Ligature points risks not mitigated at three mental health centres

We released three inspection reports this morning related to centres in Monaghan, Cork, and Donegal which identified two critical risks and six high risks non-compliances across the three inpatient services.

At all the centres inspected, there were risks associated with ligature points not being reduced to the lowest practical level. Commenting on the reports, the Inspector of Mental Health Services Dr Susan Finnerty said: “The three centres inspected had a high overall rate of compliance which should be acknowledged but issues around patient safety are paramount. It is critical for both patients and staff that these risks are dealt with and mitigated immediately”.

Issues around ligature points account for two of the critical and one of the high risks found and Chief Executive of the MHC, John Farrelly, commented: “We will be following up with these services immediately to make sure that actions are taken to deal with these risks. We note that a plan is already being progressed in Letterkenny and in Blackwater House in Monaghan.”

Blackwater House is a recently built single-storey facility located on St Davnet’s Campus outside Monaghan town. It is a 16-bedded facility, which contained two spacious bungalows and a shared services corridor. The centre is registered to provide mental health rehabilitation, psychiatry of later life, and continuing/long stay mental health care. Five multi-disciplinary teams provide care and treatment.

The centre received an overall compliance rate of 87%, a slight decrease on the 90% compliance it received in 2020. The inspectors found that the centre did not always operate safe practices to reduce the risk of harm to residents. Several ligature points remained throughout the centre and were not minimised to the lowest practicable level based on risk assessment.

Not all the components of the risk management policy were implemented throughout the centre. Ligature points which were identified in a ligature audit prior to the inspection remained at the time of the inspection. Risk management procedures did not actively reduce these identified risks.

While the privacy of residents was generally respected and the centre was kept in a good state of repair both internally and externally, the garden - which was used by residents - was visible to anyone, including constructions workers and other members of the public located in buildings and spaces overlooking and surrounding the garden area. This compromised residents’ privacy and dignity.

The Centre for Mental Health Care and Recovery is located on the grounds of Bantry General Hospital and provides acute mental health care. The centre is an 18-bed, three-storey building with the main clinical area and sleeping accommodation located on the upper floor. The dining room and staff offices are located on the ground floor, with the occupational therapy room and resident garden on the lower ground floor.

The centre recorded an overall compliance rate of 85%, again a slight decrease on its previous inspection in 2020 where it received 88% compliance.

Numerous ligature anchor points were present throughout the centre and were not minimised to the lowest practicable level based on risk assessment. The location of the toilets was not appropriate, having regard to the needs of residents in the centre. Some residents did not have a toilet near their bedroom, which resulted in them having to walk down the main corridor to access the facilities.

Residents did not have access to appropriately-sized communal rooms. Residents had access to a sitting room, which could only accommodate six residents allowing for social distancing due to the COVID-19 pandemic. The CCTV monitor in the main reception area was viewable by security personnel and was not viewed solely by the healthcare professionals responsible for the residents.

Four individual care plans that were inspected did not identify appropriate goals for the residents. These care plans also did not identify the care and treatment required to meet the goals identified, including the frequency and responsibilities for implementing care and treatment.

The Department of Psychiatry at Letterkenny University Hospital has 34 beds and is a standalone single storey building. There are six community mental health sector teams, two mental health services for older persons teams, and one mental health intellectual disability team that has admitting privileges to the centre. The centre is not modern and dated in appearance. An extensive upgrading plan is being progressed.

The centre received an overall compliance rate of 89% which was an increase on the 86% compliance recorded in its 2020 inspection.

The centre was non-compliant with the regulation regarding premises because the physical structure was not developed and maintained with due regard to the specific needs of residents as ligature points were not minimised to the lowest practicable level. An extensive ligature reduction plan was being progressed to deal with outstanding issues.

There were numerous quality initiatives which were identified upon inspection, including an admission pack developed for each resident that contained activity materials and a guide to social distancing and self-isolation in hospital. There was also a new easy-read information pamphlet called ‘My Integrated Care Plan’ which was available for all residents. This document outlined the purpose of a care plan, resident involvement, advocacy information as well as contact details and discharge planning.

You can read our full statement here. 

Blackwater House Inspection Report 2021

Centre for Mental Health Care and Recovery, Bantry Inspection Report 2021

Department of Psychiatry, Letterkenny University Hospital Inspection Report 2021