Inspection reports

MHC statement on publication of inspection reports for 14 approved mental health centres

The Mental Health Commission (MHC) has published fourteen inspection reports for approved inpatient mental health centres across Cork, Dublin, Kerry, Kilkenny, Laois, Louth, Tipperary, Waterford and Wicklow.  

The centres inspected were: 

  • St Ita’s Ward, St Brigid’s Hospital, Co. Louth, which received 90% compliance with the Rules, Regulations, and Codes of Practice.
  • Lois Bridges, Dublin 13, which received 90% compliance with the Rules, Regulations, and Codes of Practice.
  • Department of Psychiatry, University Hospital Waterford, Co. Waterford, which received 89% compliance with the Rules, Regulations, and Codes of practice.
  • Department of Psychiatry, Midland Regional Hospital, Co. Laois, which received 89% compliance with the Rules, Regulations, and Codes of Practice.
  • Sliabh Mis Mental Health Admission Unit, University Hospital Kerry, Co. Kerry, which received 88% compliance with the Rules, Regulations, and Codes of Practice.
  • Carraig Mór Centre, Co. Cork, which received 88% compliance with the Rules, Regulations and Codes of Practice.
  • Haywood Lodge, Co. Tipperary, which received 84% compliance with the Rules, Regulations, and Codes of Practice.
  • Department of Psychiatry, St Luke’s Hospital, Co. Kilkenny, which received 83% compliance with the Rules, Regulations, and Codes of Practice.
  • Linn Dara Child & Adolescent Mental Health In-Patient Unit, Cherry Orchard Hospital Campus, Dublin 10, which received 79% compliance with the Rules, Regulations and Codes of Practice.
  • St Gabriel’s Ward, St Canice’s Hospital, Co. Kilkenny, which received 77% compliance with the Rules, Regulations, and Codes of Practice.
  • Acute Mental Health Unit, Cork University Hospital, Co. Cork, which received 76% compliance with the Rules, Regulations, and Codes of Practice.
  • Elm Mount Unit, St Vincent’s University Hospital, Dublin 4, which received 76% compliance with the Rules, Regulations, and Codes of Practice.
  • Centre for Mental Health Care and Recovery, Bantry General Hospital, Co. Cork, which received 75% compliance with the Rules, Regulations and Codes of Practice.
  • Avonmore and Glencree Units, Newcastle Hospital, Co. Wicklow, which received 69% compliance with the Rules, Regulations, and Codes of Practice. 

The inspector found varying levels of compliance with the Rules, Regulations and Codes of Practice. Two centres were between 90-100% compliant; six centres were between 80-90% compliant; a further five centres were between 70-80% compliant; while one centre was between 60-70% compliant.  

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

  • Implementation of the Community Rehabilitation Services Communications Bridge Tool (CRS C-Bridge Tool) at St Ita’s Ward, St Brigid’s Hospital, which was developed in direct collaboration with primary care providers. St Ita’s also embedded a dedicated GP representative within the CRS team which significantly enhanced continuity of care. By streamlining clinical information between the inpatient rehabilitation service and community services, St Ita’s has established a robust framework for safer and more integrated transitions to the community. This will reduce clinical risks and ensure cohesive continuity of care.
  • Management of anorexia nervosa treatment (MANTRA) commenced at Lois Bridges, provided by the lead nurse. Furthermore, the peer support worker at Lois Bridges collaborated with the local recovery college to ensure that residents could avail of their services, if they wished. 

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

  • One critical non-compliance with the Regulation on premises; and three high-risk non-compliances with the Regulations on use of closed circuit television; staffing; and risk management procedures at Linn Dara Child & Adolescent Mental Health In-Patient Unit.
  • One critical non-compliance with the Regulation on medication; and two high-risk non-compliances with the Regulations on premises; and risk management procedures at Haywood Lodge.
  • Nine high-risk non-compliances with the Regulations on individual care plan; therapeutic services; privacy; premises; ordering, prescribing, storing, and administration of medicines; use of closed circuit television; risk management procedures; Rules on use of seclusion; and Code of Practice on the use of physical restraint at Avonmore and Glencree Units, Newcastle Hospital.
  • Seven high-risk non-compliances with the Regulations on individual care plan; privacy; premises; ordering, prescribing, storing and administration of medicines; staffing; Codes of Practice on the use of physical restraint; and admission, transfer and discharge at Centre for Mental Health Care and Recovery, Bantry General Hospital.
  • Seven high-risk non-compliances with the Regulations on residents’ property; privacy; premises; maintenance of records; risk management procedures; Rules governing the use of electro-convulsive therapy; and Code of Practice on electro-convulsive therapy at Elm Mount Unit, St Vincent’s University Hospital.
  • Five high-risk non-compliances with the Regulations on residents’ personal property and possessions; ordering, prescribing, storing and administration of medicines; maintenance of records; risk management procedures; and Code of Practice on the use of physical restraint at Department of Psychiatry, St Luke’s Hospital.
  • Four high-risk non-compliances with the Regulations on privacy; premises; ordering, prescribing, storing and administration of medicines; and risk management procedures at Acute Mental Health Unit, Cork University Hospital.
  • Four high-risk non-compliances with the Regulations on therapeutic services; staffing; Rules governing the use of mechanical means of bodily restraint; and Code of Practice on admission, transfer and discharge to and from an Approved Centre at St Gabriel’s Ward, St Canice’s Hospital.
  • Three high-risk non-compliances with the Regulations on individual care plan; therapeutic services and programmes; and staffing at St Ita’s Ward, St Brigid’s Hospital.
  • Two high-risk non-compliances with the Regulations on premises; and medication at Sliabh Mis Mental Health Admission Unit, University Hospital Kerry.
  • Two high-risk non-compliances with the Regulations on privacy; and premises at Department of Psychiatry, University Hospital Waterford.
  • Two high-risk non-compliances with the Regulations on searches; and individual care plan at Lois Bridges.
  • One high-risk non-compliance with the Regulation on premises at Department of Psychiatry, Midland Regional Hospital.
  • One high-risk non-compliance with the Code of Practice on admission, transfer of residents at Carraig Mór Centre. 

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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