Mental Health Commission Approved Centre Inspection Report (Mental Health Act 2001) APPROVED CENTRE NAME: IDENTIFICATION NUMBER: APPROVED CENTRE TYPE: REGISTERED PROPRIETOR: REGISTERED PROPRIETOR NOMINEE: Linn Dara Child and Adolescent In-patient Unit, Cherry Orchard AC0097 Child and Adolescent In-patient Unit Health Service Executive Mr Kevin Brady MOST RECENT REGISTRATION DATE: 10 December 2015 NUMBER OF RESIDENTS REGISTERED FOR: INSPECTION TYPE: 24 Unannounced INSPECTION DATE: 21, 22 December 2015 PREVIOUS INSPECTION DATE: CONDITIONS ATTACHED: N/A None LEAD INSPECTOR: Dr Fionnuala O Loughlin MCN 008108 INSPECTION TEAM: THE INSPECTOR OF MENTAL HEALTH SERVICES: Ms Mary Corrigan Ms Marianne Griffiths Dr Susan Finnerty MCN 009711 (Acting) Ref MHC FRM 001- Rev 1 Page 1 of 61
Contents 1.0 Mental Health Commission Inspection Process... 4 2.0 Approved Centre Inspection - Overview... 6 2.1 Overview of the Approved Centre... 6 2.2 Governance... 6 2.3 Inspection scope... 6 2.4 Outstanding issues from previous inspection... 7 2.5 Conditions to Registration... 7 2.6 Non-compliant areas on this inspection... 7 2.7 Areas of compliance rated on this inspection... 7 2.8 Areas of good practice identified on this inspection... 8 2.9 Reporting on the National Clinical Guidelines... 8 2.10 Resident Interviews... 8 2.11 Feedback Meeting... 8 3.0 and Required Actions - Regulations... 9 3.1 Regulation 1: Citation... 9 3.2 Regulation 2: Commencement... 9 3.3 Regulation 3: Definitions... 9 3.4 Regulation 4: Identification of Residents... 10 3.5 Regulation 5: Food and Nutrition... 11 3.6 Regulation 6: Food Safety... 12 3.7 Regulation 7: Clothing... 13 3.8 Regulation 8: Residents Personal Property and Possessions... 14 3.9 Regulation 9: Recreational Activities... 15 3.10 Regulation 10: Religion... 16 3.11 Regulation 11: Visits... 17 3.12 Regulation 12: Communication... 18 3.13 Regulation 13: Searches... 19 3.14 Regulation 14: Care of the Dying... 22 3.15 Regulation 15: Individual Care Plan... 23 3.16 Regulation 16: Therapeutic Services and Programmes... 25 3.17 Regulation 17: Children s Education... 26 3.18 Regulation 18: Transfer of Residents... 27 3.19 Regulation 19: General Health... 28 3.20 Regulation 20: Provision of Information to Residents... 29 3.21 Regulation 21: Privacy... 30 3.22 Regulation 22: Premises... 31 3.23 Regulation 23: Ordering, Prescribing, Storing and Administration of Medicines... 33 Ref MHC FRM 001- Rev 1 Page 2 of 61
3.24 Regulation 24: Health and Safety... 36 3.25 Regulation 25: Use of Closed Circuit Television (CCTV)... 37 3.26 Regulation 26: Staffing... 39 3.27 Regulation 27: Maintenance of Records... 41 3.28 Regulation 28: Register of Residents... 42 3.29 Regulation 29: Operating Policies and Procedures... 43 3.30 Regulation 30: Mental Health Tribunals... 44 3.31 Regulation 31: Complaints Procedure... 45 3.32 Regulation 32: Risk Management Procedure... 47 3.33 Regulation 33: Insurance... 49 3.34 Regulation 34: Certificate of Registration... 50 4.0 and Required Actions - Rules... 51 4.1 Section 59: The Use of Electro-Convulsive Therapy... 51 4.2 Section 69: The Use of Seclusion... 52 4.3 Section 69: The Use of Mechanical Restraint... 53 5.0 and Required Actions - The Mental Health Act 2001... 54 5.1 Part 4: Consent to Treatment... 54 6.0 and Required Actions Codes of Practice... 55 6.1 The Use of Physical Restraint... 55 6.2 Admission of Children... 57 6.3 Notification of Deaths and Incident Reporting... 58 6.4 Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities... 59 6.5 The Use of Electro-Convulsive Therapy (ECT) for Voluntary Patients... 60 6.6 Admissions, Transfer and Discharge... 61 Ref MHC FRM 001- Rev 1 Page 3 of 61
1.0 Mental Health Commission Inspection Process The principal functions of the Commission are to promote, encourage and foster the establishment and maintenance of high standards and good practices in the delivery of mental health services and to take all reasonable steps to protect the interests of persons detained in approved centres under this Act. The Mental Health Commission strives to ensure its principal legislative functions are achieved through the registration of approved centres. The process for determination of the compliance level of approved centres, against the statutory regulations, rules, Mental Health Act 2001 and codes of practice shall be transparent and standardised. Section 51 (1) (a) of the Mental Health Act (2001). States that the principal function of the Inspector shall be to visit and inspect every approved centre at least once a year in which the commencement of this section falls and to visit and inspect any other premises where mental health services are being provided as he or she thinks appropriate. Section 52 of the Mental Health Act (2001), states that when making an inspection under section 51, the Inspector shall: a) See every resident (within the meaning of Part 5) whom he or she has been requested to examine by the resident himself or herself or by any other person, b) See every patient the propriety of whose detention he or she has reason to doubt, c) Ascertain whether or not due regard is being had, in the carrying on of an approved centre or other premises where mental health services are being provided, to this Act and the provisions made thereunder, and d) Ascertain whether any regulations made under section 66, any rules made under section 59 and 60 and the provision of Part 4 are being complied with. Each approved centre shall be assessed against all regulations, rules, codes of practice and Section 4 of the Mental Health Act 2001 at least once on an annual basis. Inspectors shall use the triangulation process of documentation review, observation and interview to assess compliance with the requirements. Where non-compliance is determined the individual regulation, or rule, shall also be risk assessed. The approved centre is required to act on all aspects identified as non-compliant or with a high / critical risk rating. Demonstration of immediate corrective rectifications, and ongoing preventative actions must be clearly identified. These actions are required to be specific, measurable, achievable and time-bound. All actions must have identified timeframes and responsibilities. A copy of the draft report was forwarded to the service and comments and review on the report were invited from the Registered Proprietor. These comments were reviewed by the lead inspector and incorporated into the report, where relevant. In circumstances where the Registered Proprietor fails to comply with the requirements of the Mental Health Act 2001 (Approved Centres) Regulations 2006 and Rules, the Mental Health Commission has the authority to initiate escalating enforcement actions up to, and including, Ref MHC FRM 001- Rev 1 Page 4 of 61
removal of an approved centre from the Register and the prosecution of the Registered Proprietor. Ref MHC FRM 001- Rev 1 Page 5 of 61
2.0 Approved Centre Inspection - Overview 2.1 Overview of the Approved Centre The approved centre commenced operation on 11 December 2015 and replaced an interim facility for children and adolescents which was located in Palmerstown, West Dublin. The approved centre was situated on the grounds of Cherry Orchard Hospital in Ballyfermot, Dublin and was a newly constructed, purpose-built two-storey building. The building was an attractive, brightly painted unit; some of the outdoor areas of the approved centre were awaiting final preparation. The unit was laid out in three wards: Hazel (11 beds), Rowan (11 beds) and Oak (two intensive care beds). At the time of inspection, only Hazel and Oak wards were in operation. It was envisaged that children up to age 15 years would be accommodated in Hazel ward with 16 and17 year olds in Rowan ward, when it opened. Although there were 24 beds in the approved centre, the policy of the approved centre was that only 22 of those would ever be in use at any one time; this was because if a child was in the intensive care ward, their bed in Hazel or Rowan ward would remain available to them for transfer back. There were 11 residents in the approved centre at the time of inspection and all were voluntary patients. The ages of the residents ranged from 11 to 16 years and comprised nine female and two male residents. 2.2 Governance There was a governance structure in place which had transferred its role from the former unit to the new approved centre. Minutes from meetings between January and June 2015 were available to the inspection team. Meetings were held monthly and were attended by the clinical director, senior nursing staff and members of senior administration. The meetings addressed issues relating to the Linn Dara service as a whole, including the community services, and not just the approved centre. Recurrent issues in the minutes related to the ongoing work in preparation for the opening of the new approved centre and vacancies at consultant psychiatrist level. 2.3 Inspection scope This was an unannounced annual inspection. All aspects of the regulations, rules and codes of practice, where applicable, were inspected. Areas of the inspection which were not applicable included Regulation 30 Mental Health Tribunals, the Rules Governing the Use of Seclusion and Mechanical Means of Bodily Restraint, Rule and Code of Practice on the Use of ECT and Consent to Treatment, Part 4 of the Mental Health Act 2001. The inspection was undertaken onsite in the approved centre on: 21 December 2015 from 09:00 to 17:30 22 December 2015 from 09:00 to 16:00. Ref MHC FRM 001- Rev 1 Page 6 of 61
2.4 Outstanding issues from previous inspection As this was the first inspection of the approved centre, there were no outstanding issues for consideration. 2.5 Conditions to Registration There were no conditions attached to the registration of this approved centre at the time of inspection. 2.6 Non-compliant areas on this inspection Regulation/Rule/Act/Code Regulation 13: Searches Regulation 15: Individual Care Plan Regulation 23: Ordering, Prescribing, Storing and Administration of Medicines Risk Rating Low Low Low The approved centre was requested to provide Corrective and Preventative Actions (CAPAs) for areas of non-compliance and these are included in the report, in the relevant areas. 2.7 Areas of compliance rated on this inspection Regulation/Rule/Act/Code Regulation 4: Identification of Residents Regulation 5: Food and Nutrition Regulation 6: Food Safety Regulation 7: Clothing Regulation 8: Residents Personal Property and Possessions Regulation 9: Recreational Activities Regulation 10: Religion Regulation 11: Visits Regulation 12: Communication Regulation 14: Care of the Dying Regulation 16: Therapeutic Services and Programmes Regulation 17: Children s Education Regulation 18: Transfer of Residents Regulation 19: General Health Regulation 20: Provision of Information to Residents Regulation 27: Maintenance of Records Regulation 28: Register of Residents Regulation 31: Complaints Procedures Regulation 33: Insurance Regulation 34: Certificate of Registration COP Admission of Children COP on Notification of Deaths and Incident Reporting Ref MHC FRM 001- Rev 1 Page 7 of 61
Code of Practice on Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities COP on Admission, Transfer and Discharge 2.8 Areas of good practice identified on this inspection The school was an excellent facility and was very well equipped with classrooms and specialised rooms for providing education. The leaflets giving information on medication and diagnoses were well designed and appropriate to the age and needs of residents. The use of fittings to minimise the risk of their use as ligature anchor points was excellent. The bedroom accommodation was spacious and well designed. 2.9 Reporting on the National Clinical Guidelines The service reported that it was cognisant of and implemented, where indicated, the National Clinical Guidelines as published by the Department of Health. 2.10 Resident Interviews The residents were invited to meet with the inspectors and relate their experience of the approved centre, if they wished, and three residents met with the inspection team. The residents expressed satisfaction with meals and were aware of their individual care plans. They reported they would like more one-to-one time with staff and more opportunities for outdoor activities. 2.11 Feedback Meeting Prior to the conclusion of the inspection, the inspection team facilitated a feedback session with senior management for the purpose of clarification and for providing initial feedback on the findings of the two day inspection. Members of staff who attended this feedback meeting were the clinical director of the approved centre, the executive clinical director for the area, the area director of nursing, the area manager, the general manager, one assistant director of nursing, three senior nursing staff with responsibility for the approved centre, the psychologist and occupational therapist for the approved centre. Clarification was sought on the members of the Policy Development Group and whether the approved centre accepted admissions out of hours and at weekends; the senior management team clarified these matters. Ref MHC FRM 001- Rev 1 Page 8 of 61
3.0 and Required Actions - Regulations PART TWO: EVIDENCE OF COMPLIANCE WITH REGULATIONS, RULES AND CODES OF PRACTICE, AND PART 4 OF THE MENTAL HEALTH ACT 2001 EVIDENCE OF COMPLIANCE WITH REGULATIONS UNDER MENTAL HEALTH ACT 2001 SECTION 52 (d) 3.1 Regulation 1: Citation Not 3.2 Regulation 2: Commencement Not 3.3 Regulation 3: Definitions Not Ref MHC FRM 001- Rev 1 Page 9 of 61
3.4 Regulation 4: Identification of Residents The registered proprietor shall make arrangements to ensure that each resident is readily identifiable by staff when receiving medication, health care or other services. Processes: There was a policy on identification of residents. The policy outlined the procedure for taking photographic identification and the consent obtained for this from the parent or guardian. Training: Staff were aware of the processes in place to ensure identification of the resident. Monitoring of Compliance: Monitoring of this process was not applicable due to the short period of time the approved centre was in operation. Evidence of Implementation: Photographic identification was attached to each clinical file and prescription booklet. Written consent was obtained from the parent or guardian and this was documented in the clinical file. Two identifiers were used prior to administration of treatment. Poor Ref MHC FRM 001- Rev 1 Page 10 of 61
3.5 Regulation 5: Food and Nutrition (1) The registered proprietor shall ensure that residents have access to a safe supply of fresh drinking water. (2) The registered proprietor shall ensure that residents are provided with food and drink in quantities adequate for their needs, which is properly prepared, wholesome and nutritious, involves an element of choice and takes account of any special dietary requirements and is consistent with each resident's individual care plan. Processes: There was a policy relating to food and nutrition which included the roles and responsibilities of staff. There was a process for the provision of fresh drinking water. Training: Staff were aware of the processes relating to food and nutrition. A trained dietician was involved in developing meal plans which were nutritious. Monitoring of Compliance: As the unit was in operation for a short time only, monitoring was not applicable. Evidence of Implementation: Nutritional needs were documented in individual care plans and menus were evaluated for nutritional value. Specific dietary needs were catered for and hot meals were provided daily; meals provided a choice of options. When indicated, weight charts were used to record progress. Fresh drinking water was available at different locations in the approved centre. Poor Ref MHC FRM 001- Rev 1 Page 11 of 61
3.6 Regulation 6: Food Safety (1) The registered proprietor shall ensure: (a) the provision of suitable and sufficient catering equipment, crockery and cutlery (b) the provision of proper facilities for the refrigeration, storage, preparation, cooking and serving of food, and (c) that a high standard of hygiene is maintained in relation to the storage, preparation and disposal of food and related refuse. (2) This regulation is without prejudice to: (a) the provisions of the Health Act 1947 and any regulations made thereunder in respect of food standards (including labelling) and safety; (b) any regulations made pursuant to the European Communities Act 1972 in respect of food standards (including labelling) and safety; and (c) the Food Safety Authority of Ireland Act 1998. Processes: The service had a policy relating to food safety which referred to relevant legislation and requirements for staff working in food preparation. Training: Relevant staff had received training in Hazard Analysis and Critical Control Point (HACCP) and food safety regulations. Monitoring of Compliance: Food temperature was monitored by staff in the kitchen area and samples retained for future testing. Evidence of Implementation: The approved centre had a sufficient number of catering staff and the dining room was of adequate size to accommodate the residents. Hand washing facilities and personal protective equipment were available to staff and all catering areas were clean. There was a process for the disposal of waste produce. There was sufficient cutlery and crockery for the number of residents. Meals were prepared in the kitchen of the main Cherry Orchard Hospital and transported to the approved centre; a log of food temperatures was maintained and was seen by the inspection team. A dietician provided input into the meal plan and a choice was available at each meal. Poor Ref MHC FRM 001- Rev 1 Page 12 of 61
3.7 Regulation 7: Clothing The registered proprietor shall ensure that: (1) when a resident does not have an adequate supply of their own clothing the resident is provided with an adequate supply of appropriate individualised clothing with due regard to his or her dignity and bodily integrity at all times; (2) night clothes are not worn by residents during the day, unless specified in a resident's individual care plan. Processes: There was a policy in place relating to clothing which directed that residents wore night attire during the day only when clinically indicated. The policy also stated that a supply of clothing was available to residents, if necessary. Training: Staff were aware of the process to obtain a supply of clothes for residents, if necessary. Monitoring of Compliance: Monitoring of this process was not applicable due to the short period of time the approved centre was in operation. Evidence of Implementation: All residents wore day clothes as observed during the course of the inspection. There was no supply of clothes in the approved centre at the time of inspection. However, there was a fund to purchase spare clothes, if required, which would be suitable for the age and size of the child. Poor Ref MHC FRM 001- Rev 1 Page 13 of 61
3.8 Regulation 8: Residents Personal Property and Possessions (1) For the purpose of this regulation "personal property and possessions" means the belongings and personal effects that a resident brings into an approved centre; items purchased by or on behalf of a resident during his or her stay in an approved centre; and items and monies received by the resident during his or her stay in an approved centre. (2) The registered proprietor shall ensure that the approved centre has written operational policies and procedures relating to residents' personal property and possessions. (3) The registered proprietor shall ensure that a record is maintained of each resident's personal property and possessions and is available to the resident in accordance with the approved centre's written policy. (4) The registered proprietor shall ensure that records relating to a resident's personal property and possessions are kept separately from the resident's individual care plan. (5) The registered proprietor shall ensure that each resident retains control of his or her personal property and possessions except under circumstances where this poses a danger to the resident or others as indicated by the resident's individual care plan. (6) The registered proprietor shall ensure that provision is made for the safe-keeping of all personal property and possessions. Processes: There was an up-to-date policy on residents property and possessions. This policy specified that a list of residents property was taken at the time of admission and retained in the clinical file and that residents money should be kept by the approved centre for safe custody. Training: Staff were aware of the procedures relating to residents property and possessions. Monitoring of Compliance: Monitoring of this process was not applicable due to the short period of time the approved centre was in operation. Evidence of Implementation: There was a locked press in the nursing office for securing money, if necessary; this was empty at the time of inspection. Residents were requested not to bring certain items into the approved centre such as mobile phones or laptops. Each resident had a locker and wardrobe in their room; these were not lockable but bedrooms were locked when unoccupied. Property lists were retained in the clinical files. Poor Ref MHC FRM 001- Rev 1 Page 14 of 61
3.9 Regulation 9: Recreational Activities The registered proprietor shall ensure that an approved centre, insofar as is practicable, provides access for residents to appropriate recreational activities. Processes: The service had a policy on recreational activities which addressed the provision of facilities for residents of the approved centre. Information about recreation was included in the Patient Information booklet. Training: Staff displayed knowledge of the processes relating to recreational activities. Monitoring of Compliance: As the approved centre had been in operation for a short period of time only, monitoring of compliance with the processes was not applicable. Evidence of Implementation: Recreational activities were supervised by staff and there were opportunities for both indoor and outdoor activities. A range of recreational activities was available and included board games, TVs, DVDs, a gym, pool table and table tennis table. There was space outdoors for a basketball court and football pitch but this was not yet completed. Attendance at recreational activities was recorded in the clinical files. Poor Ref MHC FRM 001- Rev 1 Page 15 of 61
3.10 Regulation 10: Religion The registered proprietor shall ensure that residents are facilitated, insofar as is reasonably practicable, in the practice of their religion. Processes: There was a policy entitled Religion and Cultural Diversity. The policy addressed the rights of residents to practice their religion and included guidelines for ensuring residents beliefs were respected. Training: Staff were aware of the processes relating to facilitation of residents in the practice of their religion. Monitoring of Compliance: Monitoring of the processes was not applicable at this time. Evidence of Implementation: A list of multi-faith ministers was available to staff so that they could be contacted if requested by a resident. There was access to Mass in the hospital chapel on the grounds of Cherry Orchard Hospital and residents attending services were accompanied, if necessary. Poor Ref MHC FRM 001- Rev 1 Page 16 of 61
3.11 Regulation 11: Visits (1) The registered proprietor shall ensure that appropriate arrangements are made for residents to receive visitors having regard to the nature and purpose of the visit and the needs of the resident. (2) The registered proprietor shall ensure that reasonable times are identified during which a resident may receive visits. (3) The registered proprietor shall take all reasonable steps to ensure the safety of residents and visitors. (4) The registered proprietor shall ensure that the freedom of a resident to receive visits and the privacy of a resident during visits are respected, in so far as is practicable, unless indicated otherwise in the resident's individual care plan. (5) The registered proprietor shall ensure that appropriate arrangements and facilities are in place for children visiting a resident. (6) The registered proprietor shall ensure that an approved centre has written operational policies and procedures for visits. Processes: The service had an up-to-date policy on visits. The policy identified a suitable location within the approved centre for visits and specified the process for restricting visitors on occasion. The visiting hours specified in the policy did not correspond with the times displayed in the approved centre. Training: Staff were aware of the processes relating to visits. Monitoring of Compliance: Monitoring of the processes was not applicable due to the very recent opening of the unit. Evidence of Implementation: Visiting times were displayed at the entrance and in the information leaflet provided to residents. Parents or guardians of residents completed a document indicating appropriate visitors which was included in the residents clinical files. There was a sufficient number of visiting areas in the approved centre and parents could also visit in the child s bedroom. The visiting areas were suitable for child visitors and the Safety Statement addressed the safety of visitors amongst others. Poor Ref MHC FRM 001- Rev 1 Page 17 of 61
3.12 Regulation 12: Communication (1) Subject to subsections (2) and (3), the registered proprietor and the clinical director shall ensure that the resident is free to communicate at all times, having due regard to his or her wellbeing, safety and health. (2) The clinical director, or a senior member of staff designated by the clinical director, may only examine incoming and outgoing communication if there is reasonable cause to believe that the communication may result in harm to the resident or to others. (3) The registered proprietor shall ensure that the approved centre has written operational policies and procedures on communication. (4) For the purposes of this regulation "communication" means the use of mail, fax, email, internet, telephone or any device for the purposes of sending or receiving messages or goods. Processes: There was a policy in relation to communication; this policy stipulated that residents did not bring their mobile phones into the unit. The policy also outlined the process where residents mail and communication was restricted. Training: Staff were aware of the processes in relation to communication within the approved centre. Monitoring of Compliance: Monitoring of the processes was not applicable due to the short period of time since commencing operation. Evidence of Implementation: Residents were not permitted to bring a mobile phone into the unit for safety reasons and access to laptops and tablet computers was restricted to school use. A telephone kiosk was available to make and receive phone calls in private. An interpreter and sign language service was readily accessible, if required. Poor Ref MHC FRM 001- Rev 1 Page 18 of 61
3.13 Regulation 13: Searches (1) The registered proprietor shall ensure that the approved centre has written operational policies and procedures on the searching of a resident, his or her belongings and the environment in which he or she is accommodated. (2) The registered proprietor shall ensure that searches are only carried out for the purpose of creating and maintaining a safe and therapeutic environment for the residents and staff of the approved centre. (3) The registered proprietor shall ensure that the approved centre has written operational policies and procedures for carrying out searches with the consent of a resident and carrying out searches in the absence of consent. (4) Without prejudice to subsection (3) the registered proprietor shall ensure that the consent of the resident is always sought. (5) The registered proprietor shall ensure that residents and staff are aware of the policy and procedures on searching. (6) The registered proprietor shall ensure that there is be a minimum of two appropriately qualified staff in attendance at all times when searches are being conducted. (7) The registered proprietor shall ensure that all searches are undertaken with due regard to the resident's dignity, privacy and gender. (8) The registered proprietor shall ensure that the resident being searched is informed of what is happening and why. (9) The registered proprietor shall ensure that a written record of every search is made, which includes the reason for the search. (10) The registered proprietor shall ensure that the approved centre has written operational policies and procedures in relation to the finding of illicit substances. Processes: There was a policy in place on searches. The policy outlined the processes for searches to be carried out, both with and without consent, and described the areas where a search could be carried out including a resident s environment, resident s property and person. The policy stipulated that a search would be carried out following an assessment of the situation and always with a minimum of two nurses. Training: Staff reported they were aware of the processes relating to searches, but a search observed by one inspector indicated that this was not the case. Monitoring of Compliance: Monitoring of the processes was not carried out due to the short time since commencing operation. Evidence of Implementation: Consent for searches was obtained from residents and parent/guardians at the time of admission. Searches of the environment were carried out routinely four times daily. There was a record of searches in several clinical files inspected; these were conducted routinely when a resident returned from leave. There was no evidence that an individual risk assessment had been carried out in each case or that it was carried out by two nurses. One inspector observed a search of a resident s suitcase, which was being conducted on the desk of the nurses station by one nurse and without the presence of the resident. As searches were not always conducted following a risk assessment and were not carried out by two nurses, the service was not compliant with this regulation. Ref MHC FRM 001- Rev 1 Page 19 of 61
Poor Risk Rating: Low Moderate High Critical Not - Ref MHC FRM 001- Rev 1 Page 20 of 61
3.13 Regulation 13: Searches The following Corrective and Preventative Actions (CAPAs) were provided by the Registered Proprietor or nominee and are subject to ongoing review by the Mental Health Commission. All actions should be Specific, Measurable, Achievable, Realistic and Time-bound with defined responsibilities for implementation: Date received 18 th February 2016 CAPAs Specific Measureable Achievable & Realistic Define the action and state if it is corrective or preventative and state post-holder(s) responsible 1.Corrective action has been taken Staff education session re: search policy including prior risk assessment and location of searches (e.g. take place in young person bedroom in order to respect privacy and dignity) A search form has been introduced which: which records the rational for the search Includes a risk assessment Conforms with the service policy. On completion this will be filed in the Young person s clinical file Signatures of the two staff who conducted search recorded on the form Post-Holder(s): CNM3 - Staff education sessions have taken place CNM2 - on each unit will review each search procedure and documentation CNM3 - will ensure a monthly audit of searches forms will occur Define the area of noncompliance addressed by this CAPA Disconnect with service policy & practice (Search conducted by 1 nurse rather than 2 no risk assessment in advance of search search took place in public area ( nurses station) State method of evaluation and monitoring of outcome review of each search conducted and documentation by the CNM2 Monthly audit of all searches by CNM3 State feasibility of action Search form was introduced Jan 2016, Achievable and realistic Time-bound State time-frame for completion of action Completed Ref MHC FRM 001- Rev 1 Page 21 of 61
3.14 Regulation 14: Care of the Dying (1) The registered proprietor shall ensure that the approved centre has written operational policies and protocols for care of residents who are dying. (2) The registered proprietor shall ensure that when a resident is dying: (a) appropriate care and comfort are given to a resident to address his or her physical, emotional, psychological and spiritual needs; (b) in so far as practicable, his or her religious and cultural practices are respected; (c) the resident's death is handled with dignity and propriety, and; (d) in so far as is practicable, the needs of the resident's family, next-of-kin and friends are accommodated. (3) The registered proprietor shall ensure that when the sudden death of a resident occurs: (a) in so far as practicable, his or her religious and cultural practices are respected; (b) the resident's death is handled with dignity and propriety, and; (c) in so far as is practicable, the needs of the resident's family, next-of-kin and friends are accommodated. (4) The registered proprietor shall ensure that the Mental Health Commission is notified in writing of the death of any resident of the approved centre, as soon as is practicable and in any event, no later than within 48 hours of the death occurring. (5) This Regulation is without prejudice to the provisions of the Coroners Act 1962 and the Coroners (Amendment) Act 2005. Processes: There was a policy in place relating to care of the dying. The policy outlined the procedures for addressing physical, emotional and spiritual needs for a resident who is dying and provision of care to the family in those circumstances. Training: Staff were aware of the processes relating to care of residents who are dying. Monitoring of Compliance: Monitoring was not applicable at this time. Evidence of Implementation: As no resident had died or required end of life care in the approved centre, this aspect of inspection was not applicable. Poor Ref MHC FRM 001- Rev 1 Page 22 of 61
3.15 Regulation 15: Individual Care Plan The registered proprietor shall ensure that each resident has an individual care plan. [Definition of an individual care plan:... a documented set of goals developed, regularly reviewed and updated by the resident s multi-disciplinary team, so far as practicable in consultation with each resident. The individual care plan shall specify the treatment and care required which shall be in accordance with best practice, shall identify necessary resources and shall specify appropriate goals for the resident. For a resident who is a child, his or her individual care plan shall include education requirements. The individual care plan shall be recorded in the one composite set of documentation.] Processes: There was a policy on individual care plans (ICPs) and processes in place to ensure each child had an ICP. The policy specified the contents of the ICP and the involvement of the resident in drawing up their ICP. Training: Staff were aware of the processes relating to ICPs but a review of ICPs indicated a lack of understanding of the documentation of goals for residents in the ICPs. Monitoring of Compliance: As the unit was only recently opened, monitoring was not applicable. Evidence of Implementation: All residents had an ICP. The template for completing an ICP included a section to record needs, goals, person responsible and review date. The names of staff attending the ICP review meetings were also recorded and there was input from a range of disciplines. In many cases, the young person had signed their ICP and the template included a section to record whether the resident was offered a copy of their ICP. The regulation states that the ICP will specify appropriate goals for the resident. In many cases, the goals documented in the ICP were goals for staff to accomplish rather than goals for the resident, e.g. assist to settle into unit, assessment of mental state, assess occupational therapy needs, to support school attendance. This indicated a lack of understanding on the part of staff for the requirement to document residents goals as part of the ICP. As the ICP did not adequately document the goals for the resident, which is a requirement, the service was not compliant with this regulation. Poor Risk Rating: Low Moderate High Critical Not - Ref MHC FRM 001- Rev 1 Page 23 of 61
3.15 Regulation 15: Individual Care Plan The following Corrective and Preventative Actions (CAPAs) were provided by the Registered Proprietor or nominee and are subject to ongoing review by the Mental Health Commission. All actions should be Specific, Measurable, Achievable, Realistic and Time-bound with defined responsibilities for implementation: Date received 18 th February 2016 CAPAs Specific Measureable Achievable & Realistic Define the action and state if it is corrective or preventative and state post-holder(s) responsible 1.Corrective Action has been taken A Review of the Integrated Care Plan (ICP) commenced in late 2015 undertaken by a Working Group. The proposed new ICP promotes increased collaboration with the YP in all aspects of care planning. So that goals are clearer and more relevant to the young person Careful consideration has been given to the use of language it includes a new communication tool My Recovery Goals which will be completed by the YP with members of the MDT. Define the area of noncompliance addressed by this CAPA Current ICP did not adequately document the goals for the resident: Goals were more treatment orientated goals rather than individual goals. State method of evaluation and monitoring of outcome Review of new ICP after six weeks pilot by working group. Feedback from YP at weekly Young Persons forum. State feasibility of action New ICP currently at draft stage and being reviewed by working group. Achievable and realistic Time-bound State time-frame for completion of action Pilot of New ICP to be commenced 1 st March 2016 Post-Holder(s): CNM 2, CNM 3 & Consultants - Staff education sessions CNM2 - Collate feedback collected from young person s forum to inform further development of the ICP Working Group to review feedback from Pilot. Ref MHC FRM 001- Rev 1 Page 24 of 61
3.16 Regulation 16: Therapeutic Services and Programmes (1) The registered proprietor shall ensure that each resident has access to an appropriate range of therapeutic services and programmes in accordance with his or her individual care plan. (2) The registered proprietor shall ensure that programmes and services provided shall be directed towards restoring and maintaining optimal levels of physical and psychosocial functioning of a resident. Processes: There was a policy which outlined the roles and responsibilities of staff in relation to the provision of therapeutic services. Training: Staff were appropriately trained to facilitate groups and therapeutic services. Monitoring of Compliance: Monitoring of the processes was not applicable due to the short period of time the approved centre was in operation. Evidence of Implementation: A range of therapeutic services was available to the residents, in accordance with the individual s ICP. These services included occupational therapy, social groups, arts and crafts, anxiety management groups, eating disorder groups and speech and language therapies. In addition to group work, residents attended individual sessions with relevant therapists. Two trained family therapists provided sessions in the approved centre. Attendance at therapies was recorded in residents clinical files. There were dedicated areas within the approved centre for providing therapeutic services. Poor Ref MHC FRM 001- Rev 1 Page 25 of 61
3.17 Regulation 17: Children s Education The registered proprietor shall ensure that each resident who is a child is provided with appropriate educational services in accordance with his or her needs and age as indicated by his or her individual care plan. Processes: There was a policy relating to education in the approved centre. The policy outlined the need for an educational assessment for each resident and identified provision of resources to support the residents education. Training: Staff working in the approved centre school were qualified secondary school teachers. A special needs assistant (SNA) worked to assist the teachers. Teachers were registered by the Teaching Council and were qualified to teach a range of subjects. However, only two of the six teachers and one SNA had received training in Children First principles. Monitoring of Compliance: Monitoring of compliance with the processes was not applicable due to the short period of time in operation. Evidence of Implementation: Assessment of educational requirements was carried out at the time of admission and an educational plan for each resident was maintained electronically. The school had six teachers, including a principal teacher, equivalent to four whole time equivalent posts (WTE). The school day operated from 10:00 to 15:30, Monday to Friday. Classrooms were situated in the school which was an integral part of the approved centre, but located away from the accommodation and day room areas. In addition to the classrooms, there was an art room, pottery room, home economics room and science room. Poor Ref MHC FRM 001- Rev 1 Page 26 of 61
3.18 Regulation 18: Transfer of Residents (1) When a resident is transferred from an approved centre for treatment to another approved centre, hospital or other place, the registered proprietor of the approved centre from which the resident is being transferred shall ensure that all relevant information about the resident is provided to the receiving approved centre, hospital or other place. (2) The registered proprietor shall ensure that the approved centre has a written policy and procedures on the transfer of residents. Processes: There was a policy relating to the transfer of residents which outlined the process for transferring both voluntary and involuntary patients and for transferring relevant documentation. Training: Staff were aware of the processes relating to transfer of residents. Monitoring of Compliance: No monitoring had been carried out to date as the approved centre was in operation a short time only. Evidence of Implementation: No resident had been transferred to another facility since the approved centre opened. However, one resident had been transferred from one ward to another; all relevant information had been transferred with the resident as the clinical file accompanied the resident. Notification to the resident s next of kin was documented in the clinical file. Poor Ref MHC FRM 001- Rev 1 Page 27 of 61
3.19 Regulation 19: General Health (1) The registered proprietor shall ensure that: (a) adequate arrangements are in place for access by residents to general health services and for their referral to other health services as required; (b) each resident's general health needs are assessed regularly as indicated by his or her individual care plan and in any event not less than every six months, and; (c) each resident has access to national screening programmes where available and applicable to the resident. (2) The registered proprietor shall ensure that the approved centre has written operational policies and procedures for responding to medical emergencies. Processes: There was a policy on general health and a separate policy on responding to medical emergencies. The policy on responding to emergencies specified the procedures for responding to a medical emergency, access to medical specialists as required, and that staff attend training courses in First Aid and Basic Life Support (BLS). Training: All clinical staff were trained healthcare professionals and were aware of the processes relating to residents general health. Monitoring of Compliance: Monitoring of the processes was not applicable due to the short time the unit was open. Evidence of Implementation: Physical health assessments were carried out at the time of admission and documented in the resident s clinical file. In the event of a medical emergency, the procedure was to call an ambulance and a member of the nursing staff would accompany the child. An Automated Emergency Defibrillator (AED) was located in each nurses station. These had been newly purchased and were checked weekly. As the approved centre was only recently opened, no resident had been admitted for longer than six months. Poor Ref MHC FRM 001- Rev 1 Page 28 of 61
3.20 Regulation 20: Provision of Information to Residents (1) Without prejudice to any provisions in the Act the registered proprietor shall ensure that the following information is provided to each resident in an understandable form and language: (a) details of the resident's multi-disciplinary team; (b) housekeeping practices, including arrangements for personal property, mealtimes, visiting times and visiting arrangements; (c) verbal and written information on the resident's diagnosis and suitable written information relevant to the resident's diagnosis unless in the resident's psychiatrist's view the provision of such information might be prejudicial to the resident's physical or mental health, wellbeing or emotional condition; (d) details of relevant advocacy and voluntary agencies; (e) information on indications for use of all medications to be administered to the resident, including any possible side-effects. (2) The registered proprietor shall ensure that an approved centre has written operational policies and procedures for the provision of information to residents. Processes: The service had a policy on the provision of information to residents. The policy outlined the provision of a resource area within the approved centre with information leaflets and for information to be provided at the time of admission as well as in the Patient Information leaflet. The policy also specified that provision of information on medication was to be provided to the resident and their family, as applicable. Training: Staff were aware of the processes relating to the provision of information to residents. Monitoring of Compliance: Monitoring of the processes had not been conducted due to the recent opening of the unit. Evidence of Implementation: There was an information booklet about the unit which contained information on housekeeping matters of the approved centre, visiting times, details of the multi-disciplinary team and the process for making complaints. No information on advocacy services was provided as the HSE did not have an advocacy service for children; the service, however, used the MHC Headspace Toolkit, which facilitated young people in being their own advocate. Information about medications and diagnoses was available in a format easily understood by children. Poor Ref MHC FRM 001- Rev 1 Page 29 of 61
3.21 Regulation 21: Privacy The registered proprietor shall ensure that the resident's privacy and dignity is appropriately respected at all times. Processes: There was a policy on privacy which specified the need for confidentiality in relation to medical records. The process of admitting residents to single rooms provided for privacy. Training: Staff were aware of the processes to ensure privacy. Monitoring of Compliance: Monitoring of the processes was not applicable due to the short duration of time since the commencement of the approved centre. Evidence of Implementation: All residents were accommodated in single rooms which ensured privacy for the occupants. The bedroom doors had a glass panel with an in-built blind which could be operated by the resident and staff. En suite bathrooms, toilets and bedrooms could be locked from inside; bedrooms which were locked had to be individually opened by staff in the event of staff wishing to enter the bedroom. An outdoor area, designed to be used as a basketball court, was easily visible from the main road outside the unit. There was a separate treatment room for examinations but this room had a large glass panel in the door which had no screening; this was corrected at the time of inspection when pointed out by the inspection team. An enclosed phone kiosk ensured that the residents could make and receive telephone calls in private. Resident details, displayed on the noticeboard inside the nursing office, were not visible to passers-by. Clinical files were stored in a locked trolley in the nurses station. Poor Ref MHC FRM 001- Rev 1 Page 30 of 61
3.22 Regulation 22: Premises (1) The registered proprietor shall ensure that: (a) premises are clean and maintained in good structural and decorative condition; (b) premises are adequately lit, heated and ventilated; (c) a programme of routine maintenance and renewal of the fabric and decoration of the premises is developed and implemented and records of such programme are maintained. (2) The registered proprietor shall ensure that an approved centre has adequate and suitable furnishings having regard to the number and mix of residents in the approved centre. (3) The registered proprietor shall ensure that the condition of the physical structure and the overall approved centre environment is developed and maintained with due regard to the specific needs of residents and patients and the safety and well-being of residents, staff and visitors. (4) Any premises in which the care and treatment of persons with a mental disorder or mental illness is begun after the commencement of these regulations shall be designed and developed or redeveloped specifically and solely for this purpose in so far as it practicable and in accordance with best contemporary practice. (5) Any approved centre in which the care and treatment of persons with a mental disorder or mental illness is begun after the commencement of these regulations shall ensure that the buildings are, as far as practicable, accessible to persons with disabilities. (6) This regulation is without prejudice to the provisions of the Building Control Act 1990, the Building Regulations 1997 and 2001, Part M of the Building Regulations 1997, the Disability Act 2005 and the Planning and Development Act 2000. Processes: There was a policy in place relating to the premises. However, the policy related to the previous building which housed the approved centre and stated that the unit was an interim building. There were processes in place relating to the current approved centre. Training: Staff were aware of the processes relating to the premises. Monitoring of Compliance: Monitoring of the processes was not applicable at the time of inspection as the unit was in operation for a short period of time only. Evidence of Implementation: The approved centre was a newly constructed building specifically designed for use as an in-patient unit for children and adolescents and was wheelchair accessible. It was laid out in three wards for accommodation and recreational use. One of these wards operated as an intensive care unit and contained two separate apartments, each composed of a bedroom and sitting room. A further area of the approved centre contained the school, therapy areas and administration offices. A three-bed apartment was situated on the ground floor and was to facilitate families visiting a resident in the approved centre who required accommodation. Bedrooms were of a good size and the temperature of each bedroom could be regulated by the occupant. Each of the two main units had two sitting rooms, games room and smaller rooms for visiting or consultations. There were a number of outdoor spaces, some of which were not yet in use as the grass surfaces had not yet had time to mature. Each unit had an enclosed garden. The outdoor area, designed to be used as a basketball court, was easily visible from the main road outside the unit. Ref MHC FRM 001- Rev 1 Page 31 of 61