Inspection reports

MHC statement on publication of inspection reports for 10 approved mental health centres

MHC statement on publication of inspection reports for 10 approved mental health centres

The Mental Health Commission has published inspection reports for 10 approved inpatient mental health centres across Cavan, Clare, Dublin, Galway, Laois, Limerick, Roscommon, Waterford, and Westmeath. 

The centres inspected were:

  • Tearmann Ward, St Camillus’ Hospital, Co. Limerick, which received 100% compliance with the Rules, Regulations, and Codes of Practice.
  • Creagh Suite, Co. Galway, which received 97% compliance with the Rules, Regulations, and Codes of Practice.
  • Cappahard Lodge, Co. Clare, which received 93% compliance with the Rules, Regulations, and Codes of Practice.
  • Acute Psychiatric Unit, Cavan General Hospital Centre, Co. Cavan, which received 91% compliance with the Rules, Regulations, and Codes of Practice.
  • O'Casey Rooms, Fairview Community Unit, Dublin 3, which received 90% compliance with the Rules, Regulations, and Codes of Practice.
  • St Vincent's Hospital, Fairview, Dublin 3, which received 88% compliance with the Rules, Regulations, and Codes of Practice.
  • Grangemore Ward, St Otteran’s Hospital, Co. Waterford, which received 84% compliance with the Rules, Regulations, and Codes of Practice.
  • Maryborough Centre, St Fintan’s Hospital, Co. Laois, which received 84% compliance with the Rules, Regulations, and Codes of Practice.
  • St Bridget’s Ward & St Marie Goretti’s Ward, Cluain Lir Care Centre, Co. Westmeath, which received 79% compliance with the Rules, Regulations, and Codes of Practice.
  • Department of Psychiatry, Roscommon University Hospital, Co. Roscommon, which received 72% compliance with the Rules, Regulations, and Codes of Practice. 

The inspector found varying levels of compliance with the Rules, Regulations, and Codes of Practice. Five centres were between 90-100% compliant; a further three centres were between 80-90% compliant, while two centres were between 70-80% compliant. 

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

  • An evidenced-based palliative care suite was designed, and a sensory room for residents established at Tearmann Ward, St Camillus’ Hospital.
  • As part of the Safewards Initiative, Creagh Suite introduced a virtual reality headset for the residents, which provided simulated experiences and activities that were individualised based on residents known preferences, such as outdoor scenery or golf.
  • Each resident at Cappahard Lodge took part in the ‘make every contact count’ (MECC) programme, which is aimed at preventing chronic disease by discussing interventions with staff to reduce alcohol or smoking use and to discuss healthy eating and activities.
  • A 'You Said....We Did' initiative was developed at the Acute Psychiatric Unit, Cavan General Hospital Centre which documented feedback from resident community meetings and highlighted actions taken by the centre to resolve any issues raised.
  • A daily programme called ‘sense-ability’ was developed at O'Casey Rooms, Fairview Community Unit and included individual sensory programmes for residents who were unable to attend group activities.

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

  • One critical-risk non-compliance with the Rule Governing the Use of Seclusion; and six high-risk non-compliances with the Regulations on Individual Care Plan; Privacy; Premises; Staffing; and with the Codes of Practice on Physical Restraint; and the Admission, Transfer and Discharge at the Department of Psychiatry, Roscommon University Hospital.
  • One critical-risk non-compliance with the Regulation on Premises; and four high-risk non-compliances with the Regulations on Privacy; Ordering, Prescribing, Storing and Administration of Medicines; Staffing; and Risk Management Procedures at Grangemore Ward, St Otteran’s Hospital.
  • Five high-risk non-compliances with the Regulations on Therapeutic Services; Premises; Medication; Staffing; and Risk Management Procedures at St Bridget’s Ward & St Marie Goretti’s Ward, Cluain Lir Care Centre.
  • Three high-risk non-compliances with the Regulations on Premises; Staffing; and Risk Management Procedures at Maryborough Centre, St Fintan’s Hospital.
  • One high-risk non-compliance with the Regulations on Risk Management Procedures at St Vincent’s Hospital, Fairview.
  • Two high-risk non-compliances with the Regulations on Premises; and Ordering, Prescribing, Storing, and Administration of Medicines at O’Casey Rooms, Fairview Community Unit.
  • One high-risk non-compliance with the Regulation on Medication at Cappahard Lodge.
  • One high-risk non-compliance with the Regulation on Premises at Creagh Suite. 

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.

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).

Links to Reports

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