Inspection reports

MHC statement 04.06.2025 on publication of inspection reports for thirteen approved mental health centres

The Mental Health Commission (MHC) has published 13 inspection reports for approved inpatient mental health centres across Cavan, Clare, Dublin, Kilkenny, Westmeath, and Laois. 

The centres inspected were:

  • Cappahard Lodge, which received 93% compliance with the rules, regulations and codes of practice.
  • Acute Psychiatric Unit, Cavan General Hospital, which received 83% compliance with the rules, regulations and codes of practice.  
  • Maryborough Centre, St Fintan’s Hospital, which received 84% compliance with the rules, regulations and codes of practice.  
  • Admission Unit and St Edna’s Unit in St Loman’s Hospital, which received 89% compliance with the rules, regulations and codes of practice.
  • St Patrick’s University Hospital, which received 97% compliance with the rules, regulations and codes of practice.
  • Lois Bridges, Sutton, which received 97% compliance with the rules, regulations and codes of practice.  
  • Department of Psychiatry, Midland Regional Hospital, Portlaoise, which received 81% compliance with the rules, regulations and codes of practice.
  • Central Mental Hospital, Portrane, which received 51% compliance with the rules, regulations and codes of practice.
  • Elm Mount Unit, St Vincent’s University Hospital, which received 56% compliance with the rules, regulations and codes of practice.  
  • Department of Psychiatry, Connolly Hospital, which received 88% compliance with the rules, regulations and codes of practice.  
  • Department of Psychiatry, St Luke’s Hospital, which received 86% compliance with the rules, regulations and codes of practice.
  • Jonathan Swift Clinic, St James’s Hospital, which received 75% compliance with the rules, regulations and codes of practice.  
  • St Vincent’s Hospital, Fairview, which received 79% compliance with the rules, regulations and codes of practice. 

The inspector found varying levels of compliance with the rules, regulations and codes of practice.  Three centres were between 90-100% compliant; a further six were between 80-90% compliant; two centres were between 70-80% compliant; while two centres were between 50-60% compliant.

Some areas of good practices observed over the course of the inspections included:

  • St Patrick’s University Hospital developed and delivered Support Seminar Series – ‘Depression Programme’. The programme was established as a group intervention aimed at providing information to friends and family who support residents with their recovery. It ran over two half day sessions. Topics included types of depression, treatment options, relapse prevention and caring for the caregiver. Each session included the resident and up to two nominated supporters. Feedback surveys were completed after each session.
  • Cappahard Lodge purchased a new car that supports residents’ involvement in the community.
  • Lois Bridges initiated an ‘Extend Gender-Affirming’ care campaign to include a full review of all paperwork and care plans to ensure inclusivity and the use of diverse language.

Critical and high non-compliances observed during the inspections were:

  • One high risk non-compliance with the regulation on maintenance of records at Cappahard Lodge.
  • Two critical risk non-compliances with the regulations on therapeutic services and programmes, and with staffing; and one high risk non-compliance with the regulation on premises at the Acute Psychiatric Unit at Cavan General Hospital.
  • One high risk non-compliance with the regulation on risk management procedures at Maryborough Centre, St Fintan’s Hospital.  
  • Four critical risk non-compliances with the regulations on therapeutic services; premises; staffing; and risk management procedures; and one high risk non-compliance with the code of practice on admission, transfer and discharge at the Department of Psychiatry, Midland Regional Hospital, Portlaoise.
  • One critical risk non-compliance with the rules governing the use of seclusion; and 10 high risk non-compliances with the regulations on food and nutrition; searches; individual care plan; therapeutic services and programmes; general health; premises; staffing; complaints; risk management procedures; and the rules governing the use of mechanical means of bodily restraint at the Central Mental Hospital, Portrane.
  • One critical risk non-compliance with the regulation on maintenance of records; and 11 high risk non-compliances with the regulations on food and nutrition; individual care plan; therapeutic services and programmes; general health; privacy; premises; staffing; risk management; the rule governing the use of electro-convulsive therapy; the codes of practice on the use of physical restraint; and the admission, transfer and discharge at Elm Mount Unit, St Vincent’s University Hospital.
  • One high risk non-compliance with the regulation on premises at the Department of Psychiatry, Connolly Hospital.
  • Three high risk non-compliances with the regulations on individual care plan; premises; and staffing at the Department of Psychiatry, St Luke’s Hospital.
  • One high risk non-compliance with the regulation on staffing at the Admission Unit and St Edna’s Unit in St Loman’s Hospital.
  • Three high risk non-compliances with the regulations on individual care planning; therapeutic services and programmes; and staffing at the St Vincent’s Hospital, Fairview.
  • Four high risk non-compliances with the regulations on visits; privacy; premises; and risk management procedures at the Jonathan Swift Clinic, St James’s Hospital.

The MHC requires corrective and preventive actions 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 at 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. 

The MHC’s Regulatory Management Team (RMT) considers all critical risk issues 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:

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