Inspection reports

Mental Health Commission publishes nine inspection reports for eight approved centres

26 May 2023

The Mental Health Commission (MHC) has published seven annual inspection reports, and two focused reports, which show non-compliances for the regulation on staffing across eight out of the nine approved mental health centres inspected.

In total, the inspections found a total of two critical-risk non-compliances for the regulation on staffing, and sixteen additional high-risk non-compliances for staffing, individual care planning and risk management across centres in Mayo, Roscommon, Dublin, Cork, Louth, Laois and Clare.

The reports released today focus on:

The Inspector of Mental Health Services, Dr Susan Finnerty highlighted the links between staff shortages, staff training and risk management.

Dr Finnerty said: “There are risks associated with an inability to recruit and retain staff which results in an inappropriate skill mix to meet the needs of residents – concerns all of which are highlighted across today’s eight inspection reports. The provision of up-to-date training for staff to ensure the centre meets the basic and mandatory requirement for compliance is essential for the safety and wellbeing of patients and residents”.

Good practices and quality initiatives observed during inspections at the centres included a physical health information tool developed for six-monthly physical health assessments required by regulation; a new patient diagnosis information sheet written in a patient-friendly language and made available to residents; a family clinic initiative for family members, and carers and supporters/close friends of people who were inpatients; and a new infrared system that significantly reduces risk of falls for residents within a centre.

Poor practices found by inspectors during inspections included insufficient numbers of registered psychiatric nurses in order to meet resident needs; no occupational therapist working in, or available to, the approved centre; nursing vacancies; two vacant social worker posts; two vacant occupational therapist posts; one vacant psychologist post; not all healthcare staff trained in basic life support, fire safety, the management of violence and aggression, and the Mental Health Act 2001; and critical risks identified in regards to fire safety.

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:

 

 

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