Training for staff falls short at several mental health centres

The Mental Health Commission has this morning published inspection reports for centres in Dublin, Cork and Mayo which have identified two critical and eight high-risk ratings for non-compliances on legal regulations.

One critical risk was imposed on a centre in Cork as the inspection team found that the health checks and records of several residents were not properly carried out or retained, while the needs of one resident were not being met.

By law, the general health needs of patients are assessed regularly, not less than six months apart and in line with their care plan, while each patient has access to general health services or can be referred to these as required. St Catherine’s Ward in St Finbarr’s Hospital in Cork was deemed to be non-compliant in this area and a risk rating of critical was ascribed to it, given issues were found that related to four separate patients.

“This is a very basic and critical requirement for residents in any of the approved centres across Ireland and it is simply not good enough that this standard of care is not being met,” said the Chief Executive of the Mental Health Commission, John Farrelly.

While the numbers and skill mix of staffing were sufficient to meet resident needs and an appropriately qualified staff member was on duty and in charge at all times at St Catherine’s, not all health professionals had up-to-date mandatory training. This training issue was also the case at St. Aloysius Ward in the Mater Hospital, Dublin and at St Anne’s Unit in the Sacred Heart Hospital, Castlebar.

“While we recognise the difficulties with recruitment and retention in the health sector, mandatory training is just that,” Mr Farrelly continued. “You cannot be permitted to work in certain environments, including approved centres for mental health, if you do not have the critical training required. We are working with these approved centres to ensure they have a schedule of training in place for all staff to be properly trained as required.”

The Inspector of Mental Health Services, Dr Susan Finnerty, said that while the COVID-19 pandemic did pose challenges and cause issues for some approved centres, staff must keep up with mandatory training in order to provide safe care for residents.

“It is vitally important that the physical health of residents is monitored and treated where necessary. Failure to do so puts the resident at risk of serious illness.”

St Catherine’s Unit is an approved centre located on the grounds of St. Finbarr’s Hospital on Douglas Road in Cork City. Responsibility for the residents' care was undertaken by a dedicated consultant psychiatrist. St. Catherine’s Ward consisted of an upper floor comprised of rooms for day activities, a dining room and a sitting room; and a ground floor comprised of all the bedrooms, a night sitting room and an activity therapy kitchen. A phased building refurbishment programme, paused due to COVID-19-related restrictions, was ongoing on the ground floor. There were 21 registered beds, and 17 were occupied on the day of inspection.

There were two conditions attached to the centre related to staff training and resourcing, although the centre was not in breach of either condition at the time of the inspection.

Overall compliance increased from 66% in 2021 to 74% in 2022. The centre received a critical non-compliance with the regulation on general health. There were gaps in clinical files which could lead to inconsistent or poor care practices. Five clinical files were examined in relation to the provision of general health services during the inspection process. In one clinical file examined, adequate arrangements were not identified for the resident to access general health services and for their referral to other health services as required.

Of five residents who had been in the approved centre for over six months, one clinical file did not have the resident’s blood pressure documented as part of the general health assessment. Two clinical files did not have each of the resident’s waist circumference documented as part of the general health assessment.

The centre also received a critical non-compliance with the regulation on risk management procedures, which did not actively reduce identified risks to the lowest practicable level. Clinical risks were not identified, assessed, treated, reported, monitored, and documented in the risk register as appropriate. Risks associated with the provision of acute clinical care in emergency situations had not been appropriately identified through the centre’s own risk management processes. The inspectors were also concerned that a significant corporate risk had not been sufficiently addressed. This risk related to the lack of resourcing to run a rehabilitation and recovery programme in accordance with the approved centre’s registration certificate.

The centre implemented a plan to reduce risks to residents while any works to the premises were ongoing. However, structural risks, including ligature points, were not removed or effectively mitigated. Ligature risks were not reduced to the lowest practicable level. The centre had reduced risks in some bedrooms that were renovated. However, other bedrooms contained significant ligature risks. 

Following the inspection, the MHC initiated enforcement steps by way of an immediate action notice, requiring the Health Service Executive (HSE), as the registered proprietor, to urgently review and address the critical areas of non-compliance. Following this engagement, the centre submitted specific assurances in relation to risk management which included the specific arrangements for responding to emergency clinical risks. The MHC continues to closely monitor the approved centre’s responses in relation to these issues.

St. Aloysius Ward in the Mater Misericordiae University Hospital (MMUH), Dublin, provided acute adult inpatient psychiatric services for the Dublin North Central catchment area. The registered bed capacity of the unit was 13 beds, and there were 10 residents in situ on the day of the inspection.

The size and capacity of the approved centre was unsuitable for the catchment area and population. The bedrooms were small, multi-occupancy and not en-suite. The layout and size of the approved centre did not accommodate residents who were acutely unwell or exhibiting behaviours required to be facilitated in a low stimulus environment. A new larger purpose-built unit on the MMUH site was a long-term goal; however, there was no definitive plans identified in relation to this.

Compliance rates increased from 72% in 2019 to 88% in 2020 but dropped back down to 73% in 2022. There were no conditions attached to the registration of this approved centre at the time of inspection.

While the numbers and skill mix of staffing were sufficient to meet resident needs and an appropriately qualified staff member was on duty and in charge at all times, not all health professionals had up-to-date mandatory training. In addition, not all health care staff were trained in the fire safety, basic life support and the management of violence and aggression. Staff provided therapeutic activities and physical health monitoring appropriate to the needs of residents and treated - and communicated with - residents in a respectful manner. 

The centre received a high-risk non-compliance with the regulation on premises. Reasons for this included findings that the centre was not kept in a good state of repair internally; several hazards were identified in the unit including low quality glass panes that posed a potential risk to the resident and plastic corner buffers that could easily be removed; and ligatures were not minimised to the lowest practicable level based on risk assessments.

The centre also received a high-risk non-compliance with the regulation on risk management procedures because not all health and safety risks were assessed, reported, monitored and documented, as appropriate, as per the approved centre’s risk management policy.

St Anne’s Unit is a single storey 12-bed unit adjacent to the Sacred Heart Hospital in Castlebar, Co. Mayo. The approved centre provides admission, assessment, care and treatment for two Psychiatry of Later Life teams which covered north and south Mayo. There were only five residents in the unit and the overall bed occupancy rate in 2021 was 40%.

The centre’s compliance rating dropped from 93% in 2021 to 83% in 2022. Three fire doors were observed to be wedged open. This was rectified when pointed out to staff. A fire extinguisher was out of date. The service also managed this risk during the week of inspection. Radiators were not guarded and were hot to touch during the inspection, which resulted in a risk of burns for the residents. Not all staff were trained in basic life support, fire safety or management of violence and aggression.

It was found that the approved centre provided services in a way that met the needs of residents and their families, and that staff provided therapeutic activities and physical health monitoring appropriate to needs of residents. Recreational activities included a gentle exercise group, quizzes, musician on a Monday, jigsaws, colouring, boardgames, movies, music, gardening, cards, television and arts and crafts. Quality initiatives identified on inspection included the establishment of a ligature reduction subgroup to reduce ligatures; and the introduction of a new patient information booklet in November 2021. 

At the time of the inspection a double lock system - a magnetic lock and a lock and key mechanism - was in place for the front door, which was a main fire exit. The approved centre’s rationale for this measure related to safety concerns for individuals with dementia; however, at the time of the inspection five individuals using the service were voluntary and did not have a diagnosis of dementia. This risk was not on the risk register. This was one of the primary causes of a high-risk rating being ascribed to St Anne’s risk management procedures. Fire safety training was not up to date within the nursing department; 36% of nursing staff had not completed the relevant fire training at the time of the inspection.

In terms of corrective and preventative action, staff have been facilitated to attend or have completed all mandatory training. In terms of the locking system, a risk assessment has been completed and the locking system has been added to the local risk register. Advice has also been sought from the maintenance manager and the HSE fire officer with regard to amending the locking system and an update from the fire officer was expected by the end of September 2022. In the interim, all staff hold exit door keys and have a code for exit doors; they have completed online fire training, while unannounced fire drills are completed regularly by an external fire inspector or trainer. An emergency plan policy is also in place that specifies responses by staff in relation to possible emergencies.

You can find our full statement here

St Catherine’s Unit: Inspection Report

St. Aloysius Ward: Inspection Report

St Anne’s Unit: Inspection Report