Acute Mental Health Unit, Cork University Hospital ID Number: AC0096 2017 Approved Centre Inspection Report (Mental Health Act 2001) Acute Mental Health Unit Cork University Hospital Wilton Cork Conditions Attached: None Approved Centre Type: Acute Adult Mental Health Care Psychiatry of Later Life Registered Proprietor: HSE Most Recent Registration Date: 4 February 2015 Registered Proprietor Nominee: Ms Sinead Glennon, Head of Mental Services Cork & Kerry Inspection Team: Siobhán Dinan, Lead Inspector Orla O Neill Marianne Griffiths Donal O Gorman Inspection Date: 16 19 May 2017 Inspection Type: Unannounced Annual Inspection Previous Inspection Date: 8 10 November 2016 The Inspector of Mental Health Services: Dr Susan Finnerty MCRN009711 Date of Publication: 28 September 2017 COMPLIANCE RATINGS 2017 8 REGULATIONS RULES AND PART 4 OF THE MENTAL HEALTH ACT 2001 1 1 2 CODES OF PRACTICE 1 Compliant Non-compliant Not applicable 22 3 3
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 25 25 24 20 15 10 5 0 9 10 11 7 6 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 12 Low Moderate High Critical 10 8 1 3 4 6 4 3 6 4 2 0 5 3 1 2015 2016 2017 AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 2 of 95
Contents 1.0 Introduction to the Inspection Process... 4 2.0 Inspector of Mental Health Services Summary of Findings... 6 3.0 Quality Initiatives... 9 4.0 Overview of the Approved Centre... 10 4.1 Description of approved centre... 10 4.2 Conditions to registration... 10 4.3 Reporting on the National Clinical Guidelines... 10 4.4 Governance... 11 5.0 Compliance... 12 5.1 Non-compliant areas from 2016 inspection... 12 5.2 Non-compliant areas on this inspection... 13 5.3 Areas of compliance rated Excellent on this inspection... 13 6.0 Service-user Experience... 14 7.0 Interviews with Heads of Discipline... 15 8.0 Feedback Meeting... 16 9.0 Inspection Findings Regulations... 17 10.0 Inspection Findings Rules... 64 11.0 Inspection Findings Mental Health Act 2001... 68 12.0 Inspection Findings Codes of Practice... 71 Appendix 1 Corrective and Preventative Action Plan... 80 AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 3 of 95
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. AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 4 of 95
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. AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 5 of 95
2.0 Inspector of Mental Health Services Summary of Findings Inspector of Mental Health Services Dr Susan Finnerty As Inspector of Mental Health Services, I have provided a summary of inspection findings under the headings below. This summary is based on the findings of the inspection team under the regulations and associated Judgement Support Framework, rules, Part 4 of the Mental Health Act 2001, codes of practice, service user experience, staff interviews and governance structures and operations, all of which are contained in this report. Safety in the approved centre The approved centre had a written policy in relation to health and safety, and a safety statement. There were comprehensive risk management policies and processes in place. The person-specific resident identifiers in use in the approved centre consisted of wristbands with details of each resident s name, address, date of birth, and medical record number. Food safety audits had been completed and hygiene was maintained to support food safety. Catering areas and associated equipment were appropriately cleaned. There were a number of prescription, administration and storage of medication errors. Not all health care professional were up to date with their training in fire safety, Basic Life Support, Professional Management of Aggression and Violence, and the Mental Health Act 2001. At the time of the inspection, the high observation area was not functioning as such and was used for general admission beds. 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 Of concern was that six residents did not have an individual care plan (ICP) and not all ICPs identified the necessary resources or specified appropriate goals for the residents. Not all residents were aware of their individual care plan. There was a wide range of therapeutic services and programmes facilitated by an activities nurse, psychology staff, an art therapist, and community voluntary organisations. Although residents received appropriate general health care as indicated in their individual care plans, one resident had not received a six-monthly general health check. There was no system for organising six-monthly physicals, and records of residents completed health checks and the associated results were not consistently maintained. Clinical files were in poor condition. Almost all of the clinical files in question contained loose pages and investigation/test reports, undated individual care plans and misfiled documents. Records were not maintained in a logical sequence and two appropriate resident identifiers were not recorded on all documentation. AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 6 of 95
The approved centre was compliant with Part 4 of the Mental Health Act 2001: Consent to Treatment. AREAS REFERRED TO Regulations 5, 14, 15, 16, 17, 18, 19, 23, 25, 27, Part 4 of the Mental Health Act 2001, Rule Governing the Use of Seclusion and Mechanical Means of Bodily Restraint, Rule Governing the Use of ECT, Code of Practice on Physical Restraint, Code of Practice on the Admission of Children, Code of Practice on the Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities, Code of Practice on Admission, Transfer and Discharge, service user experience, and interviews with staff. Respect for residents privacy and dignity Residents could bring personal possessions into the approved centre and were supported to manage their own property. All residents had an adequate supply of individualised clothing, and each had a large lockable wardrobe and bedside locker for the storage of clothing and belongings. Residents consent to a search was sought and searches were attended by at least two clinical staff and implemented with due regard to the resident s dignity, privacy and gender. Residents were informed by those implementing the search of what was happening and why. End of life care was appropriate to the resident s physical, emotional, social, psychological, and spiritual needs. Bathrooms, showers, toilets, and single rooms had locks on the inside of the doors. Most of the accommodation comprised single, en suite rooms. The approved centre s internal courtyard was overlooked by nearby houses. This was an ongoing concern since the 2016 inspection. The inspection team was informed that the estates department intended to erect privacy screening to address the issue. Residents were facilitated in making and taking private phone calls. There was prominent signage indicating where CCTV cameras were located. Residents were monitored solely for the purposes of ensuring their health, safety, and welfare by a healthcare professional. Cameras were incapable of recording or storing a resident s image in any format. Seclusion was not used in the approved centre. AREAS REFERRED TO Regulations 7, 8, 13, 14, 21, 25, Rule Governing the Use of Seclusion, Code of Practice on Physical Restraint, Code of Practice on the Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities, service user experience, and interviews with staff. Responsiveness to residents needs Residents were complimentary about the care received from the nursing staff and the food provided by the approved centre. Food, including modified consistency diets, was presented in an appealing manner and was wholesome and nutritious food choices. There was a lack of laundry facilities for residents who did not have visitors to take home their laundry. There was excellent provision of recreational activities during the week and at weekends. Information about recreational activities was provided to residents via notices and timetables posted up throughout the approved centre and activities were developed, maintained, and implemented with resident involvement. There was a chapel in the general hospital, which residents could visit weekly. Residents also had access to multi-faith chaplains. There were three separate, dedicated visitors rooms where residents could meet visitors in private. Residents had access to external communications, including telephone, mail, fax, e-mail, and Internet. Required information was given to residents and/or their representatives at admission in the form of a resident information booklet. Diagnosisand medication-related information, including risks and potential side-effects, was readily available, and medication leaflets were in an easy-to-read, uncomplicated, and user-friendly format. A new information AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 7 of 95
leaflet had been developed for family members of residents explaining the admission process, confidentiality, and available support services. There was a robust and well-advertised complaints procedure in place. The approved centre s physical environment was of a high standard and there was a documented programme of general maintenance. A daily cleaning schedule was in place. 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 approved centre was part of the HSE s Community Healthcare Organisation 4 area. The governance structures included an area executive management team, a local Acute Mental Health Unit management team, a quarterly incident review committee, and a quality initiatives and audit committee. The minutes of executive management team meetings provided outlined an active governance process. Both individual and operational risks were monitored. There was an organisational chart to identify the leadership and management structure and lines of authority and accountability. Each clinical discipline had its own governance structure, with clear line management and supervision. Management and staff of the approved centre had an annual audit plan. There was evidence from the audit reports that the approved centre was collecting and analysing data to identify opportunities for improvement. Operating policies and procedures, which incorporated relevant legislation, evidence-based best practice, and clinical guidelines, were communicated to all relevant staff. Not all policies and procedures required by the regulations had been reviewed at least every three years. AREAS REFERRED TO Regulations 26 and 32, interviews with heads of discipline, and minutes of area management team meetings. AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 8 of 95
3.0 Quality Initiatives The following quality initiatives were identified on this inspection: 1. A new information leaflet had been developed for family members of residents explaining the admission process, confidentiality, and available support services. 2. A dual diagnosis group had been developed and took place weekly in the approved centre. 3. A multi-disciplinary team had been established to work with individuals with emotionally unstable personality disorder. AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 9 of 95
4.0 Overview of the Approved Centre 4.1 Description of approved centre The Acute Mental Health Unit (AMHU) was well signposted and located towards the rear of the Cork University Hospital campus in Wilton, Cork city. This purpose-built, free-standing, two-storey building opened in August 2015. The approved centre comprised of three units; the acute male unit, the acute female unit and the Psychiatry of Later Life (POLL) unit. The acute male and female admission units, each with 18 beds, were located on the ground floor alongside an additional six-bed high observation area. At the time of the inspection, the high observation area was not functioning as such: The six beds were being used as additional beds for the admissions unit. The admissions unit was configured into 21 male and 21 female beds. The eight-bed Psychiatry of Later Life (POLL) unit was located on the first floor alongside administration offices and therapy rooms. Visitors entered the premises via a large reception area where there was a reception desk staffed 24 hours a day by HSE security personnel. The entrance doors to the individual units were locked, and access was via keypad or by staff releasing the electronic door mechanism. The link corridor between the reception hallway and the admissions unit contained interview rooms and three visitors rooms. Six general adult sector teams and two POLL teams admitted residents to the AMHU. The resident profile on the first day of inspection was as follows: Resident Profile Number of registered beds 50 Total number of residents 49 Number of detained patients 16 Number of Wards of Court 0 Number of children 0 Number of residents in the approved centre for more than 6 months 5 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. AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 10 of 95
4.4 Governance The approved centre was part of the HSE s Community Healthcare Organisation 4 area. The approved centre had established governance mechanisms in place. The governance structures included an area executive management team, a local AMHU management team, a quarterly incident review committee, and a quality initiatives and audit committee. The minutes of meetings for these committees were provided to the inspection team. The minutes of executive management team meetings provided outlined an active governance process. Both individual and operational risks were monitored. The minutes demonstrated an action-oriented focus with clear time lines. Ongoing constraints on staff recruitment meant that staff vacancies and the provision of services were the main priorities on the agenda at each area management team meeting. There was an organisational chart to identify the leadership and management structure and lines of authority and accountability. Each clinical discipline had its own governance structure, with clear line management and supervision. Management and staff of the approved centre had an annual audit plan. There was evidence from the audit reports that the approved centre was collecting and analysing data to identify opportunities for improvement. AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 11 of 95
5.0 Compliance 5.1 Non-compliant areas from 2016 inspection The previous inspection of the approved centre on 8 10 November 2016 identified the following areas that were not compliant. The approved centre was requested to provide Corrective and Preventative Actions (CAPAs) for areas of non-compliance and these were published with the 2016 inspection report. Regulation/Rule/Act/Code 2017 Inspection Findings Regulation 7: Clothing Compliant Regulation 15: Individual Care Plan Non-Compliant Regulation 21: Privacy Non-Compliant Regulation 23: Ordering, Prescribing, Storing and Administration of Non-Compliant Medicines Regulation 26: Staffing Non-Compliant Regulation 27: Maintenance of Records Non-Compliant Regulation 28: Register of Residents Non-Compliant Code of Practice on the Use of Physical Restraint in Approved Centres Non-Compliant Code of Practice Guidance for Persons Working in Mental Health Services Non-Compliant with People with Intellectual Disabilities Code of Practice on Admission, Transfer and Discharge to and from an Non-Compliant Approved Centre AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 12 of 95
5.2 Non-compliant areas on this inspection Non-compliant (X) areas on this inspection are detailed below. Also shown is whether the service was compliant () or non-compliant (X) in these areas in 2016 and 2015: Regulation/Rule/Act/Code 2015 Compliance 2016 Compliance 2017 Compliance Regulation 15: Individual Care Plan X X X Regulation 19: General Health X Regulation 21: Privacy X X X Regulation 23: Ordering, Prescribing, Storing and X X X Administration of Medicines Regulation 26: Staffing X X Regulation 27: Maintenance of Records X X X Regulation 28: Register of Residents X X X Regulation 29: Operating Policies and Procedures X Code of Practice on the Use of Physical Restraint in Approved Centres Code of Practice Guidance for Persons Working in Mental Health Services with People with Intellectual Disabilities Code of Practice on Admission, Transfer and Discharge to and from an Approved Centre X X X X X X X The approved centre was requested to provide Corrective and Preventative Actions (CAPAs) for areas of noncompliance. These are included in Appendix 1 of the report. 5.3 Areas of compliance rated Excellent on this inspection The following areas were rated excellent on this inspection: Regulation Regulation 4 : Identification of Residents Regulation 7: Clothing Regulation 9: Recreational Activities Regulation 10: Religion AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 13 of 95
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. All those that provided feedback to the inspection team gave permission that their experience could be 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. Two residents and a family member of a resident provided feedback to the inspection team. All were complimentary about the care received from the nursing staff and the food provided by the approved centre. Staff were described as patient, kind, and helpful. It was felt that the visitors room in the Psychiatry of Later Life unit was uninviting and therefore not used often. Residents were invited to complete a questionnaire about their experience in the Acute Mental Health Unit. One questionnaire was returned. Not all residents were aware of their individual care plan (ICP). The inspection team also met with a representative of the Irish Advocacy Network (IAN). The IAN representative noted some issues relating to the lack of laundry facilities for residents who do not have visitors to take home their laundry. The IAN representative provided feedback that they had previously received from residents that there was a need for a better selection of activities in the acute unit and that activity programmes were repeated, leading to boredom amongst more long-term residents. AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 14 of 95
7.0 Interviews with Heads of Discipline The inspection team sought to meet with heads of discipline during the inspection. The inspection team met with the following individuals: Clinical Director Area Director of Nursing Occupational Therapy Manager Principal Psychologist Social Work Manager All clinical heads of discipline made themselves available to speak with the inspectors. Representatives from nursing, medical, social work, occupational therapy, and psychology each provided a clear overview of the governance within their respective departments. The Area Director of Nursing visited the approved centre on a regular basis. The clinical director was based in the approved centre and was on site daily. The Occupational Therapy Manager, Principal Psychologist and Social Work Manager had no direct input to the approved centre. 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. These were agenda items at senior management meetings. Key performance indicators assisted the organisation to measure how well it was doing in relation to achieving goals. None of the disciplines operated staff performance review appraisals. Clear systems were in place to support quality improvement. Service user input was facilitated by engagement with advocacy within the approved centre. AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 15 of 95
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: Clinical Director Area Director of Nursing Assistant Director of Nursing x 2 Occupational Therapy Manager Principal Social Worker Compliance and Regulations Officer Clinical Nurse Manager 3 Clinical Nurse Manager 2 x 3 Area Administrator Apologies were received on behalf of the registered proprietor nominee and the principal psychologist. 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. A number of clarifications were provided regarding various issues that had arisen during the course of this inspection, and these are incorporated into this report. AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 16 of 95
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 AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 17 of 95
Regulation 4: Identification of Residents COMPLIANT Quality Rating Excellent The registered proprietor shall make arrangements to ensure that each resident is readily identifiable by staff when receiving medication, health care or other services. INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the identification of residents, which was last reviewed in October 2016. 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 identifying residents, as set out in the policy. Monitoring: An annual audit had been undertaken to ensure that clinical files contained appropriate resident identifiers. Analysis had been completed to identify opportunities for improving the resident identification process. Evidence of Implementation: The person-specific resident identifiers in use in the approved centre consisted of wristbands with details of each resident s name, address, date of birth, and medical record number. The identifiers, which were appropriate to residents communication abilities, were used before the administration of medication, the undertaking of medical investigations, and the provision of health care services and therapeutic services and programmes. A caution sticker system was in place to alert staff to the presence of residents with the same or a similar name. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework. AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 18 of 95
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 February 2017. It included all of the requirements of the Judgement Support Framework. Training and Education: All relevant staff had not signed a log indicating that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for food and nutrition, as set out in the policy. Monitoring: A systematic review of menu plans had been undertaken to ensure that residents received wholesome and nutritious food in accordance with their needs. Analysis had been completed to identify opportunities for improving the processes for food and nutrition. Evidence of Implementation: Menus were nutritionally analysed by a nutritionist/dietician to ensure nutritional adequacy in accordance with residents needs. Food, including modified consistency diets, was presented in an appealing manner. Residents were provided with a wide range of wholesome and nutritious food choices, and hot meals were provided on a daily basis. Residents had regular access to hot and cold drinks and to a source of safe, fresh drinking water. Weight charts were implemented, monitored, and acted upon, where required. Residents, their representatives, family, and next of kin were educated about residents diets, where appropriate. The needs of residents identified as having special nutritional requirements were regularly reviewed by a nutritionist. Nutritional and dietary needs were assessed, where necessary, and addressed in the resident s individual care plan. The approved centre did not use an evidence-based nutrition tool to assess residents with special dietary requirements. 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 and evidence of implementation pillars. AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 19 of 95
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 February 2017. It included all of the requirements of the Judgement Support Framework. Training and Education: All relevant staff had not signed a log indicating that they had read and understood the policy. Relevant staff interviewed could articulate the processes for food safety, as set out in the policy. All staff handling food had up-to-date training in the application of Hazard Analysis and Critical Control Point (HACCP). The training was documented. Monitoring: Food safety audits had been completed. Food temperatures were in line with food safety recommendations, and a temperature log sheet was maintained and monitored. Analysis had been completed to identify opportunities for improving food safety processes. Evidence of Implementation: Appropriate hand-washing areas were provided for catering services, and there was suitable catering equipment, with appropriate facilities for the refrigeration, storage, preparation, cooking, and serving of food. Hygiene was maintained to support food safety, and catering areas and associated equipment were appropriately cleaned. Residents had access to a supply of suitable crockery and cutlery, which addressed their specific needs. 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. AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 20 of 95
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 clothing, which was last reviewed in February 2017. 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 on clothing. Relevant staff interviewed could articulate the processes in relation to residents clothing, as set out in the policy. Monitoring: An emergency supply of clothing for residents was maintained in the property room and monitored by the clinical nurse manager 2 on an ongoing basis. A record of residents wearing nightclothes during the day was maintained and monitored. At the time of the inspection, one resident had been prescribed night attire during the day. Evidence of Implementation: Residents were supported to keep and wear their personal clothing, and residents clothing was observed to be clean and appropriate to their needs. Residents clothing was sent home to family members or to the launderette for cleaning. An emergency supply of clothing was available, which took account of the residents preferences, dignity, bodily integrity, and religious and cultural practices. Residents changed out of nightclothes during the day, unless otherwise specified in their individual care plan (ICP). All residents had an adequate supply of individualised clothing, and each had a large lockable wardrobe and bedside locker for the storage of clothing and belongings. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework. AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 21 of 95
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 October 2016. It included requirements of the Judgement Support Framework, with the exception of the process for allowing residents to have access to and control over their personal property, unless this posed a danger to the resident or others, as indicated in their individual care plans (ICPs), following a risk assessment. Training and Education: Relevant staff had signed a log indicating that they had read and understood the policy. Relevant staff interviewed could articulate the processes relating to residents property and possessions, as set out in the policy. Monitoring: The approved centre monitored personal property logs. Analysis was completed to identify opportunities to improve the processes for residents personal property and possessions. This is documented. Evidence of Implementation: Residents could bring personal possessions into the approved centre and were supported to manage their own property, unless this posed a danger to themselves or others, as indicated in their ICPs. All residents personal property and possessions were recorded and signed for by both staff and the residents. The approved centre had a duplicate property log book and residents were given copies of their property logs. Residents wardrobes had code-enabled locking mechanisms, which allowed residents to store personal property, safely and securely. There was also a safe in the nurses station where residents could secure money, although residents were encouraged to limit the amount of money they brought in to the approved centre. AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 22 of 95
Two members of staff oversaw the process of providing residents with access to their monies, and signed records of staff issuing the money were retained and, where possible, countersigned by the resident or their representative. Residents individual property checklists were kept separately from their ICPs. 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 pillar. AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 23 of 95
Regulation 9: Recreational Activities COMPLIANT Quality Rating Excellent 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 February 2017. The policy 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 could articulate the processes relating to recreational activities, as set out in the policy. Monitoring: A record of the occurrence of planned recreational activities, including a log of resident uptake/attendance was maintained. Analysis had been completed to identify opportunities for improving the processes relating to recreational activities. Evidence of Implementation: Residents had access to appropriate recreational activities. The activities available on the Psychiatry of Later Life (POLL) unit included bingo, music, ball games, newspaper review, radio, knitting, card games, and arts and crafts. Residents in the POLL unit had access to a newly refurbished rooftop patio area, with raised beds and a small space for walking. There was also a lounge area with a TV and a multi-sensory room. The acute admission unit had three lounges, each with a TV. Residents had access to newspapers, magazines, books, table games, and arts and crafts. There was also a small gym room and outdoor garden space. There was a weekly yoga class, and the activities nurses ran a weekly baking group and brought residents for walks in the hospital grounds. Recreational activities were scheduled in the approved centre on weekdays and at weekends. Information about recreational activities was provided to residents via notices and timetables posted up throughout the approved centre. Activities were developed, maintained, and implemented with resident involvement. Recreational activities were appropriately resourced, and opportunities were available for indoor and outdoor exercise and physical activity. Documented records of attendance were retained for recreational activities within the residents clinical files. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework. AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 24 of 95
Regulation 10: Religion COMPLIANT Quality Rating Excellent The registered proprietor shall ensure that residents are facilitated, insofar as is reasonably practicable, in the practice of their religion. INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the facilitation of religious practice by residents, which was last reviewed in February 2017. 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 facilitating residents in the practice of their religion, as set out in the policy. Monitoring: The implementation of the policy to support residents religious practices was reviewed to ensure it reflects the identified needs of the residents. Evidence of Implementation: Residents were facilitated in the practice of their religion insofar as was practicable. There was a chapel in the general hospital, which residents could visit weekly. Residents also had access to multi-faith chaplains. Following a risk assessment, residents could attend religious services outside of the approved centre, if deemed appropriate. The care and services provided within the approved centre were respectful of residents religious beliefs and values, and residents were facilitated in observing or abstaining from religious practice in line with their wishes. The approved centre was compliant with this regulation. The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework. AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 25 of 95
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: The approved centre had a written policy in relation to visits, which was last reviewed in February 2017. It included requirements of the Judgement Support Framework, with the exception of required visitor identification methods. 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 relating to visits, as set out in the policy. Monitoring: Restrictions on residents rights to receive visitors were monitored and reviewed on an ongoing basis. Analysis was completed to identify opportunities to improve visiting processes. This was documented. Evidence of Implementation: Visiting times, which were appropriate and reasonable, were publicly displayed in the approved centre. There were three separate, dedicated visitors rooms where residents could meet visitors in private, unless there was an identified risk to the resident or to others or a health and safety risk. Appropriate steps were taken to ensure visitor safety and the safety of residents during visits. Children were welcome when accompanied at all times for their safety. Visiting areas had facilities suitable for visiting children. 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 pillar. AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 26 of 95
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 February 2017. It included requirements of the Judgement Support Framework, with the following exceptions: The roles and responsibilities for resident communication processes. The process whereby resident communications could be examined by a senior member of staff. The individual risk assessment requirements in relation to limiting resident communication activities. Training and Education: Relevant staff had signed a log indicating that they had read and understood the policy. Relevant staff interviewed could articulate the processes for facilitating residents communication, as set out in the policy. Monitoring: There was no evidence that residents 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 had access to external communications, including telephone, mail, fax, e-mail, and Internet. Where appropriate, individual risk assessments were completed for residents in relation to risks associated with their external communication. These were documented in their individual care plans. Only the clinical director or a senior staff member could examine incoming and outgoing resident communication where there was reasonable cause to believe that the communication may result in harm to the resident or to others. 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. AC0096 Acute Mental Health Unit, Cork University Hospital Approved Centre Inspection Report 2017 Page 27 of 95