Mental Health Commission Approved Centre Inspection Report ... · Ref MHC – FRM – 001- Rev 1 Page 6 of 71 2.0 Approved Centre Inspection - Overview 2.1 Overview of the Approved

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Mental Health Commission

Approved Centre Inspection Report

(Mental Health Act 2001)

APPROVED CENTRE NAME: Selskar House

IDENTIFICATION NUMBER: AC0092

APPROVED CENTRE TYPE: Old Age Psychiatry

REGISTERED PROPRIETOR: Health Service Executive

REGISTERED PROPRIETOR NOMINEE: Ms Stephanie Lynch

MOST RECENT REGISTRATION DATE: 02 May 2013

NUMBER OF RESIDENTS REGISTERED

FOR:

20

INSPECTION TYPE: Unannounced

INSPECTION DATE: 14, 15, 16 October 2015

PREVIOUS INSPECTION DATE: 06 March 2014

CONDITIONS ATTACHED: Yes

LEAD INSPECTOR: Ms Geraldine Corr

INSPECTION TEAM: Dr Fionnuala O’Loughlin MCN08108

THE INSPECTOR OF MENTAL HEALTH

SERVICES:

Dr Susan Finnerty MCN009711 (Acting)


Contents

1.0 Mental Health Commission Inspection Process .................................................................. 4

2.0 Approved Centre Inspection - Overview ............................................................................... 6

2.1 Overview of the Approved Centre .......................................................................................... 6

2.2 Governance ............................................................................................................................. 6

2.3 Inspection scope ...................................................................................................................... 6

2.4 Outstanding issues from previous inspection ......................................................................... 6

2.5 Conditions to Registration ....................................................................................................... 7

2.6 Non-compliant areas on this inspection ................................................................................. 7

2.7 Areas of compliance rated Excellent on this inspection ......................................................... 8

2.8 Areas of good practice identified on this inspection .............................................................. 8

2.9 Reporting on the National Clinical Guidelines......................................................................... 9

2.10 Resident Interviews ................................................................................................................. 9

2.11 Feedback Meeting ................................................................................................................... 9

3.0 Inspection Findings and Required Actions - Regulations ................................................. 10

3.1 Regulation 1: Citation............................................................................................................ 10

3.2 Regulation 2: Commencement ............................................................................................. 10

3.3 Regulation 3: Definitions ....................................................................................................... 10

3.4 Regulation 4: Identification of Residents .............................................................................. 11

3.5 Regulation 5: Food and Nutrition.......................................................................................... 12

3.6 Regulation 6: Food Safety ..................................................................................................... 13

3.7 Regulation 7: Clothing ........................................................................................................... 14

3.8 Regulation 8: Residents’ Personal Property and Possessions ............................................... 15

3.9 Regulation 9: Recreational Activities .................................................................................... 16

3.10 Regulation 10: Religion ......................................................................................................... 17

3.11 Regulation 11: Visits.............................................................................................................. 18

3.12 Regulation 12: Communication ............................................................................................ 19

3.13 Regulation 13: Searches ........................................................................................................ 20

3.14 Regulation 14: Care of the Dying .......................................................................................... 21

3.15 Regulation 15: Individual Care Plan ...................................................................................... 23

3.16 Regulation 16: Therapeutic Services and Programmes ........................................................ 25

3.17 Regulation 17: Children’s Education ..................................................................................... 27

3.18 Regulation 18: Transfer of Residents .................................................................................... 28

3.19 Regulation 19: General Health .............................................................................................. 29

3.20 Regulation 20: Provision of Information to Residents .......................................................... 30

3.21 Regulation 21: Privacy........................................................................................................... 32

3.22 Regulation 22: Premises ....................................................................................................... 35

3.23 Regulation 23: Ordering, Prescribing, Storing and Administration of Medicines .............. 37

3.24 Regulation 24: Health and Safety ......................................................................................... 40


3.25 Regulation 25: Use of Closed Circuit Television (CCTV) ........................................................ 42

3.26 Regulation 26: Staffing .......................................................................................................... 45

3.27 Regulation 27: Maintenance of Records ............................................................................... 48

3.28 Regulation 28: Register of Residents .................................................................................... 49

3.29 Regulation 29: Operating Policies and Procedures ............................................................... 51

3.30 Regulation 30: Mental Health Tribunals ............................................................................... 53

3.31 Regulation 31: Complaints Procedure .................................................................................. 54

3.32 Regulation 32: Risk Management Procedure ....................................................................... 55

3.33 Regulation 33: Insurance ...................................................................................................... 58

3.34 Regulation 34: Certificate of Registration ............................................................................. 59

4.0 Inspection Findings and Required Actions - Rules ............................................................ 60

4.1 Section 59: The Use of Electro-Convulsive Therapy ............................................................. 60

4.2 Section 69: The Use of Seclusion .......................................................................................... 61

4.3 Section 69: The Use of Mechanical Restraint ....................................................................... 62

5.0 Inspection Findings and Required Actions - The Mental Health Act 2001 .................... 65

5.1 Part 4: Consent to Treatment ............................................................................................... 65

6.0 Inspection Findings and Required Actions – Codes of Practice ..................................... 66

6.1 The Use of Physical Restraint ................................................................................................ 66

6.2 Admission of Children ........................................................................................................... 67

6.3 Notification of Deaths and Incident Reporting ..................................................................... 68

6.4 Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities ......................................................................................................................................... 69

6.5 The Use of Electro-Convulsive Therapy (ECT) for Voluntary Patients................................... 70

6.6 Admissions, Transfer and Discharge ..................................................................................... 71


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,


removal of an approved centre from the Register and the prosecution of the Registered

Proprietor.


2.0 Approved Centre Inspection - Overview

2.1 Overview of the Approved Centre

Selskar House was located on the ground floor of Farnogue Residential Healthcare Unit, Old

Hospital Road, Wexford. The unit was not well signposted from the main road; however, there

was a large signpost at the gateway. Access to the car park was gained by pressing a buzzer

and staff lifted the barrier. Access to the approved centre was gained by pressing a buzzer

and nursing staff opened the electronically controlled doors.

Selskar House provided long-term care to residents who, due to multiple pathology or high

dependency care needs, were no longer able to be cared for at home or in a nursing home.

The modern and bright premises provided a good care environment; all bedrooms were single

rooms with en suite facilities and the enclosed gardens provided a safe outdoor space to

residents. On the day of inspection, all 20 beds were occupied and there were no detained

patients in the centre.

2.2 Governance

There was an organisational chart and clear governance structures and processes were in

place. The minutes of the Executive Management Team were provided to the inspection team.

Attendance at these meetings by the senior management team of the approved centre was

noted to be excellent and minutes were clear and well documented. It was evident from the

minutes that Executive Management Team meetings took place on a monthly basis.

2.3 Inspection scope

This was an unannounced annual inspection that was conducted on the:

14 October from 09:00 to 18:30



There were 20 residents in the approved centre on these dates, with no detained patients. The

regulations, rules and codes of practice were inspected against; Consent, Admission of

Children, Children’s Education, Seclusion and Electro Convulsive Therapy were not applicable

to the approved centre at the time of inspection.

2.4 Outstanding issues from previous inspection

The previous inspection of the approved centre on the 06 March 2014 identified that the centre

was not fully compliant with the regulations, rules, act and codes of practice listed below. The

compliance rating achieved for each of these during the 2015 inspection is presented below.


Regulation/Rule/Act/Code Inspection Findings 2015

Regulation 7: Clothing Compliant

Regulation 15: Individual Care Plan Compliant

Regulation 16: Therapeutic Services and

Programmes

Non-Compliant

Regulation 20: Provision of Information to

Residents

Compliant

Regulation 26: Staffing Non-Compliant

Regulation 27: Maintenance of Records Compliant

Regulation 28: Register of Residents Non-Compliant

Regulation 34: Certificate of Registration Compliant

Code of Practice on the Use of Physical

Restraint in Approved Centres

Compliant

Code of Practice on the Admission, Transfer

and Discharge to and from an Approved

Centre

Compliant

2.5 Conditions to Registration

The Mental Health Commission attached a condition to the registration of this approved centre on the 18 December 2014. The condition stated: The Mental Health Commission requires that ongoing clinical audits must be conducted, by appropriately qualified clinical persons external to the approved centre, as a cyclical process to monitor compliance with Article 15 (Individual Care Plan) of S.l. No 551 of 2006; Mental Health Act 2001 (Approved Centres) Regulations 2006 for each in-patient resident of each sector team to ensure improvement has been achieved and sustained. A sectorised report of the results of the ongoing clinical audit, naming each specific sector team, must be submitted to the Commission on 1st February 2015 and on the 1st of each month thereafter. The report must detail the following.; (i)' Persons responsible for collecting the data, (ii) Audit criteria (The sample audit tool provided in the MHC Guidance Document on Individual Care Planning may be used), (iii) Outcome of Audit - level of compliance with Article 15', (iv) Quality improvement plan, (v) Implementation dates for the improvement plan, (vi) Dates to repeat the data collection to measure sustainability and/or improvement, and · (vii) Methods to communicate the results to key stakeholders. The approved centre was compliant with Regulation 15 Individual Care Plan in 2015.

2.6 Non-compliant areas on this inspection

Regulation/Rule/Act/Code Risk Rating

Regulation 16: Therapeutic Services and

Programmes

Moderate

Regulation 21: Privacy Moderate

Regulation 23: Ordering, Prescribing, Storing

and Administration of Medicine

Low

Regulation 25: Use of Closed Circuit

Television (C.C.T.V)

Moderate


Regulation 26: Staffing Moderate

Regulation 28: Register of Residents Low

Regulation 29: Operating Policies and

Procedures

Moderate

Regulation 32: Risk Management Moderate

Rules Governing the use of Mechanical

Means of Bodily Restraint (Part 5)

Moderate

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 Excellent on this inspection

Regulation/Rule/Act/Code

Regulation 7: Clothing

Regulation 10: Religion

Regulation 13: Searches

Regulation 11: Visits

Regulation 30: Mental Health Tribunals

Regulation 31: Complaints Procedures

Regulation 33: Insurance

2.8 Areas of good practice identified on this inspection

Since the 2014 inspection, there had been a significant improvement in individual care

planning. All 20 residents had an individual care plan on inspection and a standardised

format was being used. Each resident had needs, goals, interventions and resources

identified.

There were two external activities coordinators employed at the centre and records of

who attended and engaged in activities were kept. It was evident that the activity

programme was tailored to residents’ needs and changed when it was appropriate.

The admission booklet was very comprehensive and well formatted. It provided

structured assessments in falls risk assessments, waterlow scores and manual

handling assessments (easymove) and facilitated a standardised approach to each

admission. The page entitled ‘this is me’ was a good example of eliciting residents’

preferences.

It was recognised that the service was in the process of migrating its policies into

regional policies (Waterford/Wexford). The new format was an improvement on the

previous formatting. It was evident that it would facilitate a standardised approach to

the development of Operating Procedures and Policies that would be clear and easy

for staff to follow and understand.


2.9 Reporting on the National Clinical Guidelines

Staff on the unit did not have any awareness of the National Clinical Guidelines regarding

infection control (MRSA, Clostridium Difficile, Sepsis) when asked. In addition, a significant

majority of the infection control policies and procedures were out of date and, therefore, did

not reflect the information in the National Clinical Guidelines on infection control.

2.10 Resident Interviews

Due to the nature of the residents’ clinical conditions (i.e. progressive dementia), at the time of

the inspection, the inspectors did not arrange a formal meeting with residents. However, the

inspectors spent time on a daily basis talking with residents who were able to engage with

them. Residents reported that they “liked” being at the centre and considered it their “home”.

They referred to the fact that there was plenty of activity to engage in during the day and that

staff were “nice” to them and provided good care. Residents complimented the gardens and

liked having access to this amenity.

2.11 Feedback Meeting

The inspection team met with members of the senior management team at the conclusion of

inspection on the 16 October 2015. The registered proprietor nominee did not attend but the

following individuals were present:

Director of Nursing

Treating Consultant Psychiatrist

Assistant Director of Nursing

Clinical Placement Co-ordinator

Clinical Nurse Manager 2

Acting Clinical Nurse Manager 2

Deputy Manager

The inspection team thanked the staff for their hospitality and cooperation over the course of

the inspection. It was noted that staff were very helpful and, where possible, provided all

information requested. Each inspector gave an overview of the regulations that they were

responsible for and took the opportunity to clarify any issues that were outstanding. A number

of clarifications were provided by the senior management team regarding various issues which

had arisen during the course of this inspection and these are incorporated into this report.

The senior management team reported that funding for the position of an Occupational

Therapist had been submitted recently and they were hopeful that this would resolve some of

the issues in relation to Therapeutic Services and Programmes (Regulation 16).


3.0 Inspection Findings 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 Applicable

3.2 Regulation 2: Commencement

Not Applicable

3.3 Regulation 3: Definitions

Not Applicable


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.

Inspection Findings Processes: There was a policy in place on this regulation. Training: Staff interviewed were aware of the policy requirements and types of identifiers that could be used. In addition, staff stated that residents were well known to them as all residents were in long-term care in the approved centre. Monitoring of Compliance: There was no formal or informal monitoring of practice pertaining to this regulation. Evidence of Implementation: There were several unique identifiers observed to be available in residents’ records. These included photographs, date of birth, name and record number. As many residents had conditions that impinged on their ability to communicate, the photographic ID was deemed to be particularly appropriate to the setting. Staff were observed to call residents by their names and knew who each resident was as residents were long term.

Compliance Rating:

Non – Compliant – Negligible

Achievement (1)

Non – Compliant – Poor

Achievement (2)

Compliant – Good

Achievement (3)

Compliant – Excellent

Achievement (4)

Not- Applicable

X


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.

Inspection Findings Processes: There was a policy in place on this regulation. Training: All staff involved in assisting residents who required support with dietary intake were registered nurses, and health care assistants had Further Education and Training Awards level five. Student nurses were supervised by qualified staff when feeding residents. Monitoring of Compliance: There was no formal or informal monitoring of practice pertaining to this regulation. Evidence of Implementation: No formal nutritional assessment tool was used but staff reported that, where indicated by a resident’s needs, the service could access a speech and language therapist and/or dietician. Where the resident had a special dietary requirement, this was facilitated by staff liaising directly with the kitchen that provided the food. Information was observed to be displayed on a notice board in the locked kitchen about residents’ specific dietary needs (i.e. altered consistency, specialised dietary requirements, e.g. diabetic diet). However, there was no evidence of dietary needs being integrated into the residents’ individual care plans even though a large proportion of residents required assistance with this activity. Each resident was weighed on a monthly basis and staff reported that any significant changes in weight were acted upon by the multidisciplinary team. A weekly menu was displayed and there were several options available for each meal. Food was observed to be presented in an attractive and appealing manner and hot meals were provided. There was a process in place to ensure that residents had access to fresh drinking water when needed.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


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.

Inspection Findings Processes: There was currently no policy in the centre in relation to food safety. There were defined processes in place to ensure food safety. Training: Catering staff had received Hazard Analysis & Critical Control Point training and this was updated on a regular basis. Monitoring of Compliance: There was no formal monitoring of practice pertaining to this regulation. However, food temperatures were monitored on leaving the main kitchen and on arrival at the approved centre. A log of the temperatures on arrival was maintained. Fridge temperatures were taken on a daily basis and a log of this was also kept. Evidence of Implementation: There was a sufficient number of catering staff in the centre to ensure that food safety standards could be achieved. Food was not prepared in the kitchen but was transported from another campus (St. John’s Hospital, Enniscorthy, Co. Wexford). Catering staff were observed to perform good hand hygiene and there were separate hand hygiene sinks. Personal protective equipment was observed to be worn by staff as appropriate. There were no inappropriate items stored in the fridge; only food was observed in each fridge. The kitchen area was observed to be very clean and there was a regular cleaning schedule to maintain food safety. All surfaces were observed to be stainless steel. The waste was appropriately disposed of and was removed from the kitchen on regular basis. There was no Environmental Health Officer Report for the approved centre.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


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.

Inspection Findings Processes: There was a policy in place on this regulation. Training: All staff were aware of the requirements in relation to this regulation. Monitoring of Compliance: There was a process in relation to the provision of clothing and this was reviewed as necessary. Evidence of Implementation: Residents maintained their own clothes in their own rooms. Each resident had an individual wardrobe and those inspected contained a plentiful supply of clean clothes. Residents’ families were encouraged to launder residents’ clothes but, where this was not possible, facilities were available for laundering. In order to ensure that residents’ clothes did not become confused, they were placed into individual laundry bags prior to laundering. In addition, residents’ clothes were labelled with the resident’s name. If new clothes needed to be labelled, nursing staff ordered labels and hand sewed them on. Residents were observed to be wearing their own clothes that were clean and appropriate for their age and all residents were observed to be dressed in their day clothes. An emergency supply of clothing was available if needed.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


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.

Inspection Findings Processes: There was a policy in place on this regulation. Training: Staff were aware of the requirements to record a resident’s property on admission and of the processes in respect of lost property. Monitoring of Compliance: There was no formal monitoring of practice pertaining to this regulation. Evidence of Implementation: There was a process in place where residents and their relatives were advised of what personal items could be brought into the centre. All property was recorded on admission in a property book; a copy of the property list was placed in clinical files separate to the resident’s individual care plan. Restrictions only applied to valuable items or excessive amounts of cash. Where valuable items or cash was brought into the centre, there was a safe in the nurse manager’s office for safe keeping. Cash stored in this safe was double signed by two nursing staff every time it was handled. Residents were permitted to keep their property with them and the inspection team observed residents’ rooms to be personalised with pictures and bedding. Wardrobes were lockable.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


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.

Inspection Findings Processes: There was a policy in place on this regulation but it did not cover risk assessments or facilities available for recreational facilities. Training: Two activities staff facilitated recreational activities in the centre. Both staff were Further Education and Training Awards level five trained and one staff member had completed Sonas training. All staff in the centre were aware of the policy requirements and had signed to state they had read and understood the policy. Monitoring of Compliance: There was no formal monitoring of practice pertaining to this regulation. However, the activities staff regularly reviewed the activities in relation to the residents’ needs. This often resulted in changes to activities provided. Evidence of Implementation: There was a range of activities available within the centre for residents (e.g. arts and crafts, gentle exercise, jigsaws). The Sonas programme, which is a therapeutic communication activity for older people, focuses on sensory stimulation and was also available to residents. The activities staff were committed to providing activities that were appropriate to the residents’ needs and engaged with each resident to encourage participation. Inspectors observed an activity session; residents appeared to be enjoying this and were encouraged by staff to participate as much as possible. Comprehensive attendance records were kept and resident contribution in the programme was facilitated, where appropriate. There were two secure gardens in the centre that were observed to be used by the residents on a regular basis. Gardens were monitored by CCTV.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


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.

Inspection Findings Processes: There was a policy in place on this regulation. Training: Staff were aware of the requirements of the policy. Monitoring of Compliance: There was no formal monitoring of practice pertaining to this regulation. However, staff monitored the residents’ needs in relation to their religious practice. Where a resident’s need was observed to change (e.g. palliative care) religious practices were altered as appropriate. Evidence of Implementation: Staff supported residents in their religious practices. There was a prayer room available for use by residents that was warm and clean. Residents were accompanied by staff to this room as needed and mass was provided here on a weekly basis. Mass could be transmitted to residents’ televisions in their bedrooms; this facilitated those patients who could not attend the prayer room. In addition, the priest regularly visited the unit and this was observed by the inspector. At the time of inspection, all residents were of Roman Catholic faith. However, other faiths would be facilitated where necessary. In addition, a resident’s decision not to engage in religious practices would also be supported.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


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.

Inspection Findings Processes: There was a policy in place on this regulation but it did not cover private visiting or visitor identification methods. Training: Staff were aware of the process involved in facilitating visits. Monitoring of Compliance: Visiting processes were reviewed as necessary. Evidence of Implementation: There was a notice displayed on the visiting times within the unit and relatives of new admissions were informed by staff of the visiting hours. Visiting information was also included in the information booklet. Visiting hours were noted to be appropriate and staff reported that the hours are flexible depending on patients’ needs. Children were facilitated to visit the residents and remained in the company of an appropriate adult throughout the visit. There was no dedicated visiting room in the approved centre but it was acknowledged that visits could be taken in the residents’ bedrooms which facilitated privacy. Staff reported that residents’ wishes about visitor restrictions would be taken into account and recorded in the residents’ individual care plans.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


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.

Inspection Findings Processes: There was a policy in place on this regulation. Training: Staff were aware of the processes in place to facilitate communication. Monitoring of Compliance: There was no formal or informal monitoring of practice pertaining to this regulation. Evidence of Implementation: Risk assessments were carried out where indicated. To facilitate privacy, residents had

access to a portable ward phone and calls were taken in the residents’ bedrooms. Staff

would only open mail where a need had been identified in relation to a particular resident.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


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.

Inspection Findings Processes: There was a policy in place on this regulation but it did not cover the staff training requirements. Training: Staff were aware of the procedures in relation to the searching of a resident, his or her belongings and the environment in which he or she was accommodated. Monitoring of Compliance: There were no searches conducted in the centre during 2015. It was therefore not possible for staff to monitor compliance with the processes at the time of inspection. Evidence of Implementation: There were no searches conducted in the centre during 2015. It was therefore not possible for the inspection team to assess the evidence of implementation.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


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.

Inspection Findings Processes: There was a policy in place on this regulation. Training: Staff were aware of the process for caring for residents who were dying. In addition, there was a good working relationship with the palliative care team of Wexford General, and guidance received by this team was disseminated to and followed by all staff when necessary. Monitoring of Compliance: No formal or informal monitoring of practice pertaining to this regulation was conducted. Evidence of Implementation: The privacy of residents who were dying was protected as each resident had a single room with en suite facilities. There were no visiting restrictions in place when caring for a resident who was dying and relatives would be encouraged to visit as much as they wished. There was a GP who attended the centre and the resident’s condition, including pain management, would be managed in conjunction with the GP. The centre had cared for a number of residents in 2015 who had died and the Mental Health Commission had been notified, as appropriate, of these deaths. The clinical file for one of these residents was reviewed; the care plan did not reflect the end of life care needs for this resident. Due to the nature of residents’ conditions there was a significant number of DNAR orders in place. It was difficult to find evidence of the DNAR in the residents’ clinical files. In addition, the documentation of DNAR orders varied according to practitioner and was not always documented by the Consultant Psychiatrist responsible for treatment.


Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


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”.]

Inspection Findings Processes: There was a policy in place on this regulation but it did not cover a section detailing the staff training requirements. Training: There was training available to staff on individual care planning and staff had received this training. Monitoring of Compliance: There was no evidence of incident forms being completed for non-compliance with the processes. However, there were monthly audits of care plans conducted by the approved centre and these were forwarded to the Mental Health Commission in line with the condition on registration which states:

The Mental Health Commission requires that ongoing clinical audits must be conducted, by appropriately qualified clinical persons external to the approved centre, as a cyclical process to monitor compliance with Article 15 (Individual Care Plan) of S.l. No 551 of 2006; Mental Health Act 2001 (Approved Centres) Regulations 2006 for each in-patient resident of each sector team to ensure improvement has been achieved and sustained. A sectorised report of the results of the ongoing clinical audit, naming each specific sector team, must be submitted to the Commission on 1st February 2015 and on the 1st of each month thereafter. The report must detail the following.; (i)' Persons responsible for collecting the data, (ii) Audit criteria (The sample audit tool provided in the MHC Guidance Document on Individual Care Planning may be used), (iii) Outcome of Audit - level of compliance with Article 15', (iv) Quality improvement plan, (v) Implementation dates for the improvement plan, (vi) Dates to repeat the data collection to measure sustainability and/or improvement, and · (vii) Methods to communicate the results to key stakeholders.

Evidence of Implementation: On inspection, all 20 residents had an individual care plan documented in their clinical file. There was multidisciplinary team involvement in individual care planning. Care plans had needs, goals, interventions and resources documented and were individually tailored to the residents’ needs. There was poor documentation of the resident and family involvement in the process. Although there was a key worker system in operation, this was not well documented on care plans. Care plans were currently being reviewed every six months.


Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


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.

Inspection Findings Processes: There were processes and a policy in place on this regulation. Training: Staff delivering the available therapies in the centre were Further Education and Training Awards level five trained. Monitoring of Compliance: There was no formal or informal monitoring of practice pertaining to this regulation. Evidence of Implementation: Therapies available in the centre were aimed at the particular resident population. Records of attendance were kept. External referrals were made for some therapies (e.g. physiotherapy, speech and language therapist, dietician). However, there was no occupational therapy or psychology input in the centre which was resulting in residents having unmet needs. There were several patients in Buxton chairs who had not been adequately assessed for these chairs due to the lack of Occupational Therapy input. Residents who had a need for behavioural management programmes lacked the input of psychology to fully facilitate this intervention. This resulted in assaultive behaviour towards staff as one residents’ needs-driven behaviour continued without an adequate behavioural management programme. There was no dedicated room for the provision of services and the services provided did not fully meet the needs of the residents. As the approved centre did not have access to an appropriate range of therapeutic services and programmes in accordance with resident needs it was non-compliant with this Regulation.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X

Risk Rating:

Low Moderate High Critical Not - Applicable

X


3.16 Regulation 16: Therapeutic Services and Programmes

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 30th November 2015

CAPAs Specific Measureable Achievable & Realistic

Time-bound

Define the action and state if it is corrective or preventative and state post-holder(s) responsible

Define the area of non-compliance addressed by this CAPA

State method of evaluation and monitoring of outcome

State feasibility of action

State time-frame for completion of action

1.The requirement is to recruit an Occupational Therapy post. MHS Waterford/Wexford have (as evidenced by our management team minutes) prioritised the appointment of a Senior Occupational Therapist for the Old Age Team in Wexford. We await national approval and funding for this post Post-Holder(s):Stephanie Lynch

Residents would have access to an appropriate range of therapeutic services and programmes in accordance with resident needs

Appointment of an Occupational Therapist

Dependent on national approval for the post as part of National Service Plan 2015/2016

31.12.2016

2.Seating Assessment referrals will be made for any resident who requires same to the Primary Care seating clinic In addition as there is a problem with Primary Care accepting our referrals a private company will be contracted to do seating assessments for any client referred to Primary Care who is not offered a primary care appointment Post-Holder(s): CNM2 Paula O’Shaughnessy

Lack of seating assessments and postural seating tailored to each residents needs

Review of the residents file to evidence the referral and following from that details of appointments attended

Dependent on the seating clinic in Primary Care accepting the referral as there are waiting lists for seating clinics in primary care

30/03/2016

3. Behavioural needs assessments will be completed for residents by the Senior Psychologist in the Old Age team Post-Holder(s):Senior Psychologist Rosemary James

Lack of behavioural assessments of residents

Input on the residents care plans in Selskar to assess and provide behavioural programmes where clinically indicated

Realistic as there is a Senior Psychologist assigned for three days per week to the Old Age Psychiatric Team

28/02/2016


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.

Inspection Findings As children were not admitted to the approved centre, this regulation was not applicable.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


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.

Inspection Findings Processes: There was a policy in place on this regulation. The policy did not make any reference to management of medication on transfer, the process for ensuring privacy and confidentiality during transfer, the safety of the staff and resident and staff training requirements. Training: Staff were aware of the processes involved in transferring a resident to another facility. Monitoring of Compliance: There was no formal or informal monitoring of practice pertaining to this regulation. Evidence of Implementation: At the time of inspection, no current resident had been transferred to another facility and it was therefore not possible to assess evidence of implementation.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


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.

Inspection Findings Processes: There were processes and policies in place on this regulation. Training: All nursing staff were trained in the Automated Electronic Defibrillator and had attended Basic Life Support training and staff were aware of the processes in place in the approved centre. Monitoring of Compliance: Residents did undertake national screening and this was monitored as necessary. However, outside of this, there was no formal or informal monitoring of practice pertaining to this regulation. Evidence of Implementation: All residents had a physical examination on admission. Residents had access to the national screening programmes and were facilitated to attend them. All residents had a physical examination carried out by the GP within the last six months and appropriate clinical testing was carried out. There were opportunities for residents to engage in physical activity as there were two secure gardens for residents to use. In addition, the activities staff did gentle exercise with residents. A chiropodist attended the centre regularly and residents had access to speech and language therapists and dietician where clinically indicated. Appropriate emergency equipment was available to staff at the time of inspection and this equipment was regularly checked by nursing staff.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


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, well-being 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.

Inspection Findings Processes: There was a policy in place on this regulation. The policy did not make any reference to assessment of residents’ communication needs, identifying residents’ preferred methods of communication, methods for providing information to residents with specific communication needs, access to interpreter services, content and approval of resident information for distribution or the advocacy arrangements. Training: All staff had a good understanding of the processes surrounding the provision of information to residents. Monitoring of Compliance: There was no formal monitoring of practice pertaining to this regulation. However, some limited informal monitoring of information provided to residents was ongoing; the information booklet had been updated. Evidence of Implementation: There was a centre specific information booklet available to residents and their relatives. It included information on housekeeping arrangements, members of the multidisciplinary team and visiting times. There was no information on advocacy access or resident’s rights in the booklet but details of advocacy arrangements were prominently displayed in the centre. There was no evidence of communication needs being documented in the residents’ care plan despite the resident population having significant communication barriers due to their conditions. However, there were appropriate information leaflets available on the unit from recognised bodies. The medication information leaflets had been specifically tailored to the residents’ needs and were a very good example of appropriately tailoring the information to meet the residents’ needs. These leaflets contained information on indications and side-effects of medication. Staff often verbally explained information to residents as due to their condition, their ability to comprehend written information was poor. Information was never shared with a third party unless consent was obtained from the


resident or nominated next of kin. Health and safety notices were prominently displayed in the centre in a format that was easily understood.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


3.21 Regulation 21: Privacy

The registered proprietor shall ensure that the resident's privacy and dignity is appropriately respected at all times.

Inspection Findings Processes: There was a policy in place on this regulation but it did not cover information on the process to be applied where a resident’s privacy and dignity was not respected by staff. Training: All staff caring for the residents were formally trained. Nursing staff were registered psychiatric nurses and healthcare assistants had completed Further Education and Training Awards level five training. Staff were aware of the policy. Monitoring of Compliance: There was no formal or informal monitoring of practice pertaining to this regulation. Evidence of Implementation: Residents were observed to be treated by staff in a manner that protected their privacy and dignity. Staff acted in a kind and patient manner that was respectful of residents. Residents had access to their bedrooms and the gardens throughout the day if they wished to avail of some quiet time. All bedrooms in the centre were single en suite facilities. Residents were observed to be dressed in their own individual clothing and were never observed to be dressed/undressed by staff in communal areas. All examinations were carried out in their bedrooms and all bedrooms and en suite bathrooms had locks for privacy. However, there were a number of issues that infringed on residents’ privacy as outlined below. This resulted in the centre being deemed non-compliant with this regulation. A notice was observed to be displayed in the dining area detailing residents’ names and their required care needs. This was displayed in a very public area and could be observed by residents, visitors and non-clinical personnel. It was brought to the attention of the Clinical Nurse Manager and removed immediately. The nurses’ station was not enclosed and this resulted in information stored at this area being easily accessible to residents, visitors and non-clinical personnel. The desk was located next to the entrance of the centre, in a very busy area, and all phone calls taken at this area were easily overheard. Lastly, the location of CCTV monitors that observed residents in the garden areas breached the privacy of residents. One monitor was located at the reception desk. When observed, it was observed by non-clinical personnel and it was also easily observed by members of the public visiting the facility. The second monitor was located at the nursing station and was easily accessible to residents, visitors and non-clinical personnel.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


Risk Rating:


X


3.21 Regulation 21: Privacy

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 submitted 17.11.2015


Time-bound






1. Notice was observed to be displayed in the dining area detailing residents names and their required care needs and the sign is now removed Post-Holder(s): CNM2 Paula O’Shaughnessy

The sign was in a public area which was visible by other residents and visitors

Visual inspection of the dining room

Completed Completed

2. All patient files will be stored in the review room rather than at the nurses station. The review room is a lockable room with filing cabinets and patient files will be reviewed in the review room rather than at the nurses’ station. Phone calls which relate to residents of a private nature will be made from either the review room or CNM2 office. If on receipt of a phone call it is evident that the matter is private the call will be transferred to the review room Post-Holder(s): CNM2 Paula O’Shaughnessy

Stored information was easily accessible by residents and other visitors and phone calls can be overheard

Visual inspection by the ADON responsible for Selskar and the Registered Provider

Achievable & Realistic 16/11/2015

3.CCTV monitors were set on record rather than visual picture and the recording function is now turned off following the inspection Post-Holder(s): CNM2 Paula O’Shaughnessy

CCTV Monitors were recording residents and visitors rather than just monitoring

The system which records is now turned off and that can be inspected visually


4. The CCTV could be observed by health professionals responsible for the residents care and others so a cover will be installed to shield the view from others Post-Holder(s): Stephanie Lynch Hospital Manager

Lack of privacy of residents as the monitors can be observed by non staff

The monitors will have a shield to cover the monitors so that others cannot observe the monitors

Realistic and achievable

31.12.2015


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.

Inspection Findings Processes: There was a policy in place on this regulation but it did not cover the staff training requirements. Training: Staff were aware of the processes in relation to premises. Monitoring of Compliance: There was no formal or informal monitoring of practice pertaining to this regulation. Evidence of Implementation: The premises was modern, bright and well maintained; all bedrooms were single rooms with en suite facilities. There were locks on bedroom and bathroom facilities that could be overridden by staff in the event of an emergency. Communal areas were comfortable and adequately furnished and the centre was observed to be very clean. The temperature of the centre was comfortable and the temperature could be adjusted when needed. The lighting was noted to be suitable and dim lighting was used at night. There was a back-up generator for use in emergencies. The dining room was not adequately sized to facilitate all residents; this resulted in some residents being fed in the corridor adjacent to the dining room. Both gardens were well maintained but some slips, trips and falls hazards were noted by inspectors in the internal garden.


Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


3.23 Regulation 23: Ordering, Prescribing, Storing and Administration of Medicines

(1) The registered proprietor shall ensure that an Approved Centre has appropriate and suitable practices and written operational policies relating to the ordering, prescribing, storing and administration of medicines to residents.

(2) This Regulation is without prejudice to the Irish Medicines Board Act 1995 (as amended), the Misuse of Drugs Acts 1977, 1984 and 1993, the Misuse of Drugs Regulations 1998 (S.I. No. 338 of 1998) and 1993 (S.I. No. 338 of 1993 and S.I. No. 342 of 1993) and S.I. No. 540 of 2003, Medicinal Products (Prescription and control of Supply) Regulations 2003 (as amended).

Inspection Findings Processes: There was a policy in place on this regulation but it did not cover the management of resident medication on transfer. Training: Only qualified registered nurses were involved in the ordering, handling and storage of medication. Doctors prescribed all medication. A refresher course on medication management was available to staff if necessary. Monitoring of Compliance: There was no formal monitoring of practice pertaining to this regulation. Incident forms for medication incidents were completed. Evidence of Implementation: Medication was observed to be stored appropriately in a locked trolley in a locked room. The medication fridge contained only medication and was capable of recording temperature. Logs of the fridge temperature were kept. Control drugs were stored and managed appropriately; there was a controlled drug register that recorded a complete record of control drugs received, used and returned. The clinical room was clean, tidy and appropriate to the purpose of storage of medication. Medication was received from Wexford General Hospital in individual packets for each resident. It was received by nursing staff and verified prior to storage. A system of stock-rotation was implemented, stock was used as per expiration dates and an inventory was done monthly. Out of date medication was sent back to the pharmacy. All medication was administered by registered nursing staff. Nursing staff were cognisant of relevant legislation and professional codes of practice. Appropriate identifiers were used for identification of residents and staff checked expiration dates. Staff administering medication observed good hand hygiene practices. A medication administration record (MAR) was maintained for each resident. All prescriptions were written by the GP or the Consultant Psychiatrist. Medication withheld was recorded using a specified code. The MAR included generic drug names, frequency of administration, dosage, route of administration and signature of medical prescriber. Some residents were receiving crushed medication but this was not specified on the MAR. Where a medication error occurred, incident reports were observed to be completed. Medication requirements during leave were adhered to. Information was given to relatives when a resident went on leave; this was recorded in a diary specific to this purpose. Following the return of the resident, all medication was reconciled if necessary.


Medical Council Registration Numbers (MCRN) were not included in all prescriptions. This was a breach of primary legislation (Medical Practitioners Act 2007) and therefore the centre was non-compliant in this regulation.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X

Risk Rating:


X


3.23 Regulation 23: Ordering, Prescribing, Storing and Administration of Medicines



Time-bound






1. The Medical Council Registration Numbers are now included on all prescriptions by the Medical Officer Dr Stephen Bowe and the Consultant Psychiatrist Dr Niall Gormley. Post-Holder(s): Dr Niall Gormley and Dr Stephen Bowe

The Medication Administration Record (MAR) did not have along with the signatures a record of the Medical Council Registration Number

Audit of the MAR Achievable & Realistic 31/10/2015

2.Some medicines were crushed without instruction so all instructions on medications will be recorded in the front of the Medicine Chart Post-Holder(s): Dr Niall Gormley and Dr Stephen Bowe

Medicines crushed but this was not specified on the MAR

Audit of MAR Achievable & Realistic 31/10/2015

3. A new MAR is currently being devised to allow for more space for the instructions to be given Post-Holder(s): Stephanie Lynch Hospital Manager

MCRN not always stated and instructions regarding medicines not always stated

Audit of MAR Achievable & Realistic 31/12/2015


3.24 Regulation 24: Health and Safety

(1) The registered proprietor shall ensure that an Approved Centre has written operational policies and procedures relating to the health and safety of residents, staff and visitors.

(2) This regulation is without prejudice to the provisions of Health and Safety Act 1989, the Health and Safety at Work Act 2005 and any regulations made thereunder.

Inspection Findings Processes: There was no policy in place on this regulation. There was a policy for the management of patients absent without permission. A large proportion of the centre’s infection control policies were out of date including the policies available to staff for management of sharps injuries. Training: There was no specific health and safety training provided to staff. However, staff did attend mandatory training on fire safety, manual handling, hand hygiene and basic life support and this training was up to date. There was no evidence of fall prevention training being provided. Catering staff had received Hazard Analysis and Critical Control Point training. Staff were aware of the requirements for maintenance of equipment. Staff had signed the safety statement for the approved centre. Monitoring of Compliance: The staff vaccination system was monitored and maintained by the Occupational Health Department of Wexford General Hospital. Audits in hand hygiene and infection control had been completed in the last 12 months. No other health and safety audits were conducted. Evidence of Implementation: Equipment in the approved centre was well maintained and fire drills were completed several times a year. Fire extinguishers and break glass fire units were available and maintained appropriately. Emergency lighting was available in the centre and furnishing and bedding were fire retardant. There was a weekly fire safety checklist that included an action plan if necessary. The checklist was very comprehensive. However, the action plan had no completed status added. Hazards were resolved but the action was not updated with this information. The Clinical Nurse Manager was identified as the safety representative and reported no difficulties in discharging the duties of this role. There were easily understood health and safety notices (including fire safety, hot water, extinguisher information, hand hygiene) prominently displayed. Patients were routinely assessed for falls risks and there was an incident reporting system in place. The centre had access to the infection control team in Wexford General Hospital and local responsibility resided with the Clinical Nurse Manager. Basic infection control practices were observed to be of a high standard; staff performed hand hygiene with the most recent audit showing a compliancy rate of 90%, personal protective equipment was available and observed to be used appropriately and waste was appropriately segregated with sharp bins being located in locked areas. There was access to hand hygiene facilities. In the event of a sharps injury, staff would attend Wexford General Hospital. Hazard identification forms were completed when a hazard was identified. However, there was no risk register maintained for health and safety risks. Slips, trips and falls hazard was observed by and reported to the inspection team but there was no associated hazard form completed. There was no Environmental Health Officer, Fire Officer or Health and Safety


reports available to the inspection team on inspection. There was no emergency plan for the approved centre.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


3.25 Regulation 25: Use of Closed Circuit Television (CCTV)

(1) The registered proprietor shall ensure that in the event of the use of closed circuit television or other such monitoring device for resident observation the following conditions will apply:

(a) it shall be used solely for the purposes of observing a resident by a health

professional who is responsible for the welfare of that resident, and solely for the purposes of ensuring the health and welfare of that resident;

(b) it shall be clearly labelled and be evident;

(c) the Approved Centre shall have clear written policy and protocols articulating its function, in relation to the observation of a resident;

(d) it shall be incapable of recording or storing a resident's image on a tape, disc,

hard drive, or in any other form and be incapable of transmitting images other than to the monitoring station being viewed by the health professional responsible for the health and welfare of the resident;

(e) it must not be used if a resident starts to act in a way which compromises his or

her dignity.

(2) The registered proprietor shall ensure that the existence and usage of closed circuit television or other monitoring device is disclosed to the resident and/or his or her representative.

(3) The registered proprietor shall ensure that existence and usage of closed circuit television or other monitoring device is disclosed to the Inspector of Mental Health Services and/or Mental Health Commission during the inspection of the Approved Centre or at anytime on request.

Inspection Findings Processes:

There was a policy in place on this regulation. It was not clear in the policy if ‘general CCTV’ refered to observing a resident for the purposes of ensuring the health and welfare of that resident. The policy did not contain information on who was authorised to view CCTV, the measures used to ensure the privacy and dignity of patients observed by CCTV, the maintenance of the system, disclosure of CCTV to the Mental Health Commission or the number and location of cameras within the approved centre. The policy did not clearly state that where CCTV was used to observe a resident for the purposes of ensuring health and welfare, it shall be incapable of recording or storing a resident’s image.

Training: Staff were familiar with the processes surrounding the use of CCTV and could inform the inspection team of the location of the cameras. Monitoring of Compliance: There was no formal or informal monitoring of practice pertaining to this regulation. Evidence of Implementation: There were clear signs in prominent positions where CCTV cameras were located. The location of CCTV monitors that observed residents in the garden areas breached the privacy of residents. One monitor was located at the reception desk. When observed, it was observed by non-clinical personnel and it was also easily observed by members of the public visiting the facility. The second monitor was located at the nursing station and was easily


accessible to residents, visitors and non-clinical personnel. The system observing residents in the garden was reported as being capable of recording residents.

The approved centre was non-compliant with this regulation as the CCTV system was not only observed by health professionals responsible for residents’ care. It could be observed by non-clinical personnel and the general public. CCTV was being used to observe a resident for the purposes of ensuring health and welfare but it was capable of recording or storing a resident’s image. In addition, the approved centre did not have a clear policy articulating its function in relation to the observation of a resident.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X

Risk Rating:


X


3.25 Regulation 25: Use of Close Circuit Television (CCTV)



Time-bound






1. The CCTV could be observed by health professionals responsible for the residents care and others so a cover will be installed to shield the view from others Post-Holder(s): Stephanie Lynch Hospital Manager

Lack of privacy of residents as the monitors can be observed by non staff

The monitors will have a shield to cover the monitors so that others cannot observe the monitors

Realistic and achievable

31.12.2015

2. The CCTV internal cameras have been disconnected from the recording devise and only provide live feed. Post-Holder(s): Paula O’Shaughnessy CNM2

Lack of privacy for residents and visitors and staff

The CCTV system can be observed


3.A clear policy will be developed to articulate the function of the CCTV cameras in relation to the observation of residents Post-Holder(s): Ursula ONeill CPC

The centre did not have a policy regarding CCTV

The policy can be inspected on the shared folder where policies are stored



3.26 Regulation 26: Staffing

(1) The registered proprietor shall ensure that the Approved Centre has written policies and procedures relating to the recruitment, selection and vetting of staff.

(2) The registered proprietor shall ensure that the numbers of staff and skill mix of staff are appropriate to the assessed needs of residents, the size and layout of the Approved Centre.

(3) The registered proprietor shall ensure that there is an appropriately qualified staff member on duty and in charge of the Approved Centre at all times and a record thereof maintained in the Approved Centre.

(4) The registered proprietor shall ensure that staff have access to education and training to enable them to provide care and treatment in accordance with best contemporary practice.

(5) The registered proprietor shall ensure that all staff members are made aware of the provisions of the Act and all regulations and rules made thereunder, commensurate with their role.

(6) The registered proprietor shall ensure that a copy of the Act and any regulations and rules made thereunder are to be made available to all staff in the Approved Centre.

Inspection Findings Processes: There was no policy in the centre in relation to staffing. Training: A staff training log was maintained in the approved centre. Mandatory training in manual handling, control and restraint, fire safety and basic life support were completed as required. Continued professional development was encouraged, supported and easy to access. Monitoring of Compliance: Staff levels for the approved centre were constantly evaluated and were based on the residents’ assessed needs. Training plans were monitored and evaluated and an audit on staff training was currently underway. Evidence of Implementation: An organisational chart was available in the Safety Statement for the approved centre. A staff rota was maintained and managed at a local level and a staff member was allocated to be in charge at all times. An Assistant Director of Nursing was on-call during night shifts. Nursing and healthcare assistant levels were sufficient. However, there was no occupational therapy or psychology input in the centre which was resulting in residents having some unmet needs. There were several patients in Buxton chairs who had not been adequately assessed for these chairs due to the lack of Occupational Therapy input. Residents who had a need for behavioural management programmes lacked the input of psychology to fully facilitate this intervention. This resulted in assaultive behaviour towards staff as one resident’s needs-driven behaviour continued without an adequate behavioural management programme. Staff had the appropriate qualifications, skills, knowledge and experience to do their job; the Clinical Nurse Manager reported that all nursing staff were Registered Psychiatric Nurses and all healthcare assistants had Further Education and Training Awards level five training. Mandatory staff training was completed and staff files reviewed contained the majority of information required. There were no curriculum vitaes or records of training undertaken in both files and one file did not have evidence of current registration with the professional body. There was no formal documentation of staff orientation or induction held in the


approved centre and there was no formal method of evaluating staff performance and competency. The approved centre were non-compliant with this regulation as there was no policy and the lack of Psychology and Occupational Therapy staff resulted in residents having unmet needs.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X

Risk Rating:


X


3.26 Regulation 26: Staffing



Time-bound






1.The Waterford/Wexford Management Team has prioritised the post of senior Occupational Therapist in our request for new development funding The Psychologist who is assigned to the Old Age Team will arrange to assess all residents in Selskar and where appropriate offer behavioural therapy Post-Holder(s):Rosemary James Sen. Psychologist & Stephanie Lynch Hospital Manager

No Occupational Therapy or Psychology input in the centre which resulted in residents having some unmet needs

Appointment of an Occupational Therapist The ICP will reflect the inputs of the Senior Psychologist

Appointment of the OT is resource dependent The Senior Psycho gist is already assigned to the Old Age Team so realistic

28/02/2016 (Psychology) 31/12/2016 (Sen. OT)

2. Registration of nursing staff is recorded by the Area Director of Nursing and all staff are instructed to provide their registration numbers annually Post-Holder(s):Kevin Plunkett Area Director of Nursing

No evidence of current registration of a staff member

Inspection of Personnel File


3.Records of Training and CVs should be maintained on each personnel file. The documentation of staff orientation or induction will be held on each staff members personnel file. Staff evaluation and performance is not nationally agreed or formalised for HSE staffPost-Holder(s):Kevin Plunkett Area DON

No record held of CV or training records of two staff members on day of inspection

Inspection of Personnel Files/ training record files held on computer for each staff member


A policy for Regulation 26 Staffing will be developed Post-Holder(s):Ursula ONeill CPC

No policy in place for Regulation 26 Staffing

Policies will be available on the shared folder in the computer system



3.27 Regulation 27: Maintenance of Records

(1) The registered proprietor shall ensure that records and reports shall be maintained in a manner so as to ensure completeness, accuracy and ease of retrieval. All records shall be kept up-to-date and in good order in a safe and secure place.

(2) The registered proprietor shall ensure that the Approved Centre has written policies and procedures relating to the creation of, access to, retention of and destruction of records.

(3) The registered proprietor shall ensure that all documentation of inspections relating to food safety, health and safety and fire inspections is maintained in the Approved Centre.

(4) This Regulation is without prejudice to the provisions of the Data Protection Acts 1988 and 2003 and the Freedom of Information Acts 1997 and 2003.

Note: Actual assessment of food safety, health and safety and fire risk records is outside the scope of this Regulation which refers only to maintenance of records pertaining to these areas.

Inspection Findings Processes: There was a policy in place on this regulation but it did not cover the staff training. Training: Staff were aware of the process involved in maintenance of records. Monitoring of Compliance: There was no formal or informal monitoring of practice pertaining to this regulation. Evidence of Implementation: Residents’ files were kept securely in the interview room. Entries were up to date and they were accessed by appropriate staff only. Each resident had an individual record and all information in relation to the resident was maintained in this record. Entries were legible and accurate but did not always specify the time of writing. Records were maintained in sequential order but some records had loose pages. Information in relation to Do Not Resuscitate orders was not easy to retrieve.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


3.28 Regulation 28: Register of Residents

(1) The registered proprietor shall ensure that an up-to-date register shall be established and maintained in relation to every resident in an Approved Centre in a format determined by the Commission and shall make available such information to the Commission as and when requested by the Commission.

(2) The registered proprietor shall ensure that the register includes the information specified in Schedule 1 to these Regulations.

Inspection Findings Processes: There was a process in place but this did not include the registering of all the required details. Training: Staff did not maintain the register as required. Monitoring of Compliance: Some patient details were updated but not as required in Schedule 1. Evidence of Implementation: The approved centre was non-compliant in this regulation as the register did not include the information specified in Schedule 1 of the regulations.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X

Risk Rating:


X


3.28 Regulation 28: Register of Residents



Time-bound






1. The register will be amended to include the information specified in Schedule 1 of the regulations Post-Holder(s):Paula O’Shaughnessy and Stephanie Lynch

The register did not include the information specified in Schedule 1 of the regulations

Audit of the register and devise a new register and have it printed

Achievable and Realistic

15/12/2015


3.29 Regulation 29: Operating Policies and Procedures

The registered proprietor shall ensure that all written operational policies and procedures of an Approved Centre are reviewed on the recommendation of the Inspector or the Commission and at least every 3 years having due regard to any recommendations made by the Inspector or the Commission.

Inspection Findings Processes: There was a policy in place on this regulation but it did not cover information on the process for making obsolete, and retaining, previous versions of operating procedures, the standardised layout or the method of disseminating policies. Training: Relevant staff had attended training on policies and procedures. Monitoring of Compliance: The Mechanical and Physical Restraint policies were in date and reviewed annually. Seclusion was not applicable to the centre. There was no formal monitoring of practice pertaining to this regulation. Evidence of Implementation: Large sections of the policies were out of date and a significant number of policies were in draft format. There was difficulty getting draft policies through the approval process. Where policies had been updated, it was evident that a significant amount of work had taken place in standardising the formatting. Policies were developed with the required input from clinical and managerial staff and were appropriately approved. Recently updated policies incorporated legislation, evidence-based practice and clinical guidelines. There were large sections of policies out of date (e.g. infection control policies). Policies were accessed on the computer, the layout of the system was easy to navigate around and only current policies were available to staff. Staff reported that they were in the process of migrating all polices to a new standardised format. Recently updated policies were standardised and easy to follow and understand. The approved centre was non-compliant in this regulation as there was no policy in place for Regulation 24 Health and Safety and Regulation 26 Staffing. In addition, the policy on CCTV did not comply with the requirements of Regulation 25.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X

Risk Rating:


X


3.29 Regulation 29: Operating Policies and Procedures



Time-bound






1.A policy for Regulation 24 Health and Safety & Regulation 26 Staffing will be developed Post-Holder(s):Ursula ONeill CPC

No policy in place for Regulation 24 Health and Safety and Regulation 26 Staffing

Policies will be available on the shared folder in the computer system


2.A policy on CCTV will be developed which will comply with Regulation 25 Post-Holder(s):Ursula ONeill CPC

The policy on CCTV did not comply with regulation 25

Policies will be available for inspection on the shared folder on the computer system



3.30 Regulation 30: Mental Health Tribunals

(1) The registered proprietor shall ensure that an Approved Centre will co-operate fully with Mental Health Tribunals.

(2) In circumstances where a patient's condition is such that he or she requires assistance from staff of the Approved Centre to attend, or during, a sitting of a mental health tribunal of which he or she is the subject, the registered proprietor shall ensure that appropriate assistance is provided by the staff of the Approved Centre.

Inspection Findings Processes: There was a comprehensive policy in place on this regulation. Training: Mental Health Act training was provided to staff. Monitoring of Compliance: The policy was up to date and reviewed as appropriate. Evidence of Implementation: There were no detained patients in the centre on inspection. Adequate resources and private facilities were provided by the centre to support the Mental Health Tribunal process.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


3.31 Regulation 31: Complaints Procedure

(1) The registered proprietor shall ensure that an Approved Centre has written operational policies and procedures relating to the making, handling and investigating complaints from any person about any aspects of service, care and treatment provided in, or on behalf of an Approved Centre.

(2) The registered proprietor shall ensure that each resident is made aware of the complaints procedure as soon as is practicable after admission.

(3) The registered proprietor shall ensure that the complaints procedure is displayed in a prominent position in the Approved Centre.

(4) The registered proprietor shall ensure that a nominated person is available in an Approved Centre to deal with all complaints.

(5) The registered proprietor shall ensure that all complaints are investigated promptly.

(6) The registered proprietor shall ensure that the nominated person maintains a record of all complaints relating to the Approved Centre.

(7) The registered proprietor shall ensure that all complaints and the results of any investigations into the matters complained and any actions taken on foot of a complaint are fully and properly recorded and that such records shall be in addition to and distinct from a resident's individual care plan.

(8) The registered proprietor shall ensure that any resident who has made a complaint is not adversely affected by reason of the complaint having been made.

(9) This Regulation is without prejudice to Part 9 of the Health Act 2004 and any regulations made thereunder.

Inspection Findings Processes: There was a policy in place on this regulation. All policy requirements were met except for a section detailing the staff training and the provision of advocacy support to the resident if required. Training: Staff were aware of how to manage complaints. Monitoring of Compliance: There was no evidence of complaints in the approved centre since the last inspection. Evidence of Implementation: There was a mechanism in the approved centre whereby residents and relatives were informed of the complaints procedure. The complaints procedure was documented in the approved centre’s information booklet and posters displaying the complaints procedure were observed to be displayed. There was access to an advocacy service and there was a procedure for recording complaints when necessary. There was a nominated person responsible for management of complaints in the approved centre.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


3.32 Regulation 32: Risk Management Procedure

(1) The registered proprietor shall ensure that an Approved Centre has a comprehensive written risk management policy in place and that it is implemented throughout the Approved Centre.

(2) The registered proprietor shall ensure that risk management policy covers, but is not limited to, the following:

(a) The identification and assessment of risks throughout the Approved Centre;

(b) The precautions in place to control the risks identified;

(c) The precautions in place to control the following specified risks:

(i) resident absent without leave,

(ii) suicide and self harm,

(iii) assault,

(iv) accidental injury to residents or staff;

(d) Arrangements for the identification, recording, investigation and learning from

serious or untoward incidents or adverse events involving residents;

(e) Arrangements for responding to emergencies;

(f) Arrangements for the protection of children and vulnerable adults from abuse.

(3) The registered proprietor shall ensure that an Approved Centre shall maintain a record of all incidents and notify the Mental Health Commission of incidents occurring in the Approved Centre with due regard to any relevant codes of practice issued by the Mental Health Commission from time to time which have been notified to the Approved Centre.

Inspection Findings Processes: The approved centre had two policies in place to govern the management of risk and the reporting of incidents. However, the policies did not contain some relevant information such as the person with responsibility for risk, the record keeping requirements, the risk rating of incident reports, the investigation process for incidents, the incident reviewing and monitoring process, and the learning process for incidents. While the risk policy did outline specific risks as per the regulation, there were no control measures mentioned within the policy for these risks. Training: Staff identified as having local responsibility for risk management had not received any training on identifying, assessing and managing risk. Monitoring of Compliance: There was no formal or informal monitoring of practice pertaining to this regulation. The review and monitoring of risk incidents for trends or patterns was not observed to be implemented within the approved centre. On examining the completed risk incident forms, the inspection team identified a pattern of incidents in relation to mechanical restraint malfunction and assaults on staff. However, the approved centre had not identified these as issues of concern at the time of inspection. Evidence of Implementation: Senior management reported that there was a risk officer. However, staff in the approved centre could not readily identify the risk officer at the time of inspection. The policy required that local risk registers are developed but this had not occurred within the approved centre. Initially, staff identified hazard notification forms as the risk register for the approved centre


but these did not meet the requirements for a risk register. Senior management confirmed that local risk registers were not maintained but reported that there was a corporate risk register. Hazard notification forms were completed and escalated to the appropriate personnel when a hazard was identified. However, these forms were not consistently used when hazards were identified; there was a slips, trips, and falls hazard but there was no corresponding hazard notification form. The fire safety action plan was not reviewed to accurately reflect when a risk was resolved. Trend analysis of incidents was not implemented within the approved centre and there was no emergency management plan in the centre. Incident forms were freely available for staff to complete and they were of a standardised format. Deaths were notified to the Mental Health Commission within the specified time frame. The approved centre maintained an incident record and a summary of this was forwarded to the Mental Health Commission. Clinical risk assessments on individual residents were completed as part of the individual care planning process but there was no evidence of resident/family involvement in this process. Incident forms were completed in a timely manner by nursing staff and residents were assessed for physical injury as soon as possible after the incident by the GP. However, there was no evidence of a multidisciplinary team review of a resident after an incident or multiple incidents had occurred. The approved centre was non-compliant as there were no control measures for specific risk identified in the policy, there were no local risk registers, risks were not consistently identified and reported accordingly, trend analysis was not evident and staff were not trained in the management of risks.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X

Risk Rating:


X


3.32 Regulation 32: Risk Management Procedure



Time-bound






1. Risk Register Training will be given to all staff of Selskar to enable them to understand the process to identify, deal with a risk or escalate as appropriate and develop a risk register for Selskar Post-Holder(s): Kay Cullen ADON

Staff were not trained in the management of risks

Evidence of risk notifications and access to view the risk register


2.Analysis and trend analysis of each risk will be completed on a monthly basis by the Assistant Director of Nursing with the Old Age Team Post-Holder(s): James Leacey ADON

No control measures for specific risk identified and risks were no trend analysis

Evidence of a record of the of the meetings and copies of the risks notifications and clinical incidents for inspection


3. All risks are considered by QSEC which is the Quality and Safety Committee for Waterford/Wexford. All staff will have access to the risk registers which will indicate the location of the specific risk if appropriate Post-Holder(s): Dr Stephen Browne, ECD QSEC Chair

No local risk registers and no control measures for specific risks

Minutes of the QSEC meetings are available for inspection


4. A ward management meeting will be held monthly chaired by the ADON for the ward and the agenda will include Risk Post Holder: Mr Jim Leacey ADON Selskar

Risks were not consistently identified and reported in the approved centre

Risk Register will be available for inspection Records of meetings will be available



3.33 Regulation 33: Insurance

The registered proprietor of an Approved Centre shall ensure that the unit is adequately insured against accidents or injury to residents.

Inspection Findings The approved centre was indemnified by the State Claims Agency. This covered public liability, employer’s liability, professional indemnity and property. The inspection team examined a copy of this statement.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


3.34 Regulation 34: Certificate of Registration

The registered proprietor shall ensure that the Approved Centre's current certificate of registration issued pursuant to Section 64(3)(c) of the Act is displayed in a prominent position in the Approved Centre.

Inspection Findings The approved centre had a condition attached to its registration at time of inspection. The Certificate of Registration was therefore two pages in total. On day two of the inspection, only the second page of the certificate, displaying the conditions of registration, was on display in the centre. This was brought to the attention of management and rectified. Both pages were observed to be displayed prior to the completion of inspection and the centre were therefore deemed to be compliant with this regulation.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


4.0 Inspection Findings and Required Actions - Rules

EVIDENCE OF COMPLIANCE WITH RULES – MENTAL HEALTH ACT 2001 SECTION 52(d)

4.1 Section 59: The Use of Electro-Convulsive Therapy

Section 59 (1) “A programme of electro-convulsive therapy shall not be administered to a patient unless either – (a) the patient gives his or her consent in writing to the administration of the programme of therapy, or (b) where the patient is unable or unwilling to give such consent – (i) the programme of therapy is approved (in a form specified by the Commission) by the consultant psychiatrist responsible for the care and treatment of the patient, and (ii) the programme of therapy is also authorised (in a form specified by the Commission) by another consultant psychiatrist following referral of the matter to him or her by the first-mentioned psychiatrist. (2) The Commission shall make rules providing for the use of electro-convulsive therapy and a programme of electro-convulsive therapy shall not be administered to a patient except in accordance with such rules.”

Inspection Findings As ECT was not administered in the approved centre, this Rule was not applicable.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


4.2 Section 69: The Use of Seclusion Mental Health Act 2001 Bodily restraint and seclusion Section 69 (1) “A person shall not place a patient in seclusion or apply mechanical means of bodily restraint to the patient unless such seclusion or restraint is determined, in accordance with the rules made under subsection (2), to be necessary for the purposes of treatment or to prevent the patient from injuring himself or herself or others and unless the seclusion or restraint complies with such rules. (2) The Commission shall make rules providing for the use of seclusion and mechanical means of bodily restraint on a patient. (3) A person who contravenes this section or a rule made under this section shall be guilty of an offence and shall be liable on summary conviction to a fine not exceeding £1500. (4) In this section “patient” includes – (a) a child in respect of whom an order under section 25 is in force, and (b) a voluntary patient”.

Inspection Findings As seclusion was not used in the approved centre, this Rule was not applicable.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


4.3 Section 69: The Use of Mechanical Restraint Mental Health Act 2001 Bodily restraint and seclusion Section 69 (1) “A person shall not place a patient in seclusion or apply mechanical means of bodily restraint to the patient unless such seclusion or restraint is determined, in accordance with the rules made under subsection (2), to be necessary for the purposes of treatment or to prevent the patient from injuring himself or herself or others and unless the seclusion or restraint complies with such rules. (2) The Commission shall make rules providing for the use of seclusion and mechanical means of bodily restraint on a patient. (3) A person who contravenes this section or a rule made under this section shall be guilty of an offence and shall be liable on summary conviction to a fine not exceeding £1500. (4) In this section “patient” includes – (a) a child in respect of whom an order under section 25 is in force, and (b) a voluntary patient”.

Inspection Findings Processes: The approved centre was using Mechanical restraint under Part 5 of the Rules governing Mechanical Means of Bodily Restraint. While there was a policy in place on this governing the use of Mechanical Restraint, the policy did not address Part 5 of the Rules whereby Mechanical Restraint can be used for enduring risk of harm to self or others. Therefore, the practice observed in the centre was not governed by the policy. Training: Staff had not received training but were aware of the need to prescribe Mechanical Restraint. Monitoring of Compliance: The policy was reviewed annually. A number of incident reports had been completed where residents had fallen from their chairs due to a malfunction of the mechanical restraint (i.e. lap belt open). However, these incident reports reported the fall not the mechanical restraint malfunction and the service did not recognise the trend prior to inspection. Evidence of Implementation: The approved centre was using Mechanical restraint under Part 5 of the Rules governing Mechanical Means of Bodily Restraint (i.e. lap belt). Clinical risk assessments were completed prior to the use of Mechanical Restraint and the type of restraint used was specified in the residents’ clinical record. The situation in which the Mechanical Restraint was to be used, the duration of the order and the review date of the order were also specified in the residents’ clinical record. However, the duration of the restraint was not specified. The approved centre was non-compliant as the policy did not reflect the practice within the centre, the duration of restraint was not specified in the resident’s record and there was no monitoring of this practice.


Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X

Risk Rating:


X


4.3 Section 69: Use of Mechanical Restraint



Time-bound






1.A new form ( copy attached) is introduced for residents who are prescribed mechanical restraint and the duration is specified on the form (up to a maximum of 3 months) Post-Holder(s): Dr Niall Gormley, Consultant Psychiatrist in Old Age

The policy did not reflect the practice within the centre as the duration of restraint was not specified in the residents record

Forms will be in each residents file where mechanical restraint is prescribed

Achievable and realistic

31/10/2015

2. The current policy is being reviewed and enduring risk of self harm has been addressed in the new draft and will be considered and ratified by QSEC in January 2016 Post-Holder(s):

The policy does not set out the use of Mechanical Restraint for enduring risk of self harm as is the practice in Selskar

Policy will be available for inspection

Achievable and realistic

31/01/2016


5.0 Inspection Findings and Required Actions - The Mental Health Act 2001

5.1 Part 4: Consent to Treatment 56.- In this Part “consent”, in relation to a patient, means consent obtained freely without

threat or inducements, where – (a) the consultant psychiatrist responsible for the care and treatment of the patient is

satisfied that the patient is capable of understanding the nature, purpose and likely effects of the proposed treatment; and

(b) The consultant psychiatrist has given the patient adequate information, in a form and language that the patient can understand, on the nature, purpose and likely effects of the proposed treatment.

57. - (1) The consent of a patient shall be required for treatment except where, in the opinion of the consultant psychiatrist responsible for the care and treatment of the patient, the treatment is necessary to safeguard the life of the patient, to restore his or her health, to alleviate his or her condition, or to relieve his or her suffering, and by reason of his or her mental disorder the patient concerned is incapable of giving such consent.

(2) This section shall not apply to the treatment specified in section 58, 59 or 60. 60. – Where medicine has been administered to a patient for the purpose of ameliorating

his or her mental disorder for a continuous period of 3 months, the administration of that medicine shall not be continued unless either-

(a) the patient gives his or her consent in writing to the continued administration of that medicine, or

(b) where the patient is unable or unwilling to give such consent – i. the continued administration of that medicine is approved by the consultant

psychiatrist responsible for the care and treatment of the patient, and ii. the continued administration of that medicine is authorised (in a form specified

by the Commission) by another consultant psychiatrist following referral of the matter to him or her by the first-mentioned psychiatrist,

And the consent, or as the case may be, approval and authorisation shall be valid for a period of three months and thereafter for periods of 3 months, if in respect of each period, the like consent or, as the case may be, approval and authorisation is obtained. 61. – Where medicine has been administered to a child in respect of whom an order under section 25 is in force for the purposes of ameliorating his or her mental disorder for a continuous period of 3 months, the administration shall not be continued unless either –

(a) the continued administration of that medicine is approved by the consultant psychiatrist responsible for the care and treatment of the child, and

(b) the continued administration of that medicine is authorised (in a form specified by the Commission) by another consultant psychiatrist, following referral of the matter to him or her by the first-mentioned psychiatrist,

And the consent or, as the case may be, approval and authorisation shall be valid for a period of 3 months and thereafter for periods of 3 months, if, in respect of each period, the like consent or, as the case may be, approval and authorisation is obtained.

Inspection Findings There were no detained patients in the approved centre at the time of inspection. Therefore, consent to treatment was not applicable.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


6.0 Inspection Findings and Required Actions – Codes of Practice

EVIDENCE OF COMPLIANCE WITH CODES OF PRACTICE – MENTAL HEALTH ACT 2001 SECTION 51 (iii)

Section 33(3)(e) of the Mental Health Act 2001 requires the Commission to: “prepare and review periodically, after consultation with such bodies as it considers appropriate, a code or codes of practice for the guidance of persons working in the mental health services”. The Mental Health Act, 2001 (“the Act”) does not impose a legal duty on persons working in the mental health services to comply with codes of practice, except where a legal provision from primary legislation, regulations or rules is directly referred to in the code. Best practice however requires that codes of practice be followed to ensure that the Act is implemented consistently by persons working in the mental health services. A failure to implement or follow this Code could be referred to during the course of legal proceedings. Please refer to the Mental Health Commission Codes of Practice, for further guidance for compliance in relation to each code.

6.1 The Use of Physical Restraint Please refer to the Mental Health Commission Code of Practice on the Use of Physical Restraint in Approved Centres, for further guidance for compliance in relation to this practice.

Inspection Findings Processes: There was a policy in place on this code of practice. However, the policy did not identify who provided training or the frequency at which training should occur. In addition, physical restraint was not used in the centre and it was not considered a treatment option for the resident population. There was no evidence of any occurrence of restraint during 2015. The policy for the centre did, therefore, not reflect the current practice. Training: Appropriate staff had received training in Control and Restraint. Monitoring of Compliance: At the time of inspection, no current resident had been physically restrained so it was not possible for the approved centre to monitor compliance with this Code of Practice. Evidence of Implementation: At the time of inspection, no current resident had been physically restrained and it was, therefore, not possible to assess evidence of implementation.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


6.2 Admission of Children Please refer to the Mental Health Commission Code of Practice Relating to the Admission of Children under the Mental Health Act 2001 and the Mental Health Commission Code of Practice Relating to Admission of Children under the Mental Act 2001 Addendum, for further guidance for compliance in relation to this practice.

Inspection Findings As children were not admitted to the approved centre, this Code of Practice was not applicable.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


6.3 Notification of Deaths and Incident Reporting Please refer to the Mental Health Commission Code of Practice for Mental Health Services on Notification of Deaths and Incident Reporting, for further guidance for compliance in relation to this practice.

Inspection Findings Processes: There was a policy in place on this Code of Practice. The policy did not identify the risk manager for the service. Training: Relevant staff were aware of the requirements in relation to reporting deaths and incidents to the Mental Health Commission. Monitoring of Compliance: There was no formal or informal monitoring of practice pertaining to this regulation. Evidence of Implementation: Deaths were notified to the Mental Health Commission within the specified timeframe. A risk management policy was in place. The approved centre maintained an incident record and a summary of this was forwarded to the Mental Health Commission.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


6.4 Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities Please refer to the Mental Health Commission Code of Practice Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities, for further guidance for compliance in relation to this practice.

Inspection Findings Processes: There was a policy in place on this regulation. However, the policy did not identify the need for communication protocols between the approved centre and the relevant external agencies, timeframes for assessment, planning and implementation of care or an appropriately qualified trainer. There was also no information on evaluating the implementation of the policy. Training: Staff had not received training for working with people with intellectual disabilities. Monitoring of Compliance: There was no formal or informal monitoring of practice pertaining to this code of practice. Evidence of Implementation: There were two residents in the approved centre at the time of inspection with an identified Intellectual Disability. The residents were long term residents of the service and were well known to the staff. Staff were aware of residents’ likes and dislikes and facilitated these in so far as was practicable. The design of the unit adequately addressed the residents’ needs. Both residents had been assessed by the multidisciplinary team and were reviewed every six months. The care and treatment provided was in line with each resident’s assessed need. However, the inspection team noted that one resident was involved in a significant number of incidents of aggressive behaviour. A key worker system was in operation and advocacy services were provided.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


6.5 The Use of Electro-Convulsive Therapy (ECT) for Voluntary Patients Please refer to the Mental Health Commission Code of Practice on the Use of Electro-Convulsive Therapy for Voluntary Patients, for further guidance for compliance in relation to this practice.

Inspection Findings As ECT was not administered in the approved centre, this Code of Practice was not applicable.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X


6.6 Admissions, Transfer and Discharge Please refer to the Mental Health Commission Code of Practice on Admission, Transfer and Discharge to and from an Approved Centre, for further guidance for compliance in relation to this practice.

Inspection Findings Processes: There were policies in place for Admission, Transfer and Discharge of Residents to and from the approved centre. Training: Staff were aware of the processes involved in admitting a resident, transferring a resident to another facility and discharging a resident. Monitoring of Compliance: There was no formal or informal monitoring of practice pertaining to this code of practice. Evidence of Implementation: All admissions to the approved centre were planned and unplanned/emergency admissions

were not facilitated. Decisions to admit or not to admit were made by the Consultant

Psychiatrist. On admission, residents were comprehensively assessed by the

multidisciplinary team using a standardised admission booklet. The admission booklet was

well formatted. It provided structured assessments in falls risk assessments, waterlow

scores and manual handling assessments (easymove) and facilitated a standardised

approach to each admission. The page entitled ‘this is me’ elicited residents’ preferences

and the residents’ family or next of kin who provided the information in this section. However,

it was not documented as to how or from whom the information was gathered. Family and

resident involvement in the admission process was not well documented. All clinical records

reviewed had documented initial care plans that had been reviewed and updated by the

multidisciplinary team. Clinical records were generally well maintained but on occasion it

was noted that some pages were loose and DNAR orders were not easily retrieved.

Residents’ personal property and clothing were managed appropriately on admission and

there was a system in place to manage residents’ valuables. A key worker system was in

operation in the approved centre but the responsible key worker was not always documented

in the resident’s clinical record. Admissions were facilitated in a private area.

At the time of inspection, no current resident had been transferred to another facility and it was, therefore, not possible to assess evidence of implementation in relation to transfer of a resident. At the time of inspection, no current resident had been discharged and it was, therefore, not possible to assess evidence of implementation in relation to discharge of a resident.

Compliance Rating:


Achievement (1)


Achievement (2)

Compliant – Good

Achievement (3)


Achievement (4)

Not- Applicable

X

Documents

Mental Health Commission Approved Centre Inspection Report ... · Ref MHC – FRM – 001- Rev 1 Page 6 of 71 2.0 Approved Centre Inspection - Overview 2.1 Overview of the Approved