Mental Health Commission publishes four inspection reports
7 June 2023The Mental Health Commission (MHC) has today published four inspection reports which show either critical or high risk non-compliances for the regulations on premises, risk management and complaints across three of the mental health centres inspected.
The reports released today focus on:
- Eist Linn Child and Adolescent Mental Health Centre in Cork City
- St Vincent's Hospital in Fairview, Dublin 3
- The Avonmore and Glencree Units at Newcastle Hospital in Co. Wicklow
- The Central Mental Hospital in Portrane, Co. Dublin.
Good practices and quality initiatives observed during inspections included the completion and distribution to residents of a ‘Service User Satisfaction Survey’; the launch in one centre of the HSE ‘Rainbow Badge’ initiative, the aim of which was for HSE staff to demonstrate that they are aware of the issues that LGBTQ+ people can face when accessing healthcare services; an introduction by one centre of processes to reduce the use of restrictive practices (the centre reported a 44% reduction in episodes of seclusion since the commencement of the project); the introduction of positive behaviour plans and adaptive accommodation to assist residents in need; the introduction of sensory modulation therapy and trauma-informed yoga; and the completion of training in ‘decider skills’ by nursing staff to equip them with cognitive and dialectical behaviour therapy-based techniques to assist residents experiencing thoughts of self-harm or suicidal ideation.
Poor practices found by inspectors included the failure by one centre to have an occupational therapist, a speech and language therapist, or a dietitian; no documentary evidence in another centre that a capacity assessment had been carried out by the responsible consultant psychiatrist in respect of one patient who had been in the centre longer than three months and who was in continuous receipt of medication; the failure to publicly display a centre’s complaints procedure or a named person or contact details through which to make a complaint; sparsely-furnished bedrooms in one centre, including marked and stained furniture; and health and safety risks – including heating not working, leaks in the heating system, damaged fire doors, and mould - not identified, assessed, treated, reported and monitored by another centre.
The MHC requires corrective and preventive action plans (CAPAs) from all services where non-compliances are identified, each of which must address each non-compliance specifically. The MHC monitors the implementation of these CAPAs on an ongoing basis and requests further information and action as necessary. Enforcement action is taken when the MHC is concerned that the care and treatment provided in an approved centre may be a risk to the safety, health, and wellbeing of residents, or where there has been a failure by the provider to address an ongoing area of non-compliance. All critical risk issues are considered by the MHC’s Regulatory Management Team (RMT) as a matter of course.
Enforcement actions commonly arise from inspection findings, quality and safety notifications, and compliance monitoring. Enforcement actions available to the MHC range from the aforementioned CAPAs (at the lower end of enforcement) to removing an approved centre from the register and/or pursuing prosecution (at the higher end).
Links to all reports published today can be found at the links below.
