Mental Health Commission Approved Centre Inspection Report (Mental Health Act 2001) APPROVED CENTRE NAME: IDENTIFICATION NUMBER: APPROVED CENTRE TYPE: REGISTERED PROPRIETOR: REGISTERED PROPRIETOR NOMINEE: Department of Psychiatry, Our Lady s Hospital, Navan AC031 Acute Mental Health Unit Health Service Executive (HSE) Mr Dermot Monaghan MOST RECENT REGISTRATION DATE: 1 March 2014 NUMBER OF RESIDENTS REGISTERED FOR: INSPECTION TYPE: 25 Unannounced INSPECTION DATE: 1, 2 and 3 December 2015 PREVIOUS INSPECTION DATE: 15 and 16 July 2014 CONDITIONS ATTACHED: LEAD INSPECTOR: INSPECTION TEAM: THE INSPECTOR OF MENTAL HEALTH SERVICES: None Ms Lydia Martin Ms Lisa Kiernan Dr Susan Finnerty MCN 009711 (Acting) Ref MHC FRM 001- Rev 1 Page 1 of 64
Contents 1.0 Mental Health Commission Inspection Process... 4 2.0 Approved Centre Inspection - Overview... 6 2.1 Overview of the Approved Centre... 6 2.2 Governance... 6 2.3 Inspection scope... 6 2.4 Outstanding issues from previous inspection... 6 2.5 Conditions to Registration... 7 2.6 Non-compliant areas on this inspection... 7 2.7 Areas of compliance rated on this inspection... 7 2.8 Areas of good practice identified on this inspection... 7 2.9 Reporting on the National Clinical Guidelines... 8 2.10 Resident Interviews... 8 2.11 Feedback Meeting... 8 3.0 and Required Actions - Regulations... 9 3.1 Regulation 1: Citation... 9 3.2 Regulation 2: Commencement... 9 3.3 Regulation 3: Definitions... 9 3.4 Regulation 4: Identification of Residents... 10 3.5 Regulation 5: Food and Nutrition... 11 3.6 Regulation 6: Food Safety... 12 3.7 Regulation 7: Clothing... 13 3.8 Regulation 8: Residents Personal Property and Possessions... 14 3.9 Regulation 9: Recreational Activities... 15 3.10 Regulation 10: Religion... 16 3.11 Regulation 11: Visits... 17 3.12 Regulation 12: Communication... 18 3.13 Regulation 13: Searches... 19 3.14 Regulation 14: Care of the Dying... 21 3.15 Regulation 15: Individual Care Plan... 23 3.16 Regulation 16: Therapeutic Services and Programmes... 24 3.17 Regulation 17: Children s Education... 25 3.18 Regulation 18: Transfer of Residents... 26 3.19 Regulation 19: General Health... 27 3.20 Regulation 20: Provision of Information to Residents... 28 3.21 Regulation 21: Privacy... 30 3.22 Regulation 22: Premises... 31 3.23 Regulation 23: Ordering, Prescribing, Storing and Administration of Medicines... 33 Ref MHC FRM 001- Rev 1 Page 2 of 64
3.24 Regulation 24: Health and Safety... 36 3.25 Regulation 25: Use of Closed Circuit Television (CCTV)... 37 3.26 Regulation 26: Staffing... 38 3.27 Regulation 27: Maintenance of Records... 41 3.28 Regulation 28: Register of Residents... 42 3.29 Regulation 29: Operating Policies and Procedures... 43 3.30 Regulation 30: Mental Health Tribunals... 45 3.31 Regulation 31: Complaints Procedure... 46 3.32 Regulation 32: Risk Management Procedure... 48 3.33 Regulation 33: Insurance... 50 3.34 Regulation 34: Certificate of Registration... 51 4.0 and Required Actions - Rules... 52 4.1 Section 59: The Use of Electro-Convulsive Therapy... 52 4.2 Section 69: The Use of Seclusion... 53 4.3 Section 69: The Use of Mechanical Restraint... 54 5.0 and Required Actions - The Mental Health Act 2001... 55 5.1 Part 4: Consent to Treatment... 55 6.0 and Required Actions Codes of Practice... 57 6.1 The Use of Physical Restraint... 57 6.2 Admission of Children... 59 6.3 Notification of Deaths and Incident Reporting... 60 6.4 Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities... 61 6.5 The Use of Electro-Convulsive Therapy (ECT) for Voluntary Patients... 62 6.6 Admissions, Transfer and Discharge... 63 Ref MHC FRM 001- Rev 1 Page 3 of 64
1.0 Mental Health Commission Inspection Process The principal functions of the 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 under this Act. The Mental Health Commission strives to ensure its principal legislative functions are achieved through the registration 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). 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 Mental Health Act (2001), 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, and 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 shall be assessed against all regulations, rules, codes of practice and Section 4 of the Mental Health Act 2001 at least once on an annual basis. Inspectors shall use the triangulation process of documentation review, observation and interview to assess compliance with the requirements. Where non-compliance is determined the individual regulation, or rule, shall also be risk assessed. The approved centre is required to act on all aspects identified as non-compliant or with a high / critical risk rating. Demonstration of immediate corrective rectifications, and ongoing preventative actions must be clearly identified. These actions are required to be specific, measurable, achievable and time-bound. All actions must have identified timeframes and responsibilities. A copy of the draft report was forwarded to the service and comments and review on the report were invited from the Registered Proprietor. These comments were reviewed by the lead inspector and incorporated into the report, where relevant. In circumstances where the Registered Proprietor fails to comply with the requirements of the Mental Health Act 2001 (Approved Centres) Regulations 2006 and Rules, the Mental Health Commission has the authority to initiate escalating enforcement actions up to, and including, Ref MHC FRM 001- Rev 1 Page 4 of 64
removal of an approved centre from the Register and the prosecution of the Registered Proprietor. Ref MHC FRM 001- Rev 1 Page 5 of 64
2.0 Approved Centre Inspection - Overview 2.1 Overview of the Approved Centre The approved centre was located on the grounds of Our Lady s Hospital in Navan, Co. Meath. The Department of Psychiatry was a 25-bed acute admissions unit which opened in 1996. There were 20 residents in the approved centre on the days of inspection, seven of whom were detained under the Mental Health Act 2001. The entrance to the reception area was open on arrival and the inspection team was escorted to the ward which was locked on arrival. Sleeping accommodation mainly consisted of 5 and 6 bedded rooms with only three single rooms in the approved centre. Throughout the inspection process, information was gathered from observations of processes and procedures, residents, interviews with staff from various disciplines, photographic evidence and review of clinical documents. 2.2 Governance The service provided copies of their Senior Business and Clinical Governance Meeting minutes to the inspection team. These minutes showed evidence of regular senior management meetings. One of the main items at the meetings reflected the preparation for the move to the new unit in 2016. There was an organisational chart and clear governance structures and processes in place. The senior management team met on a monthly basis. 2.3 Inspection scope This was an unannounced annual inspection. All aspects of the regulations, rules and codes of practice were inspected against, with the exception of those which were not applicable: Children s Education, Mechanical Restraint and Electro-Convulsive Therapy. The inspection was undertaken onsite in the approved centre on: 1 December 2015 from 09:00 to 17:30 2 December 2015 from 09:00 to 17:30 3 December 2015 from 11:00 to 15:00 2.4 Outstanding issues from previous inspection The previous inspection of the approved centre on 15 and 16 July 2014 identified the following areas that were not fully compliant: Regulation/Rule/Act/Code 2015 Regulation15 Individual Care Plan Compliant Regulation 16 Therapeutic Services and Compliant Programmes Regulation 21 Privacy Compliant Regulation 27 Maintenance of Records Compliant Ref MHC FRM 001- Rev 1 Page 6 of 64
Code of Practice on Admission of Children Code of Practice on Admission, Transfer and Discharge to and from an Approved Centre Compliant Compliant 2.5 Conditions to Registration There were no conditions attached to the registration of this approved centre at the time of inspection. 2.6 Non-compliant areas on this inspection Regulation/Rule/Act/Code Regulation 23 Ordering, Prescribing, Storing & Administration of Medicines Regulation 26 Staffing Regulation 29 Operating Policies and Procedures Risk Rating Moderate Moderate Low The approved centre was requested to provide Corrective and Preventative Actions (CAPAs) for areas of non-compliance and these are included in the report, in the relevant areas. 2.7 Areas of compliance rated on this inspection Regulation/Rule/Act/Code Regulation 13 Searches Regulation 15 Individual Care Plan Regulation 19 General Health Regulation 27 Maintenance of Records Regulation 28 Register of Residents Regulation 30 Mental Health Tribunals Regulation 31 Complaints Procedures Regulation 32 Risk Management Procedures Regulation 33 Insurance Regulation 34 Certificate of Registration Rule on the Use of Seclusion Code of Practice on the use of Physical Restraint in Approved Centres 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 2.8 Areas of good practice identified on this inspection Nursing care was of a high standard. All staff were observed to interact with residents in a respectful manner. Ref MHC FRM 001- Rev 1 Page 7 of 64
The Information Booklet for residents and family was comprehensive in its scope and oriented residents to all aspects of the approved centre. The information booklet was also available in French and Polish. The approved centre held a group, how to use your care plan, which was facilitated by the occupational therapist and social worker for the residents. The approved centre used an information leaflet for residents on care planning. Our Lady s Hospital, Navan had recently introduced a smoke free campus. All residents were encouraged and facilitated to refrain from smoking within and around the approved centre. 2.9 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. 2.10 Resident Interviews During the inspection process, the inspection team arranged to meet with those residents who wished to speak with them. Two residents chose to meet the inspectors and generally related a positive experience of the approved centre. One resident felt there could be more groups and activities in the approved centre. 2.11 Feedback Meeting A feedback session was facilitated between the inspection team and senior members of the management team for the approved centre. The feedback meeting was held on Thursday 3 December to present the initial findings and offer an opportunity for clarification on any issues from the inspection. This meeting was attended by Business Manager Consultant Psychiatrist 2 x Assistant Directors of Nursing Clinical Nurse Manager 2 Quality and Risk Manager Senior Occupational Therapist Principal Social Worker Principal Psychologist Ref MHC FRM 001- Rev 1 Page 8 of 64
3.0 and Required Actions - Regulations PART TWO: EVIDENCE OF COMPLIANCE WITH REGULATIONS, RULES AND CODES OF PRACTICE, AND PART 4 OF THE MENTAL HEALTH ACT 2001 EVIDENCE OF COMPLIANCE WITH REGULATIONS UNDER MENTAL HEALTH ACT 2001 SECTION 52 (d) 3.1 Regulation 1: Citation Not 3.2 Regulation 2: Commencement Not 3.3 Regulation 3: Definitions Not Ref MHC FRM 001- Rev 1 Page 9 of 64
3.4 Regulation 4: Identification of Residents The registered proprietor shall make arrangements to ensure that each resident is readily identifiable by staff when receiving medication, health care or other services. Processes: The approved centre had processes in place for the identification of residents. There was a process in place to alert staff of similar or same-named residents. Training: Staff were aware of the processes in relation to the identification of residents. Monitoring of Compliance: There was no audit of the processes. Resident meetings were held within the approved centre. The use of wristbands and photographs was discussed with residents for identification purposes. Residents were not open to the use of these. Evidence of Implementation: Clinical files were inspected and contained identifiers: name, address, unique hospital number and date of birth. Staff were observed administering medication and only used one identifier. Identifiers used were appropriate to the residents communication needs. Compliance Rating: Poor Ref MHC FRM 001- Rev 1 Page 10 of 64
3.5 Regulation 5: Food and Nutrition (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. Processes: There were clear operational processes in place for ensuring that residents received adequate food and nutrition in line with their nutritional needs. Training: All staff working in the main kitchen and servery were trained in Hazard Analysis and Critical Control Points (HACCP). The dietician who provided input to the approved centre was trained professionally. Monitoring of Compliance: Residents were weighed on admission and weight was monitored throughout their admission, if required, in line with their individual care plan. Evidence of Implementation: Menus were reviewed by a dietician and healthy choices were available at mealtimes. Special diets were catered for, including soft diets and those based on religious beliefs. The approved centre had access to the dietician within the general hospital. The menu was rotated every three weeks and offered a choice of meals. Residents submitted their preferences a day in advance to the kitchen staff. Water was available throughout the approved centre from water coolers. Hot drinks and extra food supply was available to residents outside of normal meal times. The dining room was located off the sitting room in the approved centre. Compliance Rating: Poor Ref MHC FRM 001- Rev 1 Page 11 of 64
3.6 Regulation 6: Food Safety (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 1998. Processes: There were clear operational processes in place for ensuring food safety within the approved centre by the staff working in the kitchen pantry and the main kitchen in Our Lady s General Hospital. Training: All staff working in the main kitchen and servery were HACCP trained. Monitoring of Compliance: All food deliveries and refrigeration temperatures were checked daily. There was a deep cleaning schedule for the approved centre. Evidence of Implementation: Food was prepared in the main kitchen at Our Lady s General Hospital and delivered to the approved centre in a closed heated food trolley. The service kitchen in the approved centre was clean but small. Facilities and equipment were suitable and well maintained. Refuse was disposed of adequately. The service kitchen had sufficient crockery and cutlery. There were hand washing facilities for the kitchen staff and all kitchen staff wore protective clothing in the service kitchen. There were sufficient staff employed to oversee food safety. Compliance Rating: Poor Ref MHC FRM 001- Rev 1 Page 12 of 64
3.7 Regulation 7: Clothing 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. Processes: There were processes in place to manage, store and launder residents clothing. It was the policy of the approved centre that residents would not be nursed in night clothes during the day. Training: Staff were aware of the processes in relation to clothing. Monitoring of Compliance: There was no formal monitoring of the processes within the approved centre. Evidence of Implementation: Residents were encouraged to keep their own clothing. The approved centre had a supply of emergency clothing and petty cash was available to purchase clothing, if required. All residents had their own locker and wardrobe beside their own bed space. However, these could not be locked. There were no residents in their night clothes during the day. Compliance Rating: Poor Ref MHC FRM 001- Rev 1 Page 13 of 64
3.8 Regulation 8: Residents Personal Property and Possessions (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. Processes: There was a policy pertaining to residents personal property and possessions. This policy had not been reviewed in the last three years. The policy covered processes for communicating with residents about the processes within the approved centre. Training: Staff were aware of the policy in relation to personal property and possessions. Monitoring of Compliance: There was no formal monitoring of the processes within the approved centre. Evidence of Implementation: The approved centre had a safe for residents to store their valuables. At admission, a checklist of all residents possessions and property was completed by nursing staff. This inventory book was stored in the nursing station and a copy was also kept in the residents clinical files. Compliance Rating: Poor Ref MHC FRM 001- Rev 1 Page 14 of 64
3.9 Regulation 9: Recreational Activities The registered proprietor shall ensure that an approved centre, insofar as is practicable, provides access for residents to appropriate recreational activities. Processes: The approved centre had processes in place for the provision and facilitation of recreational activities. Training: The occupational therapist and nursing staff were professionally qualified. Monitoring of Compliance: Resident meetings were facilitated on the ward by the nursing staff. These meetings reviewed recreational activities and operational procedures within the approved centre. Feedback was also sought at the end of group meetings to improve the service. A satisfaction survey was available to residents who wished to give feedback. Evidence of Implementation: The approved centre had a large sitting room which had a television, book corner, games, internet, pool table and table tennis table. There was also an occupational therapy group room which had art materials, a television and games console. This room was open and accessible to residents during the day, only when the groups were being facilitated. There was also a meeting room which doubled as a quiet room for residents to play or listen to music. The approved centre had an enclosed garden which was well maintained, had seating and was accessible to residents 24 hours a day. An activity timetable was issued monthly by the occupational therapist (OT). Information was available on the ward noticeboards and from the nursing staff. The OT and nursing staff reminded residents of groups that were taking place. Residents were invited to contribute ideas for recreational activities through the resident meetings. One resident felt more activities during the day would benefit all residents, especially physical exercise and activities. Compliance Rating: Poor Ref MHC FRM 001- Rev 1 Page 15 of 64
3.10 Regulation 10: Religion The registered proprietor shall ensure that residents are facilitated, insofar as is reasonably practicable, in the practice of their religion. Processes: The approved centre had processes in place to facilitate religious practice. Training: Staff were aware of the processes in relation to religion. Monitoring of Compliance: There was no documented evidence that audits or analysis had taken place in relation to religion. Evidence of Implementation: Residents individual religious and spiritual beliefs were recorded at admission and they had access to multi-faith ministers. The approved centre held a weekly Catholic service and there was an out of hours priest available for end of life care. Compliance Rating: Poor Ref MHC FRM 001- Rev 1 Page 16 of 64
3.11 Regulation 11: Visits (1) The registered proprietor shall ensure that appropriate arrangements are made for residents to receive visitors having regard to the nature and purpose of the visit and the needs of the resident. (2) The registered proprietor shall ensure that reasonable times are identified during which a resident may receive visits. (3) The registered proprietor shall take all reasonable steps to ensure the safety of residents and visitors. (4) The registered proprietor shall ensure that the freedom of a resident to receive visits and the privacy of a resident during visits are respected, in so far as is practicable, unless indicated otherwise in the resident's individual care plan. (5) The registered proprietor shall ensure that appropriate arrangements and facilities are in place for children visiting a resident. (6) The registered proprietor shall ensure that an approved centre has written operational policies and procedures for visits. Processes: There was a policy which set out the processes in place to facilitate visits. The policy outlined the arrangements in place for children visiting. The policy also specified the need to restrict visitors at times as a result of a risk assessment. The Health and Safety policy contained processes to ensure the safety of visitors. Training: Staff were aware of the policy and processes in place to facilitate visitors. Monitoring of Compliance: There was no documented evidence that audits or analysis had taken place in relation to visits. Evidence of Implementation: Visiting arrangements were communicated to residents at admission and displayed at the entrance to the approved centre. Visiting times were flexible as long as they did not interfere with residents treatments. There was a room available for visits. Children visiting the approved centre were supervised at all times. There was a room provided for children visiting off the ward. Admission assessments documented a resident s wishes in relation to visits. There were visiting restrictions in place if there was concern for a resident s safety and welfare or at the resident s request. Compliance Rating: Poor Ref MHC FRM 001- Rev 1 Page 17 of 64
3.12 Regulation 12: Communication (1) Subject to subsections (2) and (3), the registered proprietor and the clinical director shall ensure that the resident is free to communicate at all times, having due regard to his or her wellbeing, safety and health. (2) The clinical director, or a senior member of staff designated by the clinical director, may only examine incoming and outgoing communication if there is reasonable cause to believe that the communication may result in harm to the resident or to others. (3) The registered proprietor shall ensure that the approved centre has written operational policies and procedures on communication. (4) For the purposes of this regulation "communication" means the use of mail, fax, email, internet, telephone or any device for the purposes of sending or receiving messages or goods. Processes: The approved centre had a policy in place outlining the roles and responsibilities in relation to communication. Communication services available were identified in the policy. The policy outlined risk assessment requirements in relation to communication for the approved centre. Training: All staff were aware of the policy relating to communication. Monitoring of Compliance: There was no monitoring of the processes. Evidence of Implementation: Risk assessments were completed on each resident in relation to communication access. Incoming and outgoing mail was not checked unless there was concern for a resident s safety and welfare. The residents had access to mail, fax, internet and phone within the approved centre. Residents were observed using their own mobile phones. Compliance Rating: Poor Ref MHC FRM 001- Rev 1 Page 18 of 64
3.13 Regulation 13: Searches (1) The registered proprietor shall ensure that the approved centre has written operational policies and procedures on the searching of a resident, his or her belongings and the environment in which he or she is accommodated. (2) The registered proprietor shall ensure that searches are only carried out for the purpose of creating and maintaining a safe and therapeutic environment for the residents and staff of the approved centre. (3) The registered proprietor shall ensure that the approved centre has written operational policies and procedures for carrying out searches with the consent of a resident and carrying out searches in the absence of consent. (4) Without prejudice to subsection (3) the registered proprietor shall ensure that the consent of the resident is always sought. (5) The registered proprietor shall ensure that residents and staff are aware of the policy and procedures on searching. (6) The registered proprietor shall ensure that there is be a minimum of two appropriately qualified staff in attendance at all times when searches are being conducted. (7) The registered proprietor shall ensure that all searches are undertaken with due regard to the resident's dignity, privacy and gender. (8) The registered proprietor shall ensure that the resident being searched is informed of what is happening and why. (9) The registered proprietor shall ensure that a written record of every search is made, which includes the reason for the search. (10) The registered proprietor shall ensure that the approved centre has written operational policies and procedures in relation to the finding of illicit substances. Processes: The approved centre had a policy in place outlining the roles, responsibilities and management of searches. The policy included guidelines for assessing risk, consent and documentation of the search. The policy had procedures in place for the finding of illicit substances. Training: All staff were aware of the policy in relation to searches. Monitoring of Compliance: Incident logs, where searches were documented, were reviewed by the senior management team. Evidence of Implementation: Staff were aware of the policy and the importance of consent. Staff were also cognisant of the need for clear communication and respecting the resident s dignity prior to and during a search. In every instance, the resident was informed of what was happening and a written record of the search was maintained. The information booklet contained information about the policy on searches for residents; this information booklet was given to residents on admission. One clinical file was inspected along with the incident log. All documentation was completed in line with the policy. Ref MHC FRM 001- Rev 1 Page 19 of 64
Compliance Rating: Poor Ref MHC FRM 001- Rev 1 Page 20 of 64
3.14 Regulation 14: Care of the Dying (1) The registered proprietor shall ensure that the approved centre has written operational policies and protocols for care of residents who are dying. (2) The registered proprietor shall ensure that when a resident is dying: (a) appropriate care and comfort are given to a resident to address his or her physical, emotional, psychological and spiritual needs; (b) in so far as practicable, his or her religious and cultural practices are respected; (c) the resident's death is handled with dignity and propriety, and; (d) in so far as is practicable, the needs of the resident's family, next-of-kin and friends are accommodated. (3) The registered proprietor shall ensure that when the sudden death of a resident occurs: (a) in so far as practicable, his or her religious and cultural practices are respected; (b) the resident's death is handled with dignity and propriety, and; (c) in so far as is practicable, the needs of the resident's family, next-of-kin and friends are accommodated. (4) The registered proprietor shall ensure that the Mental Health Commission is notified in writing of the death of any resident of the approved centre, as soon as is practicable and in any event, no later than within 48 hours of the death occurring. (5) This Regulation is without prejudice to the provisions of the Coroners Act 1962 and the Coroners (Amendment) Act 2005. Processes: The approved centre had a policy that covered the management of care of the dying and the death of a resident. Training: All staff were responsible for reading and adhering to the policy and were aware of the process for this regulation. Monitoring of Compliance: There was no monitoring of the processes. Evidence of Implementation: No dying resident had been cared for in the approved centre as residents who were physically ill were transferred to the general hospital. Staff were aware of the policy. There was one death of a resident since the last inspection. The Mental Health Commission was notified of this death within the specified timeframe. The inspection team reviewed the documentation in relation to this death. The steps the approved centre had taken at the time of inspection included: completing an incident form; debriefing for staff and residents; liaising with the resident s family; and initiating a systems analysis review. This review was to be completed over the next few weeks. The systems analysis review was to review the factual circumstances leading up to the death, explore factors that may have occurred and recommend actions that would address these factors so that the risk of future harm arising from these factors would be eliminated or, if this was not possible, would be reduced as far as was reasonably practicable. Ref MHC FRM 001- Rev 1 Page 21 of 64
Compliance Rating: Poor Ref MHC FRM 001- Rev 1 Page 22 of 64
3.15 Regulation 15: Individual Care Plan The registered proprietor shall ensure that each resident has an individual care plan. [Definition of an individual care plan:... a documented set of goals developed, regularly reviewed and updated by the resident s multi-disciplinary team, so far as practicable in consultation with each resident. The individual care plan shall specify the treatment and care required which shall be in accordance with best practice, shall identify necessary resources and shall specify appropriate goals for the resident. For a resident who is a child, his or her individual care plan shall include education requirements. The individual care plan shall be recorded in the one composite set of documentation.] Processes: The approved centre had processes in place to ensure the multi-disciplinary team (MDT) were responsible for the creation and ongoing review of individual care plans (ICPs). The approved centre also had a good practice guide for staff on contributing to individual care plans. This was developed in August 2014 by the Louth/Meath Mental Health Services. Training: Staff had attended information sessions on care planning and were aware of the requirements relating to each resident having an ICP. Monitoring of Compliance: Audits on ICPs had been carried out. Results and recommendations were discussed at the clinical governance meetings and discussed with staff. The approved centre also facilitated a weekly group for residents on how to use your care plan. Evidence of Implementation: Ten clinical files were inspected in detail and all had evidence of goals, needs, treatment plans and resources. All residents had access to their individual care plan and weekly reviews through their key worker. Photocopies were given to residents of their ICP, if desired, and this was documented. The key worker in all cases was the resident s nurse for that day. The ICPs were reviewed weekly and reflected the residents current needs. On admission, all residents had an initial care plan completed based on their assessed risk. There was evidence of ongoing review and discharge planning. Residents and their families were involved in the ICP process. Compliance Rating: Poor Ref MHC FRM 001- Rev 1 Page 23 of 64
3.16 Regulation 16: Therapeutic Services and Programmes (1) The registered proprietor shall ensure that each resident has access to an appropriate range of therapeutic services and programmes in accordance with his or her individual care plan. (2) The registered proprietor shall ensure that programmes and services provided shall be directed towards restoring and maintaining optimal levels of physical and psychosocial functioning of a resident. Processes: There were processes in place within the approved centre in relation to the provision and facilitation of therapeutic services and programmes. Training: Staff were aware of the processes in relation to therapeutic services and programmes. Monitoring of Compliance: No monitoring of the processes took place. Evidence of Implementation: There was a weekly schedule of therapeutic activities for residents. Residents were informed of the schedule by the nursing staff and the OT. The OT documented interventions and group participation within the clinical files. There was evidence of social work, dietician, speech and language and psychology involvement. Each resident had a needs assessment completed on admission by the multi-disciplinary team. Group and individual therapy was provided in accordance with those needs. Each resident had a programme of activities timetabled for that week. Therapeutic services and programmes were outlined in each resident s ICP. Discharge planning was evident from the clinical files with all members of the multidisciplinary team and the resident part of the process. The approved centre and community mental health teams worked collaboratively and provided an integrated therapeutic services to residents being discharged. Therapies not available within the approved centre were delivered to the residents from the general hospital using a referral form. Compliance Rating: Poor Ref MHC FRM 001- Rev 1 Page 24 of 64
3.17 Regulation 17: Children s Education The registered proprietor shall ensure that each resident who is a child is provided with appropriate educational services in accordance with his or her needs and age as indicated by his or her individual care plan. Processes: The service had a policy relating to the procedures for accessing education for children who were admitted to the approved centre. Two children had been admitted to the approved centre in 2015 up to the time of inspection. Provision of education was not applicable as the children were transferred to another approved centre within five days. Compliance Rating: Poor Ref MHC FRM 001- Rev 1 Page 25 of 64
3.18 Regulation 18: Transfer of Residents (1) When a resident is transferred from an approved centre for treatment to another approved centre, hospital or other place, the registered proprietor of the approved centre from which the resident is being transferred shall ensure that all relevant information about the resident is provided to the receiving approved centre, hospital or other place. (2) The registered proprietor shall ensure that the approved centre has a written policy and procedures on the transfer of residents. Processes: A policy on transfers was available and included the requirements necessary for the transfer of an involuntary patient and a voluntary patient. The policy listed the roles and responsibilities for the approved centre. Training: Staff were aware of the system in place, including the need for a transfer form and summary. Monitoring of Compliance: There was no monitoring of the processes. Evidence of Implementation: At the time of inspection, there was no resident who had been transferred to another approved centre. However, one discharge was observed whereby the resident was transferred to a nursing home. A nursing transfer report was completed and sent with the resident and family to the nursing home. All processes were followed for this transfer. A key nurse was involved in coordinating the discharge and communicating with the receiving facility. Compliance Rating: Poor Ref MHC FRM 001- Rev 1 Page 26 of 64
3.19 Regulation 19: General Health (1) The registered proprietor shall ensure that: (a) adequate arrangements are in place for access by residents to general health services and for their referral to other health services as required; (b) each resident's general health needs are assessed regularly as indicated by his or her individual care plan and in any event not less than every six months, and; (c) each resident has access to national screening programmes where available and applicable to the resident. (2) The registered proprietor shall ensure that the approved centre has written operational policies and procedures for responding to medical emergencies. Processes: The approved centre had a policy outlining the processes for responding to medical emergencies. The policy also outlined staff training, the use of emergency equipment and debriefing support for staff following a medical emergency. Training: Staff were trained in Basic Life Support (BLS). Documented evidence of this was provided to the inspection team. Monitoring of Compliance: All six-monthly physical reviews were monitored by the Mental Health Act administrator. Weekly checks were completed on the emergency equipment. Evidence of Implementation: General health interventions were recorded in the residents ICPs. Physical reviews were undertaken as and when required. Four residents had been in the approved centre for longer than six months and all clinical files showed evidence of physical reviews within the specified timeframes. Referrals were made to general health services not available in the approved centre using the general hospital referral form. The approved centre had a private space to carry out physical reviews. Regular weekly checks were carried out on emergency equipment within the unit and these were documented. Residents had access to screening programmes if needed. There was information available on screening programmes. Records were available on emergency responses within the approved centre. Compliance Rating: Poor Ref MHC FRM 001- Rev 1 Page 27 of 64
3.20 Regulation 20: Provision of Information to Residents (1) Without prejudice to any provisions in the Act the registered proprietor shall ensure that the following information is provided to each resident in an understandable form and language: (a) details of the resident's multi-disciplinary team; (b) housekeeping practices, including arrangements for personal property, mealtimes, visiting times and visiting arrangements; (c) verbal and written information on the resident's diagnosis and suitable written information relevant to the resident's diagnosis unless in the resident's psychiatrist's view the provision of such information might be prejudicial to the resident's physical or mental health, wellbeing or emotional condition; (d) details of relevant advocacy and voluntary agencies; (e) information on indications for use of all medications to be administered to the resident, including any possible side-effects. (2) The registered proprietor shall ensure that an approved centre has written operational policies and procedures for the provision of information to residents. Processes: The approved centre had a policy in place outlining the roles, responsibilities and procedures for providing information to residents. Training: All staff were responsible for reading and adhering to the policy. Staff were aware of the processes in relation to the provision of information to residents. Monitoring of Compliance: There was no documented evidence of formal audit or analysis on the provision of information to residents. Evidence of Implementation: There was evidence that residents communication needs were assessed at admission. The approved centre had an information booklet which outlined housekeeping arrangements, details of the multi-disciplinary teams, complaints procedure, visiting times, residents rights and advocacy services available. This information booklet was also available in French and Polish. All residents detained under the Mental Health Act 2001 were provided with a copy of the Act. The approved centre had a press which contained information on the Mental Health Act 2001, information booklets, information on diagnosis and treatments and information leaflets on care planning. Staff indicated that specific information on diagnosis and medication was provided on request. Noticeboards were displayed throughout the approved centre with information on advocacy, complaints procedures, support groups, the therapeutic timetable and the Charter of Rights for Patients. There was a resident in the approved centre, at the time of inspection, whose primary language was not English. There was evidence that a translator was involved in that resident s care. Ref MHC FRM 001- Rev 1 Page 28 of 64
Compliance Rating: Poor Ref MHC FRM 001- Rev 1 Page 29 of 64
3.21 Regulation 21: Privacy The registered proprietor shall ensure that the resident's privacy and dignity is appropriately respected at all times. Processes: There were processes in place within the approved centre in relation to privacy. Training: Staff were aware of the processes in relation to resident privacy. Monitoring of Compliance: There was no monitoring of the processes in relation to privacy. Evidence of Implementation: Private facilities were available to residents to meet with visitors and with staff in the approved centre. There was a private space to complete physical examinations. Each bed space in the shared bedrooms had curtains surrounding them. Each bedroom door had a glass panel which had no blinds. All bedroom windows had blinds. All bathrooms had locks which could be unlocked by staff in an emergency. There was an enclosed outdoor space which was not overlooked by the main hospital. All resident clinical files were securely stored in the nursing office along with the monitor for the seclusion room s closed circuit television (CCTV) and the resident information board. Compliance Rating: Poor Ref MHC FRM 001- Rev 1 Page 30 of 64
3.22 Regulation 22: Premises (1) The registered proprietor shall ensure that: (a) premises are clean and maintained in good structural and decorative condition; (b) premises are adequately lit, heated and ventilated; (c) a programme of routine maintenance and renewal of the fabric and decoration of the premises is developed and implemented and records of such programme are maintained. (2) The registered proprietor shall ensure that an approved centre has adequate and suitable furnishings having regard to the number and mix of residents in the approved centre. (3) The registered proprietor shall ensure that the condition of the physical structure and the overall approved centre environment is developed and maintained with due regard to the specific needs of residents and patients and the safety and well-being of residents, staff and visitors. (4) Any premises in which the care and treatment of persons with a mental disorder or mental illness is begun after the commencement of these regulations shall be designed and developed or redeveloped specifically and solely for this purpose in so far as it practicable and in accordance with best contemporary practice. (5) Any approved centre in which the care and treatment of persons with a mental disorder or mental illness is begun after the commencement of these regulations shall ensure that the buildings are, as far as practicable, accessible to persons with disabilities. (6) This regulation is without prejudice to the provisions of the Building Control Act 1990, the Building Regulations 1997 and 2001, Part M of the Building Regulations 1997, the Disability Act 2005 and the Planning and Development Act 2000. Processes: There were processes in place for managing the premises. There were clearly defined roles and responsibilities in place for the daily maintenance and cleaning of the approved centre. Training: Relevant staff were aware of the processes and procedures for premises. Monitoring of Compliance: The approved centre completed a hygiene audit in June 2014 and a ligature audit in September 2014 which outlined recommended and remedial actions for ligature points identified within the premises. Evidence of Implementation: The approved centre was purpose-built in 1996 and located on the ground floor of Our Lady s Hospital in Navan. It was spacious and wheelchair accessible. The approved centre was warm, well ventilated with hot water and adequate lighting. Toilets and shower facilities were shared between many residents. There was a cleaning schedule in place and the approved centre was observed to be well maintained. Infection control guidelines were followed. The approved centre had a designated sluice room, cleaning room, laundry room and appropriately furnished communal rooms and therapy space. Bedrooms were a good size and all had access to an en suite. There was an enclosed outdoor space in the approved centre. Ref MHC FRM 001- Rev 1 Page 31 of 64
Compliance Rating: Poor Ref MHC FRM 001- Rev 1 Page 32 of 64
3.23 Regulation 23: Ordering, Prescribing, Storing and Administration of Medicines (1) The registered proprietor shall ensure that an approved centre has appropriate and suitable practices and written operational policies relating to the ordering, prescribing, storing and administration of medicines to residents. (2) This Regulation is without prejudice to the Irish Medicines Board Act 1995 (as amended), the Misuse of Drugs Acts 1977, 1984 and 1993, the Misuse of Drugs Regulations 1998 (S.I. No. 338 of 1998) and 1993 (S.I. No. 338 of 1993 and S.I. No. 342 of 1993) and S.I. No. 540 of 2003, Medicinal Products (Prescription and control of Supply) Regulations 2003 (as amended). Processes: The approved centre had a detailed policy on medication management. The policy outlined the roles, responsibilities and procedures for the management of medication within the approved centre. The policy covered the responsibilities for prescribing, administration, ordering and storing medication. It also covered training, consent, medication for a resident on approved leave, reporting errors and controlled drugs. Training: Registered psychiatric nurses, non-consultant hospital doctors and pharmacists involved in medication management were all trained as part of their professional qualifications and worked in line with the legislation relevant to their area. Monitoring of Compliance: A medication administration audit was carried out in May 2015 for all centres under the Louth Meath Mental Health Services. There was evidence of three audits completed over a one year period. Continuous improvement was evident through the recommendations and results from the audits. Medication errors were recorded in the incident logs for the approved centre. Evidence of Implementation: Ten medication records were examined. Medical Council Registration Numbers (MCNs) were not used in six of the ten examined. This was a breach of the Medical Practitioners Act 2007. Four medication records had no allergy section completed and four used trade names in the prescriptions instead of generic names. Medication was stored in a locked trolley in the clinical room. The trolley was not secured to the wall. The approved centre had a pharmacist who visited monthly. Medications that were out of date were returned to the pharmacy for disposal. Controlled drugs were stored securely in a locked press and two nurses signed for the administration of a controlled drug. There was a fridge in the clinical room which was only used for storing medication. There was no log maintained of fridge temperature. A medication round was observed. The nursing staff administered medication through a hatch door in the clinical room. There was evidence of staff using identifiers in the administration of medication, good hand hygiene and good provision of information to residents. As six out of the ten medication records did not contain MCNs this was a breach of the Medical Practitioners Act 2007. Allergy sections of medication records were not completed, trade names were used instead of generic names on prescriptions and no log was maintained of the clinical room fridge temperature. The approved centre was deemed noncompliant with this regulation. Ref MHC FRM 001- Rev 1 Page 33 of 64