Inspection reports

MHC statement 14.11.2024: publication of 10 inspection reports

The Mental Health Commission (MHC) has published ten inspection reports for approved inpatient mental health centres across Cork, Dublin, Galway, Kerry, Mayo, Monaghan, Westmeath and Wicklow.

The centres inspected were:

  • Cois Dalua, which received 90% compliance with the rules, regulations and codes of practice
  • Deer Lodge, which received 91% compliance with the rules, regulations and codes of practice
  • Creagh Suite, St Brigid’s Healthcare Campus, which received 97% compliance with the rules, regulations and codes of practice
  • Teach Aisling, which received 94% compliance with the rules, regulations and codes of practice
  • Willow Grove Adolescent Unit, which received 100% compliance with the rules, regulations and codes of practice (for the fifth year in succession)
  • Ginesa Suite, St John of God Hospital, which received 94% compliance with the rules, regulations and codes of practice
  • Blackwater House, St Davnet’s Hospital Campus, which received 90% compliance with the rules, regulations and codes of practice
  • St Bridget’s Ward and St Marie Goretti’s Ward at the Cluain Lir Care Centre, which received 85% compliance with the rules, regulations and codes of practice
  • Avonmore & Glencree Units, Newcastle Hospital, which received 69% compliance with the rules, regulations and codes of practice
  • St Catherine’s Ward, St Finbarr’s Hospital, which received 73% 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 10 centres reported on, seven centres were between 90-100% compliant; one was between 80-90%; another was between 70-80%; and just one was between 60-70% compliant.

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

  • Creagh Suite had screening in place for venous thromboembolism (VTE) and sepsis which is an indication of the quality of general healthcare provided to residents.
  • Teach Aisling hosted a weekly nutrition group to support its residents to make healthy decisions around food and provide education on the importance of implementing a healthy lifestyle for positive physical and mental health. 
  • Blackwater House had introduced Namaste training to enable staff to cater to the personal needs of residents with advanced dementia, by focusing on the person rather than the process and protocol.
  • Deer Lodge had developed and was in the process of implementing an improved individual care plan (ICP) booklet to replace the current sheeted format. The new booklet also included an additional section on restrictive practices with a supplementary six- monthly physical health monitoring sheet and an appointment procedure assessment record which supported the six-month general health document.
  • Willow Grove used an electronic patient record (EPR) system which was inclusive on care planning documentation, and the Individual Care Plans could be printed and a copy given to the young people when required.
  • A specialist mental health pharmacist in the Ginesa Suite led a project in collaboration with Spunout, the Royal College of Surgeons in Ireland and the University of Edinburgh to develop a medicines information resource website called ‘youthmed’ which provided young people and their families with accessible information on mental health medicines. 
  • Cois Dalua provided a physical environment and facilities that promoted privacy: all residents had either single ensuite bedrooms or a one-bedroom self-contained apartment.

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

  • One critical risk non-compliance with the regulation on therapeutic services and programmes; and seven high risk non-compliance with the regulations on premises; ordering, prescribing, storing and administration of medicines; staffing; operating policies and procedures; risk management procedures; with the rules governing the use of seclusion; and the rules governing the use of mechanical means of bodily restraint at Avonmore and Glencree Units at Newcastle Hospital. 
  • One critical risk non-compliance with the regulation on general health; and three high risk non-compliance with the regulations on food and nutrition; premises; and with Part 4 of the rules governing mechanical restraint at St Catherine’s Ward, St Finbarr’s Hospital.
  • Five high risk non-compliances with the regulations on general health; premises; staffing; maintenance of records; and on risk management at St Bridget’s Ward and St Marie Goretti’s Ward at the Cluain Lir Care Centre.
  • Two high risk non-compliances with the regulation on premises; and with the rules governing the use of seclusion at Teach Aisling
  • One high risk non-compliance for the regulation on staffing at Deer Lodge
  • One high risk non-compliance with the Code of Practice on the Use of Physical Restraint at Blackwater House

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 the full statement: MHC statement on publication of inspection reports for ten approved mental health centres

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