Mental Health Commission Approved Centre Inspection ...Subsequent to the report publication of the 2015 inspection, services within the approved centre were requested to submit a Corrective

Ref MHC – FRM – 001- Rev 1 Page 1 of 82

Mental Health Commission

Approved Centre Inspection Report

(Mental Health Act 2001)

APPROVED CENTRE NAME An Coillín

IDENTIFICATION NUMBER AC0060

APPROVED CENTRE TYPE Continuing Care Unit

REGISTERED PROPRIETOR Health Service Executive

REGISTERED PROPRIETOR NOMINEE Mr Steve Jackson

MOST RECENT REGISTRATION DATE 17 May 2016

NUMBER OF RESIDENTS REGISTERED

FOR

22

INSPECTION TYPE Unannounced

INSPECTION DATE 4, 5, 6, 7 October 2016

PREVIOUS INSPECTION DATE 19 and 20 November 2015

CONDITIONS ATTACHED None

LEAD INSPECTOR Ms Noeleen Byrne

INSPECTION TEAM Ms Ann Wallace, Ms Barbara Morrissey

THE INSPECTOR OF MENTAL HEALTH

SERVICES

Dr Susan Finnerty MCRN 009711


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 Conditions to Registration ...................................................................................................... 6

2.3 Governance ............................................................................................................................. 6

2.4 Inspection scope ..................................................................................................................... 6

2.5 Non-compliant areas from 2015 inspection ........................................................................... 6

2.6 Corrective and Preventative Action plan ................................................................................ 7

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

2.8 Areas of compliance rated Excellent on this inspection ......................................................... 7

2.9 Areas not applicable ............................................................................................................... 7

2.10 Areas of good practice identified on this inspection .............................................................. 7

2.11 Reporting on the National Clinical Guidelines ........................................................................ 8

2.12 Section 26 Mental Health Act 2001 - Absence with Leave ..................................................... 8

2.13 Resident Interviews................................................................................................................. 8

2.14 Resident Profile ....................................................................................................................... 8

2.15 Feedback Meeting ................................................................................................................... 8

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 ........................................................................................................ 14

3.7 Regulation 7: Clothing .............................................................................................................. 16

3.8 Regulation 8: Residents’ Personal Property and Possessions .................................................. 17

3.9 Regulation 9: Recreational Activities ....................................................................................... 19

3.10 Regulation 10: Religion ........................................................................................................... 21

3.11 Regulation 11: Visits ................................................................................................................ 22

3.12 Regulation 12: Communication ............................................................................................... 24

3.13 Regulation 13: Searches .......................................................................................................... 26

3.14 Regulation 14: Care of the Dying ............................................................................................ 28

3.15 Regulation 15: Individual Care Plan ........................................................................................ 30

3.16 Regulation 16: Therapeutic Services and Programmes .......................................................... 31

3.17 Regulation 17: Children’s Education ....................................................................................... 32

3.18 Regulation 18: Transfer of Residents ...................................................................................... 33


3.19 Regulation 19: General Health ................................................................................................ 34

3.20 Regulation 20: Provision of Information to Residents ............................................................ 36

3.21 Regulation 21: Privacy ............................................................................................................. 38

3.22 Regulation 22: Premises .......................................................................................................... 39

3.23 Regulation 23: Ordering, Prescribing, Storing and Administration of Medicines ................... 41

3.24 Regulation 24: Health and Safety ............................................................................................ 43

3.25 Regulation 25: Use of Closed Circuit Television ...................................................................... 44

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

3.27 Regulation 27: Maintenance of Records ................................................................................. 47

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

3.29 Regulation 29: Operating Policies and Procedures ................................................................. 50

3.30 Regulation 30: Mental Health Tribunals ................................................................................. 51

3.31 Regulation 31: Complaints Procedures ................................................................................... 52

3.32 Regulation 32: Risk Management Procedures ........................................................................ 54

3.33 Regulation 33: Insurance......................................................................................................... 56

3.34 Regulation 34: Certificate of Registration ............................................................................... 57

4.0 Inspection Findings and Required Actions - Rules ........................................................... 58

4.1 Section 59: The Use of Electro-Convulsive Therapy ................................................................. 58

4.2 Section 69: The Use of Seclusion .............................................................................................. 59

4.3 Section 69: The Use of Mechanical Restraint ........................................................................... 60

5.0 Inspection Findings and Required Actions - The Mental Health Act 2001 ....................... 61

5.1 Part 4: Consent to Treatment................................................................................................... 61

6.0 Inspection Findings and Required Actions – Codes of Practice ..................................... 62

6.1 The Use of Physical Restraint ................................................................................................... 63

6.2 Admission of Children .............................................................................................................. 64

6.3 Notification of Deaths and Incident Reporting ........................................................................ 65

6.4 Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities ......................................................................................................................................... 66

6.5 The Use of Electro-Convulsive Therapy (ECT) for Voluntary Patients ...................................... 67

6.6 Admission, Transfer and Discharge .......................................................................................... 68

Appendix 1: Corrective action and preventative action (CAPA) plans for areas of non-compliance 2016 ................................................................................................................................ 70


1.0 Mental Health Commission Inspection Process

The principal functions of the Mental Health Commission are to promote, encourage and foster

the establishment and maintenance of high standards and good practices in the delivery of

mental health services and to take all reasonable steps to protect the interests of persons

detained in approved centres.

The Commission strives to ensure its principal legislative functions are achieved through the

registration and inspection of approved centres. The process for determination of the

compliance level of approved centres against the statutory regulations, rules, Mental Health

Act 2001 and codes of practice shall be transparent and standardised.

Section 51(1)(a) of the Mental Health Act 2001 (the 2001 Act) states that the principal function

of the Inspector shall be to “visit and inspect every approved centre at least once a year in

which the commencement of this section falls and to visit and inspect any other premises

where mental health services are being provided as he or she thinks appropriate”.

Section 52 of the 2001 Act, states that when making an inspection under section 51, the

Inspector shall:

a) See every resident (within the meaning of Part 5) whom he or she has been requested

to examine by the resident himself or herself or by any other person,

b) See every patient the propriety of whose detention he or she has reason to doubt,

c) Ascertain whether or not due regard is being had, in the carrying on of an approved

centre or other premises where mental health services are being provided, to this Act

and the provisions made thereunder, 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

Part 4 of the 2001 Act as applicable, 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 risk level of the

non-compliance shall be assessed.

The Inspector will also assess the quality of services provided against the criteria of the

Judgement Support Framework. As the requirements for the rules, codes of practice and Part

4 of the 2001 Act are set out exhaustively, the Inspector will not undertake a separate quality

assessment. Similarly, due to the nature of Regulations 28, 33 and 34 a quality assessment

is not required.

Following the inspection of an approved centre, the Inspector prepares a report on the findings

of the inspection. A draft of the inspection report, including provisional compliance ratings, risk

ratings and quality assessments, is provided to the registered proprietor of the approved

centre. The registered proprietor is given an opportunity to review the draft report and

comment on any of the content or findings. The Inspector will take into account the comments

by the registered proprietor and amend the report as appropriate.


The registered proprietor is requested to provide a Corrective and Preventative Action (CAPA)

plan for each finding of non-compliance in the draft report. Corrective actions address the

specific non-compliance(s). Preventative actions mitigate the risk of the non-compliance

reoccurring. CAPAs must be specific, measurable, realistic, achievable and time-bound

(SMART).

The approved centre’s CAPAs are included in the published inspection report, as submitted.

The Commission monitors the implementation of the CAPAs on an ongoing basis and requests

further information and action as necessary.

If at any point the Commission determines that the approved centre’s plan to address an area

of non-compliance is unacceptable, enforcement action may be taken.

In circumstances where the registered proprietor fails to comply with the requirements of the

2001 Act, Mental Health Act 2001 (Approved Centres) Regulations 2006 and Rules made

under the 2001 Act, the Commission has the authority to initiate escalating enforcement

actions up to, and including, removal of an approved centre from the register and the

prosecution of the registered proprietor.


2.0 Approved Centre Inspection - Overview

2.1 Overview of the Approved Centre

The approved centre was located on the grounds of Mayo General Hospital and close to the

town of Castlebar. An Coillín provided assessment and treatment for people with mental health

difficulties. Residents were admitted voluntarily and there were no patients detained under the

Mental Health Act 2001.The approved centre provided Psychiatry of Later Life and continuing

care for residents. At the time of the inspection there were 21 residents, one was a Ward of

Court. An Coillín provided person-centred care that included a daily therapeutic activity

programme.

2.2 Conditions to Registration There were no conditions attached to the registration of this approved centre at the time of inspection.

2.3 Governance

The minutes of the management team meeting for the previous twelve months were made

available to the inspection team. They showed that the management team met approximately

every month. In addition to policy development and capital development, the management

team discussed health promotion issues including smoking cessation.

2.4 Inspection scope

This was an unannounced annual inspection. All aspects of the regulations, rules and codes

of practice were inspected against with the exception of non-applicable areas (please refer to

section 2.9 below for non-applicable areas).

The inspection was undertaken onsite in the approved centre from:

4 October 2016 at 13:00 to 4 Oct 2016 at 17:00




2.5 Non-compliant areas from 2015 inspection

The previous inspection of the approved centre on 19 and 20 November 2015 identified the

following area that was not compliant:

Regulation/Rule/Act/Code Inspection Findings 2016

Regulation 22: Premises Non-compliant


2.6 Corrective and Preventative Action plan

Subsequent to the report publication of the 2015 inspection, services within the approved centre were requested to submit a Corrective and Preventative Action plan (CAPA) for each aspect of inspection with which they were non-compliant. The service submitted three CAPAs in total with regard to Regulation 22 Premises which remains non-compliant.

2.7 Non-compliant areas on this inspection

Regulation/Rule/Act/Code Risk Rating

Regulation 15 Individual Care Plan High

Regulation 21 Privacy High

Regulation 22 Premises Moderate

Regulation 26 Staffing High

Code of Practice on the Use of Physical

Restraint

Moderate

Code of Practice on Notification of Deaths

and Incident Reporting

Moderate

Code of Practice on Guidance for persons

working in in Mental Health Services with

People with Intellectual Disabilities

Low

Code of Practice on Admission, Transfer and

Discharge to and from an Approved Centre

Moderate

2.8 Areas of compliance rated Excellent on this inspection

There were no areas of compliance rated Excellent on this inspection.

2.9 Areas not applicable

The following areas were not applicable as the rule, regulation, code of practice or Part 4 of the Mental Health Act 2001 was not relevant to this approved centre at the time of inspection.

Regulation/Rule/Act/Code

Regulation 17 Children’s Education

Rules Governing the Use of Seclusion

Rules Governing the Use of Mechanical Means of Bodily Restraint

Rules Governing the Use of Electro-Convulsive Therapy

Code of Practice on The Admission of Children

Code of Practice on The Use of Electro-Convulsive Therapy

2.10 Areas of good practice identified on this inspection

A new staffing policy that included a staffing plan and training needs analysis.


2.11 Reporting on the National Clinical Guidelines

The service reported that it was cognisant of and implemented, where indicated, the National

Clinical Guidelines as published by the Department of Health.

2.12 Section 26 Mental Health Act 2001 - Absence with Leave

As there were no residents on leave at the time of inspection, this section was not applicable.

2.13 Resident Interviews

Residents were invited to speak with the inspection team. Four residents were interviewed

and all were happy with the food and the accommodation. The activities they were involved in

included day trips to Westport, and surrounding areas, and playing instruments in a music

group. Residents attended a prayer group and mass. Residents were involved in meetings to

develop their care plans.

2.14 Resident Profile

Resident Category Less than

6 months

Longer than

6 months Children TOTAL

DAY 1

Voluntary Residents 1 19 0 20

Involuntary Patients 0 0 0 0

Wards of Court 0 1 0 1

DAY 2




DAY 3




2.15 Feedback Meeting

A feedback meeting was facilitated prior to the conclusion of the inspection. This was attended

by the inspection team and the following representatives of the service:

Registered Proprietor

Area Director of Nursing

Business Manager

Clinical Nurse Manager (Grade 2)

Clinical Nurse Manager (Grade 3)

Consultant Psychiatrist

Executive Clinical Director

Occupational Therapy Manager

Principal Psychologist

Principal Social Worker


The inspection team outlined the initial findings of the inspection process and provided an

opportunity for the service to offer any corrections or clarifications as appropriate.


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 no policy in place on the identification of residents within An Coillin. Training and Education: There was no policy for staff to read. Staff were able to articulate the processes for identifying residents within the approved centre. Monitoring: Ten clinical files were audited, in June 2016, to ensure that there were appropriate resident identifiers in each clinical file and the result was 100% compliant. Analysis was conducted to identify opportunities to enhance the resident identification process within the approved centre. Evidence of Implementation: There was a minimum of two resident identifiers in place appropriate to the resident group profile and the identifiers were detailed within each resident’s clinical file. The identifiers were used when staff administered medication, health care and other services. The approved centre used coloured photographic identification and personal details specific to the resident such as name, address, date of birth and record number. The photographic identifiers were evident on both the MPARs (Medication, Prescription and Administration Records) and the resident file. The identifiers were appropriate to the residents’ needs and communication abilities. There was an alert system in place for same/similar named residents within the approved centre and a colour-coded system was used, where necessary, on clinical files and within the MPARs. The approved centre was compliant with this regulation. The quality assessment was satisfactory but not rated excellent as the approved centre did not adhere to all criteria within the Judgement Support Framework under processes, staff training and education.

Compliant Non-Compliant

Compliance with Regulation

X

Excellent Satisfactory Requires

Improvement Inadequate

Quality Assessment 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 food and nutrition dated September 2016 within the approved centre. The policy included all of the requirements of the Judgement Support Framework. Training and Education: There was no written evidence that staff had read the policy. Staff were able to articulate the processes for food and nutrition. Monitoring: There was evidence that a systematic review of menu plans had been conducted to ensure residents were provided with wholesome and nutritious food suitable to their needs. The dietician had carried out an audit and analysis of meals across the Mayo Mental Health Service (MMHS) and had developed a nutritional improvement plan for implementation across the MMHS. Evidence of Implementation: The approved centre’s menus were reviewed and approved by a dietician to ensure nutritional adequacy in accordance with the residents’ needs. Residents were provided with a variety of wholesome, nutritious and varied food choices and menus. There was a choice of at least three options at each meal and these were displayed on the menu board outside the dining room. A cooked breakfast was offered once a week, and hot cereal/porridge was available daily. A choice of hot meals was provided each lunch time with one hot choice at the evening meal. Both hot and cold drinks were offered regularly to residents. Water dispensers were located on the link corridor and at the nurse’s station. They provided a supply of safe and fresh drinking water in easily accessible locations for the residents. The St. Andrew’s Screening Tool, an evidence-based nutritional assessment tool, was used for residents with special dietary needs. The dietician visited the approved centre weekly to monitor and review residents identified as having special nutritional requirements. An Coillin was compliant with this regulation. The quality assessment was satisfactory but not rated excellent as the approved centre did not adhere to all the criteria of the Judgement Support Framework under staff training and education.




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: The approved centre had a policy in place on food safety, dated June 2015. The policy included all of the requirements of the Judgement Support Framework. Training and Education: The external catering team had food safety training and had read the relevant food safety policies and procedures. The care and nursing staff who served food to residents and helped the residents to eat their meals had not read the relevant policies and procedures. All care and nursing staff interviewed could articulate the processes for food safety. An external catering team had completed up-to-date training in the application of Hazard Analysis and Critical Control Point (HACCP) and this was documented. Monitoring: Food temperatures were recorded in line with food safety recommendations and a temperature log sheet was maintained and monitored. There was evidence of food safety audits periodically completed and a documented analysis was completed to identify opportunities to improve food safety processes. Evidence of Implementation: There was appropriate and sufficient catering equipment, crockery and cutlery. Specialist cutlery and plate guards were available for residents with specific needs. There were proper facilities for the refrigeration, storage, preparation, cooking and serving of food. Hygiene was maintained to support food safety requirements. There were separate handwashing sinks within the kitchen. Catering staff wore appropriate personal protective equipment (PPE) during the catering processes. Food from Corporate Catering was prepared in the main kitchen away from the approved centre, then transported and served in the approved centre’s kitchen. Food temperatures were checked before food left the main kitchen and before it was served in the approved centre. Records were kept of all checks. The approved centre was compliant with this regulation. The quality assessment was satisfactory but not rated excellent as the approved centre did not adhere to all the criteria in the Judgement Support Framework under training and education.




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 written policy dated October 2016 in relation to residents’ clothing within the approved centre. The policy included all of the requirements of the Judgement Support Framework. Training and Education: There was no written evidence that staff had read the policy in relation to residents clothing. Staff were able to articulate the processes for residents’ clothing as per policy requirements. Monitoring: There was no evidence that the supply of emergency clothing was monitored regularly. A record of residents wearing night clothes during the day was kept and monitored. Evidence of Implementation: Residents were supported to keep and use personal clothing and Multi-Task Attendants (MTA) took responsibility for organising clothes to be laundered. Personal storage areas were tidy and clean. Residents were observed to be well presented throughout the inspection process. There was a limited store of indoor and outdoor clothing, not including underwear and night clothes, but these items would be purchased when the need arose, specifically for the particular resident requiring them, using an emergency fund. Residents had an adequate supply of their own clothing. No residents were seen to be wearing their night clothes during the inspection process. The approved centre was compliant with this regulation. The quality assessment was satisfactory but not rated excellent as the approved centre did not adhere to all the Judgement Support Framework criteria under staff training and education and monitoring.



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 written policy dated October 2016 in place on residents’ personal property and possessions within the approved centre. The policy included all of the requirements of the Judgement Support Framework. Training and Education: There was no documented evidence that staff had read and understood the policy but staff were able to articulate the processes for residents’ personal property and possessions as set out in the policy. Monitoring: Personal property logs were maintained and monitored within the approved centre and were checked every six months. Analysis was not completed to identify opportunities to improve the processes with regard to managing residents’ personal property and possessions. Evidence of Implementation: Residents could bring in their personal possessions from home, as agreed with staff, following admission. The approved centre had a safe in the nurse’s office and the nurse in charge held the key. Residents’ monies and valuables were kept in separate purses clearly labelled with the name of the residents they belonged to and a record was kept. An up-to-date copy of the resident’s property checklist was kept separate from the residents’ Individual Care Plans (ICP) within the residents’ files. The resident was offered a copy of the list. One member of staff and the resident signed the record of monies. Where the resident could not sign, two members of staff signed the entry. Staff supported residents to manage their own monies where possible. The approved centre was compliant with this regulation. The quality assessment was satisfactory but not rated excellent because the approved centre did not adhere to all criteria within the Judgement Support Framework under staff training and education and monitoring.




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 written policy dated June 2016 in relation to the provision of recreational activities in the approved centre. The policy included the majority of the requirements of the Judgement Support Framework with the exception of:

The process applied for the development of recreational activity programmes.

The process to support resident involvement in contributing to the recreational activities available.

Training and Education: There was no documented evidence that staff had read the policy on recreational activities but staff were able to articulate the relevant processes. The approved centre had an Assistant Occupational Therapist (AOP) who took responsibility for organising the recreational activities programme. Monitoring: There was a schedule of planned recreational activities, including a resident participation record, which was contained in the activities record book and the resident’s progress notes. There was no record of analysis having been completed to identify opportunities to improve recreational activity processes. The recreational activities programme was discussed during the resident’s monthly meetings and their ideas and suggestions were implemented, where possible. Evidence of Implementation: Residents had access to a range of recreational activities both inside and outside of the approved centre. Activities included one-to-one and group activities depending on resident preferences and abilities. Risk assessments were carried out for activities outside of the approved centre and for exercise activities. Nursing and care staff carried out activities within the approved centre at weekends and staff were available to take residents out to mass on Sundays. Residents were encouraged to take part in activities each day, however, staff respected their decisions not to engage if they did not want to. The activities programme was displayed in both written and pictorial format on the notice board outside the activities room and also in the main corridor. Days and times were clearly displayed. Residents were able to tell the inspector what activities were available each day and what they liked to do. There were regular walks in the grounds of the campus or into the local town as well as day trips to places of interest which gave residents access to fresh air and exercise. There were chair exercises and bowling exercise sessions available. The approved centre had an activities room and quiet lounge space. The lounge area was furnished as a traditional Irish farmhouse. There was also a small chapel/Oratory beside the activities room. All communal areas were being used by the residents during the inspection. The approved centre was compliant with this regulation. The quality assessment was satisfactory but not rated excellent as the approved centre did not adhere to all the criteria within the Judgement Support Framework under processes, staff training and education and monitoring.




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 on religion dated October 2016 regarding the approved centre’s facilitation of religious practices. The policy included all the requirements of the Judgement Support Framework. Training and Education: There was no documented evidence that staff had read and understood the policy on religion but staff were able to articulate the processes for facilitating residents in the practice of their religion as set out in the policy. Monitoring: There was no formal monitoring and analysis of the policy and processes in relation to religion within the approved centre. Evidence of Implementation: Staff supported individual residents to practice their religion within the approved centre or within the local community. Residents could attend prayers in the Oratory within the approved centre. Mass was held every Tuesday. There were religious texts available in the nurse’s office for residents who might need them. The approved centre had contacts within the local town for multi-faith chaplains/religious leaders. Three residents went to mass in the local town every Sunday. The approved centre was compliant with this regulation. The quality assessment was rated satisfactory but not excellent because the approved centre did not adhere to all criteria within the Judgement Support Framework under staff training and education and monitoring.



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 written policy dated December 2013 in relation to visits. The policy included all of the requirements of the Judgement Support Framework. Training and education: There were no records to show that staff had read the policy on visits. Staff were able to articulate the processes for welcoming visitors to the unit. Monitoring: There was no record of the policy requirements on visits having been reviewed within the last three years to ensure they were suitable for the defined needs of the residents. There was no ongoing monitoring or review of restrictions on residents’ rights to receive visitors. There was no documentation of analysis of the processes on visits with the goal of improving the visiting processes. Evidence of Implementation: Visiting times were publicly displayed at the main entrance door and throughout the unit. The visiting times were 10.00-12.00 and 14.00-16.00. Records in the residents’ Individual Care Plans showed that the Multi-Disciplinary Team supported and facilitated visiting. There were no visiting restrictions in place. A separate visitor’s room was available to accommodate visitors. All residents had a risk profile completed in their resident file. Children could visit, if accompanied by a responsible adult and supervised at all times, and the approved centre provided a designated visiting area for children. This was communicated to all relevant individuals publicly. The visiting room/area and facilities were suitable for visiting children. It was very large with couches, armchairs and a fireplace and appeared to be a warm family room. There was a large box of suitable children’s toys in the room. The approved centre was compliant with this regulation and the quality assessment was satisfactory but not excellent as the approved centre did not adhere to all criteria within the Judgement Support Framework under monitoring and staff training and education.




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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 written policy dated August 2016 available in relation to communication. The policy included all of the requirements of the Judgement Support Framework with the exception of access to an interpreter for the residents within the approved centre. Training and Education: There was no documented evidence to indicate that staff had read the policy on communication, however, staff were able to articulate the processes for communication as set out in the policy. Monitoring: There was no evidence of resident communication needs and restrictions on communications having been monitored on an ongoing basis. There was no evidence of analysis of the communication processes. Evidence of Implementation: The approved centre completed individual risk assessments for residents, when considered necessary, in relation to any risks associated with their external communications and this was documented in each resident’s individual care plan and clinical file. Relevant senior staff only examined incoming and outgoing resident communication if there was cause to believe the resident or other residents would be harmed by the content. Residents had mobile phones and there was a cordless phone in the office that residents could use for incoming and outgoing calls. Residents could use e-mail and fax if they wished and were aware of the outgoing postal service. Post was delivered to the ward daily. The approved centre was compliant with this regulation. The quality assessment was satisfactory but not rated excellent as the approved centre did not adhere to all criteria within the Judgement Support Framework under processes, staff training and education and monitoring.




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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 written policy, dated December 2015, available in relation to the implementation of resident searches by the approved centre. The policy included the full requirements of the Judgement Support Framework, including:

The processes and procedures for searching a resident, his/her belongings and their environment in the approved centre.

The process for the finding of illicit substances during a search and the consent requirements of a resident regarding searches and the process for carrying out searches in the absence of consent.

Training and Education: There was no documented evidence that staff had read the policy on searches, however, staff were able to articulate the searching processes as set out in the policy. As there had been no searches carried out in the approved centre since the last inspection, compliance for this regulation was assessed on the basis of processes and training only. The approved centre was compliant with this regulation. The quality assessment was satisfactory but not rated excellent as the approved centre did not adhere to all criteria within the Judgement Support Framework under staff training and education.




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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 written policy dated April 2016 in relation to care of the dying. The policy included most of the requirements of the Judgement Support Framework with the exception of:

The process for ensuring that the approved centre was informed in the event of the death of a resident who had been transferred elsewhere, (e.g. for general health care services).

Specific reference to advance directives in relation to end of life care such as Do Not Attempt Resuscitation Orders (DNARS) and residents’ religious and cultural end of life preferences.

Training and Education: There was no documented evidence that staff had read the policy, however, staff were able to articulate the processes for end of life care as set out in the policy. Monitoring: One death had occurred in the approved centre since the last inspection. End of life care was systematically reviewed and analysis was completed to identify opportunities to improve the processes for the care for the dying. Evidence of Implementation: The clinical file of one resident who had died was inspected. The privacy and dignity of the resident was respected during end of life care and the resident was accommodated in a single room. Palliative care was provided, where necessary, and the management of pain was prioritised. Families, next-of-kin and friends were facilitated to spend time with the dying resident.


The Mental Health Commission was notified within 48 hours of deaths in the approved centre. The advanced directives relating to end of life care, as well as Do Not Attempt Resuscitation (DNAR) orders and associated documentation were evident in the clinical file. The approved centre was compliant with this regulation. The quality assessment was satisfactory but not rated excellent as the approved centre did not adhere to all criteria within the Judgement Support Framework under: processes, staff training and education.



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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 dated August 2016 in relation to Individual Care Plans (ICPs). The policy met all of the requirements of the Judgement Support Framework. Training and Education: There were no records that staff had read the policy on individual care planning. Staff were aware of the assessment, planning, implementation and evaluation of the ICPs and they had knowledge of the review and monitoring process. Monitoring: There were records of six-monthly audits, rather than quarterly ones, to evaluate compliance with this regulation. Analysis was completed to identify opportunities to improve the individual care planning process. Evidence of Implementation: 21 out of 22 residents had an ICP. Twenty-one care plans were reviewed in detail by the multidisciplinary team. One resident, who was admitted to the approved centre did not have an ICP within seven days of admission. ICPs identified needs and appropriate goals, however, the specific resources to meet those goals were not identified. The ICP was kept in the clinical file in a composite set of documentation. The allocation of a key worker was not documented. Residents and their families had input into the development and review of their ICP’s. Residents signed their ICP and there was a record of whether the resident wanted and received a copy of their care plan. The approved centre was not compliant with this regulation for the following reasons:

a) One resident did not have an individual care plan (ICP) as required by the regulation. b) Resources were not identified in the ICPs.



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Risk Rating

Low Moderate High Critical

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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 was a written policy dated September 2016 available in relation to therapeutic services and programmes in the approved centre. The policy included all of the requirements of the Judgement Support Framework. Training and Education: There was no documented evidence that staff had read the policy on therapeutic services and programmes, however, staff were able to articulate the processes and policy requirements for them. Monitoring: There was no evidence of on-going monitoring of the range of services and programmes provided to ensure that they met the assessed needs of residents. There was no evidence of analysis having been completed to improve the quality of therapeutic services and programmes. Evidence of Implementation: The therapeutic services and programmes provided by the approved centre were appropriate and met the needs of the residents as documented in their individual care plans. Therapeutic activities and programmes were incorporated into the ICPs. There was an Occupational Therapist and an activities nurse. Staff involved in the therapeutic programmes had the use of a unit-owned car. There was a large Occupational Therapy room used for groups and art therapy. There was a therapeutic activities room which had space for art on one side, with the other side of the room being decorated like an old country style kitchen including an electric fireplace, which residents described as feeling like home. The approved centre was compliant with this regulation. The quality assessment was satisfactory but not rated excellent as the approved centre did not adhere to all criteria within the Judgement Support Framework under training, education and monitoring.



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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 did not apply.


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 Mayo Mental Health Service policy dated June 2014 available in relation to the processes for the transfer of residents and the policy included the requirements of the Judgement Support Framework with the exception of:

The interagency involvement in the transfer process.

The process for managing resident property during the transfer process.

The process for ensuring resident privacy and confidentiality during the transfer process, specifically in relation to the transfer of personal information.

Training and Education: There was no documented evidence that staff had read the policy. No residents had been transferred since the last inspection. Staff stated that they did not transfer residents from An Coillín but discharged them and re-admitted, if necessary. As there had been no resident transfers, the approved centre was assessed under processes and training and education for this regulation only. An Coillín was compliant with this regulation. The quality assessment was satisfactory but not rated excellent as the approved centre did not adhere to all Judgement Support Framework criteria, specifically processes and staff training and education.



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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 written policies available in relation to responding to medical emergencies, dated September 2016. The medical emergency policy included the roles and responsibilities in responding to medical emergencies. The medical emergency policy did not include:

Information on managing, responding to and documenting a medical emergency, e.g., anaphylaxis and cardiac arrest.

The staff training requirements on Basic Life Support (BLS).

The management of emergency response equipment, including the resuscitation trolley and Automated External Defibrillator (AED).

There were no written policies available in relation to the provision of general health services. Staff Training and Education: There was no documented evidence that staff had read the policies on the management of medical emergencies. There was no policy on the provision of general health services available. Staff were able to articulate the process for dealing with medical emergencies. Monitoring: Resident take up of national screening programmes was recorded and monitored. A systematic review was undertaken to ensure six-monthly reviews of general health needs took place. Records of physical assessments were reviewed to make sure they took place within the required six-monthly timeframe. Analysis was completed to identify opportunities to improve general health processes. Evidence of Implementation: Residents received appropriate general health care interventions in line with their individual care plans. Registered medical practitioners assessed residents’ general health needs at admission and at six-monthly intervals thereafter. Nineteen residents had six-monthly physical examinations completed in the last six months. Two residents had refused a six-monthly physical examination and one resident was a recent admission.


Adequate arrangements were in place for residents to access general health services and be referred to other health services as required; staff supported residents in attending general health appointments or seeing the General Practitioner (GP). Residents had access to relevant national screening programmes and were given information on screening programmes through leaflets and from speaking with nurses. The approved centre was compliant with this regulation. The quality assessment was satisfactory but not rated excellent as the approved centre did not adhere to all criteria within the Judgement Support Framework under processes, staff training and education.



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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 dated August 2016 available in relation to the provision of information to residents. The policy included the staff roles and responsibilities in relation to the provision of information to residents and the information provided to residents at admission and on an ongoing basis. The policy did not include:

The process for identifying the residents’ preferred ways of receiving and giving information.

The methods for providing information to residents with specific communication needs, including appropriate translation services.

The advocacy arrangements and interpreter services available.

The processes in place to manage the provision of information to resident representatives, family and next-of-kin.

Training and Education: There was no documented evidence that staff had read the policy on the provision of information to residents. Staff were able to articulate the processes for providing information to residents as set out in the policy. Monitoring: The provision of information to residents was monitored regularly. Residents were given a leaflet which was updated regularly. Analysis to identify opportunities to improve processes did not occur. Evidence of Implementation: Residents were provided with an information leaflet on housekeeping practices including meal times, personal property arrangements, visiting times and visiting arrangements, advocacy and voluntary agencies. Diagnosis-specific information about medications, including potential side effects, was provided to each resident. Leaflets, verbal and other written information regarding diagnosis, were provided to the residents, where appropriate. Residents were also given a booklet with details of their multi-disciplinary team.


Information provided to residents was in an understandable format and language. The approved centre was compliant with this regulation. The quality assessment was satisfactory but not rated excellent as the approved centre did fully adhere to all criteria within the Judgement Support Framework under processes, staff training and education, and monitoring.



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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 dated May 2016 available in relation to privacy. The policy included all of the requirements of the Judgement Support Framework with the exception of the process to be applied where resident privacy and dignity was not respected by staff. Training and Education: There was no documented evidence that staff had read the policy relating to resident privacy, however, staff were able to articulate the processes for ensuring resident privacy and dignity as set out in the policy. Monitoring: There was no record of a formal audit having taken place regarding the policy requirements within the approved centre. There was no record of analysis having been completed to identify opportunities to improve the processes relating to residents’ privacy and dignity. Evidence of Implementation: The demeanour of staff and the way in which staff addressed and communicated with residents was respectful and courteous. Residents were dressed appropriately to ensure their privacy and dignity. The approved centre did not have a dedicated examination room. The residents who occupied the 2- and 4-bed rooms had to use privacy curtains to make their personal space private. The privacy curtains were thin and several had been pulled off the runners. In room 27 it was not possible to pull the curtains around the beds and there was little privacy for those residents. The approved centre was non-compliant because:

(a) Bed screening was not adequate. (b) Facilities for medical examinations did not ensure privacy.



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Risk Rating


X


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 on premises dated June 2016 in place within the approved centre. The policy included the full requirements of the Judgement Support Framework. Training and Education: There was no documented evidence that staff had read the policy, however, staff were able to articulate the processes and procedures regarding maintenance of the premises as detailed in the policy. Monitoring: There was evidence of ongoing monitoring of maintenance and cleaning programmes such as a hygiene and infection control audit and a ligature audit. There was documented analysis completed to identify opportunities to improve the premises. Evidence of Implementation: The lighting in communal rooms was adequate, adaptable and bright enough for residents. Heating was sufficient and the temperature was controllable throughout the approved centre. The fire doors in two areas were not kept clear. A flower pot was placed in front of the fire door in the activities door and laundry baskets and skips were in front of a fire door off the main corridor. Residents had access to personal and communal space with the approved centre. The communal lounge was large and bright and gave residents access to the enclosed garden and outside smoking area. The flooring in the communal lounge was stained and worn in several areas. The dining room provided adequate space for residents to eat at one sitting. There was also an activities room which had comfortable seating and was furnished as a traditional Irish cottage.


Though there was a programme of general maintenance, staff reported that maintenance issues were not always dealt with in a timely manner. A ligature point risk assessment had been carried out following the 2015 inspection and a risk reduction management plan was in place. The plan did not include removal of ligature anchor points and the inspection team observed several ligature anchor points throughout the unit. There was a sufficient number of toilets and showers for residents and there were wheelchair-accessible facilities available, however, signage directions to them were not very clear. The inspection team observed that the bathrooms were not clean even though there was a cleaning schedule. There was a lack of ventilation and the bathrooms were malodorous. Each resident had a small wardrobe and there was open shelving in communal rooms. The inspection team observed residents’ clothing being stored in various locations around the centre as their personal storage space was not adequate. Four privacy curtains were not clean and there was no curtain cleaning schedule in the approved centre. The approved centre was non-compliant with this regulation because:

(a) Fire doors were not free from obstruction. 22.3. (b) Bathrooms were not adequately ventilated. 22. 1(b). (c) Privacy curtains were not clean. 22. 1(a) (d) Personal storage space was not sufficient for residents’ needs. 22. 2. (e) Flooring in communal room was stained and worn. 22.1(c)



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Risk Rating


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 dated September 2016 on the ordering, prescribing, storing and administration of medicines. The policy included the requirements of the Judgement Support Framework with the exception of the process for crushing medications. Training and Education: There was no documented evidence that staff had read the policy on the prescribing, ordering, storing and administration of medicines. Staff were able to articulate the processes as set out in the policy. Staff had access to comprehensive, up-to-date information and regular training on all aspects of medication management through the pharmacist. Monitoring: There were regular quarterly audits of Medication Prescription and Administration Records (MPARs) and medication audits including a lithium audit. Incident reports were recorded for medication errors and near misses. Analysis had been completed to identify opportunities for the improvement of medication management processes and action plans were identified following audits. Evidence of Implementation: Every resident had a Medication Prescription and Administration Record (MPAR). Twenty-two MPARs were reviewed in detail. All MPARs evidenced a record of appropriate medication management practices, including the use of two resident identifiers, a photograph and date of birth, records of all medications administered, route, dose and frequency, Medical Council Registration Number (MCRN) and signature of the medical practitioner prescribing the medication. A record was kept when medication was refused by a resident or withheld – there was a suitable code in place and staff documented this and reported it to the sector team. All medication was administered by a Registered Medical Practitioner (RMP). Controlled drugs were checked by two staff members prior to administration. No resident in the approved centre was prescribed controlled drugs at the time of the inspection. The controlled drug book recorded two-staff signatories when they had been administered previously. Good hand hygiene practices were observed to be used. Medication was ordered from the pharmacist and reconciled by staff within the approved centre and the checklist was filed in the clinical room. Medication was stored in a locked medication trolley which was locked in a clean clinical room. Scheduled controlled drugs were locked in a separate cupboard from other medicinal products to ensure further security.


Refrigerators used for medication were used for their storage only and a temperature log was maintained. An inventory of medication was kept; unused or out of date medication was returned to the pharmacy. The approved centre was compliant with this regulation. The quality assessment was satisfactory but not rated excellent as the approved centre did not adhere to all criteria within the Judgement Support Framework under processes.



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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 a written policy in place dated January 2016 in relation to the health and safety of residents, staff and visitors. The policy included most of the elements of the Judgement Support Framework with the exception of the requirements relating to:

Specific roles allocated to the registered proprietor in relation to the achievement of health and safety legislative requirements.

Support to staff following exposure to infectious diseases. Training and Education: There was no documented evidence that staff had read the policy, however, staff were able to articulate the processes relating to health and safety as set out in the policy. Monitoring: The health and safety policy was monitored pursuant to Regulation 29: Operational Policies and Procedures. Evidence of Implementation: The written operational policies and procedures accurately reflected the operational practices in the approved centre. The approved centre was not rated excellent for this regulation because it did not meet all the elements of the Judgement Support Framework under processes.



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3.25 Regulation 25: Use of Closed Circuit Television

(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 written policy in place dated September 2016 in relation to the use of closed circuit television. The policy included all of the elements of the Judgement Support Framework. Education and Training: There was no documented evidence that staff had read the policy on CCTV. Staff were able to articulate the processes as set out in the policy. As CCTV was not in use within the approved centre and was only used outside the main entrance, the approved centre was assessed under processes and training and education only. The approved centre was compliant with this regulation.



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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 a policy dated September 2016 on the recruitment, selection and vetting of staff. The policy included the requirements of the Judgement Support Framework with the exception of:

The job description requirements.

The evaluation of training programmes, both internal and external.

The staff performance and evaluation requirements.

The required content of staff personnel records. Training and Education: There was no documented evidence that staff had read and understood the policy on staffing. Monitoring: There was no evidence of the implementation and effectiveness of the staff training plan being reviewed on an annual basis and there was no evidence that the number and skills mix of staff was reviewed against the levels recorded in the approved centre’s registration. Analysis was not completed of staffing processes. Evidence of Implementation: There was an organisational chart in place. A planned and actual staff roster showing the staff on duty at any one time during day and night was maintained in the approved centre. A Clinical Nurse Manager was on duty and in charge at all times. The number and skill mix of staffing was not sufficient to meet the resident needs as not all staff were adequately trained. The staff training record indicated that 16 members of staff did not have up to date fire safety training. Three were not up to date with Crisis Prevention Interventions (CPI) training and five were not up to date with Basic Life Support (BLS). Nine staff members had not completed training on the Mental Health Act.


The following is a table of staff based in the approved centre:

Ward or Unit

Staff Grade Day Night

Unit A

CNM11 CNM 111 RPN HCA Occupational Therapist Activities Nurse Social Worker Psychologist

1 0.5 3 3 0.25 1 0.25 0.5

1 2 1

Clinical Nurse Manager (CNM), Registered Psychiatric Nurse (RPN), Health Care Assistant(HCA)

There was no documented evidence that staff had been trained in manual handling, infection control and prevention, dementia care, care for residents with an intellectual disability or end of life care. The approved centre was not compliant with this regulation because staff were not adequately trained to enable them to provide care and treatment in accordance with best practice.



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Risk Rating


X


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 written policy dated January 2016 in relation to the creation of, access to, retention of and destruction of records in the approved centre. The policy included the requirements of the Judgement Support Framework with the exception of: the policy did not include the retention of inspection records relating to food safety, health and safety and fire inspections. Training and Education: There was no documented evidence that staff had read and understood the policy on the maintenance of records. Staff were able to articulate the processes for the creation of, access to, retention of and destruction of records as set out in the policy. Not all clinical staff within the approved centre were trained in best-practice record keeping. Monitoring: Resident records had been audited to ensure their completeness, accuracy and ease of retrieval. There was evidence of analysis having been completed to identify and implement opportunities to improve the maintenance of records processes. Evidence of Implementation: Ten resident records were examined and all records were secure, up-to-date and met the legislative requirements. Records were appropriately secured throughout the approved centre and locked in an office. Older records were locked in an archive room, which was kept in an orderly manner. Records were physically stored together, kept secure, up-to-date and in good order with no loose pages. Records were maintained appropriately. All files had clearly marked dividers and documents were filed in an organised way. The documentation of food safety, health and safety and fire inspections was maintained in the approved centre. The approved centre was compliant with this regulation. The quality assessment was satisfactory but not rated excellent because the approved centre did not adhere to all criteria within the Judgement Support Framework under processes and staff training and education.




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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 A documented register of every resident admitted to the approved centre was available in both hard copy and in electronic format. The register of residents was up-to-date and available to the Mental Health Commission on inspection. The register included the information specified in Schedule 1 to these regulations. The approved centre was compliant with this regulation.



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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 available dated April 2016 in relation to the development, management and review of operating policies and procedures. The policy included all requirements of the Judgement Support Framework with the exception of:

The process for making obsolete, and retaining, previous versions of operating policies and procedures.

The process for collaboration between clinical and managerial teams to provide relevant and appropriate information within the operating policies and procedures.

Training and Education: There was no documented evidence that staff had read and understood the policy on developing and reviewing operating policies. Staff were able to articulate the processes for developing and reviewing operational policies, as set out in the policy. Monitoring: An annual audit had been undertaken in June 2016 to determine compliance with review timeframes and it outlined which policies that were to be reviewed. There was no evidence of analysis of operating policies and procedures having been undertaken to identify opportunities to improve the processes for developing and reviewing policies. Evidence of Implementation: The operating policies and procedures required by the regulations were reviewed every three years. The operating policies and procedures of the approved centre were developed with input from clinical and managerial staff and in consultation with relevant stakeholders (including service users) as appropriate. The senior management team approved each policy. The operating policies and procedures of the approved centre incorporated relevant legislation, evidence-based best practice and clinical guidelines. The approved centre was compliant with the regulation on operating policies and procedures. The quality assessment was satisfactory but not rated excellent as the approved centre did not meet the full criteria of the Judgement Support Framework under processes, staff training and education.



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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 As there had been no tribunals since the last inspection this regulation was not applicable.


3.31 Regulation 31: Complaints Procedures

(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 written operational policy in place in relation to the management of complaints. The approved centre also used the national Health Service Executive (HSE) policy, Your Service Your Say. The policy included all the requirements of the Judgement Support Framework for this regulation, including a nominated complaints officer for the approved centre. Training and Education: Not all staff had signed to indicate that they had read and understood the policy. Relevant staff were trained on the complaints management process and had knowledge of the processes involved. Monitoring: There was documented evidence of audits and findings acted upon in relation to complaints in the approved centre and complaints data was analysed and considered by senior management, with required actions identified and implemented. Evidence of Implementation: There was a nominated complaints officer for the approved centre. A consistent and standardised approach was implemented for the management of all complaints. Information about the complaints procedures and the Complaint Officer’s details were provided to residents on admission in the form of a booklet. The complaints procedure was well-publicised and accessible to residents and their representatives and families through leaflets and posters displayed throughout the unit and outside the visitor’s room. Complaints were handled promptly, appropriately and sensitively which was evident within the complaints log. All complaints were dealt with by the nominated person and recorded in


the complaints log. Details of complaints were kept separate from the individual care plans. The complainant’s satisfaction, or dissatisfaction, with the investigation findings was documented. The approved centre was compliant with this regulation. The quality assessment was not deemed to be excellent as the approved centre did not adhere to all criteria within the Judgement Support Framework under staff education and training.



X





3.32 Regulation 32: Risk Management Procedures

(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: There was a comprehensive up-to-date written policy dated September 2016 available in relation to risk management. The approved centre used the Health Service Executive (HSE) national policy guidance on incident management and for the protection of children and vulnerable adults within the care of the approved centre. The policies included:

The individual roles and responsibilities in relation to risk management and recording risks.

The precautions in place to control identified risks such as residents absent without leave, suicide and self-harm, assault, accidental injury to residents or staff.

The process for responding to emergencies and recording incidents.

The process for notifying the Mental Health Commission (MHC) about incidents involving residents of the approved centre.

Arrangements for the identification, recording, investigation and learning from incidents involving residents.

The policies did not include the person responsible for the completion the of six-monthly incident summary reports required by the Mental Health Commission.


Training and Education: There was no documented evidence that staff had read the risk management policy. Relevant staff were trained in the identification, assessment and management of risk relating to their roles, however, this training was not documented. Monitoring: The risk register was not audited quarterly. All incidents were recorded and risk rated and this was documented. Incident reports were analysed. Following the 2015 inspection a ligature point risk assessment was carried out. Individual ligature points had been risk rated. Evidence of Implementation: The risk management policy was implemented within the approved centre. Staff were aware of their responsibilities in reporting risk. Clinical risks were identified, assessed, treated, reported, monitored and were documented in the risk register and incorporated into the resident’s Individual Care Plan (ICP). Following the ligature point risk assessment, an action plan was developed and included an individual assessment for risk of self-harm; the current resident profile was considered low risk. Provision was made in the event of a resident presenting with higher level supervision needs. There was no plan to remove the ligature points identified. Incidents were recorded in the HSE standard reporting form. An administrator entered these onto the National Incident Management System (NIMS). Clinical incidents were reviewed by the Multi-Disciplinary Team at their weekly meeting. A six-monthly summary of incidents was provided to the Mental Health Commission. The approved centre was compliant with the regulation. The quality assessment was satisfactory but not rated excellent as the approved centre did not meet the full criteria of the Judgement Support Framework under processes, training and education.



X





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 had an up-to-date indemnity scheme statement. The approved centre’s insurance covered: Public Liability, Employers’ Liability, Clinical Indemnity and Property. The approved centre was compliant with this regulation.



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 There was an up to date certificate of registration prominently displayed within the approved centre. The approved centre was compliant with this regulation.



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 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 Electro-Convulsive Therapy was not administered in An Coillin, therefore; this rule was not applicable.


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 The approved centre did not use seclusion, therefore; this rule was not applicable.


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 Mechanical restraint was not used within the approved centre, therefore; this rule was not applicable.


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 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 involuntary/detained patients admitted into the approved centre therefore, Part 4: Consent to Treatment of the Mental Health Act 2001, was not applicable.


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 written policy dated May 2016 on the use of physical restraint. The policy was reviewed annually. The approved centre also had training related policies and procedures. The policy included the policy requirements specified in the code of practice on the use of physical restraint with the exception of the provision of information to the resident regarding physical restraint. Training and Education: There was no documented evidence available to indicate that all staff had read and understood the policy on physical restraint. Monitoring: The approved centre completed an annual report on physical restraint and forwarded details to the Mental Health Commission (MHC). Evidence of Implementation: Physical restraint was only implemented in the resident’s best interests and in rare and exceptional circumstances where the resident posed an immediate and serious harm to him/herself or others. The file of one resident who had been restrained was reviewed. The use of physical restraint was based on a risk assessment of the resident. Staff considered all other interventions to manage the resident’s unsafe behaviour. Cultural awareness and gender sensitivity was demonstrated. The next-of-kin was informed and reasons were recorded in the resident’s clinical file. The individual resident was informed of the reasons, duration and circumstances which would lead to discontinuation of physical restraint. The episode of physical restraint was reviewed by members of the MDT and documented in the clinical file no later than two working days after the episode. The resident was given the opportunity to discuss the episode with members of MDT as soon as was practicable. The approved centre was not compliant with this code of practice because:

(a) The provision of information to the resident regarding physical restraint was not included in the policy.

(b) There was no written record that staff had read and understood the policy.


Compliance with Code of Practice

X

Risk Rating


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.


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 risk management policy which covered the notification of deaths and incident reporting. The roles and responsibilities of staff in relation to reporting of deaths was included in the policy. Incident reporting to the Mental Health Commission was not included. The risk manager was named in the policy. Training and Education: There was no documented evidence that staff had read and understood the policies on the notification of deaths and incidents, however, staff were able to articulate the policy requirements. Monitoring: Deaths and incidents were reviewed to identify and correct any problems and improve the quality of processes. Evidence of Implementation: The approved centre was compliant with Article 32 of the regulations. There was an incident reporting system in place and a standardised incident report form was used and made available to inspectors. There was one death since the last inspection and this was notified to the Mental Health Commission within 48 hours. A six-monthly summary of all incidents was provided to the Mental Health Commission. The approved centre was not compliant with this code of practice because:

(a) The roles and responsibilities for the submission of forms to the Mental Health Commission was not included in the policy.

(b) It was not documented that staff were aware of and understood the policy.



X

Risk Rating


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 were policies and protocols for staff working with people with intellectual disabilities. They reflected person-centred treatment planning and presumption of capacity. There was a policy on the management of problem behaviours. The policy did not include:

Procedures for the training of staff in working with people with intellectual disability.

Recommendations for least-restrictive interventions. Training: There was no evidence that training embodied a person-centred approach, relevant human rights principles or preventative and responsible strategies to manage problem behaviours. As there was no resident with an intellectual disability in the approved centre, this regulation was assessed on processes and training and education only. The approved centre was not compliant with this regulation as:

(a) The policy did not reflect least restrictive interventions. (b) The policy did not include staff training requirements. (c) Staff had not received training on Intellectual Disability.


Compliance with Rule

X

Risk Rating


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 Electro-Convulsive Therapy was not administered in An Coillín, therefore; this code of practice was not applicable.


6.6 Admission, 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 written discharge, transfer and admission policies in place. Admission Policy: The policy on admissions included all of the requirements of the code of practice with the exception of the protocol for timely communication with primary care and Community Mental Health Teams (CMHT). Transfer Policies: There was a transfer policy in place. The policy was generic to Mayo Mental Health centres and not approved centre-specific. An Coillín did not transfer residents; in the event of moving to another healthcare facility they were discharged and re-admitted, if necessary. Discharge Policy: There was an in date discharge policy in place, dated May 2016. The policy on discharge included the requirements of the code of practice with the exception of a discharge follow up policy as required by section 4.14 of the code of practice. Training and education: There was no documented evidence that staff had read the policy on admissions and discharge in the approved centre. Monitoring: There was no documented evidence of an audit of the admission and discharge processes. Evidence of Implementation: The approved centre was non-compliant with Regulation 15 Individual Care Plans. Admission: The clinical file of one resident was reviewed and it was found that admission was not based on a diagnosis of mental illness or disorder. Transfer: Transfer was not applicable as the approved centre did not transfer residents. Discharge: One resident’s file who had been discharged was reviewed. A comprehensive assessment was completed prior to discharge and included psychiatric and psychological needs, a mental state examination, a comprehensive risk assessment and information needs. A discharge plan documented the estimated date of discharge, a follow up plan, early warning signs of relapse and risk. A discharge meeting took place, attended by the resident, key worker and relevant members of the multi-disciplinary team. This was documented in the resident’s clinical file. The approved centre was not compliant with this Code of Practice because:

a) The policy did not include a protocol for timely communication with primary care and the CMHTs. (4.9)

b) There was no documented evidence that staff had read and understood the policy. (9.1)


c) There was no audit of admission of implementation and of adherence to admission policy. (4.19)

d) The approved centre was non-compliant with Regulation 15 Individual Care Plan as required by this code of practice. (17.1).

e) Admission was not because of mental illness or disorder. (12.1) f) The discharge policy did not have details of a follow-up policy. (4.14) g) There was no evidence that the discharge was co-ordinated by a key worker. (37.1)



X

Risk Rating


X

Page 70 of 82

Appendix 1: Corrective action and preventative action (CAPA) plans for areas of non-compliance 2016

Completed by approved centre: An Coillín Date submitted: 9th February 2017 For each finding of non-compliance the registered proprietor was requested to provide a corrective action and preventative action (CAPA) plan. Corrective actions address the specific non-compliance(s). Preventative actions mitigate the risk of the non-compliance reoccurring. CAPA plans submitted by the registered proprietor were reviewed by the Commission to ensure that they are specific, measurable, achievable, realistic and time-bound (SMART). Following the finalisation of the inspection report the implementation of CAPA plans are routinely monitored by the Commission. The Commission has not made any alterations or amendments to the returned CAPA plans, including content and formatting.

Page 71 of 82

Regulation 15: Individual Care Plan (inspection report reference 3.15)

Area(s) of non-compliance Specific Measurable Achievable/ Realistic Time-bound

Define corrective and preventative action(s) to address the non-compliant finding and post-holder(s) responsible for implementation of the action(s)

Define the method of monitoring the implementation of the action(s)

State the feasibility of the action(s) (i.e. barriers to implementation)

Define time-frame for implementation of the action(s)

1. One resident did not have an

individual care plan (ICP).

Corrective action(s):

Care Plan In Place

Post-holder(s): CNMII, MDT

Regular, three monthly scheduled audit of ICP

√ Completed

Preventative action(s):

Post-holder(s):

2. Resources were not identified

in the ICPs.


Discussion of resources required at every ICP review

Key worker to be identified in ICP

Post-holder(s): CNMII, MDT

Regular, three monthly scheduled audit of ICP

√ February 2017


Post-holder(s):

Page 72 of 82

Regulation 21: Privacy (inspection report reference 3.21)






3. Bed screening was not

adequate.


Bed screens ordered 24/01/2017, awaiting delivery.

Post-holder(s): CNMII, CNMIII

Schedule of cleaning/replacement to be put in place.

√ March 2017


Post-holder(s):

4. Facilities for medical

examinations did not ensure

privacy.


Examination room identified on an interim basis to be commissioned in the next two weeks.

Post-holder(s): CNMII, CNMIII, Maintenance

Maintenance Audit Collaboration with maintenance/ procurement.

28th February 2017


Post-holder(s):

Page 73 of 82

Regulation 22: Premises (inspection report reference 3.22)






5. Fire doors were not free from

obstruction.


All fire exits in An Coillin free from obstruction

All staff aware and signs in place

Post-holder(s): CNMII

Free from Obstruction. Regular Health and Safety Audit in place.

√ Completed


Post-holder(s):

6. Bathrooms were not

adequately ventilated.


Ventillation issue cleared in all bedrooms except room 34

Post-holder(s): CNMII, Maintenance

Maintenance Audit √

Room 34

March 2017


Post-holder(s):

7. Privacy curtains were not

clean.


Audit of privacy curtains to be cleaned/replaced

Post-holder(s): CNMII, Line Management


√ Febraury 2017

Page 74 of 82


Post-holder(s):

8. Personal storage space was

not sufficient for residents’

needs.


Review additional storage space for residents

Post-holder(s): CNMII, Maintenance

√ February 2017


Post-holder(s):

9. Flooring in communal room

was stained and worn.


Maintenance to replace flooring and schedule regular cleaning

Post-holder(s): Maintenance, Line Management, CNMII


√ March 2017


Post-holder(s):

10. Ligature points Corrective action(s): Mayo Mental Health Services can confirm that a Risk Management plan to mitigate the risks to residents regarding ligature points identified in An Coillin is in place pending the outcome of MDT review.

The revised Risk Management Policy for Mayo Mental Health Services describes the process for the Safefuarding of Vulnerable Adults from Abuse – Inter Divisional Approach Policy.

√ March 2017

Page 75 of 82

Post-holder(s): Line Management, CNMII, Clinical Director


Post-holder(s):


Regulation 26: Staffing (inspection report reference 3.26)






11. Staff were not adequately

trained to enable them to

provide care and treatment in

accordance with best practice.


Fire safety training provided.

Training on BLS, Manual handling, CPI, Mental Health Act to continue to ensure compliant levels

Post-holder(s): CNMIII, CNMII, Line Management

Records held on Unit

Schedule of training is in place

Staff are to be assigned to training as appropriate

October 2017


Regular Monitoring of numbers of staff trained

Post-holder(s):

Page 77 of 82

Code of Practice: The Use of Physical Restraint (inspection report reference 6.1)






12. The provision of information to

the resident regarding physical

restraint was not included in the

policy.


Policy to be amended to include physical restraint

Post-holder(s): Policy Committee

Policy available with information

√ May 2017


Post-holder(s):

13. There was no written record

that staff had read and

understood the policy.


Electronic Policy Documents to allow electronic signing of policy to confirm staff have read and understood policy


Electronic reports can be produced

√ Completed


Post-holder(s):

Page 78 of 82

Code of Practice: Notification of Deaths and Incident Reporting (inspection report reference 6.3)






14. The roles and responsibilities

for the submission of forms to

the Mental Health Commission

was not included in the policy.


Risk Management Policy to be amended


Policy available with amendments

√ March 2017


Post-holder(s):

15. It was not documented that

staff were aware of and

understood the policy.


Electronic Policies allow for electronic signatures of staff to confirm they were aware and understand policies



√ Completed


Post-holder(s):

Page 79 of 82

Code of Practice: Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities (inspection report reference 6.4)






16. The policy did not reflect least

restrictive interventions.


Policy to be amended to include least restrictive interventions



√ May 2017


Post-holder(s):

17. The policy did not include staff

training requirements.


Policy to be amended to include staff training requirements



√ May 2017


Post-holder(s):

18. Staff had not received training

on Intellectual Disability.


Staff received further training in May 2016, training also planned for 2017

Post-holder(s): Line Management, CNMII

Training records available on unit

√ May 2017


Post-holder(s):

Page 80 of 82

Code of Practice: Admission, Transfer and Discharge (inspection report reference 6.6)






19. The policy did not include a

protocol for timely

communication with primary

care and the CMHTs.


Policy to be amended to include Protocol for timely communication



√ May 2017


Post-holder(s):

20. There was no documented

evidence that staff had read

and understood the policy.


Electronic Policies allow for electronic signatures of staff to confirm they were aware and understand policies



√ Completed


Post-holder(s):

21. There was no audit of

admission of implementation

and of adherence to admission

policy.


Audit of admission policy and adherence to admission to occur

Post-holder(s): Line Management, Policy Committee

Audit results available on unit

√ March 2017

Page 81 of 82


Post-holder(s):

22. Admission was not because of

mental illness or disorder.


Physical disability having negative impact on patients Mental health

Through care plan continually review Mental/Physical health, review suitable community alternatives

Post-holder(s):MDT CNM11

CNM 111

Suitable accommodation Suitable supervised accommodation to be sourced

May 2017


Post-holder(s):

23. The discharge policy did not

have details of a follow-up

policy.


Policy to be amended to include details of follow up policy


√ May 2017


Post-holder(s):

24. There was no evidence that the

discharge was co-ordinated by

a key worker.


Review of discharge protocol within the unit

Post-holder(s): MDT CNM11

CNM 111

May 2017


Post-holder(s):

Page 82 of 82