Training challenges impacting on compliance with regulations at mental health centres

The Mental Health Commission has this morning published inspection reports for three approved centres in Dublin which have identified six high-risk and four moderate-risk ratings for non-compliance on legal regulations.

The high-risk ratings identified covered the areas of staffing, physical restraint, communications, and condition of premises. In one instance of physical restraint at St John of God’s Hospital in Stillorgan, there was no documentation in the clinical file of having notified the consultant psychiatrist or the duty consultant psychiatrist of the episode of physical restraint. No physical examination was completed following this episode of restraint within a timeframe, as is required.

At the Adolescent In-Patient Centre Unit in St Vincent’s Hospital, despite strong treatment and care of residents, the same attention was not shown to the premises. Windows throughout the unit were dirty, kitchen bins were dirty, excessive dust was observed behind mattresses, and markings were observed on the walls, doors and floor of the seclusion room.

On the positive side, compliance has increase from 75% in 2019 to 91% in 2022 at the Ginesa Suite approved centre on the grounds of the St John of God Campus in Stillorgan. Feedback in questionnaires from residents was that that staff were friendly and nice, and that they did baking with the residents at times, which they enjoyed.

Mental Health Commission Chief Executive John Farrelly commended progress by some approved centres in improvements in compliance ratings but said that any centre that did not follow guidance in relation to physical restraint must be held to account:

“Physical restraint should only ever be used as a last resort and there are strict reporting procedures in place in terms of documenting this - the reasons for it and informing the relevant people - and ensuring a doctor checks up on the individual involved within a short timeframe.”

The Inspector of Mental Health Services, Dr Susan Finnerty, said that a recurring issue at many approved health centres this year related to training, and not all staff or contractors employed having relevant training required:

“Mandatory training is there for a reason – it enables those in positions of care and responsibility to react in the correct and best way when a situation arises –Training in life support, fire safety and management of violence and aggression is critical yet many approved centres – for a variety of reasons - do not have complete up to date mandatory training for all staff.

St John of God’s Hospital is located in Stillorgan, is registered for 170 beds and provides a range of adult mental health and specialist services, including addiction therapy, dialectical behaviour therapy, psychiatry of later life and eating disorder programmes. There are seven separate wards or suites and ten general adult psychiatric treating teams. There were 120 residents in situ when the inspection took place.

Compliance rates increased from 89% in 2021 to 91% in 2022. There were no conditions attached to the registration of this approved centre at the time of inspection. In terms of non-compliance with regulations, these included:

• Failure to fully complete physical health checks of a number of residents.
• Not all staff had received training in life support, fire safety and management of violence and aggression
• Breach of the code of practice on physical restraint

Therapeutic activities were found to be appropriate to the needs of residents, with each receiving a multi-disciplinary care plan which was developed and reviewed with their own input. Facilities and processes were found to mostly respect residents’ privacy and dignity. Completed risk assessments showed an overall low level of risk in the hospital. Staff numbers and skill levels were deemed sufficient to meet resident needs.

Residents had found being confined to their suite during Covid-19 outbreaks difficult but praised the staff in how this was managed. All residents interviewed knew who their care team were, with many stating that they see their doctor and the team two or three times a week.

The Ginesa Suite is located on the St. John of God Hospital campus in Stillorgan, Co. Dublin on the first floor of the main building.

The centre is registered for 12 beds, and there were eight residents present at the time of inspection. The unit had adequate therapeutic and communal areas and young people had access to a gym and outdoor recreational facilities located on the grounds of St. John of God Hospital. A school facility was also available to young people in Ginesa Suite. 

Residents also had access to a gym, pitch and putt course, soccer pitch, tennis court, table tennis, basketball and exercise equipment in garden. The centre’s compliance rate has increased from 75% in 2019 to 91% in 2022. There were no conditions attached to the registration at the time of inspection.

In terms of non-compliance, it was found that:

• Ligatures were not minimized to the lowest practical level based on risk assessment
• Not all staff had completed the mandatory training, namely fire safety, basic life support and management of violence and aggression and children first
• A resident was not informed of the details and reasons for their restraint

In a feedback questionnaire the residents said that they would like to go outside more, but that was not always possible as they had to be supervised by nursing staff and they were not always available. Furthermore, some stated they did not know about their care plan and would like to talk about it more with the team.

They also stated that staff were friendly and nice, and that they did baking with the residents at times which they enjoyed. The residents were happy with the school and the teacher, who they felt was very helpful.

The Adolescent In-Patient Unit (AIPU) is located on the first floor of St. Vincent’s Hospital, Fairview. Residents had access to an external garden and a basketball court. Indoor communal areas included a common room, an art room and a relaxation room. There is a designated school for residents located within the grounds of St. Vincent’s Hospital, Fairview, around 100m from the approved centre.

The centre is registered for 12 beds, with nine patients in situ at the time of inspection. There were no conditions attached to the registration of this approved centre, at the time of the inspection. The compliance rating dropped from a high of 94% in 2020 to 88% in 2022, and the inspection team found that the approved centre did not always provide safe practices which reduced risk of harm to the residents:

• Not all healthcare staff had completed training in fire safety, basic life support or management of violence and aggression.
• There was a lock and key system for entrance and exit to the approved centre, but keys were occasionally difficult to use and were observed to stick in the locks causing delays opening and closing the doors.
• Ligature anchor points were not minimised to the lowest practicable level.
• The speech and language therapist position was vacant at the time of inspection. There was also a vacant clinical nurse specialist position.
• Windows and kitchen bins were dirty, and there were marks on some of the walls in one area
• The approved centre did not provide adequate means to facilitate ease of communication at all times for the residents. The approved centre’s communication policy didn’t allow residents to use their mobile phones in the centre, and instead only one Skype portal was available.

However, residents interviewed were very complimentary of the teachers and education received. Feedback was positive regarding food. They also reported that there was a need for a second phone as sometimes they could be waiting all day to use the one phone that was available. The inspection team subsequently discussed this issue with the management team who reported that a second phone would be made available.

The nursing department introduced an innovation project entitled “Nature Based Therapy Social and Therapeutic Horticulture.” Residents upcycled and decorated old plant pots, then replanted them for the enjoyment of residents in the continuing care unit.

You can find our full statement here. 

St John of God Inspection Report 

The Ginesa Suite Inspection Report

Adolescent In-Patient Unit (AIPU) St. Vincent’s Hospital Inspection Report