St Joseph's Intellectual Disability Service · St. Joseph’s Intellectual Disability Service (IDS)...

20

9

2

2222

Inspection Team:

Sarah Moynihan, Lead Inspector

Carol Brennan-Forsyth

Noeleen Byrne

Susan O’Neill

Dr Enda Dooley, MCRN004155

Inspection Date: 13 – 16 August 2019

Inspection Type: Unannounced Annual Inspection

Previous Inspection Date: 10 – 13 April 2018

The Inspector of Mental Health Services:

Dr Susan Finnerty MCRN009711

Date of Publication: Monday 04 August 2020

RULES AND PART 4 OF THE MENTAL HEALTH

ACT 2001

Compliant

St Joseph's Intellectual Disability Service

ID Number: AC0052

2019 Approved Centre Inspection Report (Mental Health Act 2001)

St Joseph's Intellectual Disability Service

St Ita's Campus

Portrane

Donabate

Co Dublin

Approved Centre Type:

Mental Health Care for People with Intellectual Disability

Most Recent Registration Date:

17 May 2019

Conditions Attached: Yes

Registered Proprietor:

HSE

Registered Proprietor Nominee:

Ms Anne Marie Donohue, General

Manager Mental Health Services,

CHO DNCC

REGULATIONS

CODES OF PRACTICE

Non-compliant

Not applicable

AC0052 St Joseph's Intellectual Disability Service Approved Centre Inspection Report 2019 of 97

RATINGS SUMMARY 2017 – 2019

Compliance ratings across all 39 areas of inspection are summarised in the chart below.

Chart 1 – Comparison of overall compliance ratings 2017 – 2019

Where non-compliance is determined, the risk level of the non-compliance will be assessed. Risk ratings

across all non-compliant areas are summarised in the chart below.

Chart 2 – Comparison of overall risk ratings 2017 – 2019

4 5 6

15 1013

2224

20

0

5

10

15

20

25

30

35

40

45

2017 2018 2019

Not applicable Non-compliant Compliant

5

1

3

5

4

7

49

0

2

4

6

8

10

12

14

16

2017 2018 2019

Low Moderate High Critical


Contents 1.0 Inspector of Mental Health Services – Review of Findings .............................................................. 5

2.0 Quality Initiatives ............................................................................................................................. 9

3.0 Overview of the Approved Centre ................................................................................................. 10

3.1 Description of approved centre ............................................................................................. 10

3.2 Governance ............................................................................................................................ 11

Reporting on the National Clinical Guidelines ................................................................................... 12

4.0 Compliance ..................................................................................................................................... 13

4.1 Non-compliant areas on this inspection ................................................................................ 13

4.2 Areas of compliance rated “excellent” on this inspection ..................................................... 13

4.3 Areas that were not applicable on this inspection ................................................................ 14

5.0 Service-user Experience ................................................................................................................. 15

6.0 Feedback Meeting .......................................................................................................................... 16

7.0 Inspection Findings – Regulations .................................................................................................. 17

8.0 Inspection Findings – Rules ............................................................................................................ 60

9.0 Inspection Findings – Mental Health Act 2001 .............................................................................. 64

10.0 Inspection Findings – Codes of Practice ....................................................................................... 65

Appendix 1: Corrective and Preventative Action Plan ........................................................................... 69

Appendix 2: Background to the inspection process .............................................................................. 95

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Inspector of Mental Health Services Dr Susan Finnerty

In brief

St. Joseph’s Intellectual Disability Service (IDS) was located in St. Ita’s Campus (formerly St Ita’s Hospital) in

Portrane, Co. Dublin. St Joseph’s IDS caters for the Dublin North, Dublin North Central and Dublin North West

Community Healthcare Organisation. At the time of inspection, the approved centre was registered for 96

beds and had 77 residents and was closed to new admissions excluding admissions from St Ita’s community

service. The approved centre consisted of 13 occupied houses and units. The Knockamann Resource Centre

on campus contained a café, gymnasium, multi-sensory room and other multipurpose rooms and acted as a

hub of social, vocational, educational and leisure activities for all residents.

It is planned that the approved centre would down-size and a number of units would eventually close as part

of the services’ planned transition programme. The transition programme aims to maximise residents’

independence and autonomy, by integrating residents from the approved centre into the community with

the necessary supports.

There had been little improvement in compliance with rules regulations and codes of practice over the

previous three years. In 2017 compliance was 59%; in 2018 it was 71% and this inspection in 2019, it had

decreased to 61%. There were no areas of compliance with regulations that were rated excellent.

Conditions to registration

There was one condition attached to the registration of this approved centre at the time of inspection.

Condition 1: To ensure adherence to Regulation 26(4): Staffing the approved centre shall implement a plan to ensure all healthcare professionals working in the approved centre are up-to-date in mandatory training areas. The approved centre shall provide a progress update on staff training to the Mental Health

Commission in a form and frequency prescribed by the Commission. Finding on this inspection: The approved centre was in breach of Condition 1 and the approved centre was non-compliant with Regulation 26: Staffing at the time of inspection.

Safety in the approved centre

1.0 Inspector of Mental Health Services – Review of Findings


Food safety audits had not been completed periodically. Food temperatures were not recorded in

line with food safety recommendations and a food temperature log sheet was not maintained and

monitored.

There were a number of discrepancies in the medication prescription and administration record

(MPAR) which had the potential to lead to serious medication errors:

o one resident had an allergy that was not documented on the MPAR

o one MPAR had no record of the medication administered to a resident

o one medication had been administered after the documented stop date

Not all health care professionals were trained in: fire safety, Basic Life Support, management of

violence and aggression, the Mental Health Act 2001, and Children First.

In one episode of physical restraint examined, a physical examination was not completed within the

required three hours of the episode.

Ligature points had not been minimised to the lowest practicable level, and due to the lack of

completed ligature audit, the level of associated risk was unknown.

The seclusion room door in House 2, Knockamann had torn padding around the observational panel

which exposed hard surface edging.

Hazards were not minimised in the approved centre, especially in the gardens of the Knockamann

Houses. They included:

o a broken ceramic plant pot

o tiles fallen from a mosaic, posing a risk due to sharp edges

o pieces of broken slate

o a broken goal post with exposed sharp edges

o large drain covers that were not screwed securely shut and posed a tripping hazard

o a box full of broken glass, found under a chair

o a significant amount of broken glass was present in an area where a glass table had broken

Appropriate care and treatment of residents

Each resident had a multi-disciplinary individual care plan which outlined goals and therapeutic

interventions.

There was a wide range of therapeutic services and programmes which addressed the needs of

the residents.

Residents with special dietary needs were regularly reviewed by a dietitian and were educated

about their diets, specifically in relation to any contradictions with medication.

However:

While each resident had a physical assessment every six months, a number of these were incomplete.

The clinical file of one resident who had been transferred to a general hospital was inspected. Full

and complete written information for the resident was not transferred when they moved from the


approved centre to the receiving facility and no information was sent in advance of or in

accompaniment with the resident upon transfer, to a named individual.

Respect for residents’ privacy, dignity and autonomy

The general demeanour of staff and the way in which staff addressed and interacted with residents

was respectful. All staff wore an identity badge.

All bathrooms, showers, and toilets had locks, unless there was an identified risk to a resident. Rooms

were not overlooked by public areas. Observation panels on doors of treatment rooms and bedrooms

were fitted with blinds, curtains, or opaque glass. Noticeboards did not display any identifiable

resident information.

There were designated areas where residents could meet their visitors in private.

However:

The approved centre was not kept in a good state of repair internally or externally. In addition the

aforementioned external issues regarding the gardens of a number of houses, there were various

internal issues observed, including: a broken hand towel dispenser within the disabled toilet of House

1; cracked padding in the seclusion room of House 2, as well as a broken toilet flusher, a missing

skirting board in the corridor, chipped paintwork in bedrooms, a broken shower door in the assisted

bathroom, discoloured corridor wall, and a worn floor in the padded room; some damaged wall paint

in House 7, and; a damaged wall in the corridor of House 10.

A cleaning schedule was not adequately implemented. The approved centre was not clean, hygienic,

and free from offensive odours, nor were rooms properly ventilated. There were a number of

instances of malodour found in toilets, bathrooms and bedrooms across the premises and communal

areas, corridors, bedrooms, bathrooms and toilets were observed to be unclean, sometimes

significantly so. Outdoor areas were littered with broken tiles, rubbish, including discarded skirting

boards, and cigarette butts.

The seclusion room in House 1, Knockamann was observed to be dirty with food residue on the floor.

The centre was non-compliant with the Rules Governing the Use of Mechanical Restraint in that the

clinical files did not contain a review date for the restraint and one of the files did not specify the

duration of restraint.

Responsiveness to residents’ needs

Residents were provided with a variety of wholesome and nutritious food and had at least two

choices for meals, and food, including modified consistency diets, was presented in a manner that

was attractive and appealing in terms of texture, flavour, and appearance.

The approved centre provided access to both indoor and outdoor recreational activities. A dedicated

activity resource centre was located on campus and provided a range of well-resourced activities on

weekdays and weekends. The activity centre had communal spaces available to residents and

activities were provided on a group and individual basis.


Information was available in formats to support the residents’ particular needs, including through

photographs, symbols and large letters. Symbols provided visual representation of concepts. The

service utilised “Widget” software which standardised symbols making the meaning clearer and

easier to understand.

Appropriate signage and sensory aids were not provided to support resident orientation needs.

Governance of the approved centre

St Joseph’s IDS was part of the North Dublin Mental Health Services (NDMHS). NDMHS was part of

the wider Dublin North, Dublin North Central and Dublin North West Community Health Care

Organisation.

St Joseph’s IDS was governed by a Senior Management Team that reported to the Dublin North,

Dublin North Central and Dublin North West Community Health Care Organisation Area Management

Team.

A multi-disciplinary approach was fostered within governance structures and clinical care.

Not all disciplines had formal structures and processes in place for measuring and encouraging staff

performance and personal development.

Annual staff training needs analysis and plans were completed to identify and address training needs,

but not all health professionals had up-to-date mandatary training. Multiple non-mandatary training

courses were available to staff and management supported and facilitated higher education

programmes.

The Policies Procedures, Protocols and Guidelines (PPPGS) provided a multi-disciplinary approach to

policy development, review, approval and dissemination.

There was an emerging culture of implementing quality improvement audit tools to monitor and

evaluate standards of care. There was a concise audit schedule in situ and therefore the benefits of

re-auditing was captured.

The Senior Management Team at their Quality and Patient Safety Meetings monitored and

maintained St Joseph’s Services risk register quarterly. This risk register fed into the wider Dublin

North, Dublin North Central and Dublin North West Community Healthcare Organisation risk register

when deemed appropriate.

Walkabouts by the responsible Assistant Director of Nursing and Clinical Nurse Manager II reviewed

the environment, non-clinical and clinical risks, staff training and various other clinical practices.

The voice of the service user was sought through opportunities such as the HSE’s “Comment,

Compliment or Compliant” process, community meetings situated in the approved centre, and St

Joseph’s Self-Advocacy Group were consulted about how the service was run.


The following quality initiatives were identified on this inspection:

1. The approved centre updated their Medicine Prescription Administration Record (MPAR) – January

2019.

2. The WIDGET symbol programme was purchased. This software aids resident’s communication by

standardising symbols and making their meaning clearer and easier to understand – 2019.

3. Multiple garden areas have been enhanced in Grovelogde, Seafield and Failte. Knockamann Street

House 5 and House 6 sitting developed rooms into sensory rooms in order to helps residents’ develop

and engage in their senses – 2018/2019.

4. Two compliance officer posts had been secured – 2018.

5. Clinical Nurse Specialist in Positive Behaviour Support had commenced – July 2018.

6. Quality Care Metrics was initiated in order to support and enhance measurements on the delivery of

care.

7. Tovertafel (the magic table) is an interactive game for individuals with cognitive impairment that

motivates the mind. Tovertafel utilises a ceiling based projector to displays light animations on a table

which facilitates the interactive play. It was introduced in one of the community houses in Dec 2018.

8. The Nurse Practice Development Unit in St Joseph’s has been granted approval to rollout

Preceptorship training.

9. The Self Advocacy Group meet every Wednesday and among other things have started discussion on

residents care plans and how important they are.

2.0 Quality Initiatives


3.1 Description of approved centre

St. Joseph’s Intellectual Disability Service was located in St. Ita’s Campus (formerly St Ita’s Hospital) in Portrane, Co. Dublin. The approved centre provided a service for adults who have an intellectual disability and a mental health diagnosis. Historically, service users came to St. Ita’s from all around the country; however, St. Ita’s now only caters for the Dublin North, Dublin North Central and Dublin North West Community Healthcare Organisation. Multiple houses and units had been tailored to meet residents’ needs in order to promote their independence and comfort and, where possible, residents were supported to be involved in the local community.

At the time of inspection, the approved centre was registered for 96 beds and had 77 residents. The

approved centre was closed to new admissions excluding admissions from St Ita’s community service. The

approved centre consisted of 13 occupied houses and units; 8 houses on Knockamann Street and 4 named

houses and units. A recourse centre contained a café, gymnasium, multi-sensory room and other

multipurpose rooms. The Knockamann Resource Centre acted as a hub of social, vocational, educational and

leisure activities for all residents. Offices were located on Knockamann Street in House 9 and in a renovated

part of the old St. Ita’s Hospital building.

Knockamann Street contained 11 modern self-sufficient houses. All the houses potentially catered for 6

individuals with the exception of House number 11 which had been divided into two one bedded

apartments. Houses 3 and 4 were not in use at the time of inspection.

The five named units spread across the ground of St. Ita’s included; Fáilte, Grove Lodge, Fern Lodge, St.

Claire’s and Seafield. Hillview unit had been closed and Fern Lodge had been re-opened since last year’s

(2018) inspection.

Garden areas in Knockamann were used as a storage spaces for decommissioned or unused items. These items were not only unsightly but hazardous in nature. There was a noticeable variation between the houses in relation to decorative repair and cleanliness. The named units were older buildings in need of upgrading and modernisation with the exception of Seafield. Seafield had a considerable amount of work competed in 2014. No major work was planned for the other named units as the approved centre was expected to down size and the named units would eventually close as part of the services planned transition programme. The transition programme hopes to further maximise resident’s independence and autonomy, by integrating residents from the approved centre into the community with the necessary supports.

The resident profile on the first day of inspection was as follows:

Resident Profile

Number of registered beds 96

Total number of residents 77

Number of detained patients 0

Number of wards of court 6

3.0 Overview of the Approved Centre


Number of children 0

Number of residents in the approved centre for more than 6 months 77

Number of patients on Section 26 leave for more than 2 weeks 0

3.2 Governance

St Joseph’s Intellectual Disability (ID) Service was part of the North Dublin Mental Health Services (NDMHS).

NDMHS was part of the wider Dublin North, Dublin North Central and Dublin North West Community Health

Care Organisation. St Joseph’s Intellectual Disability Service was governed by a Senior Management Team

that reported to the Dublin North, Dublin North Central and Dublin North West Community Health Care

Organisation Area Management Team. The Area Management Team met on a monthly basis. St Joseph’s

Intellectual Disability Service included the approved centre, residential houses and community services. St

Joseph’s Senior Management Team met weekly and rotated the meeting’s agenda as follows; 1) Compliance

Meeting, 2) Quality and Patient Safety Meeting, 3) Business Meeting and 4) Working Meeting.

Numerous sub-committees and working groups fed into the Senior Management Team. Some of which

included: Nurse Management Meetings, Drugs and Therapeutics Committee, Policies Procedures, Protocols

and Guidelines group, Mental Health Intellectual Disability Group, Audit group and Multidisciplinary Team

(MDT) Meetings. MDT meetings occurred weekly and like the Senior Management Team had a rotating

agenda. Multidisciplinary Team meetings rotated in a monthly cycle as follows; 1) Business Meeting, 2)

Restrictive Practice Meeting, 3) Clinical Issues and 4) Compliance. The Nurse Practice Development Unit

were immersed in the various working groups and fed into the Senior Management Team. A multidisciplinary

approach was fostered within governance structures and clinical care. The majority of the committee’s

purpose, structures, responsibilities and reporting relationships were well defined. The remit and authority

of line managers for the various disciplines were clear.

There was an induction programme for new staff and they all underwent the HSE probation process. Not all

disciplines had formal structures and process in place for measuring and encouraging staff’s performance

and personal development. The formal arrangements and availability of clinical supervision varied across

disciplines. Annual staff training needs analysis and plans were completed to identify and address training

needs, however records indicated not all health professionals had up-to-date mandatary training.

Reportedly, the main barrier for staff not achieving the required mandatory training was low staffing levels

and the prioritisation of clinical demand over training attendance. Multiple non-mandatary training courses

were available to staff and management supported and facilitated higher education programmes. At the

time of inspection numbers staff were undertaking post graduate courses in clinical and managerial areas.

The Policies Procedures, Protocols and Guidelines (PPPGS) provided a multidisciplinary approach to policy

development, review, approval and dissemination. PPPGs meetings were held as required. There was an

emerging culture of implementing quality improvement audit tools to monitor and evaluate standards of

care. There was a concise audit schedule in situ and therefore the benefits of re-auditing was captured. Audit

findings were presented to the Senior Management Team at their Quality and Patient Safety Meetings.

The approved centres registered proprietor held overall responsibility for the risk management process. The

Senior Management Team at their Quality and Patient Safety Meetings monitored and maintained St

Joseph’s Services risk register quarterly. Service wide incidents and trends and complaints were also

discussed at these meetings. This risk register fed into the wider Dublin North, Dublin North Central and


Dublin North West Community Healthcare Organisation risk register when deemed appropriate. The Area

Quality and Patient Safety Meetings governs the wider risk register. There was an overall St Joseph’s

Intellectual Disability Safety Statement. Each house or unit also holds a site specific safety statement and a

suite of anticipated risks. Walkabouts were conducted quarterly on each house or unit by the responsible

Assistant Director of Nursing and Clinical Nurse Manager II. The walkabouts reviewed the environment, non-

clinical and clinical risks, staff training and various other clinical practices. Despite clear risk process and

procedures being in place numerous environmental health and safety hazards were observed during

inspection had not been identified.

The Area Lead for Mental Health Engagement was a member of the wider Dublin North, Dublin North Central

and Dublin North West Community Healthcare Organisation management meetings. The voice of the service

user was sought by the Senior Management Team through numerous opportunities such as; the HSE’s

“Comment, Compliment or Compliant” process, community meetings situated in the approved centre and a

St Joseph’s Self-Advocacy Group were consulted about pertinent elements of how the service was run.

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.


4.1 Non-compliant areas on this inspection

Non-compliant (X) areas on this inspection are detailed below. Also shown is whether the service was

compliant () or non-compliant (X) in these areas in 2018 and 2017 and the relevant risk rating when the

service was non-compliant:

Regulation/Rule/Act/Code Compliance/Risk Rating 2017

Compliance/Risk Rating 2018

Compliance/Risk Rating 2019

Regulation 6: Food safety X High

Regulation 15: Individual Care Plan X High X Moderate

Regulation 18: Transfer of Residents X High

Regulation 19: General Health X Moderate X High

Regulation 21: Privacy X High X High

Regulation 22: Premises X High X Moderate X High

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

X High X Moderate

Regulation 26: Staffing X High X High X High

Regulation 32: Risk Management Procedures

X Moderate X High

Rules Governing the Use of Seclusion X High X High X High

Rules Governing the Use of Mechanical Restraint

X Low X Moderate

Codes of Practice on the Use of Physical Restraint

X Moderate X Moderate X Moderate

Codes of Practice on Admission, Transfer and Discharge to and from an Approved Centre

X Low X Moderate X High

The approved centre was requested to provide Corrective and Preventative Actions (CAPAs) for areas of non-

compliance. These are included in Appendix 1 of the report.

4.2 Areas of compliance rated “excellent” on this inspection

No areas of compliance were rated excellent on this inspection.

4.0 Compliance


4.3 Areas that were not applicable on this inspection

Regulation/Rule/Code of Practice Details

Regulation 17: Children’s Education As the approved centre did not admit children, this regulation was not applicable.

Regulation 30: Mental Health Tribunals As no Mental Health Tribunals had been held in the approved centre since the last inspection, this regulation was not applicable.

Part 4 of the Mental Health Act 2001: Consent to Treatment

As there were no patients in the approved centre for more than three months and in continuous receipt of medication at the time of inspection, Part 4 of the Mental Health Act 2001: Consent to Treatment was not applicable.

Code of Practice Relating to Admission of Children Under the Mental Health Act 2001

As the approved centre did not admit children, this code of practice was not applicable.

Code of Practice on the Use of Electro-Convulsive Therapy for Voluntary Patients

As the approved centre did not provide an ECT service, this code of practice was not applicable.


The Inspector gives emphasis to the importance of hearing the service users’ experience of the approved

centre. To that end, the inspection team engaged with residents in a number of different ways:

The inspection team informally approached residents and sought their views on the approved centre.

Posters were displayed inviting the residents to talk to the inspection team.

Leaflets were distributed in the approved centre explaining the inspection process and inviting

residents to talk to the inspection team.

Set times and a private room were available to talk to residents.

In order to facilitate residents who were reluctant to talk directly with the inspection team, residents

were also invited to complete a service user experience questionnaire and give it in confidence to

the inspection team. This was anonymous and used to inform the inspection process.

The Irish Advocacy Network (IAN) representative was contacted to obtain residents’ feedback about

the approved centre.

With the residents’ permission, their experience was fed back to the senior management team. The

information was used to give a general picture of residents’ experience of the approved centre as outlined

below.

During the inspection we spoke individually with six residents. Residents were very complimentary about

the care and about staff within the approved centre. Overall residents reported they enjoyed the food.

Resident reported they particularly enjoyed organised outings and events in the resource centre. No

completed resident questionnaires were returned to the inspectors.

5.0 Service-user Experience


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

Acting Senior Social Worker

Acting Executive Clinical Director

Service Manager

CNM II x2

Nurse Practice Development Co-Ordinator

Staff Nurse x1

Assistant Director of Nursing x2

Area Director of Nursing

Principal Psychologist Manager

The inspection team outlined the initial findings of the inspection process and provided the opportunity for

the service to offer any corrections or clarifications deemed appropriate.

6.0 Feedback Meeting


7.0 Inspection Findings – Regulations

The following regulations are not applicable Regulation 1: Citation Regulation 2: Commencement and Regulation Regulation 3: Definitions

EVIDENCE OF COMPLIANCE WITH REGULATIONS UNDER MENTAL HEALTH ACT 2001 SECTION 52 (d)


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: The approved centre had a written policy in relation to the identification of residents, which was last reviewed in August 2017. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for identifying residents, as set out in the policy. Monitoring: An annual audit had been undertaken to ensure that there were appropriate resident identifiers on clinical files. Documented analysis had been completed to identify opportunities for improving the resident identification process. Evidence of Implementation: A minimum of two resident identifiers appropriate to the resident group profile and individual residents’ needs were used. The preferred identifiers, detailed in residents’ clinical files, were checked when staff administered medications, undertook medical investigations, and provided other health care services. An appropriate resident identifier was used prior to the provision of therapeutic services and programmes. The identifiers used were person-specific, and appropriate to the residents’ communication abilities. There was an appropriate identifier and alert system in place on clinical files, to assist staff in distinguishing between residents with the same or a similar name. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education pillar.

COMPLIANT Quality Rating Satisfactory


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: The approved centre had a written policy in relation to food and nutrition, which was last reviewed in August 2017. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for food and nutrition, as set out in the policy. Monitoring: A systematic review of menu plans had been undertaken to ensure that residents were provided with wholesome and nutritious food in line with their needs. Documented analysis had not been completed to identify opportunities for improving the processes for food and nutrition. Evidence of Implementation: The approved centre’s menus were not approved by a dietitian to ensure nutritional adequacy in accordance with the residents’ needs. Residents were provided with a variety of wholesome and nutritious food, including portions from different food groups as per the Food Pyramid. Residents had at least two choices for meals, and food, including modified consistency diets, was presented in a manner that was attractive and appealing in terms of texture, flavour, and appearance. Hot meals were provided on a daily basis and a source of fresh drinking water was available to residents at all times in easily accessible locations in the approved centre. Hot and cold drinks were offered to residents regularly. An evidence-based nutrition assessment tool was in place, but there was no evidence it was used in the clinical files examined. Weight charts were implemented, monitored, and acted upon for residents, where appropriate. For residents with special dietary requirements, nutritional and dietary needs were assessed, where necessary, and addressed in residents’ individual care plans. Residents with special dietary needs were regularly reviewed by a dietitian and they, along with their representative, family, and next of kin, were educated about their diets, specifically in relation to any contradictions with medication. Intake and output charts were maintained for residents, where appropriate. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education, monitoring, and evidence of implementation pillars.

Regulation 6: Food Safety


NON-COMPLIANT Requires Improvement Risk Rating


(1) The registered proprietor shall ensure:

(a) the provision of suitable and sufficient catering equipment, crockery and cutlery

(b) the provision of proper facilities for the refrigeration, storage, preparation, cooking and serving of food, and

(c) that a high standard of hygiene is maintained in relation to the storage, preparation and disposal of food and related refuse.

(2) This regulation is without prejudice to:

(a) the provisions of the Health Act 1947 and any regulations made thereunder in respect of food standards (including labelling) and safety;

(b) any regulations made pursuant to the European Communities Act 1972 in respect of food standards (including labelling) and safety; and

(c) the Food Safety Authority of Ireland Act 1998.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to food safety, which was last reviewed in May 2017. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for food safety, as set out in the policy. All staff handling food had up-to-date training in food safety commensurate with their role. This training was documented, and evidence of certification was available. Monitoring: Food safety audits had not been completed periodically. Food temperatures were not recorded in line with food safety recommendations. A food temperature log sheet was not maintained and monitored. Documented analysis had not been completed to identify opportunities to improve food safety processes. Evidence of Implementation: Appropriate hand-washing areas were provided for catering services and appropriate protective equipment was used during the catering process. There was suitable and sufficient catering equipment and residents were provided with crockery and cutlery that was suitable and sufficient to address their particular needs. There were proper facilities for the refrigeration, storage, preparation, cooking, and serving of food and hygiene was maintained to support food safety requirements. Catering areas and associated catering and food safety equipment was appropriately cleaned. Food was prepared in the approved centre’s main kitchen, but was not prepared in a manner that reduced the risk of contamination, spoilage, and infection as food temperatures were not recorded in line with food safety requirements. The approved centre was non-compliant with this regulation because food temperatures were not recorded in line with food safety recommendations, 6 (1)(c).


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: The approved centre had a written policy in relation to residents’ clothing, which was last reviewed in May 2017. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for residents’ clothing, as set out in the policy. Monitoring: The availability of an emergency supply of clothing for residents was monitored on an ongoing basis. This was documented. No residents were wearing nightclothes at the time of inspection. Evidence of Implementation: Residents were supported to keep and use their personal clothing, which was clean and appropriate to their needs. Residents had an adequate supply of their own individualised clothing, which they stored in their personal wardrobes. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education pillar.



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: The approved centre had a written operational policy in relation to residents’ personal property and possessions, which was last reviewed in December 2018. The policy included all of the requirements of the Judgement Support Framework.

Training and Education: Not all relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for residents’ personal property and possessions, as set out in the policy. Monitoring: Personal property logs were monitored in the approved centre. Documented analysis had been completed to identify opportunities for improving the processes relating to residents’ personal property and possessions. Evidence of Implementation: A resident’s personal property and possessions were safeguarded when the approved centre assumed responsibility for them: residents had wardrobes and lockers which could be locked. Secure facilities were provided for the safe-keeping of the residents’ monies, valuables, personal property, and possessions, as necessary, with a safe in the nurses’ offices or clinical rooms of each house. The access to and use of resident monies was overseen by two members of staff and the resident or their representative. Residents had access to personal storage facilities for their personal property, and they were entitled to bring personal property and possessions with them as agreed at admission. The approved centre maintained a signed property checklist detailing each resident’s personal property and possessions. The property checklist was kept separately to the resident’s ICP and was available to the resident. Residents were supported to manage their own property, unless this posed a danger to the resident or others, as indicated in their ICP. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education pillar.



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: The approved centre had a written policy in relation to the provision of recreational activities, which was last reviewed in January 2018. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for recreational activities, as set out in the policy. Monitoring: A record was maintained of the occurrence of planned recreational activities, including a log of resident uptake and attendance. Documented analysis had been completed to identify opportunities for improving the processes relating to recreational activities. Evidence of Implementation: The approved centre provided access to both indoor and outdoor recreational activities appropriate to the resident group profile. A dedicated activity resource centre was located on campus and provided a range of well-resourced activities on weekdays and weekends. The activity centre had communal spaces available to residents and activities were provided on a group and individual basis. Activities included knitting, movies, art, swimming, gardening, walking and cycling, and there was a large gym available too. Recreational activities were provided within the houses too, and these included television, movies, reading, colouring and games. Information was provided to residents in an accessible format by way of a specific schedule for each resident based on their individual needs, preferences and abilities. These were held in the nurses’ station of each house. Recreational activities programmes were developed, implemented, and maintained for residents, with resident involvement. Individual risk assessments were completed for residents, where deemed appropriate, in relation to the selection of appropriate activities. Resident decisions on whether or not to participate in activities were respected and documented. Records of attendance were retained for recreational activities in group records or within the resident’s clinical file, as appropriate. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education pillar.



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: The approved centre had a written policy in relation to the facilitation of religious practice by residents, which was last reviewed in May 2017. The policy included all of the requirements of the Judgement Support Framework.

Training and Education: Not all relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for facilitating residents in the practice of their religion, as set out in the policy. Monitoring: The implementation of the policy to support residents’ religious practices was not reviewed to ensure that it reflected the identified needs of residents. Evidence of Implementation: Residents’ rights to practice religion were facilitated within the approved centre insofar as was practicable, with facilities available to support their religious practices. There was a church on the grounds of the approved centre. Residents had access to multi-faith chaplains and were facilitated to observe or abstain from religious practice in accordance with wishes. Care and services provided in the approved centre were respectful of the residents’ religious beliefs and values, and any specific religious requirements relating to the provision of services, care and treatment were clearly documented. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education and monitoring pillars.



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: The approved centre had a written policy and procedures in relation to visits. The policy was last reviewed in January 2018. The policy and procedures included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for visits, as set out in the policy. Monitoring: There were no restrictions on resident’s rights to receive visitors. Documented analysis had been completed to identify opportunities for improving visiting processes. Evidence of Implementation: Visiting times were publicly displayed in the approved centre and were appropriate and reasonable. A separate visitors’ room or visiting area was provided where residents could meet visitors in private. Residents and visitors could also make use of the coffee shop on the grounds of the approved centre and were facilitated to meet visitors in the local town, as appropriate. Adequate steps were taken to ensure the safety of residents and visitors during visits and children visiting the approved centre were accompanied at all times to ensure their safety, with this being communicated to all relevant individuals publicly. There were suitable visiting spaces for visiting children. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education pillar.



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: The approved centre had a written operational policy and procedures in relation to resident communication. The policy was last reviewed in March 2018. The policy and procedures included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for communication, as set out in the policy. Monitoring: Resident communication needs and restrictions on communication were not monitored on an ongoing basis. Documented analysis had not been completed to identify ways of improving communication processes. Evidence of Implementation: Residents had access to mail, fax and internet if they desired. Residents had access to mobile phones and there was a landline in each of the houses. Resident communications were not subject to examination. Individual risk assessments were completed for residents, as deemed necessary, in relation to any risks associated with their external communication and documented in the individual care plan. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education, monitoring, and evidence of implementation pillars.



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: The approved centre had a written operational policy and procedures in relation to the implementation of resident searches. The policy was last reviewed in January 2018. The policy and procedures addressed all of the requirements of the Judgement Support Framework, including the following:

The management and application of searches of a resident, his or her belongings, and the environment in which he or she is accommodated.

The consent requirements of a resident regarding searches and the process for carrying out searches in the absence of consent.

The process for dealing with illicit substances uncovered during a search. Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the searching processes, as set out in the policy. There were no searches conducted in the approved centre since the last inspection, therefore the approved centre was assessed under the two pillars of processes and training and education only. The approved centre was compliant with this regulation.

COMPLIANT


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: The approved centre had a written operational policy and protocols in relation to care of the dying. The policy was last reviewed in October 2018. The policy and protocols addressed requirements of the Judgement Support Framework, with the exception of the process for ensuring that the approved centre is informed in the event of the death of a resident who has been transferred elsewhere. Training and Education: Not all relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for end of life care, as set out in the policy. Monitoring: End of life care provided to residents was systematically reviewed to ensure section 2 of the regulation had been complied with. Systems analysis was undertaken in the event of a sudden or unexpected death in the approved centre. Documented analysis had been completed to identify opportunities for improving the processes relating to care of the dying. Evidence of Implementation: One expected death of a resident had occurred since the last inspection. The end of life care provided in the approved centre was appropriate to the resident’s physical, emotional, social, psychological, comfort, and spiritual needs, and this was documented in the resident’s individual care plan. Religious and cultural practices were respected. Advance directives relating to the end of life care as well as Do Not Resuscitate (DNR) orders and associated documentation was evidenced in the clinical file. The privacy and dignity of the resident was protected and pain management was prioritised. Representatives, family, next-of-kin, and friends of the resident were involved, supported, and accommodated during end of life care. Support was given to other residents and staff following the death. The death was reported to the Mental Health Commission in writing within the required 48-hour timeframe.



The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the processes and training and education pillars.


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: The approved centre had a written policy in relation to the development, use, and review of individual care plans (ICPs), which was last reviewed in May 2018. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Not all clinical staff had signed the signature log to indicate that they had read and understood the policy. All clinical staff interviewed were able to articulate the processes relating to individual care planning, as set out in the policy. Not all multi-disciplinary team (MDT) members received training in individual care planning. Monitoring: Residents’ ICPs were audited on a quarterly basis to determine compliance with the regulation. Documented analysis had been completed to identify ways of improving the individual care planning process. Evidence of Implementation: Ten ICP’s were inspected. ICPs were a composite set of documents. ICPs included an allocated space for goals, treatment, care, resources required and a separate space for reviews. ICP templates varied across residents clinical files and it was unclear on inspection which was the latest, definitive version. ICPs were stored within the residents’ clinical file, were not amalgamated with progress notes and were identifiable and uninterrupted. ICPs were developed by the MDT following a comprehensive assessment within seven days of admission, which included: medical, psychiatric, and psychosocial history; medication history and current medications; a physical health assessment; a detailed risk assessment; social, interpersonal, and physical environment-related issues, including resilience and strengths; communication abilities, and; educational, occupational, and vocational history. Using evidence-based assessment tools, the ICPs identified the resident’s needs, appropriate goals, and the care and treatment required to meet the goals, including the frequency and responsibilities for implementing care and treatment. However, four ICPs did not adequately identify the resources required to provide the care and treatment. Where practicable, ICPs were discussed, agreed, and drawn up with the participation of the resident and their representative, family, and next of kin. Where a resident lacked capacity due to intellectual disability, documented steps were taken to involve the resident’s next of kin or representative in the process. ICPs included an individual risk management plan and a keyworker was identified to ensure continuity in the implementation of a resident’s ICP. Three ICP were not reviewed with resident consultation, every six months, as so far as practicable. There was no documentation indicating that these residents had attended their ICP review meeting or were informed of its outcome. ICPs were updated following review, as indicated by the resident’s changing

NON-COMPLIANT Quality Rating Requires Improvement Risk Rating


needs, condition, circumstances, and goals. Residents were not offered a copy of their ICP, including any reviews, and where a resident declined or refused a copy this and the reasons given were not documented. The approved centre was non-compliant with this regulation for the following reasons:

a) Four ICPs did not identify appropriate resources required to implement residents’ goals. b) Three ICPs were not reviewed with resident consultation, every six months, as so far as

practicable.


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: The approved centre had a written policy in relation to the provision of therapeutic services and programmes, which was last reviewed in August 2018. The policy included all of the requirements of the Judgement Support Framework.

Training and Education: Not all clinical staff had signed the signature log to indicate that they had read and understood the policy. All clinical staff interviewed were able to articulate the processes relating to therapeutic activities and programmes, as set out in the policy. Monitoring: The range of services and programmes provided in the approved centre was monitored on an ongoing basis to ensure that the assessed needs of residents were met. Documented analysis had been completed to identify opportunities for improving the processes relating to therapeutic services and programmes. Evidence of Implementation: The therapeutic services and programmes provided by the approved centre were evidence-based and appropriate, and met the assessed needs of the residents, as documented in their individual care plans. The therapeutic services and programmes were individually designed and directed towards the restoring optimal levels of physical and psychosocial functioning of the residents. Where a resident required a therapeutic service or programme that was not provided internally within the approved centre, it was arranged for the service to be provided by an approved, qualified health professional in an appropriate location. Adequate and appropriate resources and facilities were available to provide therapeutic services and programmes and these were provided in a separate, dedicated space for both individual and group therapies: the approved centre had a specific resource centre for therapeutic services and programmes. There had been a significant improvement in transport options to ensure that all residents in all houses could access the approved centre’s resource centre. A record was maintained of participation and engagement in and outcomes achieved in therapeutic services and programmes in residents’ individual care plans or clinical files. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education pillar.



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: The approved centre had a written policy and procedures in relation to the transfer of residents. The policy was last reviewed in January 2019. The policy addressed requirements of the Judgement Support Framework, with the exception of the processes for ensuring the safety of the resident and staff during the resident transfer process. Training and Education: Not all relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for the transfer of residents, as set out in the policy. Monitoring: A log of transfers was not maintained. Each transfer record had not been systematically reviewed to ensure all relevant information was provided to the receiving facility. Documented analysis had not been completed to identify opportunities for improving the provision of information during transfers. Evidence of Implementation: The clinical file of one resident who had been transferred to a general hospital was inspected. Communication records with the receiving facility were not documented and available on inspection, including agreement of resident receipt prior to transfer. Verbal communication and liaison did not take place between the approved centre and the receiving facility prior to the transfer, with no verbal communication of reasons for transfer, the resident’s care and treatment plan, or the resident’s accompaniment requirements. Documented consent of the resident to transfer was available and an assessment of the resident was completed prior to the transfer, including an individual risk assessment relating to the transfer and the resident’s needs. However, there was no documented evidence that the risk assessment was provided to the receiving facility or accompanied the resident. Full and complete written information for the resident was not transferred when they moved from the approved centre to the receiving facility and no information was sent in advance of or in accompaniment with the resident upon transfer, to a named individual. A letter of referral, resident transfer form, and required medication for the resident during the transfer process were not part of the transfer documentation. A checklist was not completed by the approved centre to ensure comprehensive resident records were transferred to the receiving facility and copies of all records relevant to the resident transfer were not retained in the resident’s clinical file. The approved centre was non-compliant with this regulation for the following reasons:

a) Full and complete written information for the resident was not transferred when they moved from the approved centre to another facility, 18(1).



b) A letter of referral (including a list of current medications), a resident transfer form, and information on the required medication for the resident during the transfer process were not part of the transfer documentation, 18(1).


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: The approved centre had written operational policies and procedures in relation to the provision of general health services and responding to medical emergencies. The general health policy was last reviewed in September 2018. The policies and procedures included all of the requirements of the Judgement Support Framework. Training and Education: Not all clinical staff had signed the signature log to indicate that they had read and understood the policies. All clinical staff interviewed were able to articulate the processes relating to the provision of general health services and the response to medical emergencies, as set out in the policies. Monitoring: Residents’ take-up of national screening programmes was recorded and monitored, where applicable. A systematic review had been undertaken to ensure that six-monthly general health assessments of residents occurred. Analysis had been completed to identify opportunities for improving general health processes. Evidence of Implementation: The approved centre had three emergency resuscitation trolleys and staff had access at all times to an Automated External Defibrillator (AED). The emergency equipment was checked weekly. Records were available of any medical emergency within the approved centre and the care provided. Five clinical files were inspected and each indicated that 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 when indicated by the residents’ specific needs, and each of the files inspected evidenced that all residents had received a six-monthly general health assessment. The six-monthly general health assessments documented: physical examination, blood pressure, medication review, and weight. However, none of the clinical files examined documented residents’ Body Mass Index (BMI) and waist circumference, while two files examined did not document smoking status or dental health. None of the clinical files inspected included nutritional status (diet and physical activity, including sedentary lifestyle) as part of the general health assessment. For residents on antipsychotic medication an annual assessment recorded glucose regulation, blood lipids and prolactin but it did not detail or evidence an electrocardiogram taking place. Adequate arrangements were in place for residents to access general health services and be referred to other health services, as required. Records were available on documenting residents’ completed general



health checks and associated results, including records of any clinical testing. Residents had access to national screening programmes appropriate to age and gender. Information was provided to all residents regarding the national screening programmes available through the approved centre. Current residents had access to smoking-cessation programmes and supports. The approved centre was non-compliant with this regulation for the following reasons:

a) The six-monthly general health assessments did not document residents’ BMI and waist circumference, 19(1)(b).

b) Two six-monthly general health assessments did not document residents’ smoking status or dental health, 19(1)(b).

c) The six-monthly general health assessments did not document residents’ nutritional status (diet and physical activity, including sedentary lifestyle), 19(1)(b).

d) For residents on antipsychotic medication, an annual assessment did not document residents’ electrocardiogram (ECG), 19(1)(b).


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: The approved centre had a written policy and procedures in relation to the provision of information to residents. The policy was last reviewed in January 2018. The policy and procedures included all of the requirements of the Judgement Support Framework.

Training and Education: Not all staff had signed the signature log to indicate that they had read and understood the policy. All staff interviewed were able to articulate the processes relating to the provision of information to residents, as set out in the policy. Monitoring: The provision of information to residents was monitored on an ongoing basis to ensure it was appropriate and accurate, particularly where information changed. Documented analysis had not been completed to identify opportunities for improving the processes relating to the provision of information to residents. Evidence of Implementation: Residents were provided with information booklets on admission that included details of meal times, personal property arrangements, the complaints procedure, visiting times and visiting arrangements, relevant advocacy and voluntary agencies details, and residents’ rights. The information was available in formats to support the residents’ particular needs, including through photographs, symbols and large letters. Symbols provided visual representation of concepts. The service utilised “Widget” software which standardised symbols making the meaning clearer and easier to understand. Residents were provided with details of their multi-disciplinary team (MDT). The information booklets were available in the required formats to support resident needs and the information was clearly and simply written. Residents were provided with written and verbal information on diagnosis unless, in the treating psychiatrist’s view, the provision of such information might be prejudicial to the resident’s physical or mental health, well-being, or emotional condition. At the time of the inspection there were no restrictions on information regarding a resident’s diagnosis applied to any resident.



Information was provided to residents on the likely adverse effects of treatments, including the risks and other potential side-effects. Medication information sheets as well as verbal information were provided in a format appropriate to the resident needs. The content of medication information sheets included information on indications for use of all medications to be administered to the resident, including any possible side-effects. The information in documents provided by or within the approved centre was evidence-based and appropriately reviewed and approved prior to use. Residents had access to interpretation and translation services when needed. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education and monitoring pillars.


Regulation 21: Privacy

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

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to resident privacy, which was last reviewed in April 2018. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Not all staff had signed the signature log to indicate that they had read and understood the policy. All staff interviewed could articulate the processes for ensuring resident privacy and dignity, as set out in the policy. Monitoring: A documented annual review had not been undertaken to ensure that the policy was being implemented and that the premises and facilities in the approved centre were conducive to resident privacy. Analysis had not been completed to identify opportunities for improving the processes relating to residents’ privacy and dignity. Evidence of Implementation: Residents appeared to be called by their preferred name. The general demeanour of staff and the way in which staff addressed and interacted with residents was respectful. All staff wore an identity badge. Residents were dressed appropriately to ensure their privacy and dignity. All bathrooms, showers, and toilets had locks, unless there was an identified risk to a resident. Rooms were not overlooked by public areas. Observation panels on doors of treatment rooms and bedrooms were fitted with blinds, curtains, or opaque glass. Noticeboards did not display any identifiable resident information. Residents were facilitated to make private phone calls where residents had capacity. Certain conditions observed on inspection were not conducive to resident dignity, including the lack of easily accessible toilet roll. The approved centre was non-compliant with this regulation because conditions within the approved centre were not respectful of resident dignity as toilet paper was not always supplied or accessible within all toilets, 21.



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: The approved centre did not have a written policy in relation to its premises. Training and Education: There was no policy for staff to read, understand, or articulate. Monitoring: The approved centre had not completed a hygiene audit. The approved centre had not completed a ligature audit using a validated audit tool. Documented analysis had not been completed to identify opportunities for improving the premises. Evidence of Implementation: Residents had access to personal space and sufficient space was provided for residents to move about, including outdoor spaces and appropriately sized communal rooms. There was suitable heating in the approved centre. Rooms were centrally heated and the heating could be safely controlled in the residents own room. Communal areas were suitably bright to support the needs of residents and staff, and both private and communal areas were appropriately sized and furnished to remove excessive noise. Appropriate signage and sensory aids were not provided to support resident orientation needs. Ligature points had not been minimised to the lowest practicable level and due to the lack of completed ligature audit the level of associated risk was unknown. Hazards were not minimised in the approved centre. There was a broken ceramic plant pot in the sensory garden of House 1 and tiles had fallen from a mosaic, posing a risk due to sharp edges and objects in the space. The garden of House 2 had a broken goal post with exposed sharp edges. The large drain covers in the first garden of House 5 were not screwed securely shut and posed a tripping hazard. In the second garden of House 5, there was a box full of broken glass, found under a chair, and a significant amount of broken glass was present in an area where a glass table had broken. In one garden of House 8, a damaged drain hole cover exposed sharp edges, while a lighter was found in the grass of the second garden. Broken tiles and pieces of slate were found in the grass of House 10’s garden.



The approved centre was not kept in a good state of repair internally or externally. In addition to the aforementioned external issues regarding the gardens of a number of houses, there were various internal issues observed, including: a broken hand towel dispenser within the disabled toilet of House 1; cracked padding in the seclusion room of House 2, as well as a broken toilet flusher, a missing skirting board in the corridor, chipped paintwork in bedrooms, a broken shower door in the assisted bathroom, discoloured corridor wall, and a worn floor in the padded room; some damaged wall paint in House 7, and; a damaged wall in the corridor of House 10. There was a programme of general maintenance, but not decorative maintenance, in the approved centre. A cleaning schedule was not adequately implemented and there were many weeks for which cleaning schedules could not be found. The task of cleaning fell to nursing staff in the absence of regular cleaners; however, no formal cleaning schedule was implemented in such instances. Additionally, where a cleaner was on annual leave there was no backfill for that person, thus compounding the issue of cleaning schedules. The approved centre was not clean, hygienic, and free from offensive odours, nor were rooms properly ventilated. There were a number of instances of malodour found in toilets, bathrooms and bedrooms across the premises and communal areas, corridors, bedrooms, bathrooms and toilets were observed to be unclean, sometimes significantly so. Outdoor areas were littered with broken tiles, rubbish, including discarded skirting boards, and cigarette butts. Where faults or problems were identified in relation to the premises, this was communicated through the appropriate maintenance reporting process and current national infection control guidelines were followed. Back-up power was available. There were a sufficient number of toilets and showers for residents in the approved centre. While toilet facilities were close to day and dining areas, they were not clearly marked. There was at least one assisted toilet per floor and wheelchair accessible toilet facilities were identified for use by visitors who require them. There was a dedicated sluice room, laundry room, and cleaning room, as appropriate. All resident bedrooms were appropriately sized and suitable furnishings and assisted equipment were provided to support resident independence, comfort and their needs. The approved centre did not have dedicated therapy and examination rooms. The approved centre was non-compliant with this regulation for the following reasons:

a) Residential houses were not clean, 22(1)(a). b) Not all residential houses were adequately ventilated and malodour was detected in some of

the toilets, bathrooms and bedrooms, 22(1)(b). c) There was no programme of decorative maintenance within the approved centre, 22(1)(a). d) Ligature points had not been minimised to the lowest practicable level, and due to the lack of a

completed ligature audit the level of associated risk was unknown, 22(3).



(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: The approved centre had a written policy in relation to the ordering, storing, prescribing, and administration of medication. The policy was last reviewed in June 2018. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Not all nursing and medical staff as well as pharmacy staff had signed the signature log to indicate that they had read and understood the policy. All nursing and medical staff as well as pharmacy staff interviewed could articulate the processes relating to the ordering, prescribing, storing, and administering of medicines, as set out in the policy. Staff had access to comprehensive, up-to-date information on all aspects of medication management. All nursing and medical staff as well as pharmacy staff had received training on the importance of reporting medication incidents, errors, or near misses. The training was documented. Monitoring: Quarterly audits of Medication Prescription and Administration Records (MPARs) had been undertaken to determine compliance with the policies and procedures and the applicable legislation and guidelines. Incident reports were recorded for medication incidents, errors, and near misses. Analysis had been completed to identify opportunities for improving medication management processes. Evidence of Implementation: Ten MPARs were examined during inspection. Each MPAR contained two resident identifiers, dedicated space for routine, once-off and “as required” medication, as well as the generic name of the medication and preparations, which was written in full, and the frequency of administration, including the minimum dose interval for “as required” (PRN) medication. One resident had an allergy that was not documented in their MPAR. The dose to be given, the administration route for medication and a clear record of the date of initiation for each medication was listed in residents’ MPARs and micrograms was written in full. A record of all medications administered to the resident was not maintained in their MPARs: one MPAR had no record of the medication administered to a resident and, while one did contain a stop date, medication had been administered after the date. The Medical Council Registration Number and signature of the medical practitioner prescribing the medication were included on each MPAR. All entries in MPARs were legible and written in black, indelible ink. Medication was reviewed at least six-monthly or more frequently where there was a significant change in the resident’s care or condition; this was documented in the clinical file. All medicines, including controlled drugs, were administered by a registered nurse or registered medical practitioner. Prescriptions were not altered where a change was required. Where there was an alteration in the medication order, the medical practitioner rewrote the prescription. Medicinal products were administered in accordance with the directions of the prescriber, and the advice provided by the resident’s pharmacist regarding the appropriate use of the product.



Direction to crush medication was only accepted from the resident’s medical practitioner and reasons for the crushing of medication were provided by them and documented. The pharmacist was consulted about the type of preparation used and the MPAR documented that the medication was to be crushed. Controlled drugs were checked by two staff members prior to administration and were locked in a separate cupboard from other medicinal products. Good hand-hygiene techniques and cross-infection control techniques were observed during the administration of medication. The medication trolley and medication administration cupboard on each unit were locked at all times and secured in a locked room. Medication was stored in the appropriate environment as indicated on the label or packaging or as advised by the pharmacist. Refrigerators used for medication were used only for this purpose and a log was maintained of every single fridge temperature. Food and drink was not stored in areas used for the storage of medication. An inventory of medications was conducted on a monthly basis, checking the name and dose of medication, quantity of medication, and expiry date. Medications that were no longer required, which were past their expiry date or had been dispensed to a resident and were no longer required were stored in a secure manner, segregated from other medication, and were returned to the pharmacy for disposal. The approved centre was non-compliant with this regulation for the following reasons:

a) The allergy section of a resident’s MPAR was not completed, 23(1). b) In one MPAR reviewed medication was given after the stop date, 23(1). c) In one MPAR reviewed there was no record of medication being administered, 23(1).


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: The approved centre had a written policy in relation to health and safety of residents, staff, and visitors, which was last reviewed in August 2018. It also had an associated safety statement, dated February 2019. The policy and the safety statement included all of the requirements of the Judgement Support Framework. Training and Education: Not all staff had signed the signature log to indicate that they had read and understood the policy. All staff interviewed 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: Regulation 24 was only assessed against the approved centre’s written policies and procedures. Health and safety practices within the approved centre were not assessed. The approved centre was compliant with this regulation.

COMPLIANT


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 any time on request.

INSPECTION FINDINGS Processes: The approved centre had a written policy and protocols in relation to the use of CCTV. The policy was last reviewed in May 2018. The policy addressed requirements of the Judgement Support Framework, with the exception of the process for the maintenance of CCTV cameras by the approved centre. Training and Education: Not all relevant staff had signed the signature log to indicate that they had read and understood the policy. All staff interviewed were able to articulate the processes relating to the use of CCTV, as set out in the policy. Monitoring: The quality of the CCTV images was checked regularly to ensure that the equipment was operating appropriately. This was documented. Analysis had been completed to identify opportunities for improving the processes relating to the use of CCTV. Evidence of Implementation: CCTV was only used in the seclusion rooms of house one and two. There were clear signs in prominent positions on the doors of the seclusion rooms where CCTV was used. A resident was monitored solely for the purposes of ensuring their health, safety, and welfare. The Mental Health Commission had been informed about the approved centre’s use of CCTV. The cameras were incapable of recording or storing a resident’s image in any format, and they did not transmit images other than to a monitor that was viewed solely by the health professional responsible for the resident: monitors were only in the nurses’ station, embedded into tables so only nursing staff could view them when needed. CCTV was not used to monitor a resident if they started to act in a way that compromised their dignity. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education pillar.



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: The approved centre had a written policy and procedures in relation to its staffing requirements. The policy was last reviewed in November 2017. The policy and procedures addressed requirements of the Judgement Support Framework, including the following:

The roles and responsibilities for the recruitment, selection, vetting, and appointment processes for all staff within the approved centre.

The recruitment, selection, and appointment process of the approved centre, including the Garda vetting requirements.

Training and Education: Not all relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes relating to staffing, as set out in the policy. Monitoring: The implementation and effectiveness of the staff training plan was not reviewed on an annual basis. The numbers and skill mix of staff had been reviewed against the levels recorded in the approved centre’s registration. Analysis had not been completed to identify opportunities to improve staffing processes and respond to the changing needs and circumstances of residents. Evidence of Implementation: The numbers and skill mix of staffing was sufficient to meet resident needs. There was an organisational chart to identify the leadership and management structure and the lines of authority and accountability of the approved centre’s staff. A planned and actual rota, showing staff on duty at any one time during the day and night, was maintained in the approved centre. Staff were recruited, selected and vetted in accordance with the approved centre’s policy and procedure for recruitment, selection, and appointment. Information from referees was sought and documented. There was no consistent staffing plan; due to service reconfiguration and resultant constant change to any staffing plan that existed. Where agency staff were used, there was a comprehensive contract between the approved centre and registered/licensed staffing agency used that set out the agency's responsibilities in relation to the: vetting of staff, including Garda vetting and references and vetting from other jurisdictions as appropriate; confirmation of registration and validation of status (where applicable);



confirmation of identity; professional indemnity; confirmation of staff training, and; arrangements for responding to concerns or complaints. Annual staff training plans were completed for all staff to identify required training and skills development in line with the assessed needs of the resident group profile, and both orientation and induction training were completed by staff. Not all health care professionals were trained in; fire safety, Basic Life Support, management of violence and aggression, the Mental Health Act 2001, and Children First. Staff were trained in line with the assessed needs of the resident group profile and of individual residents, as detailed in the staff training plan, including in: manual handling, infection control and prevention, dementia care, care for residents with intellectual disability, end of life care, and residents’ rights. Not all staff were trained in risk management, which includes individual, organisational, and care and treatment provision. All staff training was documented and logs were maintained. Opportunities were made available to staff for further education and these were effectively communicated to all relevant staff and supported through tuition support, scheduled time away from work, or recognition for achievement. In-service training was completed by appropriately trained and competent individuals and facilities and equipment available for staff in-service education and training. The Mental Health Act 2001, the associated regulations and Mental Health Commission Rules and Codes, and all other relevant Mental Health Commission documentation and guidance were available to staff throughout the approved centre.

Profession Basic Life

Support

Fire Safety Management

Of Violence

and

Aggression

Mental

Health Act

2001

Children First

Nursing (124 ) 80 64.5% 94 76% 115 93% 120 97% 124 100%

Consultant

Psychiatrist (2 ) 2 100% 2 100% 2 100% 2 100% 2 100%

Medical (2 ) 2 100% 2 100% 1 100% 1 100% 2 100%

Occupational

Therapist (2 ) 0 0% 0 0% 0 0% 1 50% 0 0%

Social Worker (3 ) 3 100% 2 66.6% 1 33.3% 0 0% 0 0%

Psychologist (2 ) 1 50% 1 50% 1 50% 1 50% 0 0%

The following is a table of clinical staff assigned to the approved centre.

Ward or Unit Staff Grade Day Night

Houses 1 & 2

CNM2 RNID/RPN/RGN HCA

1 4 3

0 2 2



Houses 5 & 6


1 4 2

0 2 2


Houses 7 & 8


1 4 2

0 2 2


Houses 10 & 11


1 4 2

0 2 2


The approved centre was non-compliant with this regulation for the following reasons:

a) Not all staff had up-to-date mandatory training in Basic Life Support, Fire Safety, Professional Management of Violence and Aggression, and Children’s First, 26(4).

b) Not all staff had up-to-date mandatory training in the Mental Health Act 2001, 26(5).


St Claire’s


1 2 3

0 2 1


Seafield


1 3 3

0 2 2


Failte


1 1 2

0 1 1


Grovelodge

CNM2 (Shared CNM II with Fernlodge) RNID/RPN/RGN HCA

1 2 3

0 1 1


Fernlodge

CNM2 (Shared CNM II with Grovelodge) RNID/RPN/RGN HCA

1 1 1

0 1 1 (Staff rotate with Grovelodge)

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


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: The approved centre had a written policy and procedures in relation to the maintenance of records. The policy was last reviewed in October 2018. The policy and procedures addressed requirements of the Judgement Support Framework, including the following:

The roles and responsibilities for the creation of, access to, retention of, and destruction of records.

The required resident record creation and content.

Those authorised to access and make entries in residents’ records.

Record retention periods.

The destruction of records. The policy and procedures did not address the following:

Record review requirements.

The retention of inspection reports relating to food safety, health and safety and fire inspections.

Training and Education: Not all clinical staff and other relevant staff had signed the signature log to indicate that they had read and understood the policy. All clinical staff and other relevant staff interviewed were able to articulate the processes relating to the creation of, access to, retention of, and destruction of records, as set out in the policy. All clinical staff had been trained in best-practice record keeping. Monitoring: Resident records were audited to ensure their completeness, accuracy, and ease of retrieval. This was documented. Analysis had been completed to identify opportunities to improve the processes relating to the maintenance of records. Evidence of Implementation: The approved centre maintained a record for every resident who was assessed or provided with care. Records were reflective of the residents’ status and the care and treatment being provided. All records had a unique identifier, were secure, up to date, in good order, and maintained in line with national guidelines and legislative requirements. Resident records were physically stored together in nursing staff offices and were developed and maintained in good order and in a logical sequence. Only authorised staff could access data and make new entries, and residents could access records in line with relevant legislation. Staff had access to the information needed to carry out their job.



Records were maintained appropriately, including being factual, consistent, written legibly in indelible black ink, reflecting the residents’ current status, using date and time (using the 24 hour clock), and signed appropriately. The approved centre also maintained a record of signatures used in the resident record. All entries made by student nurses or clinical training staff were countersigned by a registered nurse or clinical supervisor. Where errors were made they were corrected appropriately. Two resident identifiers were recorded on all documentation and information or advice that was given over the phone was documented. Documentation of food safety, health and safety, and fire inspections was maintained. Records were retained or destroyed in accordance with legislative requirements. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the processes and training and education pillars.


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 The approved centre had a documented up-to-date register of residents admitted. The register contained the required information specified in Schedule 1 to the Mental Health Act 2001 (Approved Centres) regulations 2006. The approved centre was compliant with this regulation.

COMPLIANT


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: The approved centre had a written policy in relation to the development and review of operating policies and procedures required by the regulations, which was last reviewed in October 2017. It included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed the signature log to indicate that they had read and understood the policy. Relevant staff had been trained on approved operational policies and procedures. Relevant staff interviewed could articulate the processes for developing and reviewing operational policies, as set out in the policy. Monitoring: An annual audit had been undertaken to determine compliance with review time frames. Analysis had been completed to identify opportunities for improving the processes of developing and reviewing policies. Evidence of Implementation: The operating policies and procedures were developed with input from clinical and managerial staff and in consultation with relevant stakeholders, including service users. The policies incorporated relevant legislation, evidence-based best practice, and clinical guidelines. The policies were appropriately formatted, approved, and communicated to all relevant staff. Obsolete versions of operating policies and procedures were retained but removed from access by staff. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education and monitoring pillars.



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: The approved centre had a written operational policy and procedures in relation to the management of complaints. The policy was last reviewed in December 2017. The policy and procedures addressed all of the requirements, including the raising, handling, and investigation of complaints from any person regarding any aspect of the services, care, and treatment provided in or on behalf of the approved centre. Training and Education: Relevant staff had not been trained on the complaints management process. All staff had signed the signature log to indicate that they had read and understood the policy. All staff interviewed were able to articulate the processes for making, handling, and investigating complaints, as set out in the policy. Monitoring: Audits of the complaints log and related records had been completed. Audits were documented and the findings acted upon. Complaints data was analysed. Details of the analysis had been considered by senior management. Required actions had been identified and implemented to ensure continuous improvement of the complaints management process. Evidence of Implementation: There was a nominated person responsible for dealing with all complaints available in the approved centre. A consistent and standardised approach had been implemented for the management of all complaints. The complaints procedure, including how to contact the nominated person was publicly displayed, and it was detailed within the easy-to-read resident information booklet. Residents and their representatives were facilitated to make complaints using the methods detailed in the complaints policy and procedure. Complaints could be lodged verbally, in writing, electronically through e-mail, by telephone, and through complaint, feedback, or suggestion forms. Complaints folders had been placed in each house but no minor complaints were documented since the last inspection.



The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education pillar.



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

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

(a) The identification and assessment of risks throughout the approved centre;

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

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

(i) resident absent without leave,

(ii) suicide and self harm,

(iii) assault,

(iv) accidental injury to residents or staff;

(d) Arrangements for the identification, recording, investigation and learning from serious or untoward incidents or adverse events involving residents;

(e) Arrangements for responding to emergencies;

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

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

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to risk management and incident management procedures as well as a safety statement, which were last reviewed in October 2018 and February 2019 respectively. The policy addressed requirements of the Judgement Support Framework, including the following:

The process for rating identified risks.

The methods for controlling risks associated with resident absence without leave, suicide and self-harm, assault, and accidental injury to residents or staff.

The process for managing incidents involving residents of the approved centre.

The process for responding to emergencies.

The process for protecting children and vulnerable adults in the care of the approved centre. The policy did not address the following:

The process for identification, assessment, treatment, reporting, and monitoring of: - Structural risks, including ligature points. - Capacity risks relating to the number of residents in the approved centre.

Training and Education: Not all relevant staff had received training in the identification, assessment, and management of risk. All relevant staff were trained in health and safety risk management. Clinical staff were trained in individual risk management processes. Management were not trained in organisational risk management. All staff had been trained in incident reporting and documentation. Not all staff had signed the signature log to indicate that they had read and understood the policy. All staff interviewed were able to articulate the risk management processes, as set out in the policy. All training was documented.



Monitoring: The risk register was reviewed at least quarterly to determine compliance with the approved centre’s risk management policy. The audit did not measure actions taken to address risks identified against the time frames identified in the register. Analysis of incident reports had been completed to identify opportunities for improving risk management processes. Evidence of Implementation: The person with responsibility for risk was identified and known by all staff, and responsibilities were allocated at management level and throughout the approved centre to ensure their effective implementation. Risk management procedures did not actively reduced identified risks to the lowest level of risk, as was reasonably practicable. Clinical risks were identified, assessed, treated, reported, monitored and documented in the risk register as appropriate, while health and safety risks were not. Structural risks, including ligature points, were not removed or effectively mitigated. No ligature audit had been completed to assess the level of associated risk.

Multi-disciplinary teams were involved in the development, implementation, and a review of individual risk management processes occurred weekly. Individual risk assessments were completed prior to episodes of physical restraint, mechanical restraint, resident seclusion, resident admission, resident transfer, and in conjunction with medication requirements or medication administration, with the aim of identifying individual risk factors. Corporate risks were identified, assessed, treated, reported, and monitored by the approved centre and were documented in a risk register. The requirements for the protection of children and vulnerable adults within the approved centre were appropriate and implemented as required. Incidents were recorded and risk-rated in a standardised format. Clinical incidents were reviewed by the multi-disciplinary team at their regular weekly meeting. A record was maintained of this review and recommended actions. A six-monthly summary of incidents was provided to the Mental Health Commission, in line with the Code of Practice on the Notification of Deaths and Incident Reporting. Information provided was anonymous at resident level. There was an emergency plan in place that specified responses by the approved centre staff in relation to possible emergencies. The emergency plan incorporated evacuation procedures. The approved centre was non-compliant with this regulation for the following reasons:

a) The risk management policy did not identify the process for identification, assessment, treatment, reporting, and monitoring of: structural risks, including ligature points and capacity risks, 32(2)(a).

b) Risk management policy and procedures were not effectively implemented as health and safety risks within multiple houses had not been identified, 32(1).


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’s insurance certificate was provided to the inspection team. It confirmed that the approved centre was covered by the State Claims Agency for public liability, employer’s liability, clinical indemnity, and property. The approved centre was compliant with this regulation.

COMPLIANT


Regulation 34: Certificate of Registration

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

INSPECTION FINDINGS The approved centre had an up-to-date certificate of registration which was displayed prominently in House 9 Administration. The approved centre was compliant with this regulation.

COMPLIANT


8.0 Inspection Findings – Rules

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


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 Processes: The approved centre had a written policy on the use of seclusion. It had been reviewed annually and was dated May 2019. The policy addressed the following:

Who may implement seclusion.

The provision of information to the resident.

Ways of reducing rates of seclusion use. Training and Education: There was no written record to indicate that staff involved in seclusion had read and understood the policy. Monitoring: An annual report on the use of seclusion had been completed. The report was available to the inspector. Evidence of Implementation: Residents in seclusion had access to adequate toilet and wash facilities. Seclusion facilities were not furnished, maintained, and cleaned to ensure respect for dignity and privacy and not all furniture and fittings were of a design and quality so as not to endanger patient safety. The seclusion room door in House 2, Knockamann had torn padding around the observational panel which exposed hard surface edging. The seclusion room in House 1, Knockamann was observed to be dirty with food residue on the floor. Seclusion rooms were not used as bedrooms.

Seclusion was initiated by a registered medical practitioner and/or a registered nurse, and the consultant psychiatrist (CP) was notified as soon as practicable of the use of seclusion. When seclusion was initiated it only occurred after an assessment, including a risk assessment, and the seclusion initiation was recorded in the resident’s clinical file and seclusion register by the person initiating the seclusion. The seclusion order was recorded in the resident’s clinical file and seclusion register by a registered medical practitioner and this was signed by the responsible CP or duty CP within 24 hours. A medical review of the patient took place no later than four hours after the commencement of the episode of seclusion. The approved centre was non-compliant with this rule for the following reasons:

NON-COMPLIANT Risk Rating


a) Seclusion facilities were not maintained in a manner to ensure the patient’s inherent dignity as the seclusion room in House 1, Knockamann was observed to be dirty, 8.2.

b) Furniture and fittings of the seclusion room were not of a design or quality so as not to endanger patient safety as the seclusion room door in House 2, Knockamann had torn padding around the observational panel which exposed hard surface edging, 8.3.


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 Evidence of Implementation: The clinical files of two residents who had been mechanically restrained were inspected. Mechanical restraint was only practiced when the residents posed an enduring risk of harm to themselves, and it was only used when less restrictive alternatives were not suitable. Mechanical restraint was ordered by the registered medical practitioner under the supervision of the consultant psychiatrist responsible for the care and treatment of the resident or the duty consultant psychiatrist acting on their behalf. Both clinical files contained a contemporaneous record that specified that there was; an enduring risk of harm to the self, that less restrictive alternatives were implemented without success, the type of mechanical restraint, the situation in which mechanical restraint was being applied, and the duration of the order. The clinical files did not contain a review date for the restraint and one of the files did not specify the duration of restraint. The approved centre was non-compliant with this rule for the following reasons:

a) The order did not specify the duration of restraint, 21.5(e). b) The order did not specify a review date for the order, 21.5(g).



Part 4 of the Mental Health Act 2001: Consent to Treatment was not applicable to this approved centre. Please

see Section 4.3 Areas of compliance that were not applicable on this inspection for details.

9.0 Inspection Findings – Mental Health Act 2001

EVIDENCE OF COMPLIANCE WITH PART 4 OF THE MENTAL HEALTH ACT 2001


10.0 Inspection Findings – 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.


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: The approved centre had a written policy on the use of physical restraint. The policy had been reviewed annually and was dated May 2019. It addressed the following:

The provision of information to the resident.

Who can initiate and who may implement physical restraint.

Training and Education: Not all staff had signed a signature log to confirm they had read and understood the policy. Monitoring: An annual report on the use of physical restraint in the approved centre had been completed. Evidence of Implementation: The files of three residents who had been physically restrained were reviewed. Physical restraint was only used in rare and exceptional circumstances when residents posed an immediate threat of serious harm to themselves or others. The use of physical restraint was based on a risk assessment of each resident. Staff had first considered all other interventions to manage each resident’s unsafe behaviour. In all three cases, the restraint lasted for less than 30 minutes. All three residents were informed of the reasons for, duration of, and circumstances leading to discontinuation of physical restraint where this was applicable. In one case examined a physical examination was not completed within three hours of the episode. Cultural awareness and gender sensitivity was demonstrated in the three episodes of physical restraint. Each episode of physical restraint was reviewed by members of the multi-disciplinary team (MDT) and documented in the clinical file no later than two working days after the episode. The approved centre was non-compliant with this code of practice for the following reasons:

a) In one case of physical restraint a physical examination was not completed within three hours of the episode, 5.4.

b) Not all staff had signed a signature log to confirm they had read and understood the policy, 9.2(b).



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: The approved centre had a policy in relation to admission, transfer, and discharge. Admission: The admission policy, which was last reviewed in January 2019, included all of the policy-related criteria for this code of practice. Transfer: The transfer policy, which was last reviewed in January 2019, included all of the policy-related criteria for this code of practice.

Discharge: The discharge policy, which was last reviewed in January 2019, included all of the policy-related criteria for this code of practice. Training and Education: Not all relevant staff had signed the policy log to indicate that they had read and understood the admission, transfer and discharge policy. Monitoring: Audits had been completed on the implementation of and adherence to the admission, transfer and discharge policy. Evidence of Implementation: The admission, transfer, and discharge processes were non-compliant under Regulation 32: Risk Management Procedures, which is associated with this code of practice. Admission: The approved centre had a key worker system in place. The admission of one resident was examined and this admission was on the basis of a mental disorder. An admission assessment had been completed; this assessment included documentation of the presenting problem, past psychiatric history, family history, medical history, current and historic medication, and a detailed risk assessment. Transfer: The approved centre did not comply with Regulation 18: Transfer of Residents. Discharge: The discharge process relating to one resident was examined as part of the inspection process. The discharge plan included the estimated date of discharge, documented communication with the relevant general practitioner or primary care team, and a follow-up plan. The discharge assessment addressed the psychiatric and psychosocial needs of the resident, a current mental state examination, a comprehensive risk assessment and risk management plan, and social, housing and informational needs. The discharge was coordinated by a key worker and a preliminary discharge summary was sent to the general practitioner within three days. The comprehensive discharge summary issued within 14 days of discharge included details of diagnosis, prognosis, medication, mental state at discharge, outstanding health or social issues, follow-up arrangements and the names and contact details of key people for follow-up. A family member, carer or advocate was involved in the discharge process as appropriate. The approved centre was non-compliant with this code of practice for the following reasons:



a) Not all staff had signed the signature log to indicate they had read and understood the policy on

admission, transfer and discharge, 9.1. b) The approved centre was non-compliant with Regulation 18: Transfer of Residents, 30.1.

Appendix 1: Corrective and Preventative Action Plan

Regulation 06: Food Safety

Reason ID : 10000948 The approved centre was non-compliant with this regulation because food temperatures were not recorded in line with food safety recommendations, 6 (1)(c).

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action There is provision to

ensure ath a high standard of hygiene is maintained in relatio nto hte storge, preparation and disposal of food and related refuse. Food temperatures are recorded in line with food safety recommendations

Ongoing maintenance of Food temperature log sheet Food safety audit

achievable - subject to COVID 19 activity where there may be a restriction of movement in the services and therefore audits may not be completed

19/06/2020 Catering Department, Service Manager

Preventative Action Food safety policy is in place to guide and support and ensure compliance Food Temperatures are recorded in line with food safety recommendations

Food safety audits Food temperature log sheets

Achievable - subject to COVID 19 activity where there may be a restriction of movement in the services and therefore audits may not be completed

20/11/2020 Catering Department


Regulation 15: Individual Care Plan

Reason ID : 10000943 Four ICPs did not identify appropriate resources required to implement residents' goals. Specific Measurable Achievable/Realistic Time-bound Post-Holder(s)

Corrective Action All ICP's will be completed to demonstrate compliance with Regulation 15 Individual care Plan. This will ensure that all aspects of care and treatment that is required to meet the individual goals / needs, and the appropriate resources that are required to implement the residents goals will be identified and documented clearly

ICP's that will be contained in the residents' Clinical Files

Achievable 21/06/2020 Key worker Clinical Nurse Manager Assistant Director of Nursing Consultant Psychiatrist Allied Health Care Professionals Multi-Disciplinary team

Preventative Action ICP's will be developed in line with Regulation 15 Individual Care Plan policy to reflect the individualised needs and goals of the resident to include the appropriate resources required to implement the residents' goals

Quality Care Metrics are conducted on a monthly basis to determine compliance

Achievable - however due to COVID 19 pandemic there is a restriction of movement in the services and therefore audits may not be completed

31/08/2020 Key worker Clinical Nurse Manager Assistant Director of Nursing Consultant Psychiatrist Allied Health Care Professionals Multi-Disciplinary team Nurse Practice Department

Reason ID : 10000944 Three ICPs were not reviewed with resident consultation, every six months, as so far as practicable.


Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action All ICP's are held in

consultation with the resident as far as is practicable, and where the resident was not able to attend / participate this is documented.

This information is documented and stored in the resident's clinical file and will be audited on a quarterly basis to determine compliance with the regulation

in place 19/06/2020 Key worker Clinical Nurse Manager Assistant Director of Nursing Consultant Psychiatrist Allied Health Care Professionals Multi-Disciplinary team

Preventative Action ICP's will be reviewedin line with Regulation 15 Individual Care Plan policy All ICP's are held in consultation with the resident as far as is practicable, and where the resident is not able to attend / participate this is documented. Following ICP meeting each resident will be offered a copy of their ICP and if a resident declines/ refuses or unable to partake in this process the reason for this will be documented and this document will be stored in the residents' clinical file.

Quality Care Metrics are conducted monthly to determine compliance

Achievable - subject to COVID 19 pandemic where there may be a restriction of movement in the services and therefore audits may not be completed

19/06/2020 Key worker Clinical Nurse Manager Assistant Director of Nursing Consultant Psychiatrist Allied Health Care Professionals Multi-Disciplinary team Practice Development Department


Regulation 18: Transfer of Residents

Reason ID : 10000946 Full and complete written information for the resident was not transferred when they moved from the approved centre to another facility, 18(1).

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action A meeting was

convened and requirement was reiterated to staff to ensure that the transfer form that accompanies the resident's transfer to another facility is completed in full and a copy of the transfer form is retained in the residents clinical file

Copy of Transfer form will be in residents clinical file

Achievable and completed 19/06/2020 Clinical Nurse Managers Assistant Director of Nursing Consultant Psychiatrist General Practitioner

Preventative Action Policy Regulation 18 Transfer of residents is current and updated to support staff with regards compliance It will be reiterated to staff to ensure that the transfer form that accompanies the resident who is transferred to another facility is completed in full and a copy of the transfer form is retained in the residents clinical file

Copy of transfer form will be retained in the residents clinical file Audits will be conducted annually to determine compliance

Achievable - however due to COVID 19 activity there may a restriction of movement in the services and therefore audits may not be completed

19/06/2020 Clinical Nurse Managers Assistant Director of Nursing Consultant Psychiatrist Nurse Practice Development General Practitioner


Reason ID : 10000947 A letter of referral (including a list of current medications), a resident transfer form, and information on the required medication for the resident during the transfer process were not part of the transfer documentation, 18(1).

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action A meeting was

convened and reiterated requirement for all staff to ensure all relevant transfer documentation is completed in full which includes a letter of referral (including a list of current medications), a resident transfer form and information on the required medication for the resident during the transfer process and a copy of the transfer documentation is retained in the residents clinical file

Copy of transfer documentation will be retained in residents clinical file

completed 19/06/2020 Clinical Nurse Managers Assistant Director of Nursing Consultant Psychiatrist General Practitioner

Preventative Action All staff to ensure all transfer documentation is completed in full which includes a letter of referral (including a list of current medications), a resident transfer form

Copy of all transfer documentation will be present in the residents clinical file Annual audits will be conducted to determine compliance

achievable - subject to COVID 19 acitivity there may be a restriction of movement in the services and therefore audits may not be completed

03/07/2020 Clinical Nurse Managers Assistant Director of Nursing Consultant Psychiatrist General Practitioner


and information on the required medication for the resident during the transfer process and a copy of the transfer documentation is retained in the residents clinical file


Regulation 19: General Health

Reason ID : 10000926 The six-monthly general health assessments did not document residents' BMI and waist circumference, 19(1)(b). Two six-monthly general health assessments did not document residents' smoking status or dental health, 19(1)(b). The six-monthly general health assessments did not document residents' nutritional status (diet and physical activity, including sedentary lifestyle), 19(1)(b). For residents on antipsychotic medication, an annual assessment did not document residents' electrocardiogram (ECG), 19(1)(b).

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action Each resident is

assessed on a six monthly basis in accordance with Regulation 19 General Health in St. Joseph's IDS

The six monthly general health assessments will be completed and stored in the residents clinical files

Achievable new documentation in place

16/12/2020 Medical Practitioner Clinical Nurse Manager Area Director of Nursing Clinical Director

Preventative Action The nurse in charge will ensure that all relevant areas of the general assessment form that should be completed by a nurse prior to the assessment is ready the General practitioner should ensure that all relevant areas of assessment are complete, similarly, the consultant psychiatrist should ensure that all relevant areas of

Copy of Physical Health Assessment form will be retained in residents' clinical file Annual clinical audits on documentation will be completed to determine compliance and feedback given to the relevant managers where appropriate

Achievable - subject to COVID 19 acitivity, which may affect the completion of the six monthly general health assessments

16/12/2020 Nurse in Charge Clinical Nurse Manager Assistant Director of Nursing General Practitioner Consultant Psychiatrist


assessment are complete


Regulation 21: Privacy

Reason ID : 10000945 Conditions within the approved centre were not respectful of resident dignity as toilet paper was not always supplied or accessible within all toilets, 21.

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action Toilet paper is

continously available and accessible for all toilet facilities in the services. Residents privacy and dignity is appropriately respected and actively promoted at all times

Monitoring of Cleaning schedules Walkabout audits and reviews

On going 19/06/2020 All frontline staff Cleaning team Clinical Nurse Manager Assistant Director of Nursing Procurement

Preventative Action The privacy of all residents will be promoted at all times and in line with Regulation 21 Privacy Policy

audit of compliance with implementation of Regulation 21 Privacy walkabout audits cleaning schedules

Achievable 19/06/2020 All frontline staff Cleaning team Clinical Nurse Manager Assistant Director of Nursing Procurement


Regulation 22: Premises

Reason ID : 10000934 Residential houses were not clean, 22(1)(a). Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action There is a cleaning

department in St Joseph's IDS that have a comprehensive cleaning schedule in place to ensure that all areas of the residential centre are systematically cleaned on a regular basis

Cleaning schedules in place rosters of cleaning staff Supervision of staff

Achievable 17/07/2020 Operations Manager Clinical Nurse Manager Area Director of Nursing Assistant Director of Nursing Service Manager

Preventative Action Cleaning schedules in place rosters of cleaning staff Supervision of staff Training of staff

Annual audits conducted to determine compliance Cleaning schedules

Achievable - however due to COVID 19 pandemic and restrictions of movement in the services audits may not be conducted

17/06/2021 Operations Manager Clinical Nurse Manager Assistant Director of Nursing Area Director of Nursing Service Manager

Reason ID : 10000935 Not all residential houses were adequately ventilated and malodour was detected in some of the toilets, bathrooms and bedrooms, 22(1)(b).

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action Maintenance

programme is in place to ensure that all residential houses are adequately ventilated Cleaning schedule is in place to ensure all areas of the residential houses are maintained to a high level

Documented evidence of records of maintenance programme and Cleaning schedules

Achievable 17/09/2020 Estates Management Procurement service Manager Clinical Nurse Manager Assistant Director of Nursing


Preventative Action There is a reactive maintenance programme in place. There are processes involved to communicate with maintenance along with contact details when maintenance requests are necessary - phone calls Emails Out of office supports

There is a comprehensive list of service contracts (e.g. heating, plumbing) used by maintenance. There is a list of clinical equipment service contractors available (hoists, beds.medical equipment). Maintenance log books in each area maintenance records of works completed records of service contracts conducted Records of maintenance carried out Records of procurement available cleaning schedules

Achievable- however due to COVID 19 pandemic and the restrictions on movements in the services the audits may not be completed

17/09/2020 Estates Management Procurement Stores Department Service Manager Clinical Nurse Manager Assistant Director of Nursing

Reason ID : 10000936 There was no programme of decorative maintenance within the approved centre, 22(1)(a). Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action There is a reactive

maintenance programme in place

Maintenance log books in each area maintenance records of work completed records of service contracts conducted

on going 19/06/2020 Estates management Clinical Nurse Manager in each area Assistant Director of Nursing


Preventative Action There are processes involved to communicate with maintenance and contact details when maintenance requests are necessary • Phone calls • Emails • Out of office hours • Reactive maintenance response There is a comprehensive list of Services contracts (e.g. heating/plumbing/etc) used by maintenance There is a list of clinical equipment service contractors (hoists/ beds/ BP machines/ medical equipment. There is a procurement process in place

Records of procurement Maintenance records of contracts completed Maintenance logs in each area Records of maintenance carried out Records with Stores Department

On-going 19/06/2020 Estates management Procurement

Reason ID : 10000937 Ligature points had not been minimised to the lowest practicable level, and due to the lack of a completed ligature audit the level of associated risk was unknown, 22(3).

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action Hazards identified

removed from residential areas

Maintenance log in area Maintenance records of works completed

Achievable 21/08/2020 Clinical Nurse Manager Assistant Director of Nursing Maintenance Department

Preventative Action A Decorative maintenance programme in place

Maintenance records of contracts completed

Achievable - however due to COVID 19 pandemic there is a restriction of

25/03/2021 Clinical Nurse Managers Assistant Director of Nursing Maintenace


cleaning schedule is compiled to meet the needs of the service Infection, Prevention & Control Lead to provide guidance and support

Maintenance logs in each area Records of maintenance carried out Records with Stores Department Ligature Audits conducted Hygiene audits conducted

movement in the services and therefore audits may not be completed

Management Infection, Prevention & Control Lead



Reason ID : 10000938 The allergy section of a resident's MPAR was not completed, 23(1). In one MPAR reviewed medication was given after the stop date, 23(1). In one MPAR reviewed there was no record of medication being administered, 23(1).

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action MPAR to be rewritten

to demonstrate compliance with Regulation 23 ordering, prescribing, storing and administration of medicines to residents. An incident report will be completed for all cases of non compliance identified

MPARs will demonstrate compliance to Regulation 23 Completed incident reports will be maintained

Achievable 19/08/2020 Consultant Psychiatrist General Practitioner Assistant Director of Nursing Clinical Nurse Manager

Preventative Action Managers (Nursing & Medical) will reiterate the requirements to comply with Regulation 23 Ordering, Prescribing, Storing and Administration of Medicines. Managers (Nursing & Medical) will ensure that this requirement is included in induction training

Nursing Metrics audits are conducted on an monthly basis Six monthly audits will be conducted of MPAR/ Medication management to determine compliance of Regulation 23 Ordering, Prescribing, Storing and Administration of Medicines

Achievable - however due to COVID 19 pandemic there is a restrictions on services and audits may not be completed

30/10/2020 Consultant Psychiatrist General Practitioner Assistant Director of Nursing Clinical Nurse Manager



Reason ID : 10000932 Risk management policy and procedures were not effectively implemented as health and safety risks within multiple houses had not been identified, 32(1).

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action Updated Risk

management policy and procedures now in place to ensure all risks in relation to Health and safety risks are identified and actions taken to reduce the risks to the lowest level of risk practicable.

Risk register on health and Safety risks is maintained and audited regularly. CHODNCC Health & Safety Lead has provided consultancy and guidance to the Service.

Achievable 25/09/2020 Heads of Discipline, Nursing, Estates, Administration, Clinical Director, H&S Risk Advisor

Preventative Action Risk Management Policy implemented to all areas and will be periodically reviewed Risk Register on health and Safety risks is maintained and audited regularly Risk management training implemented Health and Safety risk management training implemented Organisational risk management training implemented

Regular Audits conducted to determine compliance Organisational risk register for the identification and assessment of risks; precautions in place to control the risks identified.

Achievable 25/09/2020 Heads of Discipline in Operations, Nursing, Estates, Administration, Clinical Director Risk Advisor

Reason ID : 10000933 The risk management policy did not identify the process for identification, assessment, treatment, reporting, and monitoring of: structural risks, including ligature points and capacity risks, 32(2)(a).

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s)


Corrective Action 23The Risk Management Policy will be revised to include the process for identification, assessment, treatment, reporting, and monitoring of: structural risks, including ligature points and capacity risks, 32(2)(a).

Risks will be reviewed periodically at QPS/Management Team meetings

Achievable 23/10/2020 Policy, Procedures, Protocols, Guidelines Review Group Senior Management Team

Preventative Action PPPGs will be developed in compliance with the requirements of Regulation 32 Risk Management Procedures

Audits will be conducted to determine compliance with the requirements of Reg 32 Risk Management Procedures

Achievable - however due to COVID 19 pandemic there is a restriction of movement in the services and therefore audits may not be completed

23/10/2020 Policy Review Group Senior Management Team


Rules Governing the Use of Seclusion

Reason ID : 10000949 Seclusion facilities were not maintained in a manner to ensure the patient's inherent dignity as the seclusion room in House 1, Knockamann was observed to be dirty, 8.2.

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action The Seclusion room

was cleaned urgently

Cleaning Schedule and Records Observation and review

Completed 22/06/2020 Clinical Nurse Manager House 1 Assistant Director of Nursing

Preventative Action Scheduled cleaning programme in place Education and Training for staff in Infection, Prevention & Control

Environmental audits conducted monthly

Achievable 31/07/2020 Lead person in infection, Prevention & Control Clinical NUrse Managers house 1 Assistant Director of Nursing

Reason ID : 10000950 Furniture and fittings of the seclusion room were not of a design or quality so as not to endanger patient safety as the seclusion room door in House 2, Knockamann had torn padding around the observational panel which exposed hard surface edging, 8.3.

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action The RP has

approved requisite minor works and the torn padding around the observational panel in the seclusion room was repaired immediately

Records of contract works and approvals by the Service Manager

Completed 19/06/2020 Estates- Maintenance Department Service Manager Clinical Nurse Manager Assistant Director of Nursing

Preventative Action Clinical Nurse Manager will ensure that a risk assessment is conducted on all furniture and

Walkabout audits conducted Environmental Audits conducted Risk assessments Maintenance Logs

Achievable - subject to COVID 19 activity where there may be a restriction of movement in the services and audits may not be completed

03/07/2020 All frontline staff Clinical Nurse Manager Assistant Director of Nursing Service Manager Estates - maintenacne department


fittings in the seclusion room to determine resident safety while in the seclusion room. These will be escalated to the Service Manager for inclusion in the Minor Works allocations. Clinical nurse manager will ensure that residents have no access to hazardous objects while in seclusion room Clinical Nurse Manager will ensure all staff are orientated on the process of reporting and recording of furniture and fittings that in need of repair or replacement Operations manager will ensure that all furniture and fittings that are determined to compromise the safety of the resident are

Maintenance works records Incident Forms


replaced with furniture and fittings that are designed to protect the resident while in seclusion


Rules Governing the Use of Mechanical Means of Bodily Restraint

Reason ID : 10000930 The order did not specify the duration of restraint, 21.5(e). The order did not specify a review date for the order, 21.5 (g).

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action All incidents on the

Use of Mechanical Restraint will be recorded in the residents clinical files and associated mechanical restraint forms. All areas of the forms will completed in full by the consultant Psychiatrist

The order will be recorded in - the associated mechanical restraint form (which will be stored in the residents clinical files) - in the residents clinical notes / MDT clinical notes

Achievable 18/06/2020 Consultant Psychiatrist

Preventative Action Associated mechanical restraint form will be completed for each order of mechanical restraint

Clinical audits are conducted annually to determine compliance

Achievable 30/09/2020 Consultant Psychiatrist


Code of Practice on the Use of Physical Restraint in Approved Centres

Reason ID : 10000924 In one case of physical restraint a physical examination was not completed within three hours of the episode, 5.4.

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action Following all

incidents of Physical Restraint the resident will have a physical examination completed within three hours of the episode

The information will be recorded in the residents clinical notes

achievable 20/08/2020 Consultant Psychiatrist Clinical Director

Preventative Action When a resident requires physical restraint - the nurse in charge will ensure that the residents clinical file is ready for the Consultant Psychiatrist to document in relation to the physical examination conducted following a physical restraint. - the consultant psychiatrist will conduct the physical

Annual Clinical audits on documentation used in physical Restraint and the Policy

Achievable - to monitor compliance - subject of to COVID 19 activity where audits may not conducted due to restricition on movement in services

20/08/2020 Nurse in Charge Consultant Psychiatrist Clinical Director


examination and document this in the clinical notes

Reason ID : 10000925 Not all staff had signed a signature log to confirm they had read and understood the policy, 9.2(b). Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action Heads of each

relevant discipline will reiterate to all staff the requirements to sign to indicate that they have read and understood the policy on Physical Restraint

Clinical audits will be conducted annually / Documentation evidence of signatures of staff will demonstrate this

Achievable - to monitor compliance - subject to COVID 19 activity where audits may not conducted due to restriction on movement in services

31/10/2020 Area Director of Nursing / ADONs/CNM's/NPDC/Consultant Psychiatrist

Preventative Action There is a monitoring document in place for the policy that all relevant staff must sign to indicate that staff have read and understood the policy on Physical Restraint. The line manager will ensure that this is signed by all staff..

Line Managers will ensure that the monitoring document is signed by all relevant staff. A clinical audit will be conducted annually by Nurse Practice Department to determine compliance and feedback of the audit with action plans will be given back to the line managers.

Achievable - to monitor compliance - subject to COVID 19 activity where audits may not conducted due to restriction on movement in services

31/10/2020 All line managers


Code of Practice on Admission, Transfer and Discharge to and from an approved centre

Reason ID : 10000922 Not all staff had signed the signature log to indicate they had read and understood the policy on admission, transfer and discharge, 9.1.

Specific Measurable Achievable/Realistic Time-bound Post-Holder(s) Corrective Action Heads of

discipline to reiterate to all staff the requirement to sign to indicate that they have read and understood the policy on Admission, Transfer and Discharge

1. Audit will be conducted annually by Nurse Practice Development 2. Each line manager is required to ensure the policy is read, understood and signed by all staff

Realistic 31/10/2020 All Heads of Discipline - Nursing, Medical, Administration, Operations

Preventative Action Heads of discipline will continue to reiterate to all staff the requirement to sign to indicate that they have read and understood the policy. There is a monitoring document in place for the policy that all relevant staff must sign to indicate that staff

Each line manager is required to ensure the policy is read, understood and signed by all staff Line Managers will ensure that the monitoring document is signed by all relevant staff. A clinical audit will be conducted annually by Nurse Practice Department to

Achievable - due to COVID 19 there's a restriction of movement in services and audits may not be conducted

31/10/2020 All heads of discipline - Nursing, Medical, Administration, Operations


have read and understood the policy. The line manager will ensure that this is signed by all staff.

determine compliance and feedback of the audit with action plans will be given back to the line managers.

Appendix 2: Background to the inspection process

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

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

services and to take all reasonable steps to protect the interests of persons detained in approved centres.

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

inspection of approved centres. The process for determination of the compliance level of approved centres

against the statutory regulations, rules, Mental Health Act 2001 and codes of practice shall be transparent

and standardised.

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

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

commencement of this section falls and to visit and inspect any other premises where mental health services

are being provided as he or she thinks appropriate”.

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

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

by the resident himself or herself or by any other person.

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

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

premises where mental health services are being provided, to this Act and the provisions made

thereunder.

d) Ascertain whether any regulations made under section 66, any rules made under section 59 and 60

and the provision of Part 4 are being complied with.

Each approved centre will be assessed against all regulations, rules, codes of practice, and Part 4 of the 2001

Act as applicable, at least once on an annual basis. Inspectors will use the triangulation process of

documentation review, observation and interview to assess compliance with the requirements. Where non-

compliance is determined, the risk level of the non-compliance will be assessed.

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

Framework. As the requirements for the rules, codes of practice and Part 4 of the 2001 Act are set out

exhaustively, the Inspector will not undertake a separate quality assessment. Similarly, due to the nature of

Regulations 28, 33 and 34 a quality assessment is not required.

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

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

assessments, is provided to the registered proprietor of the approved centre. Areas of inspection are

deemed to be either compliant or non-compliant and where non-compliant, risk is rated as low, moderate,

high or critical.


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, achievable, realistic, 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.

COMPLIANCE, QUALITY AND RISK RATINGS The following ratings are assigned to areas inspected:

COMPLIANCE RATINGS are given for all areas inspected. QUALITY RATINGS are generally given for all regulations, except for 28, 33 and 34. RISK RATINGS are given for any area that is deemed non-compliant.

COMPLIANCE RATING

COMPLIANT

EXCELLENT

LOW

QUALITY RATING

RISK RATING

NON-COMPLIANT

SATISFACTORY

MODERATE REQUIRES IMPROVEMENT

INADEQUATE HIGH

CRITICAL

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