St. Aloysius Ward, Mater Misericordiae University Hospital ID Number: AC0028 2017 Approved Centre Inspection Report (Mental Health Act 2001) St. Aloysius Ward Mater Misericordiae University Hospital North Circular Road Dublin 7 Approved Centre Type: Acute Adult Mental Health Care Most Recent Registration Date: 25 September 2015 Conditions Attached: None Registered Proprietor: Mr Gordon Dunne Registered Proprietor Nominee: N/A Inspection Team: Donal O Gorman, Lead Inspector Noeleen Byrne Carol Brennan-Forsyth David McGuinness Inspection Date: 28 February 3 March 2017 Inspection Type: Unannounced Annual Inspection Previous Inspection Date: 18 20 April 2016 The Inspector of Mental Health Services: Dr Susan Finnerty MCRN009711 Date of Publication: 31 August 2017 2017 COMPLIANCE RATINGS REGULATIONS RULES AND PART 4 OF THE MENTAL HEALTH ACT 2001 9 1 1 2 CODES OF PRACTICE Compliant Non-compliant Not applicable 21 3 4
RATINGS SUMMARY 2015 2017 Compliance ratings across all 41 areas of inspection are summarised in the chart below. Chart 1 Comparison of overall compliance ratings 2015 2017 Not applicable Non-compliant Compliant 45 40 35 30 25 27 17 22 20 15 10 6 17 13 5 0 8 7 6 2015 2016 2017 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 2015 2017 Low Moderate High Critical 18 16 14 12 10 1 5 1 4 8 6 4 2 0 8 1 5 1 1 3 3 3 2015 2016 2017 AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 2 of 91
Contents 1.0 Introduction to the Inspection Process... 5 2.0 Inspector of Mental Health Services Summary of Findings... 7 3.0 Quality Initiatives... 10 4.0 Overview of the Approved Centre... 11 4.1 Description of approved centre... 11 4.2 Conditions to registration... 11 4.3 Reporting on the National Clinical Guidelines... 11 4.4 Governance... 12 5.0 Compliance... 13 5.1 Non-compliant areas from 2016 inspection... 13 5.2 Non-compliant areas on this inspection... 14 5.3 Areas of compliance rated Excellent on this inspection... 14 6.0 Service-user Experience... 15 7.0 Interviews with Heads of Discipline... 16 8.0 Feedback Meeting... 17 9.0 Inspection Findings Regulations... 18 10.0 Inspection Findings Rules... 61 11.0 Inspection Findings Mental Health Act 2001... 66 12.0 Inspection Findings Codes of Practice... 68 AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 3 of 91
AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 4 of 91
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. AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 5 of 91
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. AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 6 of 91
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 used a minimum of two identifiers, appropriate to the residents needs. Ligature points had been minimised but some remained in the approved centre. Medication was prescribed, ordered, stored and administered in a safe manner. The approved centre had a written policy in relation to the health and safety of staff, residents, and visitors. Not all staff had received and completed training in Basic Life Support, Fire Safety, Mental Health Act 2001 and prevention and management of violence and aggression. A risk management process was in place. 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 Individual care plans (ICPs) did not contain details of appropriate needs and goals; there was a lack of resident involvement in their ICPs and there was a lack of MDT involvement in the ICP process. Therapeutic services and programmes only took place when nursing staff were available and the only therapeutic programmes available were goal setting, relaxation, and discharge planning, which were all nurse-led. No occupational therapist was assigned to the approved centre and residents did not have access to a social worker. This was rated as a critical risk. There was a delay in responding to an observed clinical emergency and uncertainty among staff as to how to manage it. All residents had up to date physical assessments. The use of seclusion was compliant with the Rules. The approved centre did not provide age-appropriate facilities for children and was unsuitable for the admission of children. The policies required under the Code of Practice for admission, transfer and discharge were not adequate. 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. AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 7 of 91
Respect for residents privacy and dignity Residents wore their own clothing. Resident s clothing was clean and appropriate to their needs. Secure facilities were provided for the safe-keeping of the residents monies, valuables, personal property and possessions and residents were facilitated to manage their own possessions. The care and services provided were respectful of residents religious beliefs and values, and residents were facilitated in observing or abstaining from religious practice in line with their wishes. With regard to searches, relevant staff interviewed were unable to clearly articulate the processes for conducting a search. A log of all resident searches was not maintained. Beds in the six-bed room were too close together to allow and ensure privacy. The glass observation panel on the door to the examination room had no blind or curtain to ensure privacy. The use of seclusion was compliant with the Rules. Physical restraint was compliant with the relevant Code of Practice. 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 One resident complained of a lack of recreational activities, therapies, and outdoor space and of ongoing boredom. One resident noted that activities were often cancelled or did not take place and suggested that two scheduled activities a day was not sufficient, especially if they were cancelled. Residents were provided with a variety of wholesome and nutritious food choices in the approved centre. Menus were approved by a dietician to ensure nutritional adequacy in accordance with residents needs. There were recreational activities during the week but not at weekends. A visitors room had opened. Visiting times were reasonable and displayed clearly. Residents were permitted to keep their mobile phones and residents had access to an office to make/take calls in private. The approved centre had recently introduced a new patient information leaflet, which was supplied to residents on admission. The approved centre was in a good state of repair both internally and externally. There was a complaints process in place and all complaints were addressed appropriately. 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 CEO of the Mater Misericordiae University Hospital (MMUH) was the registered proprietor of the approved centre. There was an organisational chart and clear governance structures and processes in place. The HSE provided funding for the following resources: the sector consultant psychiatrists, 13 of the 18 nurses employed in the approved centre, and the clinical psychologist. MMUH funded five nurses and the three consultant psychiatrists in liaison psychiatry, and it provided the structure of the approved centre and was responsible for its maintenance. The clinical director was based in St. Vincent s Hospital, Fairview. All required policies were in place and up to date. There was an organisational chart to identify the leadership and management structure and lines of responsibility and authority in both the approved centre and the AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 8 of 91
Mater Misericordiae University Hospital. An Assistant Director of Nursing post was vacant at the time of inspection however the MMUH were actively seeking a replacement. AREAS REFERRED TO Regulations 26 and 32, interviews with heads of discipline, and minutes of area management team meetings. AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 9 of 91
3.0 Quality Initiatives The following quality initiatives were identified on this inspection: 1. The approved centre had recently purchased additional recreational equipment such as electronic games and board games for the residents. 2. The approved centre s main kitchen where food was prepared for the residents was undergoing renovation and refurbishment in keeping with the CAPAs from last year s inspection. 3. The inspection team was informed that the approved centre s internal garden area was at the final stages of completion and was expected to be fully operational by May 2017, following discussions with the Mater Misericordiae University Hospital s chief executive officer, operations manager, and clinical director. The internal garden had areas mapped out for the installation of exercise machines, garden areas, and an all-weather table tennis table. 4. Workshops had been held on individual care planning and Medication Prescription and Administration Records. AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 10 of 91
4.0 Overview of the Approved Centre 4.1 Description of approved centre The approved centre was located in the original building of the Mater Misericordiae University Hospital, necessitating a walk through a general medical ward to gain access. The approved centre consisted of a long corridor, with rooms on either side. There was a large sitting/dining room with an internal smoking room, an activation room, and a relaxation room. There was one single bedroom, a double bedroom, and six-bed and four-bed dormitories. At the time of inspection, there was restricted access to an outdoor space/garden and renovations were ongoing. The kitchen was being renovated and work on the garden was in progress; it was reported that this would be completed by end of May 2017. The female bathrooms and toilets had recently been refurbished, with anti-ligature fixtures and fittings installed. The smoking room was due to be removed as part of the renovations. On the first day of the inspection, there were eight residents, including one detained patient. There were no residents who had a delayed discharge. There had been one child admitted to the approved centre since the previous inspection. The resident profile on the first day of inspection was as follows: Resident Profile Number of registered beds 15 Total number of residents 8 Number of detained patients 1 Number of Wards of Court 0 Number of children 0 Number of residents in the approved centre for more than 6 months 0 4.2 Conditions to registration There were no conditions attached to the registration of this approved centre at the time of inspection. 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. AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 11 of 91
4.4 Governance The CEO of the Mater Misericordiae University Hospital (MMUH) was the registered proprietor of the approved centre. There was an organisational chart and clear governance structures and processes in place. The HSE provided funding for the following resources: the sector consultant psychiatrists, 13 of the 18 nurses employed in the approved centre, and the clinical psychologist. MMUH funded five nurses and the three consultant psychiatrists in liaison psychiatry, and it provided the structure of the approved centre and was responsible for its maintenance. The clinical director was based in St. Vincent s Hospital, Fairview. Nursing staff reported to three directors of nursing, one in MMUH, one in St. Vincent s, and the area director of nursing. Minutes for the St. Aloysius/consultant psychiatrist governance meeting, the quarterly nursing governance meeting, and the psychiatry governance meeting were provided to the inspection team. They addressed issues such as recruitment, policy development, audits, staff training, nursing metrics, estates and facilities, and risk. AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 12 of 91
5.0 Compliance 5.1 Non-compliant areas from 2016 inspection The previous inspection of the approved centre on 18 20 April 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 6: Food Safety Compliant Regulation 9: Recreational Activities Compliant Regulation 11: Visits Non-Compliant Regulation 13: Searches Compliant Regulation 15: Individual Care Plan Non-Compliant Regulation 16: Therapeutic Services and Programmes Non-Compliant Regulation 20: Provision of Information to Residents Non-Compliant Regulation 21: Privacy Non-Compliant Regulation 22: Premises Non-Compliant Regulation 23: Ordering, Prescribing, Storing and Administration of Compliant Medicines Regulation 26: Staffing Non-Compliant Regulation 27: Maintenance of Records Compliant Regulation 29: Operating Policies and Procedures Compliant Regulation 32: Risk Management Procedures Compliant Rules Governing the Use of Seclusion Compliant Code of Practice for Mental Health Services on Notification of Deaths Non-Compliant and Incident Reporting Code of Practice on Admission, Transfer and Discharge to and from an Non-Compliant Approved Centre AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 13 of 91
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 13: Searches X X Regulation 15: Individual Care Plan X X Regulation 16: Therapeutic Services and Programmes X X X Regulation 19: General Health X Regulation 20: Provision of Information to Residents X X Regulation 21: Privacy X X Regulation 22: Premises X X Regulation 26: Staffing X X X Regulation 28: Register of Residents X Code of Practice on the Use of Physical Restraint in X Approved Centres Code of Practice Relating to the 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 N/A X X X X X The approved centre was requested to provide Corrective and Preventative Actions (CAPAs) for areas of noncompliance. These are included in Appendix 1 of the report. 5.3 Areas of compliance rated Excellent on this inspection The following areas were rated excellent on this inspection: Regulation Regulation 7: Clothing AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 14 of 91
6.0 Service-user Experience The Inspector gives emphasis to the importance of hearing the service users experience of the approved centre. To that end, the inspection team engaged with residents in a number of different ways: The inspection team informally approached residents and sought their views on the approved centre. Posters were displayed inviting the residents to talk to the inspection team. Leaflets were distributed in the approved centre explaining the inspection process and inviting residents to talk to the inspection team. Set times and a private room were available to talk to residents. In order to facilitate residents who were reluctant to talk directly with the inspection team, residents were also invited to complete a service user experience questionnaire and give it in confidence to the inspection team. This was anonymous and used to inform the inspection process. The Irish Advocacy Network (IAN) representative was contacted to obtain residents feedback about the approved centre. With the residents permission, their experience was fed back to the senior management team. The information was used to give a general picture of residents experience of the approved centre as outlined below. All residents highly praised the care they were receiving and said that the nursing staff were kind and listened to them. They also praised the quality of the food and, in particular, mentioned that the catering staff were approachable and friendly. One resident complained of a lack of recreational activities, therapies, and outdoor space and of ongoing boredom. One resident noted that activities were often cancelled or did not take place and suggested that two scheduled activities a day was not sufficient, especially if they were cancelled. AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 15 of 91
7.0 Interviews with Heads of Discipline The inspection team sought to meet with heads of discipline during the inspection. The inspection team met with the following individuals: Executive Clinical Director Clinical Director Psychologist CEO/Registered Proprietor Business Operations Manager Risk Manager All clinical heads of discipline made themselves available to speak with the inspectors. Representatives from pharmacy, nursing, medical, and psychology each provided a clear overview of the governance within their respective departments. There was no occupational therapist assigned to the approved centre and residents did not have access to a social worker. Not all heads of discipline were based in the approved centre, thus not allowing them to fulfil their management role on-site. Defined lines of responsibility were evident in each department. Consequently, staff supervision was facilitated within the departments and regular meetings were scheduled with staff to ensure that they were adequately supported. All heads of discipline identified strategic aims for their teams and discussed potential operational risks with their departments including difficulties in recruiting and retaining staff. There was a culture of performance appraisal within the approved centre particularly in relation to medical and nursing and clear systems in place to support quality improvement. Service user input to each department was facilitated by the ethos of engagement with advocacy within the approved centre. AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 16 of 91
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: Registered Proprietor/Chief Executive Officer Clinical Director Consultant Psychiatrist Director of Nursing Pharmacist Clinical Pharmacy Manager Ward Clerk Operations Manager A/Clinical Nurse Manager 1 Area Director of Nursing 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. AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 17 of 91
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 AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 18 of 91
Regulation 4: Identification of Residents COMPLIANT Quality Rating Satisfactory The registered proprietor shall make arrangements to ensure that each resident is readily identifiable by staff when receiving medication, health care or other services. INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the identification of residents, which was last reviewed in May 2015. It included requirements of the Judgement Support Framework, with the exception of the following: The required use of two appropriate resident identifiers prior to the administration of medications, performance of medical investigations, or provision of other services. The process of identification used for residents with the same or a similar name. Training and Education: Relevant staff had signed a log indicating that they had read and understood the policy. Staff were able to articulate the processes for the identification of residents, as set out in the policy. Monitoring: No audit had been undertaken to ensure that appropriate resident identifiers were included on clinical files. No analysis had been completed to identify opportunities for improving the resident identification process. Evidence of Implementation: The approved centre used a minimum of two identifiers, appropriate to the residents needs. The identifiers were person-specific and suited to the residents communication abilities. They included name and date of birth. Two appropriate identifiers were used when administering medication. There was no alert system in place for residents with the same or a similar name. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the processes, monitoring, and evidence of implementation pillars. AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 19 of 91
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 had a written policy in relation to the provision of appropriate food and nutrition to residents, which was last reviewed in May 2015. It included requirements of the Judgement Support Framework, with the exception of the following: The methods for assessing the dietary and nutritional needs of residents. The process for monitoring food and water intake. Training and Education: Not all relevant staff had signed a log indicating that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for the provision of food and nutrition. Monitoring: Menus were regularly reviewed in the main kitchen by the dietician. Analysis of menus had been completed to identify opportunities for improving the processes relating to food and nutrition. Evidence of Implementation: Residents were provided with a variety of wholesome and nutritious food choices in the approved centre. Menus were approved by a dietician to ensure nutritional adequacy in accordance with residents needs. Residents had continual access to hot and cold drinks. Hot meals were served at lunchtime and teatime. Weight charts were implemented, monitored, and acted upon for residents by nursing staff where appropriate. An evidence-based nutrition assessment tool was not used in the approved centre. 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 evidence of implementation pillars. AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 20 of 91
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 1998. INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to food safety, which was last reviewed in May 2015. It included all the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed a log indicating that they had read and understood the policy. Relevant staff were able to articulate the processes for the provision of food and nutrition to residents. Staff had up-to-date training in the application of Hazard Analysis Critical Care Points (HACCP). Monitoring: The catering staff completed regular food safety audits, including food temperatures, fridge temperatures, dishwasher temperatures, and hygiene audits. Analysis had been completed to identify opportunities for improving food safety processes. Evidence of Implementation: During the inspection, the approved centre s kitchen was closed because of ongoing renovation works. Food was brought in from the main hospital kitchen, and food safety procedures were in place there. Food-handling staff wore appropriate personal protective equipment. Residents were provided with crockery and cutlery that was suitable and sufficient for their specific needs. There was appropriate hand-washing areas for catering services. 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. AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 21 of 91
Regulation 7: Clothing COMPLIANT Quality Rating Excellent The registered proprietor shall ensure that: (1) when a resident does not have an adequate supply of their own clothing the resident is provided with an adequate supply of appropriate individualised clothing with due regard to his or her dignity and bodily integrity at all times; (2) night clothes are not worn by residents during the day, unless specified in a resident's individual care plan. INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to residents clothing, which was last reviewed in March 2015. It included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed a log indicating that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for residents clothing, as set out in the policy. Monitoring: A supply of emergency clothing was maintained in the approved centre. Staff had access to petty cash if they need to purchase clothes for residents. A record of residents wearing nightclothes during the day was kept and monitored. One resident was wearing night attire during the day and this was reflected and documented in their individual care plan. Evidence of Implementation: Residents were supported to keep and use their personal clothing. Resident clothing was clean and appropriate to their needs. Each resident had a wardrobe for storing their clothing and had an adequate supply of individualised clothing. Residents had access to emergency clothing in the form of hospital pyjamas; emergency clothing was stored in the laundry room and was clean and in good condition. Nursing staff had access to petty cash in the event of emergency clothing being required to be purchased for any resident. The approved centre was compliant with this regulation. The quality assessment was excellent because the approved centre met all criteria of the Judgement Support Framework. AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 22 of 91
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 2015. It included all of the requirements of the Judgement Support Framework. Training and Education: Relevant staff had signed a log indicating that they had read and understood the policy. Relevant staff were able to articulate the processes for residents personal property and possessions, as set out in the policy. Monitoring: Individual property logs were maintained and kept in residents clinical files. No analysis had been completed to identify opportunities for improving the processes relating to residents personal property and possessions. Evidence of Implementation: Residents personal property and possessions were safeguarded when the approved centre assumed responsibility for them. Secure facilities were provided for the safe-keeping of the residents monies, valuables, personal property, and possessions. Residents were facilitated to manage their own possessions. An individual property list was in place, separate from the individual care plan. Access to residents money was overseen by two staff, both of whom signed the record with the resident. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the monitoring pillar. AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 23 of 91
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 had a written policy in relation to the provision of recreational activities, which was last reviewed in March 2015. It included elements of the Judgement Support Framework, with the exception of details of the facilities available for recreational activities, including the identification of suitable locations for recreation within and outside the approved centre. Training and Education: Relevant staff had signed a log indicating that they had read and understood the policy. Relevant staff were able to articulate the processes for the provision of recreational activities, as set out in the policy. Monitoring: A record of the occurrence of planned recreational activities, including a record of resident uptake/attendance, was maintained in each resident s clinical file. No analysis had been completed to identify opportunities for improving the processes relating to recreational activities. Evidence of Implementation: There was a resident activity list, with programmes rotating every four weeks. Group activities could change depending on residents preferences and the availability of nursing staff to run them. Recreational activities included arts and crafts held in the designated activity room and current affairs, music, and alcohol information groups. There were no scheduled recreational activities for residents at weekends. Residents had access to books, games, DVDs, and a TV in the activity room and sitting area. Recreational activities were discussed at the resident community meeting on a weekly basis and residents were encouraged to get involved in recreational and activity planning programmes. There was no activities nurse nor occupational therapist. The approved centre had developed a garden, but this was not fully operational at time of inspection. Residents had restricted access to this outdoor space, where they had to be supervised by nursing staff. Plans were in place for the installation of outdoor gym equipment and a table tennis table, but these were not available at the time of inspection. Other recreational equipment had been purchased for the unit, including exercise equipment, electronic games, and softball equipment, which were stored in the clinical nurse manager 2 s office and were not in use during the inspection. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the processes, monitoring, and evidence of implementation pillars. AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 24 of 91
Regulation 10: Religion COMPLIANT Quality Rating Satisfactory The registered proprietor shall ensure that residents are facilitated, insofar as is reasonably practicable, in the practice of their religion. INSPECTION FINDINGS Processes: There approved centre had a written policy in relation to the facilitation of religious practice by residents, which was last reviewed in March 2012. It included all of the elements of the Judgement Support Framework. Training and Education: All relevant staff had signed a log indicating that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for facilitating residents in the practice of their religion, as set out in the policy. Monitoring: The policy was dated March 2012 and had not been reviewed and updated within appropriate time frames in response to the identified needs of residents. Evidence of Implementation: Residents had access to multi-faith chaplains; this was organised when required by the nursing staff. A chaplain visited the approved centre regularly. Depending on a risk assessment, residents could attend religious services away from the approved centre. An information sheet was available in which details of the major religious denominations in the city and surrounding areas were provided, along with associated contact details. The care and services provided were respectful of residents religious beliefs and values, and residents were facilitated in observing or abstaining from religious practice in line with their wishes. An examination of clinical files indicated that there was a protocol in place for providing meals in accordance with religious practices. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the monitoring pillar. AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 25 of 91
Regulation 11: Visits COMPLIANT Quality Rating Satisfactory (1) The registered proprietor shall ensure that appropriate arrangements are made for residents to receive visitors having regard to the nature and purpose of the visit and the needs of the resident. (2) The registered proprietor shall ensure that reasonable times are identified during which a resident may receive visits. (3) The registered proprietor shall take all reasonable steps to ensure the safety of residents and visitors. (4) The registered proprietor shall ensure that the freedom of a resident to receive visits and the privacy of a resident during visits are respected, in so far as is practicable, unless indicated otherwise in the resident's individual care plan. (5) The registered proprietor shall ensure that appropriate arrangements and facilities are in place for children visiting a resident. (6) The registered proprietor shall ensure that an approved centre has written operational policies and procedures for visits. INSPECTION FINDINGS Processes: There approved centre had a written policy in relation to visits, which was last reviewed in May 2015. It included elements of the Judgement Support Framework, with the exception of details of the availability of appropriate locations for resident visits. Training and Education: Relevant staff had signed a log indicating that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for visits, as set out in the policy. Monitoring: At the time of the inspection, none of the residents had visitor restrictions in place. Restrictions on residents rights to receive visitors were not monitored and reviewed on an ongoing basis. Evidence of Implementation: A visitors room had opened, following completion of 2016 s Corrective and Preventative Actions. Visiting times were clearly displayed at the entrance to the approved centre. A visitors room was available, which was suitable for children visiting a resident, although it did not contain any toys or child-friendly materials. Visiting times were reasonable and appropriate for the resident population and profile. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the processes, monitoring, and evidence of implementation pillars. AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 26 of 91
Regulation 12: Communication COMPLIANT Quality Rating Satisfactory (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. INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to resident communication, which was last reviewed in May 2015. It included elements of the Judgement Support Framework, with the exception of the following: The process for assessing residents communication needs. The individual risk assessment requirements in relation to limiting residents communication activities. Training and Education: Relevant staff had signed a log indicating that they had read and understood the policy. Relevant staff were able to articulate the process for facilitating and managing resident communication. Monitoring: There was no documentary evidence that resident communications needs and restrictions on communication were monitored on an ongoing basis. Analysis had not been completed to identify opportunities for improving communication processes. Evidence of Implementation: Residents were permitted to keep their mobile phones, and staff facilitated residents who wanted to use the approved centre s cordless phone to make and receive telephone calls. Residents had access to an office to make/take calls in private. Access to mail was available, but there was no Wi-Fi service. 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. AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 27 of 91
Regulation 13: Searches Quality Rating Risk Rating NON-COMPLIANT Requires Improvement (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. INSPECTION FINDINGS Processes: The approved centre had a written policy in place in relation to searches, which was last reviewed in February 2017. There was a separate policy in relation to dealing with the discovery of illicit substances during a search. The main search policy covered elements of the Judgement Support Framework, including the following: The roles and responsibilities of staff in relation to searches. The completion of a risk assessment prior to a search. The procedures relating to searches. Consideration for resident privacy and dignity during a search. The process for obtaining resident consent for a search. The documentation of searches. The policy did not include details of the processes for communicating the search policies and procedures to residents and staff of the approved centre. Training and Education: A new policy on resident searches was furnished to the inspectors during the course of the inspection. At that time, relevant staff had not signed a log indicating that they had read and understood the policy. Relevant staff interviewed were unable to clearly articulate the processes for conducting a search and gave different accounts of what was considered a resident search and how a search was conducted. AC0028 St. Aloysius Ward, Mater Misericordiae University Hospital Approved Centre Inspection Report 2017 Page 28 of 91