 (Approved Centres) Regulations 2006 Methods you will use to Action(s) that will be taken to determine full Person achieve full compliance compliance Responsible Article(s) /Rules/ Codes not fully compliant Report of the inspector of Mental Health Services (Summary No2 For the third year in a row, the approved centre was not compliant with Article 15- Individual Care Plans and there was little evidence of multidisciplinary involvement drawing up these care plans 1. Following the inspection report each Community Mental Health Team is now required to contribute to the individual care plans in the Dept Of Psychiatry 2. The Donegal Central Sector CMHT now hold a full team meeting on a weekly basis in the Dept of Psychiatry, 3. In response to the report an audit was carried out to establish compliance with the MDT input requirement and a follow up audit is planned to be completed by end of Quarter 2. This second audit will inform the Area Mental Health Management team in prioritising MDT input into the Dept Of Psychiatry to ensure compliance with the MHC 4. Issues regarding the non filling of MTD vacancies and delays in back filling posts also has a negative impact on compliance and will lead to the AMHMT redeploying MDT staff from the Community Teams into the Dept of Psychiatry. The MDT will continue to seek additional MDT posts under the annual NSP allocation. Health and Social care Staff allocated to Approved Centre to participate in the care planning process, individual care planning and therapeutic group programmes. Audit of files to determine compliance Area Mental Health Management Team, Health and Social Care Heads of Service Timeframe for Completion Q1-Q4 ongoing

3 Report of the Inspector of Mental Health Services (Summary- No 4) Security personnel were involved in the approved centre in physical restraint but the service did not have a policy on their involvement. Physical Restraint Policy will be amended to reflect use of security staff in emergency situation Monthly Audit of Physical Restraint Forms for utilisation of security staff in emergency situations. Director of Nursing Q1-Q4 ongoing Part One: Quality of Care and Treatment Section 51 (1) (b) (i) Mental Health Act 2001 Progress on Recommendations in the 2013 Approved Centre Report (No2) The approved centre must ensure that the individual care plans for each resident meets the description of an individual care plan See below Article 15 Health and Social Care Staff allocated to Approved Centre Area Mental Health Management Team Q1-Q4 ongoing

4 Article 13(6): Searches However there was no record in the clinical file of which nurses were involved in carrying out the search. There was a policy on searches which satisfied the requirements of this article. Nursing staff to be notified to ensure that all patient searches are formally recorded on the patient clinical file. Audit of searches carried out on service users. Director of Nursing Areas of Non Compliance identified in compliance with Rules under the Mental Health Act 2001 Article(s) /Rules/ Methods you will use to Action(s) that will be taken to achieve Codes not fully determine full Person full compliance compliant compliance Responsible Article 15: Individual Care Plan It was evident from the care plans there was little, if any, input from health and social care professionals Area Mental Health Management Team to seek Health and Social Care Staff into developing an additional staffing resources and agree assignment of Area Mental Health allocated to Approved Centre individual s care plan. Health and Social Care Professionals to Dept of Management Team Psychiatry Timeframe for Completion Q1 / Q4 ongoing

5 1. As an interim measure increased inreach time limited by O.T., and Social Work on a weekly basis and Clinical Psychology on a case by case basis Health and Social care Staff allocated to Approved Centre Article 16(1) Therapeutic Services and Programmes There was no dedicated OT for the approved centre and one OT from a sector team provided sessions on one day per week. A Social Worker conducted one session per week. There was a significant lack of psychologists in the sector and specialist teams 2. The Departments therapeutic programmes now involve liaison with the OT service. Nursing Staff continue to in their commitment to deliver theraputic ward programmes until an OT resource is secured 3. An advancing recovery professional group has been established (Q1) to implement recovery principles. 4. Issues regarding the non filling of MTD vacancies and delays in back filling posts also has a negative impact on compliance. The AMHMT will continue to pursue the recruitment of new and replacement staff to strengthen the MDT input to the Dept Of Psychiatry and CMHMT s Area Mental Health Management Team Q1 / Q4 ongoing

6 Article21: Privacy Four beds did not have a surround curtain. The service reported there was a fault with the apparatus for hanging privacy curtains and this was being addressed with the supplier Consultation has taken place with manufacturer who will be engaged to carry out necessary remedial works Works to be inspected by HSE maintenance staff Business Manager Article 22(3): Premises There were a number of ligature anchor points which were identified to staff during the course of inspection. Some cracks were apparent in some of the interior walls of the unit. It is proposed to carry out an audit of ligature anchor points using an evidence based risk assessment tool. Service will also be guided by National Service Plan 2015 as follows Complete national audit of Ligature points in all acute units Rolling Work plan to be agreed to improve anti ligature environment in acute units in collaboration with HSE Estates Commission audit of ligature anchor points using evidence based risk assessment tool Minor maintenance to be carried out by Maintenance Dept AMHMT Business Manager

7 Article 23(1): Ordering, Prescribing, Storing and Administration of Medicines Several medication prescriptions did not include the doctor s Medical Council Number (MCN) Article 26(2) Staffing There was a significant lack of Psychologists in Donegal Mental Health Services There was a number of NCHD vacancies Article 27: Management of Records There were several loose pages in some clinical files, and some clinical records were not filed sequentially. In other clinical files, documentation was filed in the wrong section of the clinical file. Clinical Director to notify Medical Staff to comply with requirement. Area Mental Health management team to seek additional staffing resources and agree assignment of Health and Social Care Professionals to Dept of Psychiatry. Donegal Mental Health Services will endeavour to fill all medical manpower vacancies. All staff involved in the preparation and management of patient files will be advised of the MHC rating and the requirement to have files in the required chronological and standard format. Audit of files and prescription Kardex Clinical Director Q1 DMHS will continue to advertise &where necessary recruit via agencies Memo to be issued to all staff re Article 27. Establish MDT File Audit sub group AHMHT Business Manager AMHMT Q1 Q4 ongoing Q1 - Q4 ongoing Article 32: Risk Management Procedures Risk assessment was documented on an assessment form on admission, but often not repeated during a resident s period in the approved centre. The risk assessments did not The Clinical Director will instruct Medical staff to carry out regular continuous risk assessments and generate a risk management plan during the patients stay. Sample Audit of Risk Assessments carried out on service users Clinical Director AMHMT

8 generate a risk management plan. The service had a risk management policy which satisfied the requirements of the Regulations but as there were a number of ligature points in the premises it was not fully implemented in the Approved Centre It is proposed to carry out an audit of ligature anchor points using an evidence based risk assessment tool. Audit to determine ligature risks from which a plan will be developed to deal with ligature risks. Director of Nursing & Business Manager Physical Restraint There was one instance, however, where the individual clinical file contained a nursing record which stated holds maintained in relation to a patient who had resisted holds. There was no physical restraint order to correspond with this record. Nursing staff to be instructed to ensure that all episodes of physical restraint has a corresponding Restraint order Audit of Restraints to check for signatures and restraint orders. Clinical Director / Director Of Nursing Q1 / Q4 ongoing Security personnel from the general hospital had been involved in the application of physical restraint within the approved centre. Inspectors recommend that the physical restraint policy be amended to reflect the practice The use of Security Staff only in response to emergency situations which pose a risk to staff or patient safety will be written into the personal restraint policy. All staff will be notified to this effect Security staff will be offered Care & Responsibility training Unit Nurse Manager to regularly review clinical files to ensure compliance. Memo to be issued re utilisation of security staff and conditions re same. Policy to be amended to reflect security staff utilisation. Director of Nursing / Area Mental Health Management Team Q1 Q4 ongoing Q1

9 Admission of Children 2.5 Children have been admitted to the approved centre in previous years. The approved centre was unsuitable for the admission of children Notification of Deaths and Incident Reporting The policy on risk management did not identify the Risk Manager of the service No children were admitted to the Unit in N OChildren to be admitted Clinical Director Q1 - Q4ongoing Donegal Mental Health Services do not have a dedicated Quality & Risk Manager but have access to and support of the Donegal PCCC Quality and Risk Manager Donegal Mental Health Services will continue to uses the services of the PCCC Quality & Risk Manager AMHMT Q1 Q4 ongoing Electroconvulsive Therapy (ECT) for Voluntary Patients The ECT treatment record was not completed by treating doctor Clinical Director will instruct all Medical Staff of requirement to fully complete the relevant documents Audit of ECT files. Clinical Director Q1 Part 2 Enabling good practice through Effective Governance 7.1 The service had policies on admission, transfer and discharge of residents. The approved centre was not fully compliant with Article 32 Risk Management. The Clinical Director will instruct Medical staff to carry out regular continuous risk assessments and generate a risk management plan during the patients stay Audit of files. Clinical Director Q1 Q4 ongoing

10 Article(s) /Rules/ Codes fully comnliant Areas of Non Gompliance identified in compliance with Godes of Practice under the Mental Health Act 2001 not Action(s) that will be taken to achieve full compliance Methods you will use to determine full compliance Person Responsible The completed Compliance Report must be agreed to and signed by the registered proprietor of the above-named approved centre. The final report, as agreed with the Commission, will be published on the Commission's website, Timeframe for Gompletion lf the registered proprietor is a corporat entity, the completed report may be signed by the person with delegated responsibility for the running of the above-named approved centre (e.9. the local health manager where the registered proprietor is the Health Service Executive). Signature of Registered Proprietor/ Person with delegated responsibility for the running of the approved centre: NOTE: Electronic Siqnature Acceptable Job ritle: U^"et qf uer CL+e A<e. I Date: & ^tla!( A scanned copy of the completed and signed Compliance Report may be sent by to compliance@mhcirl.ie Alternatively, the completed and signed Report can be returned by post to: Ms Rosemary Smyth, Director Standards and Quality Assurance (lnterim), Mental Health Commission, St Martin's House, Waterloo Road, Dublin 4.