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Critical risk ratings at two mental health units

The Mental Health Commission (MHC) has today published six inspection reports, which identified two areas of ‘critical’ risk non-compliance, 10 areas of ‘high risk’ non-compliance and 52 areas of ‘excellent’ compliance across six approved centres in Galway, Kerry, Cork and Dublin. 

Woodview – a 21-bed unit situated on the Merlin Park University Hospital campus in the eastern suburbs of Galway city – had one critical risk rating for premises and one high-risk rating for ordering, prescribing, storing and administration of medicines. Food safety audits were not carried out regularly, and hygiene was not adequately maintained to support food safety requirements. The area under the stainless-steel kitchen units was dirty, and the kitchen required a deep clean.

The approved centre was in a poor state of repair, with numerous examples of inadequate repair evident. This included some external and bedroom lights not working, a handle missing on a wardrobe, a showerhead not working, cracked and peeling paint on windowsills, skirting boards, and walls, and two occurrences of decaying wood. The Commission issued an Immediate Action Notice to address these concerns and closely monitored the implementation of the service’s action plan.

Commenting on Woodview, Inspector of Mental Health Services for the Mental Health Commission, Dr Susan Finnerty, said: “There had been no significant improvement in compliance with regulations, rules and codes of practice over the past three years. Compliance in 2016 was 61 per cent; in 2017, it was 73 per cent; and in 2018, compliance was 68 per cent.”

 The Child and Adolescent Mental Health Inpatient Unit at Merlin Park also had one critical risk rating in relation to risk management. The centre was unable to ensure the safety of residents or staff due to the structural environment. The seclusion area was off a main corridor, which was an administrative area. If a patient in seclusion needed to use the toilet facilities, the area was sectioned off, leaving a very confined area for nurses and the patient to enter. This area was so confined that if the patient attempted to assault the staff there was no room to deflect contact, leaving the risk of injury much higher for both parties.

The centre had a high-risk rating in relation the use of seclusion. Residents in seclusion did not have access to adequate and private toilet and washing facilities. The seclusion room was too small and was poorly ventilated. The seclusion door was compromised as the reinforcement bars were damaged and they could not be locked. This indicated that the seclusion facilities were not furnished, maintained, and cleaned to ensure respect for resident dignity and privacy. The seclusion room was designed with a hard floor fitting which posed a risk to patient safety. The Commission issued an Immediate Action Notice and worked closely with the approved centre to monitor its concerns. 

Commenting on this unit at Merlin Park, Dr Finnerty said: “While many of the approved centres struggle to comply with regulations, Merlin Park had the highest compliance rating of 88 per cent. Encouragingly, CAMHS (Galway) had the first national pilot advocacy group in the HSE for the young person. This enables the young person to voice their views and concerns, and explore their options and rights to enable them to make informed decisions. These new initiatives are heartening as the patient is placed front and centre of the care they receive.”

 There were ten non-compliances identified by inspectors in The Jonathan Swift Clinic in Dublin, a 47-bed approved centre located in St James’s Hospital campus. The centre had two high risk ratings relating to premises and consent to treatment. The inspection report found that the centre was not clean; and the garden was littered with cigarette butts, despite it being a no smoking campus. There was evidence of smoking in one toilet, with a strong smell of smoke. Residents did not have access to adequate personal space or appropriate-sized bedrooms, as some of the four and six-bedded dormitories were cramped. As part of addressing these issues, the centre is required to provide quarterly reports to the Commission to demonstrate compliance.

Deer Lodge – a purpose-built, residential Mental Health Recovery Unit in Killarney, Co Kerry – had three high-risk ratings related to staffing, therapeutic services and programmes, and on the use of physical restraint. The therapeutic services provided by the approved centre were not appropriate and did not meet the assessed needs of the residents. 

In relation to the use of physical restraint, in three cases the residents were not informed of the reasons for, duration of, and circumstances leading to discontinuation of physical restraint. In two cases, the residents’ next of kin were not informed about the physical restraint episode. The centre provided corrective and preventative plans to address all areas of non-compliance identified and the Commission will seek an update in three months to ensure the plans are being implemented.

The Centre for Mental Health Care and Recovery (CMHCR) – an 18-bed acute unit located in the grounds of Bantry General Hospital in Cork – had three high-risk ratings in use of physical restraint, premises and complaints procedures.

The inspectors report highlighted ligature points such as door handles, radiators, beds, and window hinges that were not minimised throughout the approved centre with due regard to the specific needs, safety and wellbeing of residents. There was limited personal space for residents when the ward was at full capacity. There was one sitting room area, which could not accommodate 18 residents, and a small sitting area located beside the lift. The residents’ dining room was also too small to facilitate all residents dining together.

The inspectors found that there were seven non-compliances with the code of practice on physical restraint in the centre. While physical restraint was only used in rare, exceptional circumstances – where the resident posed immediate threat of serious harm to self or others, and only used after all alternative interventions to manage resident’s unsafe behaviour had been considered by staff – non-compliance was rated high-risk, as there were a number of discrepancies. In one of the episodes reviewed, there was no evidence that a designated staff member was responsible for leading the physical restraint, or for monitoring the head and airway of the resident during the physical restraint.  The Commission will seek an update in three months to ensure corrective and preventative plans supplied by the centre are implemented.

Dr Finnerty said: “The use of physical restraint in the management of acute mentally ill patients is a very serious intervention and the Commission has an oversight role to ensure that restrictive interventions are only used where strictly necessary and safely undertaken in line with codes of practice. There is no therapeutic benefit to restrictive practices and a focus is needed on the use of preventive approaches.”

 The Adolescent Inpatient Unit at St Vincent’s Hospital in Fairview had no high-risk ratings, while 13 areas of compliance were excellent. There were two moderate risk ratings that related to staffing and maintenance of records. At the time of the inspection, hazardous chemicals were not safely stored in the kitchen. This was remedied immediately during inspection, when staff locked the hazardous chemicals into the cleaning room. There was a significant improvement in compliance with regulations, rules and codes from 63 per cent in 2017, to 84 per cent in 2018. Corrective and preventative plans were supplied and the Commission will seek an update in three months to ensure the plans are being implemented.

Chief Executive of the Mental Health Commission, Mr John Farrelly, said, “We are publishing six inspection reports today with a compliance rating ranging from of 68 per cent to 88 per cent. None of the approved centres are reaching the 90 to 100 per cent compliance that they should be hitting. We can’t expect people in mental health acute centres to receive a service that is consistently non-compliant.

“People with a diagnosis of mental illness already experience exclusion in our society. It is incumbent on us to ensure that they get the highest standard of care in our mental health centres. As a regulator, we are committed to the provision of the highest quality mental healthcare and a consistent non-compliance rating is not acceptable in 2019. 

 “In our new strategy, we are committed to using all aspects of the current Mental Health Act to bring about significant change. Our team in the Mental Health Commission will continue to work relentlessly to pursue those operating poor standards.”

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