Critical and systemic issues around premises at two Cork mental health centres
We have found significant risks and a number of systemic issues at two inpatient mental health centres in Cork. Due to the serious nature of the issues identified in one of the centres, it was the subject of a focused inspection 10 days after its annual inspection in July. These two reports are the latest in a series which have highlighted concerns in a total of five centres in the Cork area in 2021.
Commenting on the reports, the Inspector of Mental Health Services, Dr Susan Finnerty said: “It is clear from these reports that the two centres in Cork have systemic issues when it comes to premises, risk management, therapeutic services and programmes, and individual care planning.
“I was particularly concerned to note that the culture in one unit was reminiscent of a model of mental health care that might have been provided decades ago. There was a general attitude of negativity about the possibility of improvement in the lives of the residents. There was an emphasis on what they could not do, their potential for aggression, and the fact that they would always require this type of care. This resulted in limited therapeutic input for these residents, absence of care based on recovery principles, and an environment that was stark and lacking in comfort. It should really go without saying that we need to completely remove any last vestiges of this attitude and approach to mental health care from our services.”
The Chief Executive of the Mental Health Commission, John Farrelly, said: “These reports indicate a need for the HSE to improve governance, management and oversight of investment in inpatient mental health facilities in the greater Cork area. The HSE has shown in other areas and in other counties within this CHO a clear capability to wisely use the funds allocated to it by the State. We will continue to be concerned about patterns of non-compliance across a number of centres in Cork and we continue to monitor this matter closely.”
St. Stephen’s Hospital is located north of Cork City. The hospital was originally built as a tuberculosis sanatorium in the 1950s. Residents have access to the Valley View day centre which is also located on the hospital. 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, while Unit 3 contains 18 beds for male residents with severe and enduring mental illness. Unit 8 has 25 beds and provides care to residents with enduring mental illness. Three general adult sector teams, a psychiatry of later life, and a rehabilitation team admitted residents to the centre.
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 relating to regulations on premises, risk management, staffing and individual care planning. The centre was in breach of one condition relating to premises which required the centre to implement a programme of maintenance, while the centre was in breach of a second condition relating to risk management which required the centre to ensure that a comprehensive risk management policy is implemented.
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 - meaning that there were not adequate precautions in place to control for the management of fire risk; 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 for reasons that included the discovery of dirty and discoloured external walls, soffit and fascia; that the walls and skirting boards in some bedrooms needed painting; that floor coverings in some showers had come loose; and that the sluice rooms on three units needed refurbishment. There were also unpleasant odours in two bathrooms; curtains were missing from one bedroom; and some wardrobes were too small to store residents’ belongings.
In response to the concerns regarding the care and treatment of residents in the service, and particularly in Unit 3, the MHC issued an immediate action notice on August 12th; conducted a focused inspection of Unit 3 on August 16th; held a regulatory compliance meeting on August 26th; and has subsequently applied a condition to the centre’s registration to restrict admissions to one of its units.
The focused inspection on August 16th focused on five regulations. Of these five, 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.
In relation to premises, it was found that the centre did not have adequate and suitable furnishings with regard to the number and mix of residents, and the condition of the physical structure and the overall environment was not 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.
It was also noted in the focused inspection report 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.
The result, the report said, was that Unit 3 was isolated within the campus as well as from the community, with little social integration in the activities happening around the hospital. While a rehabilitation and recovery service operated in other parts of the hospital, this was not available to residents in Unit 3, due to the separate governance arrangements.
The report stated that the culture in Unit 3 was reminiscent of a model of mental health care provided thirty or more years ago. There was a general attitude of negativity about the possibility of improvement in the lives of the residents. Instead, there was an emphasis on what they could not do (rather than their strengths), their potential for aggression and the fact that they would always require this type of care.
It was noted that Unit 3 was sparsely decorated with meagre furnishings observed in the sitting rooms, lack of personal items, and wardrobes that were too small to adequately store clothing. Residents displayed institutionalised behaviour and the inspectors noted crowding on the corridor, an atmosphere of tension, and irritability among the residents. There was minimal staff presence in the ward area and attitudes towards residents was noted to be dismissive.
Carraig Mór is an 18-bed Psychiatric Intensive Care Unit (PICU) in Shanakiel, Cork, which opened in 2002. Following a process of regulatory escalation initiated by the MHC, the MHC and the HSE agreed that the number of available beds at Carraig Mór would be reduced from 18 to 10 from May 2021 - with further bed reductions planned - to improve privacy and dignity issues for residents and while critical and necessary construction works to upgrade the unit were ongoing.
The centre received an overall compliance rate of 91%, an increase of 17% on the compliance rating it received in 2020. There were five conditions attached to the centre related to premises, risk management, staffing, maintenance of records, and occupancy. The centre was not in breach of any the conditions at the time of inspection, but it received one high-risk non-compliance on the regulation relating to individual care plans.
The Carraig Mór report noted that following the death of a resident there, the MHC had carried out an announced focused inspection of the centre on March 12th, 2021 and identified a number of specific measures and enforcement actions which related to the unsuitability of the premises at the time of the person’s death. These have largely been remedied and the specific actions undertaken, including the installation of a more comprehensive CCTV system within the centre, as well as a new fire alarm system, including sensors and new fire panels.
It was also noted that in further response to MHC enforcement actions and discussions, the centre was also required to implement an immediate programme of maintenance to ensure that the premises were safe and met the needs of residents. This included a fire safety risk assessment, a health and safety report and a ligature audit review and action plan. Subsequently, additional plans have been submitted by the service in relation to a planned major refurbishment of Carraig Mór. The costed and time bound plan for further refurbishment work will provide for a new entrance, enlarged communal spaces and 18 single bedrooms when completed. In the interim period of refurbishment, bed capacity will further reduce in line with the roll-out of works.
You can read our full statement here.
St. Stephen’s Hospital Focused Inspection Report 2021
