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Inspection reports

Mental Health Commission publishes six inspection reports for approved centres

13 September 2023

The Mental Health Commission (MHC) has published five annual inspection reports, and one focused inspection report, which show high or critical non-compliances for the regulation on risk management and premises across three out of the six approved mental health centres inspected.

In total, the inspections found a total of two critical-risk non-compliances in one centre - for the regulation on staffing, and therapeutic services and programmes - and three additional high-risk non-compliances for premises and risk management across centres in Dublin and Monaghan.

Four out of the six reports released today had high levels of overall compliance with regulations Creagh Suite, Ballinasloe (100%), St Patrick’s University Hospital, Dublin 8 (97%), Lois Bridges, Sutton; (97% compliance) and Blackwater House in Monaghan (90% - with one high-risk non-compliance for premises).

Two out of the six reports released today had lower rates of overall compliance and critical and high-risk non compliances. These were Le Brun House & Whitethorn House, Vergemount Mental Health Facility, Dublin 6 (83% compliance with two high-risk non-compliances for premises and risk-management) and St Vincent’s Hospital, Fairview (a focused inspection which had two critical-risk non-compliances for therapeutic services and staffing).

The MHC’s Director of Regulation, Gary Kiernan, highlighted the fundamental and basic need for patients to be cared for in suitable premises. Mr Kiernan said: “The Mental Health Commission has consistently highlighted the urgent need for investment in the premises of some HSE approved centres across the country. The provision of suitable, well-maintained premises is a fundamental requirement for providing safe and effective mental health care.”

Good practices and quality initiatives observed during inspections at the centres included the development of a medicines’ management care plan library which provided information to patients about the medicines used; a sensory and herb garden; a safeguarding of vulnerable adult’s self-assessment tool; a ten-week intensive music programme; and workshops on effective communication with people living with dementia.

Poor practices found by inspectors during inspections included ligature points which were not minimised to the lowest practicable level based on risk assessment; vertical blinds in bedrooms not functioning as required; areas in bedrooms and bathrooms that required painting; exposed pipework under the sinks in bathrooms; external doors and windows that required replacement; radiators and associated pipework that were very hot to touch; outdated and marked wardrobes that could not be locked; and curtains that were not fit for purpose.

The MHC requires corrective and preventive action plans (CAPAs) from all services where non-compliances are identified by inspections, 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 non-compliances 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 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.

  • Link to Full Statement 
  • Creagh Suite, Ballinasloe 
  • St Patrick’s University Hospital, Dublin 8 
  • Lois Bridges, Sutton
  • Blackwater House in Monaghan
  • Le Brun House & Whitethorn House, Vergemount Mental Health Facility, Dublin 6
  • St Vincent’s Hospital, Fairview
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Phone: 353(1) 636 2400
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