Inspection reports

Mental Health Commission publishes seven inspection reports

The Mental Health Commission (MHC) has this morning published seven inspection reports that, combined, show 10 high-risk and 15 moderate-risk non-compliances in areas such as premises, restrictive practices, therapeutic services and programmes, staffing, general health and risk management.

The reports released today focus on the O’Casey Rooms in Fairview (94% overall compliance, up from 91% in 2022); Teach Aisling in Castlebar, Co Mayo (88% compliance, down from 97% in 2022); the Adolescent In-patient Unit at St Vincent’s Hospital in Fairview (78% compliance, down from 87% in 2022); the Centre for Mental Health Care and Recovery in Bantry General Hospital (88% compliance, up from 78% in 2022); the Acute Psychiatric Unit in Cavan General Hospital (85% compliance, up from 83% in 2022); Linn Dara Child and Adolescent In-patient Unit located at Cherry Orchard Hospital Campus in Ballyfermot (91% compliance, down from 97% in 2022) and the Maryborough Centre at St Fintan’s Hospital located in Portlaoise, Co. Laois (94% compliance, up from 93% in 2022).

Selected good practices and quality initiatives observed during the inspections included the introduction of a nursing staff programme called ’Understanding Autism’; the establishment of monthly live music sessions; the introduction of a yoga group; the introduction of an occupational therapist led 10km greenway cycle and sports day; a weekly in-reach class provided by the Recovery College West; the initiation of a multi-family therapy programme for young people and families on an eating disorder programme; and the introduction of a selection of items (wind chimes, bells, board games, solar lighting, and a selection of fragrant plants) in a sensory garden in one of the centres.

However, there were common themes of concern across all seven centres, which included failings in regulations for premises in four centres, and in the rules and codes of practice around restrictive practices in two centres. 

“Our inspections highlight that four out of the seven centres were non-compliant with the regulation on premises because ligature points and hazards had not been minimised to the lowest practicable level based on risk assessment,” said the Inspector of Mental Health Services, Professor Jim Lucey. “Services are obliged to identify hazards and ligatures which could lead to adverse outcomes and rectify these hazards for the safety and wellbeing of people who use our mental health services, thereby helping to provide a premises for people to thrive and flourish.”

The Director of Regulation for the Mental Health Commission, Gary Kiernan, noted that two centres had critical and high-risk non-compliances relating to restrictive practices, specifically with the rules governing the use of mechanical restraint, and with the code of practice on the use of physical restraint.

Mr Kiernan said: “The Mental Health Commission’s revised rules governing the use of seclusion and mechanical means of bodily restraint, and a revised code of practice on the use of physical restraint, came into effect at the beginning of 2023,” he said. “While we have seen further positive reductions overall in the use of restrictive practices in recent years, it is, nevertheless, concerning to note that a small number of centres are still receiving high-risk non-compliances in this area. 

“We urge all services to adopt a strong human rights focus when reviewing restrictive practices, as required by our national and international human rights instruments and legislation.” 

Non-compliances observed during the inspections included:

  • two high-risk non-compliances with the regulations on therapeutic services and programmes and staffing at the Adolescent In-patient Unit at St Vincent’s Hospital
  • one high-risk non-compliance with the regulations on premises at the O’Casey Rooms
  • one high-risk non-compliance with the regulations on premises at the Centre for Mental Health Care and Recovery at Bantry General Hospital
  • two high-risk non-compliances with the regulation on risk management procedures and premises at Teach Aisling
  • two high-risk non-compliances with the regulations on premises and general health at the Acute Psychiatric Unit at Cavan General Hospital
  • one high-risk non-compliance with the code of practice on the use of physical restraint at Linn Dara Child and Adolescent In-patient Unit
  • one high-risk non-compliance with the rule on mechanical restraint at the Maryborough Centre at St Fintan’s Hospital

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 Inspection Reports

Link to the full statement Mental Health Commission publishes seven inspection reports.

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