Cork inpatient mental health unit subject of two focused inspections in 10-week period
31 March 2022This morning we published a second focused inspection report for a unit in St Stephen’s Hospital in Cork City for the care and treatment of male residents with severe and enduring mental illness.
The second focused inspection for Unit 3 of the hospital took place just over 10 weeks after a first focused inspection of the same unit, which itself took place less than two weeks after the annual inspection of all four units of the inpatient centre.
“It is clear from our annual inspection of St Stephen’s, and from both of our subsequent focused inspections of Unit 3, that we have serious concerns about the care and treatment of residents in this unit,” said the Inspector of Mental Health Services, Dr Susan Finnerty.
“While improvements have been made in some areas, it is deeply worrying that we still had to apply a high-risk non-compliance for the regulations on premises - and for the regulation on therapeutic services and programmes - at our second focused inspection. As an example, we identified a serious issue with fire doors at the annual inspection, which rendered them non-functioning. At the second focused inspection almost 12 weeks later, this issue had still not been resolved. This is simply not acceptable.”
The Chief Executive of the Mental Health Commission, John Farrelly, said it should not require this level of scrutiny and pursuit of a service to assure the regulator that the service is appropriately addressing critical or high-risk levels of non-compliance.
“Every inpatient service in the country knows only too well what they need to do to attain high standards across all the rules, regulations and codes of practice,” he said. “When we point out serious issues at an annual inspection, the very least we would expect is that the service in question make immediate efforts to assure us that these issues are going to be addressed in the near future. The last thing we want is to return to a centre three months later and find that no progress has been made. When that happens, we are left with no option but to consider all options at our disposal to ensure that patients and residents receive an appropriate level of care and treatment.”
St. Stephen’s Hospital is located north of Cork City. The centre has a total of 87 beds. Unit 4 is an admission unit; Unit 2 is a 25-bedded unit providing care and treatment to those under the psychiatry of later life team; Unit 3 contains 18 beds for male residents with severe and enduring mental illness; and Unit 8 has 25 beds and provides care to residents with enduring mental illness.
After the annual inspection, which took place from August 3rd to 6th, 2021, the centre received an overall compliance rating of 74% which was the same score as it received in 2020. There were seven conditions attached to the centre. It was in breach of one condition relating to premises, while it was also in breach of a second condition relating to risk management.
The centre received eight non-compliances on inspection, including a critical non-compliance on the regulation relating to individual care planning, and another on the regulation relating to risk management. The report found that the person with responsibility for risk management was not known by all staff; fire doors in two separate units were both failing to fulfil their function as fire doors; windows on two units needed to be replaced; and ligature points remained in the centre. The centre also received a high-risk non-compliance for the regulation on premises.
During the annual inspection, the inspectors also noted that the care and treatment in Unit 3 was not person-centred and did not follow recovery principles. The unit was sparsely decorated, with insufficient furnishings in the sitting rooms, lack of personal items, and wardrobes that were too small to adequately store clothing. Residents displayed institutionalised behaviour, such as pacing and congregating outside the nurse’s office and on the corridor, and the inspectors noted an atmosphere of tension and irritability among the residents. There was minimal staff presence in the ward area and attitudes towards residents were observed to be dismissive. Activities were generalised such as walks, watching videos, and gardening. There was no evidence of individualised therapeutic programmes based on assessed needs.
MHC was so concerned about the findings from the annual inspection that it was decided to carry out a focused inspection in Unit 3 on August 16th to ascertain the extent of the non-compliances and the impacts on residents. Inspectors focused on a number of regulations, namely personal property and possessions, individual care plans, therapeutic services and programmes, privacy, and premises. Of these five regulations, two - premises and therapeutic services and programmes - received a critical risk non-compliant rating, while another two - resident’s personal property and possessions, and individual care planning - received a high-risk non-compliant rating.
It was also noted in the focused inspection report of August 16th that St Stephen’s had a system of governance with regard to Unit 3 which was ‘inexplicable’. Whereas the other units in the hospital were staffed and managed by the North Cork Mental Health Services, the report noted that the nursing staff in Unit 3 were under the management of the North Lee services. The report noted that the governance arrangement was having a detrimental effect on the residents of Unit 3.
Following the focused inspection on August 16th, the MHC issued an immediate action notice outlining steps to be taken by the HSE to ensure residents were safe. The immediate action notice required specific actions in relation to regularising governance arrangements for Unit 3, premises, risk management and ensuring residents had access to a full range of recreational and therapeutic services. Given the seriousness of the concerns, this notice was escalated to the chief officer of Cork/Kerry Community Healthcare. A regulatory compliance meeting was held, which the chief officer and representatives of the HSE national office were requested to attend. The MHC was not adequately assured by the plans submitted or presented at the regulatory compliance meeting. Further correspondence was issued to the service and a process was initiated by the MHC which resulted in a condition being applied to the registration of the approved centre resulting in restrictions on admissions to Unit 3.
A second focused inspection took place on October 29th, 2021, to assess what progress had been made in addressing the areas of non-compliance and governance arrangements. During this inspection, it was found that there was an improvement in the governance arrangements. However, the centre received a high-risk non-compliance with the regulation on therapeutic services and programmes. Reasons for this included a finding that the assessments of the occupational therapy department were minimal with similar assessment results for most residents. In addition, despite most residents having been assessed as having needs related to activities of daily living, the appropriate supports had not been put in place. There was also no improvement in the minimal occupational therapy programme or input in place. A second immediate action notice was issued, and subsequent monitoring has shown improvements in the availability and quality of occupational therapy inputs.
The centre also received a high-risk non-compliance with the regulation on premises. Reasons for this included a finding that wardrobes did not provide sufficient storage, and some were too small to adequately store even a small amount of residents’ clothing, while it appeared that new wardrobes had not been ordered. In addition, the fire doors in the main corridor were not closing properly, leaving a gap at the top of the doors and at the closure of the door, rendering them non-functioning as fire doors. This had been identified in the annual inspection and as an immediate action notice but had still not been sufficiently addressed. The MHC subsequently referred these fire safety concerns to the chief fire officer in Cork City Council.
As observed on previous inspections, ligature points had not been minimised to the lowest practicable level, based on risk assessment, while a number of restrictive practices remained. The main door was locked at all times. The recreation room was locked, despite recommendations from the psychologist that it be opened for residents to provide a more stimulating environment and prevent residents congregating around the nurses’ office and main door.
MHC continue to closely monitor the arrangements which the HSE has put in place to bring the centre into compliance.
You can read our full statement here.
