Inspection reports

Mental Health Commission publishes six inspection reports

The Mental Health Commission (MHC) has this morning published six inspection reports on five approved inpatient mental health centres that, combined, show six critical and 19 high-risk non-compliances in areas such as premises, restrictive practices and risk management.

The reports released today focus on the Cois Dalua centre in Newmarket, Co. Cork (82% overall compliance, down from 97% in 2022); Units 2, 3, 4 and 8 on floor 2 of St Stephen’s Hospital in Glanmire, Co. Cork (67% compliance, down from 71% in 2022); Acute Psychiatric Unit 5B on the grounds of University Hospital Limerick (74% compliance, up from 69% in 2022); and Cappahard Lodge located near Ennis, Co. Clare (72% compliance, down from 87% in 2022).

There were also two reports for the Department of Psychiatry at Connolly Hospital, Blanchardstown. Following a focused report in March of 2023, the centre had its annual inspection in August, where it received an overall compliance rating of 74%, down from 76% in 2022.

Selected good practices and quality initiatives observed during the inspections included the implementation of a community-based leisure programme that aimed to enhance service users’ ability to access local leisure facilities, improve community integration and reduce the risk of isolation; the establishment of an individual care plan working group and the development of new posters; and the introduction of an initiative to ensure continuous quality improvement in restrictive practices following changes in the rules by the MHC in January 2023.

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

“We found that four of the five centres inspected were found to either have critical or high-risk non-compliances with the regulation on premises,” said The Director of Regulation for the Mental Health Commission, Gary Kiernan “These reports highlight that the current approach to capital investment in our publicly funded mental health units is not working. The four centres with non-compliant premises were HSE-operated inpatient units. The MHC is again calling for a national, comprehensive capital investment programme for inpatient mental health units which will address rapidly deteriorating physical environments.   People who use mental health services have a right to be cared for and treated in centres that are modern, fit-for-purpose, clean, and well-maintained.”

Mr 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.

“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 critical-risk and high-risk non-compliances in this area. 

We strongly 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 critical risk non-compliances with the regulations on general health, and therapeutic services and programmes; along with seven high-risk non-compliances with the regulations on residents’ personal property and possessions, individual care planning, premises, staffing, maintenance of records, with the rules governing the use of mechanical restraint, and with the code of practice on the use of physical restraint at St Stephen’s Hospital
  • two critical risk non-compliances with the regulations on privacy and premises; along with three high-risk non-compliances with the regulations on food and nutrition, general health, and risk management procedures at Cappahard Lodge
  • one critical risk non-compliance with the regulation on premises; and six high-risk non-compliances with the regulations on individual care planning, therapeutic services and programmes, privacy, staffing, risk management procedures, and the admission of children under the Mental Health Act at the APU, Limerick
  • one critical risk non-compliance with the rules governing the use of mechanical restraint; and two high-risk non-compliances with the regulation on risk management procedures, and with the code of practice on the use of physical restraint at Cois Dalua
  • high-risk non-compliances with the regulations on premises, residents’ personal property and possessions, and privacy at a focused inspection; and with premises at the annual inspection at DOP, Connolly

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).

Link to individual reports: 

Link to full inspection statement Mental Health Commission publishes six inspection reports. 

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