Inspection reports

MHC statement 04.12.2024: publication of inspection reports for 12 mental health centres

4 December 2024

The Mental Health Commission (MHC) has published 12 inspection reports for approved inpatient mental health centres across Galway, Mayo, Sligo, Roscommon, Wexford, Waterford, Kilkenny, Cork, Louth, and Dublin.

The centres inspected were:

Woodview, Co. Galway, which received 97% compliance with the rules, regulations and codes of practice.
St Ita's Ward, St Brigid's Hospital, Co. Louth, which received 97% compliance with the rules, regulations and codes of practice.
Carraig Mór Centre, Co. Cork, which received 97% compliance with the rules, regulations and codes of practice.
St Patricks Hospital in Lucan, Co. Dublin, which received 97% compliance with the rules, regulations and codes of practice.
O'Casey Rooms, Fairview Community Unit, Dublin 3, which received 94% compliance with the rules, regulations and codes of practice.
Selskar House, Farnogue Residential Healthcare Unit in Wexford Town, which received 94% compliance with the rules, regulations and codes of practice.
An Coillín, Co. Mayo, which received 88% compliance with the rules, regulations and codes of practice.
The Department of Psychiatry at University Hospital Waterford, which received 81% compliance with the rules, regulations and codes of practice.
Adult Mental Health Unit, Sligo University Hospital, which received 76% compliance with the rules, regulations and codes of practice.
St Canice's Hospital, Co. Kilkenny, which received 74% compliance with the rules, regulations and codes of practice.
The Department of Psychiatry at Roscommon University Hospital, which received 73% compliance with the rules, regulations and codes of practice.
Vergemount Mental Health Facility in Dublin 6, which received 70% compliance with the rules, regulations and codes of practice.
The inspector found an increasingly positive level of compliance with the rules, regulations and codes of practice. Of the 12 centres reported on, six centres were between 90-100% compliant; two were between 80-90%; and four were between 70-80% compliant.

Some areas of good practice observed over the course of the inspection included:

St Patrick’s Hospital Lucan had developed a designated physical health monitoring service and delivered it to all inpatients being treated with psychotropic medicines. This ensured the vast majority of inpatients prescribed psychotropic medicines had a physical health monitoring review.
O'Casey Rooms, Fairview Community Unit, hosted family days to celebrate significant holidays and birthdays. Families were supported to take residents out on trips using the approved centre’s transport and equipment. Inpatients with families and loved ones living abroad were facilitated to meet up on such occasions digitally.
Selskar House at Farnogue Residential Healthcare Unit had provided - and ensured staff completed - training in a variety of areas including ‘Life Enriching Ways through Late-Stage Dementia, ‘Final Journeys Workshop’ and cultural diversity training to enable staff to cater to the personal needs of residents.
Woodview had established a smoking cessation committee and the smoking cessation officer met with the residents on a quarterly basis to assist them.
St Ita's Ward at St Brigid's Hospital introduced the Camberwell Assessment of Need, to assist in identifying health and social needs of residents prior to each individual care plan review and to better inform the individual care planning process.
The Carraig Mór Centre enhanced the complaints procedures and developed information with input from the Speech and Language Department describing the complaints’ process, including a QR Code to facilitate access for residents to advocacy services and contact details for the complaints officer for the service.

The critical and high non-compliances observed during the inspections were:

Two critical risk non-compliances with the Regulation on premises, and with the Rule governing the use of seclusion; and five high risk non-compliance with the Regulations on staffing; individual care planning; privacy; therapeutic services and programmes, and consent to treatment, at the Department of Psychiatry, Roscommon University Hospital. The centre was also in breach of one of the Conditions attached to the approved centre (on premises) at the time of inspection.
One critical risk non-compliance with the Regulation on risk management procedures at Le Brun House & Whitethorn House, Vergemount Mental Health Facility.
Six high risk non-compliances with the Regulations on privacy; premises; risk management procedures; ordering, prescribing, storing and administration of medicines; complaints procedures; and with the Rules governing the use of mechanical means of bodily restraint at St Gabriel's Ward, St Canice's Hospital.
One critical risk non-compliance with the Rule governing the use of seclusion; and two high risk non-compliances with the Regulation on food safety; and the Code of Practice on the admission, transfer and discharge at the Adult Mental Health Unit, Sligo University 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).

Link to individual reports: