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COMPLIANCE RATINGS 2017 RATINGS SUMMARY 2015 – 2017 22 6 3 1 3 1 2 3 Inspection Team: Sandra McGrath, Lead Inspector Carol Brennan-Forsyth Leon Donovan Inspection Date: 20 – 22 June 2017 Inspection Type: Unannounced Annual Inspection Previous Inspection Date: 4 – 7 October 2016 The Inspector of Mental Health Services: Dr Susan Finnerty MCRN009711 Date of Publication: 9 November 2017 RULES AND PART 4 OF THE MENTAL HEALTH ACT 2001 Compliant Le Brun House & Whitethorn House, Vergemount Mental Health Facility ID Number: AC0095 2017 Approved Centre Inspection Report (Mental Health Act 2001) Le Brun House & Whitethorn House Vergemount Mental Health Facility Clonskeagh Hospital Clonskeagh Dublin 6 Approved Centre Type: Continuing Mental Health Care/Long Stay Psychiatry of Later Life Most Recent Registration Date: 9 February 2015 Conditions Attached: None Registered Proprietor: HSE Registered Proprietor Nominee: Ms Martina Queally, Chief Officer, CHO 6 REGULATIONS CODES OF PRACTICE Non-compliant Not applicable

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Page 1: Le Brun House & Whitethorn House, Vergemount Mental Health ... · AC0095 Le Brun House & Whitethorn House, Vergemount Mental Health Facility Approved Centre Inspection Report 2017

COMPLIANCE RATINGS 2017

RATINGS SUMMARY 2015 – 2017

22

6

3 1

3

1

2

3

Inspection Team:

Sandra McGrath, Lead Inspector

Carol Brennan-Forsyth

Leon Donovan

Inspection Date: 20 – 22 June 2017

Inspection Type: Unannounced Annual Inspection

Previous Inspection Date: 4 – 7 October 2016

The Inspector of Mental Health Services:

Dr Susan Finnerty MCRN009711

Date of Publication: 9 November 2017

RULES AND PART 4 OF THE MENTAL HEALTH ACT 2001

Compliant

Le Brun House & Whitethorn House, Vergemount Mental Health Facility

ID Number: AC0095

2017 Approved Centre Inspection Report (Mental Health Act 2001)

Le Brun House & Whitethorn House

Vergemount Mental Health Facility

Clonskeagh Hospital

Clonskeagh

Dublin 6

Approved Centre Type:

Continuing Mental Health Care/Long Stay Psychiatry of Later Life

Most Recent Registration Date:

9 February 2015

Conditions Attached: None

Registered Proprietor:

HSE

Registered Proprietor Nominee:

Ms Martina Queally, Chief Officer, CHO 6

REGULATIONS

CODES OF PRACTICE

Non-compliant

Not applicable

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Compliance ratings across all 41 areas of inspection are summarised in the chart below.

Chart 1 – Comparison of overall compliance ratings 2015 – 2017

Where non-compliance is determined, the risk level of the non-compliance will be assessed. Risk ratings

across all non-compliant areas are summarised in the chart below.

Chart 2 – Comparison of overall risk ratings 2015 – 2017

9 9 9

15 138

17 1924

0

5

10

15

20

25

30

35

40

45

2015 2016 2017

Not applicable Non-compliant Compliant

6

2 2

7

9

3

2

2

3

0

2

4

6

8

10

12

14

16

2015 2016 2017

Low Moderate High Critical

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Contents 1.0 Introduction to the Inspection Process ............................................................................................ 5

2.0 Inspector of Mental Health Services – Summary of Findings .......................................................... 7

3.0 Quality Initiatives ........................................................................................................................... 10

4.0 Overview of the Approved Centre ................................................................................................. 11

4.1 Description of approved centre ............................................................................................. 11

4.2 Conditions to registration ...................................................................................................... 11

4.3 Reporting on the National Clinical Guidelines ....................................................................... 11

4.4 Governance ............................................................................................................................ 12

5.0 Compliance ..................................................................................................................................... 13

5.1 Non-compliant areas from 2016 inspection .......................................................................... 13

5.2 Non-compliant areas on this inspection ................................................................................ 14

5.3 Areas of compliance rated Excellent on this inspection ........................................................ 14

6.0 Service-user Experience ................................................................................................................. 15

7.0 Interviews with Heads of Discipline ............................................................................................... 16

8.0 Feedback Meeting .......................................................................................................................... 17

9.0 Inspection Findings – Regulations .................................................................................................. 18

10.0 Inspection Findings – Rules .......................................................................................................... 59

11.0 Inspection Findings – Mental Health Act 2001 ............................................................................ 63

12.0 Inspection Findings – Codes of Practice ....................................................................................... 65

Appendix 1: Corrective and Preventative Action Plan Template – Le Brun House and Whitethorn House, Vergemount Mental Health Facility ............................................................................................................................ 73

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The principal functions of the Mental Health Commission are to promote, encourage and foster the

establishment and maintenance of high standards and good practices in the delivery of mental health

services and to take all reasonable steps to protect the interests of persons detained in approved centres.

The Commission strives to ensure its principal legislative functions are achieved through the registration and

inspection of approved centres. The process for determination of the compliance level of approved centres

against the statutory regulations, rules, Mental Health Act 2001 and codes of practice shall be transparent

and standardised.

Section 51(1)(a) of the Mental Health Act 2001 (the 2001 Act) states that the principal function of the

Inspector shall be to “visit and inspect every approved centre at least once a year in which the

commencement of this section falls and to visit and inspect any other premises where mental health services

are being provided as he or she thinks appropriate”.

Section 52 of the 2001 Act states that, when making an inspection under section 51, the Inspector shall

a) See every resident (within the meaning of Part 5) whom he or she has been requested to examine

by the resident himself or herself or by any other person.

b) See every patient the propriety of whose detention he or she has reason to doubt.

c) Ascertain whether or not due regard is being had, in the carrying on of an approved centre or other

premises where mental health services are being provided, to this Act and the provisions made

thereunder.

d) Ascertain whether any regulations made under section 66, any rules made under section 59 and 60

and the provision of Part 4 are being complied with.

Each approved centre will be assessed against all regulations, rules, codes of practice, and Part 4 of the 2001

Act as applicable, at least once on an annual basis. Inspectors will use the triangulation process of

documentation review, observation and interview to assess compliance with the requirements. Where non-

compliance is determined, the risk level of the non-compliance will be assessed.

The Inspector will also assess the quality of services provided against the criteria of the Judgement Support

Framework. As the requirements for the rules, codes of practice and Part 4 of the 2001 Act are set out

exhaustively, the Inspector will not undertake a separate quality assessment. Similarly, due to the nature of

Regulations 28, 33 and 34 a quality assessment is not required.

Following the inspection of an approved centre, the Inspector prepares a report on the findings of the

inspection. A draft of the inspection report, including provisional compliance ratings, risk ratings and quality

assessments, is provided to the registered proprietor of the approved centre. Areas of inspection are

deemed to be either compliant or non-compliant and where non-compliant, risk is rated as low, moderate,

high or critical.

1.0 Introduction to the Inspection Process

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The registered proprietor is given an opportunity to review the draft report and comment on any of the

content or findings. The Inspector will take into account the comments by the registered proprietor and

amend the report as appropriate.

The registered proprietor is requested to provide a Corrective and Preventative Action (CAPA) plan for each

finding of non-compliance in the draft report. Corrective actions address the specific non-compliance(s).

Preventative actions mitigate the risk of the non-compliance reoccurring. CAPAs must be specific,

measurable, realistic, achievable and time-bound (SMART). The approved centre’s CAPAs are included in the

published inspection report, as submitted. The Commission monitors the implementation of the CAPAs on

an ongoing basis and requests further information and action as necessary.

If at any point the Commission determines that the approved centre’s plan to address an area of non-

compliance is unacceptable, enforcement action may be taken.

In circumstances where the registered proprietor fails to comply with the requirements of the 2001 Act,

Mental Health Act 2001 (Approved Centres) Regulations 2006 and Rules made under the 2001 Act, the

Commission has the authority to initiate escalating enforcement actions up to, and including, removal of an

approved centre from the register and the prosecution of the registered proprietor.

COMPLIANCE, QUALITY AND RISK RATINGS

The following ratings are assigned to areas inspected. COMPLIANCE RATINGS are given for all areas inspected. QUALITY RATINGS are given for all regulations, except for 28, 33 and 34. RISK RATINGS

are given for any area that is deemed non-compliant.

COMPLIANCE

COMPLIANT

EXCELLENT

LOW

QUALITY RISK

NON-COMPLIANT

SATISFACTORY

MODERATE REQUIRES IMPROVEMENT

INADEQUATE HIGH

CRITICAL

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Inspector of Mental Health Services Dr Susan Finnerty As Inspector of Mental Health Services, I have provided a summary of inspection findings under the headings

below.

This summary is based on the findings of the inspection team under the regulations and associated

Judgement Support Framework, rules, Part 4 of the Mental Health Act 2001, codes of practice, service user

experience, staff interviews and governance structures and operations, all of which are contained in this

report.

Safety in the approved centre The approved centre had a written policy in relation to health and safety as well as a corporate safety

statement and a general safety statement. The risk management policy was satisfactory. However, the risk

management policy was not being fully implemented, as there were significant structural ligature risks

throughout the premises. The environment did not provide sufficient controls to prevent accidental injury

to residents and staff were not aware of evacuation procedures.

Resident identifiers were checked before the administration of medication, the undertaking of medical

investigations, and the provision of health care services and therapeutic services and programmes. There

was no evidence that food safety audits had been completed. Hygiene was maintained to support food

safety, and catering areas and associated equipment were appropriately cleaned. Medication ordering,

prescription, storage and administration was conducted in a safe manner. Not all staff had been trained in

Basic Life Support, fire safety, management of aggression and violence or the Mental Health Act 2001.

AREAS REFERRED TO Regulations 4, 6, 22, 23, 24, 26, 32, Rule Governing the Use of Seclusion, Code of Practice on the Use of Physical Restraint, the Rule and Code of Practice on the Use of ECT, service user experience, and interviews with staff.

Appropriate care and treatment of residents The needs of residents identified as having special nutritional requirements were regularly reviewed by the

dietitian. Individual care plans were satisfactory. There were no therapeutic programmes delivered by health

and social care professionals in the approved centre, especially for residents in the approved centre with

enduring mental illness who were identified as needing a rehabilitation and recovery model of care. There

were plans to fully implement a rehabilitation and recovery team but this was not yet in place. There was no

occupational therapy provided for the residents. Good working relationships with on-site primary care

allowed for seating assessments and reviews to continue. An activities nurse provided a range of therapeutic

and recreational activities. There was a physiotherapist actively involved within the service but there was no

dedicated therapy room and physiotherapy took place in communal areas. A GP attended the approved

centre every weekday to assess residents’ general health needs. Adequate arrangements were in place for

2.0 Inspector of Mental Health Services – Summary of Findings

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residents to access general services and for their referral to other health services, as required. Not all the

required six-monthly physical reviews of residents were completed. The clinical files were kept in good order.

The use of mechanical restraint in the approved centre was compliant with Part 5 of the Rules Governing the

Use of Mechanical Means of Bodily Restraint for Enduring Risk of Harm to Self or Others. The transfer and

discharge policies were incomplete.

AREAS REFERRED TO Regulations 5, 14, 15, 16, 17, 18, 19, 23, 25, 27, Part 4 of the Mental Health Act 2001, Rule Governing the Use of Seclusion and Mechanical Means of Bodily Restraint, Rule Governing the Use of ECT, Code of Practice on Physical Restraint, Code of Practice on the Admission of Children, Code of Practice on the Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities, Code of Practice on Admission, Transfer and Discharge, service user experience, and interviews with staff.

Respect for residents’ privacy and dignity Residents were supported to keep and wear their personal clothing, and each had an individual locker and

wardrobe in which to store it. Residents’ clothes were observed to be clean and appropriate to their needs.

Residents could bring personal possessions into the approved centre and were supported to manage their

own property. Residents had lockers in which to secure personal effects. End of life care took into account

the resident’s physical, emotional, social, psychological, and spiritual needs. Noticeboards in the nurses’

stations at the time of inspection displayed full names of residents in the approved centre which could be

viewed by staff and visitors. Apart from this, resident’s privacy was respected. No episode of physical

restraint had been recorded in the approved centre since 2015.

AREAS REFERRED TO Regulations 7, 8, 13, 14, 21, 25, Rule Governing the Use of Seclusion, Code of Practice on Physical Restraint, Code of Practice on the Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities, service user experience, and interviews with staff.

Responsiveness to residents’ needs Food, including modified consistency diets, was presented in an appealing manner and residents were

provided with a variety of wholesome and nutritious food choices. Residents had access to appropriate one-

to-one and group recreational activities on weekdays and at weekends. Recreational activities were

appropriately resourced, and opportunities were available for indoor and outdoor exercise and physical

activity. There were suitable indoor areas for recreation, with designated activities rooms in both houses.

Residents were facilitated in the practice of their religion. There was a chapel in the main hospital and the

chaplain visited regularly. Residents also had access to multi-faith chaplains, when required. Visiting times

were flexible, and private areas were available for visiting. A separate room was available to accommodate

visiting children. Residents had access to external communications, including telephone, mail, fax, e-mail,

and Internet. Required information was given to residents and/or their representatives at admission in the

form of a resident information booklet. Diagnosis- and medication-related leaflets were available. Leaflets

were accessible and contained evidence-based information. There was a satisfactory complaints procedure

in operation and guidance on how to make a complaint was clearly displayed.

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The approved centre was not in a good state of repair. There were broken floor tiles, badly scuffed walls and

architraves around doors, walls in need of repainting, a loose toilet roll holder in one toilet, and the remnants

of old towel rails on the walls of some toilets. There was no ongoing programme of decorative maintenance.

A cleaning schedule was in place, and the approved centre was clean, hygienic, and free from offensive

odours. The approved centre premises were not appropriate to the care needs of residents. No plans had

been finalised to remedy this.

AREAS REFERRED TO Regulations 5, 9, 10, 11, 12, 20, 22, 30, 31, Code of Practice on the Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities, service user experience, and interviews with staff.

Governance of the approved centre Le Brun House and Whitethorn House Vergemount Mental Health Facility was in Community Healthcare

Organisation (CHO) 6. There was an Executive Management Team which met monthly. Le Brun House and

Whitethorn House were Psychiatry of Later Life (POLL) facilities and two consultant psychiatrists had overall

responsibility for the resident group. A rehabilitation/recovery team was established and awaiting the

appointment of a consultant psychiatrist.

An organisational chart clearly outlined the governance structure. There had been recent changes to the

structure and some newly appointed roles. Reporting procedures throughout the approved centre were

clearly defined. There was a Quality and Risk group that met monthly. Significant work had been undertaken

to bring policies into line with both regulatory requirements and operations within the service.

AREAS REFERRED TO Regulations 26 and 32, interviews with heads of discipline, and minutes of area management team meetings.

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The following quality initiatives were identified on this inspection:

A garden project was under way.

Staff had sought expertise on environmental modification and visual alerts for residents with

Alzheimer’s/dementia and had started work on making the environment more comfortable for

residents.

Four staff were trained in SONAS.

A suggestion box had been introduced.

The palliative care and family room in Whitethorn was completed and the palliative care and family

room in Le Brun was close to completion.

Bed capacity in Le Brun had been reduced to allow for a review of the service.

Various audits and nursing metrics had been introduced in both units.

A number of staff were involved in train the trainer with a view to implementing the quality and

safety training programme across CHO 6.

The approved centre was in the process of reviewing all policies, with a large number having been

reviewed and approved at the time of inspection.

3.0 Quality Initiatives

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4.1 Description of approved centre The approved centre was on the grounds of Clonskeagh Hospital in south Dublin and part of Community

Healthcare Organisation (CHO) 6. It was set at the back of large grounds and there were a number of other

health care facilities on-site. Vergemount consisted of two separate units, Whitethorn and Le Brun. The

exteriors of both were clean and well maintained. Vergemount facilitated Psychiatry of Later Life:

Whitethorn provided continuing care to people with enduring mental illness and Le Brun provided

continuing care to residents with an additional diagnosis of Alzheimer’s/dementia.

Both units were in need of refurbishment and renovation to bring them up to the standards set out in

building regulations as they apply to in-patient mental health services. Senior management for CHO 6 were

aware of the environmental deficits and had plans to improve facilities for residents. There were well kept

and functional internal gardens for each unit that were used frequently by residents.

The inspection took place at a time of significant change across CHO 6 and it was evident throughout the

course of the inspection that the approved centre was going through transition. Staff and management were

continuing in efforts to streamline services and improve safety and quality within Vergemount.

Improvements were reflected throughout the course of the inspection.

The resident profile on the first day of inspection was as follows:

Resident Profile

Number of registered beds 52

Total number of residents 36

Number of detained patients 0

Number of Wards of Court 5

Number of children 0

Number of residents in the approved centre for more than 6 months 34

4.2 Conditions to registration

There were no conditions attached to the registration of this approved centre at the time of inspection.

4.3 Reporting on the National Clinical Guidelines

The service reported that it was cognisant of and implemented, where indicated, the National Clinical

Guidelines as published by the Department of Health.

4.0 Overview of the Approved Centre

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4.4 Governance

The service manager, general manager, executive clinical director, nursing management, and allied health

professional departmental heads held responsibility for the whole of CHO 6. Vergemount was a Psychiatry

of Later Life (POLL) facility and two consultant psychiatrists had overall responsibility for the resident group.

There was a psychiatric and nursing management presence within the approved centre. The mental health

social work and occupational therapy departments were undergoing development and change following the

appointment of heads of department. Neither department had any assigned clinical responsibility within the

approved centre, although they did support the service on request. This arrangement was informal and

based on good working relationships. As there was no formal, assigned responsibility to Vergemount, the

inspection team was concerned because the needs of the residents of Vergemount were not prioritised with

resources allocated mainly to the community. The POLL occupational therapist for CHO 6 was not based in

the approved centre and was not involved in the approved centre at the time of the inspection.

Meetings with senior management indicated plans to streamline CHO 6, which were well under way. A

rehabilitation/recovery team was established and awaiting the appointment of a consultant psychiatrist.

This team will have assigned responsibility for provision of care within Vergemount and will fill a current gap

for residents identified as needing a rehab/recovery model of care. This will improve therapeutic input for

POLL and continuing care residents who were not receiving adequate therapeutic services from allied

healthcare professionals at the time of inspection.

The organisational chart clearly outlined the governance structure. There had been recent changes to the

structure and some newly appointed roles. Reporting procedures throughout the approved centre were

clearly defined.

There was a Quality and Risk group that met monthly. Minutes of these meetings were provided. The

Executive Management Team also met monthly and minutes of these meetings were provided to the

inspection team. Both sets of minutes indicated transparent and responsive service across CHO 6, with

assigned responsibility for completing actions and a process of review.

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5.1 Non-compliant areas from 2016 inspection

The previous inspection of the approved centre on 4 – 6 October 2016 identified the following areas that

were non-compliant. The approved centre was requested to provide Corrective and Preventative Actions

(CAPAs) for areas of non-compliance and these were published with the 2016 inspection report.

Regulation/Rule/Act/Code 2017 Inspection Findings

Regulation 8: Residents’ Personal Property and Possessions Compliant

Regulation 15: Individual Care Plan Compliant

Regulation 20: Provision of Information to Residents Compliant

Regulation 21: Privacy Compliant

Regulation 22: Premises Non-Compliant

Regulation 23: Ordering, Prescribing, Storing and Administration of Medicines

Compliant

Regulation 26: Staffing Non-Compliant

Regulation 27: Maintenance of Records Compliant

Regulation 29: Operating Policies and Procedures Compliant

Regulation 31: Complaints Procedures Compliant

Regulation 32: Risk Management Procedures Non-Compliant

Code of Practice for Mental Health Services on Notification of Deaths and Incident Reporting

Non-Compliant

Code of Practice on Admission, Transfer and Discharge to and from an Approved Centre

Non-Compliant

5.0 Compliance

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5.2 Non-compliant areas on this inspection

Non-compliant (X) areas on this inspection are detailed below. Also shown is whether the service was

compliant () or non-compliant (X) in these areas in 2016 and 2015:

Regulation/Rule/Act/Code 2015 Compliance

2016 Compliance

2017 Compliance

Regulation 16: Therapeutic Services and Programmes X

Regulation 19: General Health X

Regulation 21: Privacy X X X

Regulation 22: Premises X X X

Regulation 26: Staffing X X X

Regulation 32: Risk Management Procedures X X

Code of Practice for Mental Health Services on Notification of Deaths and Incident Reporting

X X X

Code of Practice on Admission, Transfer and Discharge to and from an Approved Centre

X X X

The approved centre was requested to provide Corrective and Preventative Actions (CAPAs) for areas of non-

compliance. These are included in Appendix 1 of the report.

5.3 Areas of compliance rated Excellent on this inspection

No areas of compliance were rated excellent on this inspection.

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The Inspector gives emphasis to the importance of hearing the service users’ experience of the approved

centre. To that end, the inspection team engage with residents in a number of different ways:

The inspection team informally approach residents and seek their views on the approved centre.

Posters are displayed inviting the residents to talk to the inspection team.

Leaflets are distributed in the approved centre explaining the inspection process and inviting

residents to talk to the inspection team.

Set times and a private room are made available to talk to residents.

In order to facilitate residents who are reluctant to talk directly with the inspection team, residents

are also invited to complete a service user experience questionnaire and give it in confidence to the

inspection team. This is anonymous and used to inform the inspection process.

The Irish Advocacy Network (IAN) representative is contacted if they have input into the approved

centre to obtain residents’ feedback about the approved centre.

With the residents’ permission, their experience was fed back to the senior management team. The

information was used to give a general picture of residents’ experience of the approved centre as outlined

below.

Based on the resident profile, two of the inspection team went to communal areas and had informal

conversations with residents. Residents were made aware of who the inspectors were and were invited to

speak to them if they wished about their experience of the approved centre. Some residents spoke about

the approved centre, and some engaged with inspectors in general conversation about their lives. Inspectors

observed a relaxed atmosphere among residents. Residents were complimentary about the service overall.

They felt the care was good and praised the staff working in the units. Individual residents had minor

complaints, which were passed onto the nursing managers to be addressed as appropriate.

6.0 Service-user Experience

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The inspection team sought to meet with heads of discipline during the inspection. The inspection team met

with the following individuals:

Clinical Director

Assistant Director of Nursing (x2)

Occupational Therapy Manager

Head of Social Work

General Manager

Nurse Practice Development Coordinator

Consultant Psychiatrist for continuing care

Interviews with heads of discipline indicated significant operational changes across CHO 6. Operational

policies were in the process of review and those that had been reviewed and approved met the requirements

of the Judgement Support Framework (JSF). The approved centre premises were not appropriate to the care

needs of residents. This was acknowledged by senior management who communicated plans to update the

premises. However, no plans had been finalised and there was no timeframe indicated. An occupational

therapy (OT) manager had taken up post nine months prior to inspection. There were positive developments

within the department but no OT had assigned clinical responsibility in Vergemount. The social work

department had undergone positive change and development since the recruitment of a department head

18 months prior to this inspection. Efforts were being made to communicate the role of social work clearly

within the approved centre as it was reported that social work was being accessed in a limited way.

It was reported that a review was underway to ensure appropriate admissions to Vergemount going forward;

admission based on a diagnosed mental illness or mental disorder. The service is not designed to meet

continued care needs of residents where physical/medical needs become the primary concern.

Staffing remained an issue within Vergemount with senior staff reporting they are operating 51% below the

recommended levels of Vision for Change (2006). At the time of inspection there were an unconfirmed

number of nursing vacancies. The self-staffing system in place allowed for these hours to be filled, so far as

possible, by regular staff and for continuity of care for the residents in Vergemount.

7.0 Interviews with Heads of Discipline

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A feedback meeting was facilitated prior to the conclusion of the inspection. This was attended by the

inspection team and the following representatives of the service:

A feedback meeting was facilitated prior to the conclusion of the inspection. This was attended by the

inspection team and the following representatives of the service:

Clinical Director

General Manager

Clinical Psychologist

Consultant in Old Age Psychiatry

Consultant Psychiatrist

Area Lead for Mental Health Engagement

Head of Social Work Department

Assistant Director of Nursing x2

Clinical Nurse Manager 2 x2

Nurse Practice Development Coordinator

Senior Dietitian

Clinical Nurse Specialist – Activities

The inspection team outlined the initial findings of the inspection process and provided the opportunity for

the service to offer any corrections or clarifications deemed appropriate. Significant work had been

undertaken to bring policies into line with both regulatory requirements and operations within the service.

A discussion was held to ensure the inspection team had received all of the required information, which they

had not. The service was asked to forward this information to the lead inspector as soon as possible.

8.0 Feedback Meeting

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9.0 Inspection Findings – Regulations

The following regulations are not applicable Regulation 1: Citation Regulation 2: Commencement and Regulation Regulation 3: Definitions

EVIDENCE OF COMPLIANCE WITH REGULATIONS UNDER MENTAL HEALTH ACT 2001 SECTION 52 (d)

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Regulation 4: Identification of Residents

The registered proprietor shall make arrangements to ensure that each resident is readily identifiable by staff when receiving medication, health care or other services.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the identification of residents, which was dated April 2017. It included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed a log, indicating that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for identifying residents, as set out in the policy. Monitoring: An annual audit had been undertaken to ensure that clinical files contained appropriate resident identifiers, and an action plan had been put in place. Documented analysis had been completed to identify opportunities for improving the resident identification process. Evidence of Implementation: At least two of the following resident identifiers were used in the approved centre: photograph, PIN number, date of birth, and name. The person-specific identifiers were appropriate to residents’ communication abilities, the resident group profile, and individual residents’ needs. They were checked before the administration of medication, the undertaking of medical investigations, and the provision of health care services and therapeutic services and programmes. A sticker system was used on clinical files to alert staff to the presence of residents with the same or a similar name. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education pillar.

COMPLIANT Quality Rating Satisfactory

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Regulation 5: Food and Nutrition

(1) The registered proprietor shall ensure that residents have access to a safe supply of fresh drinking water.

(2) The registered proprietor shall ensure that residents are provided with food and drink in quantities adequate for their needs, which is properly prepared, wholesome and nutritious, involves an element of choice and takes account of any special dietary requirements and is consistent with each resident's individual care plan.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the provision of appropriate food and nutrition to residents, which was dated April 2017. It included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed a log, indicating that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for food and nutrition, as set out in the policy. Monitoring: A systematic review of menu plans had been undertaken to ensure that residents received wholesome and nutritious food in accordance with their needs. The dietitian had completed an analysis to identify opportunities for improving the processes for food and nutrition. Evidence of Implementation: Menus were nutritionally analysed by a dietitian to ensure nutritional adequacy in accordance with residents’ needs. Food, including modified consistency diets, was presented in an appealing manner. Residents were provided with a variety of wholesome and nutritious food choices, and hot meals were served on a daily basis. Residents had regular access to hot and cold drinks and to a source of safe, fresh drinking water from dispensers. For residents with special dietary needs, the Mini Nutritional Assessment tool was used monthly. Weight charts were implemented, monitored, and acted upon monthly and more often where required. Residents, their representatives, family, and next of kin were educated about residents’ diets, where appropriate. The needs of residents identified as having special nutritional requirements were regularly reviewed by the dietitian. The dietitian normally attended the approved centre on a weekly basis and took referrals. Nutritional and dietary needs were assessed, where necessary, and addressed in residents’ individual care plans. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education pillar.

COMPLIANT Quality Rating Satisfactory

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Regulation 6: Food Safety

(1) The registered proprietor shall ensure:

(a) the provision of suitable and sufficient catering equipment, crockery and cutlery

(b) the provision of proper facilities for the refrigeration, storage, preparation, cooking and serving of food, and

(c) that a high standard of hygiene is maintained in relation to the storage, preparation and disposal of food and related refuse.

(2) This regulation is without prejudice to:

(a) the provisions of the Health Act 1947 and any regulations made thereunder in respect of food standards (including labelling) and safety;

(b) any regulations made pursuant to the European Communities Act 1972 in respect of food standards (including labelling) and safety; and

(c) the Food Safety Authority of Ireland Act 1998.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to food safety, which was dated April 2017. It included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed a log, indicating that they had read and understood the policy. Relevant staff interviewed could articulate the processes for food safety, as set out in the policy. All staff handling food had up-to-date training in the application of Hazard Analysis and Critical Control Point (HACCP). The training was documented. Monitoring: There was no evidence that food safety audits had been periodically completed, and the last environmental health inspection had been in 2015. Food temperatures were in line with food safety recommendations, and a temperature log sheet was maintained and monitored. Analysis had not been completed to identify opportunities for improving food safety processes. Evidence of Implementation: Appropriate hand-washing areas were provided for catering services, and there was suitable and sufficient catering equipment. No meals were prepared or cooked in the approved centre, but the kitchenette had appropriate facilities for the refrigeration, storage, cooking, and serving of food. Hygiene was maintained to support food safety, and catering areas and associated equipment were appropriately cleaned. Residents had access to a supply of suitable crockery and cutlery. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education and monitoring pillars.

COMPLIANT Quality Rating Satisfactory

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Regulation 7: Clothing

The registered proprietor shall ensure that:

(1) when a resident does not have an adequate supply of their own clothing the resident is provided with an adequate supply of appropriate individualised clothing with due regard to his or her dignity and bodily integrity at all times;

(2) night clothes are not worn by residents during the day, unless specified in a resident's individual care plan.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to clothing, which was last reviewed in April 2017. It included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed a log, indicating that they had read and understood the policy. Relevant staff interviewed could articulate the processes in relation to residents’ clothing, as set out in the policy. Monitoring: The availability of an emergency supply of resident clothing was monitored. A record of residents wearing nightclothes during the day was maintained and monitored. At the time of the inspection, no residents were observed wearing night attire during the day. Evidence of Implementation: Residents were supported to keep and wear their personal clothing, and each had an individual locker and wardrobe in which to store it. Residents’ clothes were observed to be clean and appropriate to their needs. Residents’ clothing was laundered on-site and appropriately labelled. An emergency supply of clothing was available in both Le Brun and Whitethorn. The clothes were appropriate and took account of the residents’ preferences, dignity, bodily integrity, and religious and cultural practices. During the inspection, all residents were wearing day clothes. All residents had an adequate supply of individualised clothing. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education pillar.

COMPLIANT Quality Rating Satisfactory

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Regulation 8: Residents’ Personal Property and Possessions

(1) For the purpose of this regulation "personal property and possessions" means the belongings and personal effects that a resident brings into an approved centre; items purchased by or on behalf of a resident during his or her stay in an approved centre; and items and monies received by the resident during his or her stay in an approved centre.

(2) The registered proprietor shall ensure that the approved centre has written operational policies and procedures relating to residents' personal property and possessions.

(3) The registered proprietor shall ensure that a record is maintained of each resident's personal property and possessions and is available to the resident in accordance with the approved centre's written policy.

(4) The registered proprietor shall ensure that records relating to a resident's personal property and possessions are kept separately from the resident's individual care plan.

(5) The registered proprietor shall ensure that each resident retains control of his or her personal property and possessions except under circumstances where this poses a danger to the resident or others as indicated by the resident's individual care plan.

(6) The registered proprietor shall ensure that provision is made for the safe-keeping of all personal property and possessions.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to residents’ personal property and possessions, which was last reviewed in April 2017. It included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed a log, indicating that they had read and understood the policy. Relevant staff interviewed could articulate the processes relating to residents’ property and possessions, as set out in the policy. Monitoring: Each resident had a personal property log, which was monitored. Analysis had not been completed to identify opportunities for improving the processes around residents’ personal property and possessions. Evidence of Implementation: Residents could bring personal possessions into the approved centre and were supported to manage their own property, unless this posed a danger to themselves or others, as indicated in their individual care plans. Residents were allocated lockers in which to secure personal-effects. Where residents were unable to manage their own property, their families were encouraged to become involved. A resident property log was generated on admission and subsequently updated as required. Residents or their next of kin generally looked after their own money. The approved centre maintained a signed property checklist, which was kept separately from residents’ individual care plans. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education and monitoring pillars.

COMPLIANT Quality Rating Satisfactory

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Regulation 9: Recreational Activities

The registered proprietor shall ensure that an approved centre, insofar as is practicable, provides access for residents to appropriate recreational activities.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the provision of recreational activities, which was last reviewed in April 2017. The policy included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed a log, indicating that they had read and understood the policy. Relevant staff interviewed could articulate the processes relating to recreational activities, as set out in the policy. Monitoring: A record was maintained of the occurrence of planned recreational activities, including a record of resident attendance. The approved centre completed an annual audit of the provision of recreational activities, which included recommendations for improving the processes relating to recreation. Evidence of Implementation: Residents had access to appropriate one-to-one and group recreational activities. The clinical nurse specialist with responsibility for activities along with four SONAS-trained staff worked with residents in the approved centre on weekdays and at weekends. There was a timetable in place outlining weekly activities, which varied according to resident preferences and needs. Activities were discussed at the resident monthly meetings and on a daily basis, and residents had involvement in the development and implementation of activities.

Recreational activities were appropriately resourced, and opportunities were available for indoor and outdoor exercise and physical activity. There were suitable indoor areas for recreation, with designated activities rooms in both houses. Sitting rooms were also used for activities such as watching movies and music sessions. Where appropriate, residents were risk-assessed in relation to the selection of appropriate activities. Residents’ decisions on whether or not to participate in activities were respected. Records of resident attendance at events were maintained in their clinical files. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education pillar.

COMPLIANT Quality Rating Satisfactory

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Regulation 10: Religion

The registered proprietor shall ensure that residents are facilitated, insofar as is reasonably practicable, in the practice of their religion.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the facilitation of religious practice by residents, which was last reviewed in April 2017. It included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed a log, indicating that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes for facilitating residents in the practice of their religion, as set out in the policy. Monitoring: The implementation of the policy on religion had not been reviewed to ensure that residents’ identified religious needs were met. Evidence of Implementation: Residents were facilitated in the practice of their religion insofar as was practicable. There was a chapel in the main hospital where residents could attend mass, and the chaplain visited regularly. Residents also had access to multi-faith chaplains, where required, and staff consulted the Health Services Intercultural Guide if they needed information about a particular religion or culture. Following a risk assessment, residents could attend religious services outside of the approved centre, if deemed appropriate. At the time of the inspection, residents did not attend religious services outside of the hospital. The care and services provided within the approved centre were respectful of residents’ religious beliefs and values, and residents were facilitated in observing or abstaining from religious practice in line with their wishes. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education and monitoring pillars.

COMPLIANT Quality Rating Satisfactory

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Regulation 11: Visits

(1) The registered proprietor shall ensure that appropriate arrangements are made for residents to receive visitors having regard to the nature and purpose of the visit and the needs of the resident.

(2) The registered proprietor shall ensure that reasonable times are identified during which a resident may receive visits.

(3) The registered proprietor shall take all reasonable steps to ensure the safety of residents and visitors.

(4) The registered proprietor shall ensure that the freedom of a resident to receive visits and the privacy of a resident during visits are respected, in so far as is practicable, unless indicated otherwise in the resident's individual care plan.

(5) The registered proprietor shall ensure that appropriate arrangements and facilities are in place for children visiting a resident.

(6) The registered proprietor shall ensure that an approved centre has written operational policies and procedures for visits.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to visits, which was last reviewed in April 2017. It included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed a log, indicating that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes relating to visits, as set out in the policy. Monitoring: At the time of the inspection, there were no restrictions on residents’ rights to receive visitors. Analysis had not been completed to identify opportunities for improving visiting processes. Evidence of Implementation: Visiting times, which were appropriate and very flexible, were publicly displayed in the approved centre. The open veranda area was commonly used for visits, and the relaxation room could be used for private visits, unless there was an identified risk to the resident or to others or a health and safety risk. Appropriate steps were taken to ensure visitor safety and the safety of residents during visits. Children were welcome when accompanied by an adult at all times to ensure their safety. A separate room was available to accommodate visiting children. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education and monitoring pillars.

COMPLIANT Quality Rating Satisfactory

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Regulation 12: Communication

(1) Subject to subsections (2) and (3), the registered proprietor and the clinical director shall ensure that the resident is free to communicate at all times, having due regard to his or her wellbeing, safety and health.

(2) The clinical director, or a senior member of staff designated by the clinical director, may only examine incoming and outgoing communication if there is reasonable cause to believe that the communication may result in harm to the resident or to others.

(3) The registered proprietor shall ensure that the approved centre has written operational policies and procedures on communication.

(4) For the purposes of this regulation "communication" means the use of mail, fax, email, internet, telephone or any device for the purposes of sending or receiving messages or goods.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to resident communication, which was last reviewed in April 2017. It included all of the requirements of the Judgement Support Framework. Training and Education: Not all relevant staff had signed a log, indicating that they had read and understood the policy. Relevant staff interviewed could articulate the processes for facilitating residents’ communication needs. Monitoring: Residents’ communication needs were monitored on an ongoing basis, and there were no restrictions on resident communication. Documented analysis had been completed to identify opportunities for improving communication processes. Evidence of Implementation: Residents had access to external communications, including telephone, mail, fax, e-mail, and Internet. Individual risk assessments were completed for residents in relation to their external communication at admission. At the time of the inspection, no residents were assessed as being at risk. The approved centre did not monitor incoming or outgoing resident communication. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education pillar.

COMPLIANT Quality Rating Satisfactory

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Regulation 13: Searches

(1) The registered proprietor shall ensure that the approved centre has written operational policies and procedures on the searching of a resident, his or her belongings and the environment in which he or she is accommodated.

(2) The registered proprietor shall ensure that searches are only carried out for the purpose of creating and maintaining a safe and therapeutic environment for the residents and staff of the approved centre.

(3) The registered proprietor shall ensure that the approved centre has written operational policies and procedures for carrying out searches with the consent of a resident and carrying out searches in the absence of consent.

(4) Without prejudice to subsection (3) the registered proprietor shall ensure that the consent of the resident is always sought.

(5) The registered proprietor shall ensure that residents and staff are aware of the policy and procedures on searching.

(6) The registered proprietor shall ensure that there is be a minimum of two appropriately qualified staff in attendance at all times when searches are being conducted.

(7) The registered proprietor shall ensure that all searches are undertaken with due regard to the resident's dignity, privacy and gender.

(8) The registered proprietor shall ensure that the resident being searched is informed of what is happening and why.

(9) The registered proprietor shall ensure that a written record of every search is made, which includes the reason for the search.

(10) The registered proprietor shall ensure that the approved centre has written operational policies and procedures in relation to the finding of illicit substances.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to searches, which was last reviewed in April 2017. It addressed all of the requirements of the Judgement Support Framework, including requirements relating to the following:

The management and application of searches of a resident, his or her belongings, and the environment in which he or she was accommodated.

The consent requirements of a resident regarding searches and the process for conducting searches in the absence of consent.

The process for dealing with illicit substances uncovered during a search. Training and Education: Not all relevant staff had signed a log, indicating that they had read and understood the policy. Relevant staff interviewed could articulate the processes for undertaking a search, as set out in the policy. As no searches had been undertaken in the approved centre since the last inspection, the monitoring and evidence of implementation pillars for this regulation were not inspected against. The approved centre was compliant with this regulation.

COMPLIANT

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Regulation 14: Care of the Dying

(1) The registered proprietor shall ensure that the approved centre has written operational policies and protocols for care of residents who are dying.

(2) The registered proprietor shall ensure that when a resident is dying:

(a) appropriate care and comfort are given to a resident to address his or her physical, emotional, psychological and spiritual needs;

(b) in so far as practicable, his or her religious and cultural practices are respected;

(c) the resident's death is handled with dignity and propriety, and;

(d) in so far as is practicable, the needs of the resident's family, next-of-kin and friends are accommodated.

(3) The registered proprietor shall ensure that when the sudden death of a resident occurs:

(a) in so far as practicable, his or her religious and cultural practices are respected;

(b) the resident's death is handled with dignity and propriety, and;

(c) in so far as is practicable, the needs of the resident's family, next-of-kin and friends are accommodated.

(4) The registered proprietor shall ensure that the Mental Health Commission is notified in writing of the death of any resident of the approved centre, as soon as is practicable and in any event, no later than within 48 hours of the death occurring.

(5) This Regulation is without prejudice to the provisions of the Coroners Act 1962 and the Coroners (Amendment) Act 2005.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to care of the dying, which was last reviewed in April 2017. It included requirements of the Judgement Support Framework, with the exception of a process for ensuring that the approved centre was informed in the event of the death of a resident who had been transferred to another facility. Training and Education: Not all relevant staff had signed a log, indicating that they had read and understood the policy. Relevant staff interviewed could articulate the processes relating to end of life care, as set out in the policy. Monitoring: End of life care had not been systematically reviewed to ensure Section 2 of the regulation was complied with. Systems analysis was undertaken in the event of a sudden or unexpected death in the approved centre. Analysis had been completed to identify opportunities for improving the processes relating to care of the dying. Evidence of Implementation: The clinical files of two recently deceased residents of the approved centre were inspected. One resident had been transferred to a general health care facility. The relevant nursing notes detailed the pre-transfer care, which took into account the resident’s physical, emotional, social, psychological, and spiritual needs. The second resident had died suddenly in the approved centre. Religious and cultural practices were respected in both cases, insofar as was practicable. Nursing notes were comprehensive and indicated respectful and dignified care of residents at end of life. Representatives, family, next of kin, and friends were involved, supported, and accommodated during end of life care. Pain management was prioritised and managed. Support was given to other residents and to staff following the deaths of residents. The sudden death was clearly documented and managed in accordance with legal requirements. Both deaths had been notified to the Mental Health Commission within the required 48-hour time frame.

COMPLIANT Quality Rating Satisfactory

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The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the processes, training and education, and monitoring pillars.

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Regulation 15: Individual Care Plan

The registered proprietor shall ensure that each resident has an individual care plan.

[Definition of an individual care plan:“... a documented set of goals developed, regularly reviewed and updated by the resident’s multi-disciplinary team, so far as practicable in consultation with each resident. The individual care plan shall specify the treatment and care required which shall be in accordance with best practice, shall identify necessary resources and shall specify appropriate goals for the resident. For a resident who is a child, his or her individual care plan shall include education requirements. The individual care plan shall be recorded in the one composite set of documentation”.]

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the development, use, and review of individual care plans (ICPs), which was last reviewed in April 2017. It included all of the requirements of the Judgement Support Framework. Training and Education: Not all clinical staff had signed a log, indicating that they had read and understood the policy. Clinical staff interviewed could articulate the processes relating to individual care planning. Not all multi-disciplinary team (MDT) members had received training in individual care planning. Monitoring: ICPs were audited on a quarterly basis to assess compliance with the regulation. Analysis had been completed to identify opportunities for improving the individual care planning process. Evidence of Implementation: The ICPs of 15 residents were inspected, 8 from Le Brun and 7 from Whitethorn. Each was a composite set of documents, stored in the clinical file, identifiable and uninterrupted, and kept separately from progress notes. The ICPs included an individual risk management plan and a preliminary discharge plan, where appropriate. Residents were assessed at admission, and an initial care plan was put in place. The ICP was developed by the MDT within seven days of admission, following a comprehensive assessment. Evidence-based assessments were used where possible. Each ICP included details of the residents’ goals, treatment, and the care and resources required to meet identified needs. The ICPs were reviewed by the MDT in consultation with residents every six months or more frequently if indicated. The ICPs were updated following the review, as indicated by residents’ changing needs, condition, circumstances, and goals. Residents had access to their ICPs and were informed of any changes. In all of the ICPs inspected, a key worker was identified to ensure continuity in the implementation of an ICP. None of the residents had signed their ICPs. In eight ICPs, it was not documented that the residents had received a copy of their ICP. No explanation for this was recorded in four of these ICPs. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education and evidence of implementation pillars.

COMPLIANT Quality Rating Satisfactory

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Regulation 16: Therapeutic Services and Programmes

(1) The registered proprietor shall ensure that each resident has access to an appropriate range of therapeutic services and programmes in accordance with his or her individual care plan.

(2) The registered proprietor shall ensure that programmes and services provided shall be directed towards restoring and maintaining optimal levels of physical and psychosocial functioning of a resident.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the provision of therapeutic services and programmes to residents, which was last reviewed in April 2017. It included all of the requirements of the Judgement Support Framework. Training and Education: Not all clinical staff had signed a log, indicating that they had read and understood the policy. Clinical staff interviewed could articulate the processes for therapeutic activities and programmes, as set out in the policy. Monitoring: The range of therapeutic services and programmes provided was not monitored on an ongoing basis to ensure that residents’ assessed needs were met. Analysis had not been completed to identify opportunities for improving the processes for therapeutic services and programmes.

Evidence of Implementation: There was an activities nurse between both units who facilitated a full schedule of recreational activities. One to one individual sessions took place four mornings a week. The rest were group activities. Evidence based therapeutic programmes on the schedule provided were mindfulness, SONAS, cognitive stimulation and gentle exercise. Dog therapy was also facilitated once a week. There were recreational activities throughout the week such as arts and crafts, book club, reminiscence groups, board games, music groups and current affairs. Groups were observed to be engaging and active. Both Whitethorn and Le Brun had a suitable activity room for therapeutic and recreational sessions.

No health and social care professionals had direct responsibility for therapeutic services in Vergemount. There were no therapeutic programmes delivered by health and social care professionals in the approved centre that were directed towards restoring and maintaining optimal levels of psychosocial functioning, specifically for 13 residents in the approved centre with enduring mental illness who were identified as requiring a rehabilitation model of care. There were plans in place to fully implement a rehab/recovery team but this was not in place at the time of inspection. The redeployment to the community of the mental health occupational therapists (OT) left the service without OT input. Good working relationships with on-site primary care allowed for seating assessments and reviews to continue. There was a physiotherapist actively involved within the service. There was no dedicated therapy room and physiotherapy took place in communal areas.

Therapeutic services and programmes were combined with recreational activities, and a list of activities was available to residents. Records of general activities were maintained by the activities nurse, but details of the residents’ participation in, engagement with, and outcomes achieved in therapeutic services or programmes were not documented in individual care plans or clinical files.

NON-COMPLIANT Quality Rating Requires Improvement Risk Rating

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The approved centre was not compliant with this regulation for the following reasons:

a) Residents did not have access to an appropriate range of therapeutic services and programmes, 16(1).

b) Therapeutic programmes and services were not directed towards restoring and maintaining optimal levels of physical and psychosocial functioning of residents, 16(2).

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Regulation 17: Children’s Education

The registered proprietor shall ensure that each resident who is a child is provided with appropriate educational services in accordance with his or her needs and age as indicated by his or her individual care plan.

INSPECTION FINDINGS As the approved centre did not admit children, this regulation was not applicable.

NOT APPLICABLE

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Regulation 18: Transfer of Residents

(1) When a resident is transferred from an approved centre for treatment to another approved centre, hospital or other place, the registered proprietor of the approved centre from which the resident is being transferred shall ensure that all relevant information about the resident is provided to the receiving approved centre, hospital or other place.

(2) The registered proprietor shall ensure that the approved centre has a written policy and procedures on the transfer of residents.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the transfer of residents, which was dated April 2017. It included requirements of the Judgement Support Framework, with the exception of processes for the following:

Managing resident medications during transfer from the approved centre.

Ensuring resident privacy and confidentiality during the transfer process, specifically in relation to the transfer of personal information.

Managing resident property during a transfer.

Handling emergency transfers.

Ensuring the safety of the resident and staff during the resident transfer process. Training and Education: Not all relevant staff had signed a log, indicating that they had read and understood the policy. Relevant staff interviewed could articulate the processes for resident transfer, as set out in the policy. Monitoring: The approved centre maintained a transfer log, and each transfer record was systematically reviewed to ensure that all relevant information was provided to the receiving facility. Analysis had been completed to identify opportunities for improving the provision of information during transfers, and a new transfer log had been implemented. Evidence of Implementation: The clinical files of two residents were inspected in relation to transfers. Both were emergency transfers to another facility for treatment. Clinical notes indicated that a pre-transfer assessment was undertaken and the immediate risk was identified. The accompanying nurse advised the receiving facility of the risks. Full and complete information regarding the residents was transferred to the receiving facility, including a letter of referral with a list of current medications, a resident transfer form, and information on required medication for the resident during the transfer. Communication records with the receiving facility following the transfers were documented. The approved centred did not complete a checklist to ensure comprehensive resident records were transferred to the receiving facility. Copies of all records relevant to the transfer were not retained in one of the clinical files examined. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the processes, training and education, and evidence of implementation pillars.

COMPLIANT Quality Rating Satisfactory

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Regulation 19: General Health

(1) The registered proprietor shall ensure that:

(a) adequate arrangements are in place for access by residents to general health services and for their referral to other health services as required;

(b) each resident's general health needs are assessed regularly as indicated by his or her individual care plan and in any event not less than every six months, and;

(c) each resident has access to national screening programmes where available and applicable to the resident.

(2) The registered proprietor shall ensure that the approved centre has written operational policies and procedures for responding to medical emergencies.

INSPECTION FINDINGS Processes: The approved centre had two written policies in relation to the provision of general health care to residents: a general health policy dated April 2017 and an urgent medical, psychiatric review, and medical emergencies policy, which was dated January 2014 and was, therefore, out of date. Together, the policies addressed all of the requirements of the Judgement Support Framework. Training and Education: Not all clinical staff had signed a log, indicating that they had read and understood the policies. Clinical staff interviewed could articulate the processes for providing general health services and responding to medical emergencies, as set out in the policies. Monitoring: Residents’ take-up of national screening programmes was recorded in their respective clinical files and monitored. A systematic review had been undertaken to ensure that six-monthly general health assessments of residents occurred. Analysis was completed to identify opportunities to improve general health processes. Evidence of Implementation: The two units in the approved centre shared an emergency trolley, and staff had access at all times to an Automated External Defibrillator. These were checked weekly. There had been one medical emergency in the approved centre since the last inspection, and details of the event were recorded in the clinical notes. A GP attended the approved centre every weekday to assess residents’ general health needs. Residents received general health care interventions appropriate to their needs and in line with their individual care plans. Adequate arrangements were in place for residents to access general services and for their referral to other health services, as required. There was a psychiatrist with responsibility for ensuring six-monthly physical health checks were completed. The template used at reviews was comprehensive and included detailed biopsychosocial information about the resident. Thirteen files were inspected: one physical health check was out of date, another stated a client “declined a physical exam” in March with no documented attempt at follow up, and two were incomplete. It was noted that legibility in five general health checks was poor. Residents had access to age- and gender-appropriate national screening programmes. The clinical nurse manager on each unit monitored resident uptake of national screening programmes and facilitated residents to attend appointments. Information was provided regarding the national screening programmes available through the approved centre.

NON-COMPLIANT Quality Rating Requires Improvement Risk Rating

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The approved centre was not compliant with this regulation because not all residents had received a complete general health needs review within the last six months, 19(1)(b).

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Regulation 20: Provision of Information to Residents

(1) Without prejudice to any provisions in the Act the registered proprietor shall ensure that the following information is provided to each resident in an understandable form and language:

(a) details of the resident's multi-disciplinary team;

(b) housekeeping practices, including arrangements for personal property, mealtimes, visiting times and visiting arrangements;

(c) verbal and written information on the resident's diagnosis and suitable written information relevant to the resident's diagnosis unless in the resident's psychiatrist's view the provision of such information might be prejudicial to the resident's physical or mental health, well-being or emotional condition;

(d) details of relevant advocacy and voluntary agencies;

(e) information on indications for use of all medications to be administered to the resident, including any possible side-effects.

(2) The registered proprietor shall ensure that an approved centre has written operational policies and procedures for the provision of information to residents.

INSPECTION FINDINGS Processes: The approved centre had a policy in relation to the provision of information to residents, which was last reviewed in April 2017. It included all of the requirements of the Judgement Support Framework. Training and Education: Not all staff had signed the log, indicating that they had read and understood the policy. Staff interviewed could articulate the processes for providing information to residents, as set out in the policy. Monitoring: The provision of information to residents was audited on an ongoing basis to ensure it was appropriate and accurate, particularly where information changed. Analysis had been completed to identify opportunities for improving the processes around the provision of information, especially in terms of making information more accessible to residents with limited literacy skills and/or cognitive impairments.

Evidence of Implementation: Required information was given to residents and/or their representatives at admission in the form of a resident information booklet. Details were provided of the available care and services as well as of housekeeping arrangements, complaints procedures, visiting times and arrangements, relevant advocacy and voluntary agencies, and residents’ rights. Details of the complaints procedure and of relevant advocacy and voluntary agencies were also displayed in both units.

Residents were provided with information on their multi-disciplinary team. They also received information packs containing details of their diagnosis, unless, in the view of the treating psychiatrist, this might be prejudicial to their physical or mental health. Diagnosis- and medication-related leaflets were available and included information on indications for the use of all medications administered to residents, including side-effects. Leaflets were accessible and contained evidence-based information. Information provided in and by the approved centre was appropriately reviewed and approved prior to use.

The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the training and education pillar.

COMPLIANT Quality Rating Satisfactory

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Regulation 21: Privacy

The registered proprietor shall ensure that the resident's privacy and dignity is appropriately respected at all times.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to resident privacy, which was last reviewed in April 2017. It included all of the requirements of the Judgement Support Framework. Training and Education: Not all staff had signed a log, indicating that they had read and understood the policy. Staff interviewed were able to articulate the processes for ensuring resident privacy and dignity, as set out in the policy. Monitoring: An annual review had been undertaken to ensure that the policy was being implemented and that the premises and facilities were conducive to resident privacy. Analysis had been completed to identify opportunities for improving the processes relating to residents’ privacy and dignity. Evidence of Implementation: Residents were addressed by their preferred names, and staff members were observed to interact with residents in a polite and respectful manner. Staff were appropriately attired, sought permission before entering residents’ rooms, and conducted all conversations relating to residents’ clinical and therapeutic needs in private. Residents were observed to be wearing clothing that respected their privacy and dignity. Bathrooms, showers, and toilets had locks on the inside of the doors, and these had an override facility. Single rooms did not have locks with an override function that safely allowed residents to lock their bedrooms from the inside. Where residents shared a room, appropriate bed screening was in place to ensure that their privacy was not compromised. All observation panels on doors of treatment rooms and bedrooms were appropriately screened, and reflective film had been installed on bedroom windows to increase privacy. Residents were facilitated in making and taking private phone calls. Noticeboards in the nurses’ stations at the time of inspection displayed full names of residents in the approved centre which could be viewed by staff and visitors. Staff rectified this immediately and ensured that first names only were displayed on this board and that any other details displayed were in line with maintaining the privacy of residents. The approved centre was non-compliant with this regulation because the full names of residents were displayed on a noticeboard that could be viewed by visitors.

NON-COMPLIANT Quality Rating Requires Improvement Risk Rating LOW

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Regulation 22: Premises

(1) The registered proprietor shall ensure that:

(a) premises are clean and maintained in good structural and decorative condition;

(b) premises are adequately lit, heated and ventilated;

(c) a programme of routine maintenance and renewal of the fabric and decoration of the premises is developed and implemented and records of such programme are maintained.

(2) The registered proprietor shall ensure that an approved centre has adequate and suitable furnishings having regard to the number and mix of residents in the approved centre.

(3) The registered proprietor shall ensure that the condition of the physical structure and the overall approved centre environment is developed and maintained with due regard to the specific needs of residents and patients and the safety and well-being of residents, staff and visitors.

(4) Any premises in which the care and treatment of persons with a mental disorder or mental illness is begun after the commencement of these regulations shall be designed and developed or redeveloped specifically and solely for this purpose in so far as it practicable and in accordance with best contemporary practice.

(5) Any approved centre in which the care and treatment of persons with a mental disorder or mental illness is begun after the commencement of these regulations shall ensure that the buildings are, as far as practicable, accessible to persons with disabilities.

(6) This regulation is without prejudice to the provisions of the Building Control Act 1990, the Building Regulations 1997 and 2001, Part M of the Building Regulations 1997, the Disability Act 2005 and the Planning and Development Act 2000.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to its premises, which was dated April 2017. The policy addressed requirements of the Judgement Support Framework, with the following exceptions:

The approved centre’s cleaning programme.

The approved centre’s utility controls and requirements.

The process for identifying hazards and ligature points.

Training and Education: Not all relevant staff had signed a log, indicating that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes relating to the maintenance of the premises, as set out in the policy. Monitoring: The approved centre had completed hygiene and ligature audits. Analysis had been completed to identify opportunities for improving the premises, and a programme of refurbishment works was planned and had received budget approval. Evidence of Implementation: Residents had access to personal space, including suitable accommodation, and to shared space in the form of spacious communal rooms. Communal areas were adequately lit to facilitate reading and other activities. Rooms were bright, and ventilated, and they were suitably sized and furnished to suit the residents’ needs. Appropriate signage was in place to support resident orientation needs. Sufficient spaces were provided for residents to move about, including an outdoor enclosed garden area in each house. Heating could not be controlled in individual rooms. During the inspection, heating was noted to be on in the corridors on a very warm day. Over 100 ligature points were identified by the approved centre. These had not been mitigated, but individual risk assessments indicated no current risk based on the resident

NON-COMPLIANT Quality Rating Requires Improvement Risk Rating

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profile. Should there be an identified risk, staffing resources would be employed to ensure the safety of a resident. The approved centre was not in a good state of repair. The inspectors observed broken floor tiles, badly scuffed walls and architraves around doors, walls in need of repainting, a loose toilet roll holder in one toilet, and the remnants of old towel rails on the walls of some toilets. There was no ongoing programme of decorative maintenance. A cleaning schedule was in place, and the approved centre was clean, hygienic, and free from offensive odours. National infection control guidelines were followed. There were adequate toilet and bathroom facilities, including assisted needs facilities. However, a new Parker bath could not be used due to a problem with water pressure that had not been resolved. There were designated sluice, cleaning, and laundry rooms. Bedrooms were appropriately sized to address residents’ needs, and furnishings throughout the approved centre supported residents’ independence and comfort. Assisted devices and/or equipment were available, where required. The approved centre was not compliant with this regulation for the following reasons:

a) The premises were not maintained in good decorative condition, 22(1)(a). b) Heating could not be controlled to adequately heat the approved centre. Required changes had

to be responded to by maintenance, 22(1)(b). c) There was no ongoing programme of decorative maintenance, 22(1)(c). d) The physical structure and the overall approved centre environment was not developed and

maintained with due regard to the specific needs of residents and patients and the safety and well-being of residents, staff, and visitors, 22(3).

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Regulation 23: Ordering, Prescribing, Storing and Administration of Medicines

(1) The registered proprietor shall ensure that an approved centre has appropriate and suitable practices and written operational policies relating to the ordering, prescribing, storing and administration of medicines to residents.

(2) This Regulation is without prejudice to the Irish Medicines Board Act 1995 (as amended), the Misuse of Drugs Acts 1977, 1984 and 1993, the Misuse of Drugs Regulations 1998 (S.I. No. 338 of 1998) and 1993 (S.I. No. 338 of 1993 and S.I. No. 342 of 1993) and S.I. No. 540 of 2003, Medicinal Products (Prescription and control of Supply) Regulations 2003 (as amended).

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the ordering, storing, prescribing, and administration of medication, which was last reviewed in April 2017. It included requirements of the Judgement Support Framework, with the exception of processes for managing medication at admission and transfer and for reconciling medication. Training and Education: Not all nursing and medical staff had signed a log, indicating that they had read and understood the policy. Nursing, medical, and pharmacy staff interviewed were able to articulate the processes for ordering, prescribing, storing, and administering medicines, as set out in the policy. Staff had access to up-to-date information on all aspects of medication management, and all clinical staff had received training on the importance of reporting medication incidents, errors, or near misses. Monitoring: Quarterly audits of Medication Prescription and Administration Records (MPARs) were undertaken to determine compliance with the policies and procedures and the applicable legislation and guidelines. Incident reports were recorded for medication issues. Analysis had been completed to identify opportunities for improving medication management, and action plans were developed. Evidence of Implementation: An MPAR was maintained for each resident, and 15 of these were inspected, 8 from Whitethorn and 7 from Le Brun. Two appropriate resident identifiers were used when medication was being administered. Names of medications were written in full, and generic names were recorded where applicable. The frequency of administration, the dosage, and the administration route for medications were recorded. The allergy section was completed in all MPARs. In one MPAR, the resident’s reason for refusing medication was not documented. Residents’ medication was reviewed at least six-monthly or more frequently where required. Where there was an alteration in the medication order, the medical practitioner rewrote the prescription. Medication was appropriately administered by a registered nurse or registered medical practitioner. The expiration date of medication was checked prior to administration, and good hand-hygiene and cross-infection control techniques were implemented during the dispensing of medications. Where a resident’s medication was withheld, the justification was noted in the MPAR and documented in the respective clinical file. Controlled drugs were checked by two staff members against the delivery form and recorded in a controlled drug book. The controlled drug balance corresponded with the balance recorded in the book. Directions to crush medication were only accepted from the residents’ medical practitioner. Medication arriving from the pharmacy was verified against the order and stored in the appropriate environment. A daily log of medication fridge temperatures was maintained. The medication trolley was

COMPLIANT Quality Rating Satisfactory

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locked and secured, and scheduled controlled drugs were secured separately. Medication storage areas were free from damp and mould and were clean and well maintained. No food or drinks were stored in areas used for storing medication. A system of stock rotation was in place, and an inventory of medications was completed monthly. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the processes, training and education, and evidence of implementation pillars.

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Regulation 24: Health and Safety

(1) The registered proprietor shall ensure that an approved centre has written operational policies and procedures relating to the health and safety of residents, staff and visitors.

(2) This regulation is without prejudice to the provisions of Health and Safety Act 1989, the Health and Safety at Work Act 2005 and any regulations made thereunder.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to health and safety, dated April 2017. It also had a corporate safety statement and a general safety statement. Together, the policy and safety statements included requirements of the Judgement Support Framework, with the exception of the nomination of a safety representative. Training and Education: Not all staff had signed the signature log, indicating that they had read and understood the policy and safety statements. Staff interviewed were able to articulate the processes relating to health and safety, as set out in these documents. Monitoring: The health and safety policy was monitored pursuant to Regulation 29: Operational Policies and Procedures. Evidence of Implementation: Regulation 24 was only assessed against the approved centre’s written policies and procedures. Health and safety practices within the approved centre were not assessed. The approved centre was compliant with this regulation.

COMPLIANT

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Regulation 25: Use of Closed Circuit Television

(1) The registered proprietor shall ensure that in the event of the use of closed circuit television or other such monitoring device for resident observation the following conditions will apply:

(a) it shall be used solely for the purposes of observing a resident by a health

professional who is responsible for the welfare of that resident, and solely for the purposes of ensuring the health and welfare of that resident;

(b) it shall be clearly labelled and be evident;

(c) the approved centre shall have clear written policy and protocols articulating its function, in relation to the observation of a resident;

(d) it shall be incapable of recording or storing a resident's image on a tape, disc,

hard drive, or in any other form and be incapable of transmitting images other than to the monitoring station being viewed by the health professional responsible for the health and welfare of the resident;

(e) it must not be used if a resident starts to act in a way which compromises his or

her dignity.

(2) The registered proprietor shall ensure that the existence and usage of closed circuit television or other monitoring device is disclosed to the resident and/or his or her representative.

(3) The registered proprietor shall ensure that existence and usage of closed circuit television or other monitoring device is disclosed to the Inspector of Mental Health Services and/or Mental Health Commission during the inspection of the approved centre or at any time on request.

INSPECTION FINDINGS As CCTV was not in use in the approved centre, this regulation was not applicable.

NOT APPLICABLE

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Regulation 26: Staffing

(1) The registered proprietor shall ensure that the approved centre has written policies and procedures relating to the recruitment, selection and vetting of staff.

(2) The registered proprietor shall ensure that the numbers of staff and skill mix of staff are appropriate to the assessed needs of residents, the size and layout of the approved centre.

(3) The registered proprietor shall ensure that there is an appropriately qualified staff member on duty and in charge of the approved centre at all times and a record thereof maintained in the approved centre.

(4) The registered proprietor shall ensure that staff have access to education and training to enable them to provide care and treatment in accordance with best contemporary practice.

(5) The registered proprietor shall ensure that all staff members are made aware of the provisions of the Act and all regulations and rules made thereunder, commensurate with their role.

(6) The registered proprietor shall ensure that a copy of the Act and any regulations and rules made thereunder are to be made available to all staff in the approved centre.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the recruitment, selection, and vetting of staff, which was last reviewed in April 2017. It included all of the requirements of the Judgement Support Framework, including the following:

The roles and responsibilities for the recruitment, selection, vetting, and appointment of staff.

The approved centre’s recruitment, selection, and appointment process, including Garda vetting requirements.

Training and Education: Not all relevant staff had signed the signature log, indicating that they had read and understood the policy. Relevant staff interviewed were able to articulate the processes relating to staffing, as set out in the policy. Monitoring: The implementation and effectiveness of the staff training plan were reviewed annually. The number and skill mix of staff had not been assessed against the levels recorded in the approved centre’s registration. Analysis had been completed to identify opportunities for improving staffing processes and responding to the changing needs and circumstances of residents. Evidence of Implementation: There was an organisational chart in place to identify the leadership and management structure and lines of authority and accountability. A planned and actual staff rota was in place. Staff were recruited, selected, and vetted in line with the approved centre’s policy. Staff were qualified for their roles, and an appropriately qualified staff member was on duty and in charge at all times. Where agency staff were used, there was a comprehensive contract between the approved centre and the staffing agency. The numbers and skill mix of staffing were not sufficient to meet residents’ needs. At the time of the inspection, there was no rehabilitation/recovery team to address the needs of those residents who required this model of care. In addition, the approved centre was registered as having whole time equivalent posts for a psychologist, social worker, occupational therapist, and physiotherapist. In practice, there were no psychologist, social worker or occupational therapist with actual clinical responsibility to residents in the approved centre. A programme of self-staffing was allowing for continuity of care despite the approved centre also operating below necessary numbers of nursing staff due to vacancies.

NON-COMPLIANT Quality Rating Requires Improvement Risk Rating

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The approved centre did not provide a written staffing plan to the inspection team. Annual staff training plans had been completed for nursing, household, occupational therapy, and social work staff and for health care assistants. Training plans identified required training and skills development in line with the assessed needs of the resident group profile. Orientation and induction training had been completed by staff, but not all health care professionals were up to date with mandatory training in fire safety, Basic Life Support (BLS), Professional Management of Aggression and Violence (PMAV), and the Mental Health Act (MHA) 2001. Staff were trained in accordance with the assessed needs of residents, with training delivered in manual handling, infection control and prevention, dementia care, care for residents with an intellectual disability, end of life care, resident rights, and risk management. Staff training was documented, and staff training logs were maintained. Resources were available to staff for further training and education, and in-house trainers were appropriately qualified. The MHA 2001, the associated regulation, Mental Health Commission rules and codes, and all other relevant Mental Health Commission documentation and guidance were available in the approved centre. The following is a table of clinical staff assigned to the approved centre:

The approved centre was not compliant with this regulation for the following reasons:

a) The numbers and skill mix of staff were not appropriate to the assessed needs of residents, 26(2). b) Not all staff had up-to-date mandatory training in BLS, fire safety, PMAV, and the MHA 2001,

26(4) and (5).

Ward or Unit Staff Grade Day Night

Whitethorn

CNM2 CNM1 RPN/RGN HCA

1 1 2 2

2 1

Ward or Unit Staff Grade Day Night

Le Brun

CNM2 CNM1 RPN/RGN HCA

1 1 2 2

2 1

Clinical Nurse Manager (CNM), Registered Psychiatric Nurse (RPN), Registered General Nurse (RGN), Health Care Assistant (HCA)

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Regulation 27: Maintenance of Records

(1) The registered proprietor shall ensure that records and reports shall be maintained in a manner so as to ensure completeness, accuracy and ease of retrieval. All records shall be kept up-to-date and in good order in a safe and secure place.

(2) The registered proprietor shall ensure that the approved centre has written policies and procedures relating to the creation of, access to, retention of and destruction of records.

(3) The registered proprietor shall ensure that all documentation of inspections relating to food safety, health and safety and fire inspections is maintained in the approved centre.

(4) This Regulation is without prejudice to the provisions of the Data Protection Acts 1988 and 2003 and the Freedom of Information Acts 1997 and 2003.

Note: Actual assessment of food safety, health and safety and fire risk records is outside the scope of this Regulation, which refers only to maintenance of records pertaining to these areas.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to the maintenance of records, which was last reviewed in April 2017. It addressed requirements of the Judgement Support Framework, including policies and procedures relating to the following:

The roles and responsibilities for the creation of, access to, retention of, and destruction of records.

Those authorised to access and make entries in residents’ records.

The policy did not reference the following:

The required resident record creation and content.

Record review requirements.

Privacy and confidentiality of resident records and content.

Residents’ access to their records.

Record retention periods.

The destruction of records.

The way in which entries in resident records were made, corrected, and overwritten.

The process for making a retrospective entry in residents’ records.

General safety and security measures in relation to records. Training and Education: Not all staff had signed the signature log, indicating that they had read and understood the policy. Clinical staff and other relevant staff interviewed were able to articulate the processes around creating, accessing, retaining, and destroying records in the approved centre. Not all clinical staff had received training in best-practice record keeping. Monitoring: Resident records had been audited to ensure their completeness, accuracy, and ease of retrieval. Analysis had been completed to identify opportunities for improving the processes relating to the maintenance of records. Evidence of Implementation: Records were secure, up to date, in good order, and constructed, maintained, and used in accordance with the Data Protection Act 1988 and 2003, the Freedom of Information Act 1997 and 2003, and national guidelines and legislative requirements.

COMPLIANT Quality Rating Satisfactory

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Resident records were physically stored together, and all residents had a record that was reflective of their current status and the care and treatment being provided. Two appropriate resident identifiers were recorded on all documentation. Resident records were developed and maintained in a logical sequence, and entries were factual, consistent, and accurate. Records were appropriately secured throughout the approved centre. Residents’ records were accessible to authorised staff only, and only authorised staff made entries in them. Documentation relating to health and safety and fire inspections was maintained in the approved centre, but there was no up-to-date food safety documentation. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the processes, training and education, and evidence of implementation pillars.

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Regulation 28: Register of Residents

(1) The registered proprietor shall ensure that an up-to-date register shall be established and maintained in relation to every resident in an approved centre in a format determined by the Commission and shall make available such information to the Commission as and when requested by the Commission.

(2) The registered proprietor shall ensure that the register includes the information specified in Schedule 1 to these Regulations.

INSPECTION FINDINGS The approved centre had a documented register of residents, which was up to date and contained all of the required information listed in Schedule 1 to the Mental Health Act 2001 (Approved Centres) Regulations 2006. The approved centre was compliant with this regulation.

COMPLIANT

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Regulation 29: Operating Policies and Procedures

The registered proprietor shall ensure that all written operational policies and procedures of an approved centre are reviewed on the recommendation of the Inspector or the Commission and at least every 3 years having due regard to any recommendations made by the Inspector or the Commission.

INSPECTION FINDINGS Processes: The approved centre had a written policy on the development and review of operating policies and procedures, which was last reviewed in April 2017. It included requirements of the Judgement Support Framework, with the exception of the process for training staff on operating policies and procedures, including the requirements for training after the release of a new or updated document. Training and Education: Not all relevant staff had signed a log, indicating that they had read and understood the policy. Relevant staff had received training on approved operational policies and procedures. Relevant staff interviewed were able to articulate the processes for developing and reviewing operational policies, as set out in the policy. Monitoring: An annual audit was undertaken to determine compliance with review time frames, and work was ongoing to update policies to ensure compliance. Analysis had been completed to identify opportunities for improving the processes of developing and reviewing policies. Evidence of Implementation: Operating policies and procedures were developed with input from clinical and managerial staff and in consultation with all relevant stakeholders. The policies and procedures incorporated relevant legislation, evidence-based best practice, and clinical guidelines and were appropriately approved before being implemented. The policy on responding to a medical emergency was out of date under Regulation 19: General Health. However, the health and safety policy was in date and included processes for responding to a medical emergency. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the processes and training and education pillars.

COMPLIANT Quality Rating Satisfactory

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Regulation 30: Mental Health Tribunals

(1) The registered proprietor shall ensure that an approved centre will co-operate fully with Mental Health Tribunals.

(2) In circumstances where a patient's condition is such that he or she requires assistance from staff of the approved centre to attend, or during, a sitting of a mental health tribunal of which he or she is the subject, the registered proprietor shall ensure that appropriate assistance is provided by the staff of the approved centre.

INSPECTION FINDINGS As the approved centre had not admitted an involuntary patient since the last inspection, this regulation was not applicable.

NOT APPLICABLE

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Regulation 31: Complaints Procedures

(1) The registered proprietor shall ensure that an approved centre has written operational policies and procedures relating to the making, handling and investigating complaints from any person about any aspects of service, care and treatment provided in, or on behalf of an approved centre.

(2) The registered proprietor shall ensure that each resident is made aware of the complaints procedure as soon as is practicable after admission.

(3) The registered proprietor shall ensure that the complaints procedure is displayed in a prominent position in the approved centre.

(4) The registered proprietor shall ensure that a nominated person is available in an approved centre to deal with all complaints.

(5) The registered proprietor shall ensure that all complaints are investigated promptly.

(6) The registered proprietor shall ensure that the nominated person maintains a record of all complaints relating to the approved centre.

(7) The registered proprietor shall ensure that all complaints and the results of any investigations into the matters complained and any actions taken on foot of a complaint are fully and properly recorded and that such records shall be in addition to and distinct from a resident's individual care plan.

(8) The registered proprietor shall ensure that any resident who has made a complaint is not adversely affected by reason of the complaint having been made.

(9) This Regulation is without prejudice to Part 9 of the Health Act 2004 and any regulations made thereunder.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to making, handling, and investigating complaints, which was last reviewed in April 2017. It included requirements of the Judgement Support Framework, with the exception of the time frames for complaint management. Training and Education: Relevant staff had received training on complaints management processes. Not all staff had signed a log, acknowledging that they had read and understood the policy. All staff interviewed were able to articulate the processes for making, handling, and investigating complaints, as set out in the policy. Monitoring: There was no documented evidence that audits of the complaints log were completed. Complaints data had not been analysed for the purpose of identifying and implementing required actions to ensure continuous improvement of the complaints management process. Evidence of Implementation: There was a nominated complaints officer in the approved centre, and all complaints were dealt with in a consistent and standardised manner. The approved centre’s complaints management processes were well publicised in both units and accessible to residents and their representatives. Information on complaints procedures was provided at admission. All complaints, whether oral or written, were investigated promptly and handled appropriately and sensitively. The registered proprietor ensured that the quality of the service, care, and treatment of a resident was not adversely affected by reason of a complaint being lodged. Minor complaints were noted in resident meetings and were recorded either in the complaints log or the minutes of the resident meetings. Since the last inspection, there had been no minor complaints that required escalation to the nominated person.

COMPLIANT Quality Rating Satisfactory

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All non-minor complaints were addressed by the complaints officer and recorded in the complaints log. Details of complaints, subsequent investigations, and outcomes were documented and kept distinct from the resident’s individual care plan. The approved centre was compliant with this regulation. The quality assessment was satisfactory and not rated excellent because the approved centre did not meet all criteria of the Judgement Support Framework under the processes, training and education, and monitoring pillars.

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Regulation 32: Risk Management Procedures

(1) The registered proprietor shall ensure that an approved centre has a comprehensive written risk management policy in place and that it is implemented throughout the approved centre.

(2) The registered proprietor shall ensure that risk management policy covers, but is not limited to, the following:

(a) The identification and assessment of risks throughout the approved centre;

(b) The precautions in place to control the risks identified;

(c) The precautions in place to control the following specified risks:

(i) resident absent without leave,

(ii) suicide and self harm,

(iii) assault,

(iv) accidental injury to residents or staff;

(d) Arrangements for the identification, recording, investigation and learning from

serious or untoward incidents or adverse events involving residents;

(e) Arrangements for responding to emergencies;

(f) Arrangements for the protection of children and vulnerable adults from abuse.

(3) The registered proprietor shall ensure that an approved centre shall maintain a record of all incidents and notify the Mental Health Commission of incidents occurring in the approved centre with due regard to any relevant codes of practice issued by the Mental Health Commission from time to time which have been notified to the approved centre.

INSPECTION FINDINGS Processes: The approved centre had a written policy in relation to risk management, which was last reviewed in April 2017. It addressed requirements of the Judgement Support Framework, including processes for the following:

Identification, assessment, treatment, reporting, and monitoring of risks throughout the approved centre.

Rating identified risks.

Controlling risks such as resident absence without leave, suicide and self-harm, assault, and accidental injury to residents or staff.

Managing incidents involving residents of the approved centre.

Responding to emergencies.

Protecting children and vulnerable adults in the care of the approved centre. The policy did not reference capacity risks relating to the number of residents in the approved centre. Training and Education: Relevant staff had received training in the identification, assessment, and management of risk and in health and safety risk management. Clinical staff were trained in individual risk management, and management staff were trained in organisational risk management. All staff had been trained in incident reporting and documentation. Not all staff had signed the signature log, indicating that they had read and understood the policy. Staff interviewed were able to articulate the risk management processes, as set out in the policy. All training in risk management was documented. Monitoring: The risk register had been audited at least quarterly to determine compliance with the approved centre’s risk management policy. All incidents in the approved centre were documented and risk-rated using the National Incident Management System. Analysis of incident reports had been

NON-COMPLIANT Quality Rating Requires Improvement Risk Rating

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completed to identify opportunities for improving risk management processes. A report was provided to the inspection team. Evidence of Implementation: The approved centre had a designated risk manager, and responsibilities were allocated at management level to ensure the effective implementation of risk management. Risk management procedures sought to reduce identified risks to the lowest practical level. Falls risks were identified as the most significant risk among the ageing population of residents. Plans were in place for renovations, including provisions to ensure that works were completed without risk to residents. Clinical and corporate risks were identified, assessed, treated, reported, monitored, and documented in the risk register. Health and safety risks were identified, assessed, treated, reported, and monitored. The approved centre completed resident risk assessments at admission to identify individual risk factors. Assessments were also completed before and during the use of mechanical restraint, prior to resident transfer, and in conjunction with medication requirements or administration. Multi-disciplinary teams had input into the development, implementation, and review of risk management processes, as did residents and/or their representatives. The requirements for the protection of children and vulnerable adults were appropriate and implemented as necessary. There had been no serious reportable incidents in the approved centre since the last inspection, but a clear process was in place for recording, risk-rating, and reporting incidents and adverse events. Structural risks, including ligature points, had not been removed or effectively mitigated and a number of significant structural ligature risks were identified throughout the approved centre during the inspection. The process for managing ligature risks at the time of inspection was the locking of doors to unsupervised areas. The approved centre had an emergency plan that was not fully implemented as staff were unaware of evacuation procedures. The approved centre was not compliant with this regulation for the following reasons:

a) The risk management policy was not being fully implemented, as evidenced by the presence of significant structural ligature risks throughout the premises, 32(1).

b) The environment did not provide sufficient controls to prevent accidental injury to residents, 32(2)(c)(iv).

c) Staff were not aware of evacuation procedures, 32(2)(e).

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Regulation 33: Insurance

The registered proprietor of an approved centre shall ensure that the unit is adequately insured against accidents or injury to residents.

INSPECTION FINDINGS The approved centre’s insurance certificate was provided to the inspection team. It confirmed that the approved centre was insured under the auspices of the State Claims Agency for public liability, employer’s liability, clinical indemnity, and property. The approved centre was compliant with this regulation.

COMPLIANT

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Regulation 34: Certificate of Registration

The registered proprietor shall ensure that the approved centre's current certificate of registration issued pursuant to Section 64(3)(c) of the Act is displayed in a prominent position in the approved centre.

INSPECTION FINDINGS The approved centre had an up-to-date certificate of registration, which was prominently displayed in the porch area. The approved centre was compliant with this regulation.

COMPLIANT

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10.0 Inspection Findings – Rules

EVIDENCE OF COMPLIANCE WITH RULES UNDER MENTAL HEALTH ACT 2001 SECTION 52 (d)

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Section 59: The Use of Electro-Convulsive Therapy

Section 59 (1) A programme of electro-convulsive therapy shall not be administered to a patient unless either – (a) the patient gives his or her consent in writing to the administration of the programme of therapy, or (b) where the patient is unable to give such consent – (i) the programme of therapy is approved (in a form specified by the Commission) by the consultant psychiatrist responsible for the care and treatment of the patient, and (ii) the programme of therapy is also authorised (in a form specified by the Commission) by another consultant psychiatrist following referral of the matter to him or her by the first-mentioned psychiatrist. (2) The Commission shall make rules providing for the use of electro-convulsive therapy and a programme of electro-convulsive therapy shall not be administered to a patient except in accordance with such rules.

INSPECTION FINDINGS As the approved centre did not use Electro-Convulsive Therapy, this rule was not applicable.

NOT APPLICABLE

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Section 69: The Use of Seclusion

Mental Health Act 2001 Bodily restraint and seclusion Section 69 (1) “A person shall not place a patient in seclusion or apply mechanical means of bodily restraint to the patient unless such seclusion or restraint is determined, in accordance with the rules made under subsection (2), to be necessary for the purposes of treatment or to prevent the patient from injuring himself or herself or others and unless the seclusion or restraint complies with such rules. (2) The Commission shall make rules providing for the use of seclusion and mechanical means of bodily restraint on a patient. (3) A person who contravenes this section or a rule made under this section shall be guilty of an offence and shall be liable on summary conviction to a fine not exceeding £1500. (4) In this section “patient” includes –

(a) a child in respect of whom an order under section 25 is in force, and (b) a voluntary patient.

INSPECTION FINDINGS As the approved centre did not use seclusion, this rule was not applicable.

NOT APPLICABLE

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Section 69: The Use of Mechanical Restraint

Mental Health Act 2001 Bodily restraint and seclusion Section 69 (1) “A person shall not place a patient in seclusion or apply mechanical means of bodily restraint to the patient unless such seclusion or restraint is determined, in accordance with the rules made under subsection (2), to be necessary for the purposes of treatment or to prevent the patient from injuring himself or herself or others and unless the seclusion or restraint complies with such rules. (2) The Commission shall make rules providing for the use of seclusion and mechanical means of bodily restraint on a patient. (3) A person who contravenes this section or a rule made under this section shall be guilty of an offence and shall be liable on summary conviction to a fine not exceeding £1500. (4) In this section “patient” includes – (a) a child in respect of whom an order under section 25 is in force, and (b) a voluntary patient.

INSPECTION FINDINGS The use of mechanical restraint in the approved centre was compliant with Part 5 of the Rules Governing the Use of Mechanical Means of Bodily Restraint for Enduring Risk of Harm to Self or Others. The clinical files of three residents who had been prescribed mechanical restraint were inspected. In each case, mechanical restraint was used to address an identified clinical need and only after least restrictive alternatives were implemented without success. The restraint was ordered by a registered medical practitioner under the supervision of the treating consultant psychiatrist. The clinical files indicated the situation in which mechanical restraint was applied, the duration of the restraint and of the order, and the review date of the mechanical restraint. The approved centre was compliant with this rule.

COMPLIANT

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11.0 Inspection Findings – Mental Health Act 2001

EVIDENCE OF COMPLIANCE WITH PART 4 OF THE MENTAL HEALTH ACT 2001

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Part 4 Consent to Treatment

56.- In this Part “consent”, in relation to a patient, means consent obtained freely without threat or inducements, where – a) the consultant psychiatrist responsible for the care and treatment of the patient is satisfied that the patient is

capable of understanding the nature, purpose and likely effects of the proposed treatment; and b) The consultant psychiatrist has given the patient adequate information, in a form and language that the patient can

understand, on the nature, purpose and likely effects of the proposed treatment. 57. - (1) The consent of a patient shall be required for treatment except where, in the opinion of the consultant psychiatrist responsible for the care and treatment of the patient, the treatment is necessary to safeguard the life of the patient, to restore his or her health, to alleviate his or her condition, or to relieve his or her suffering, and by reason of his or her mental disorder the patient concerned is incapable of giving such consent.

(2) This section shall not apply to the treatment specified in section 58, 59 or 60. 60. – Where medicine has been administered to a patient for the purpose of ameliorating his or her mental disorder for a continuous period of 3 months, the administration of that medicine shall not be continued unless either-

a) the patient gives his or her consent in writing to the continued administration of that medicine, or b) where the patient is unable to give such consent –

i. the continued administration of that medicine is approved by the consultant psychiatrist responsible for the care and treatment of the patient, and

ii. the continued administration of that medicine is authorised (in a form specified by the Commission) by another consultant psychiatrist following referral of the matter to him or her by the first-mentioned psychiatrist,

And the consent, or as the case may be, approval and authorisation shall be valid for a period of three months and thereafter for periods of 3 months, if in respect of each period, the like consent or, as the case may be, approval and authorisation is obtained. 61. – Where medicine has been administered to a child in respect of whom an order under section 25 is in force for the purposes of ameliorating his or her mental disorder for a continuous period of 3 months, the administration shall not be continued unless either –

a) the continued administration of that medicine is approved by the consultant psychiatrist responsible for the care and treatment of the child, and

b) the continued administration of that medicine is authorised (in a form specified by the Commission) by another consultant psychiatrist, following referral of the matter to him or her by the first-mentioned psychiatrist,

And the consent or, as the case may be, approval and authorisation shall be valid for a period of 3 months and thereafter for periods of 3 months, if, in respect of each period, the like consent or, as the case may be, approval and authorisation is obtained.

INSPECTION FINDINGS As no involuntary patients had been admitted to the approved centre since the last inspection, Part 4 of the Mental Health Act 2001: Consent to Treatment was not applicable.

NOT APPLICABLE

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12.0 Inspection Findings – Codes of Practice

EVIDENCE OF COMPLIANCE WITH CODES OF PRACTICE – MENTAL HEALTH ACT 2001 SECTION 51 (iii)

Section 33(3)(e) of the Mental Health Act 2001 requires the Commission to: “prepare and review periodically, after consultation with such bodies as it considers appropriate, a code or codes of practice for the guidance of persons working in the mental health services”. The Mental Health Act, 2001 (“the Act”) does not impose a legal duty on persons working in the mental health services to comply with codes of practice, except where a legal provision from primary legislation, regulations or rules is directly referred to in the code. Best practice however requires that codes of practice be followed to ensure that the Act is implemented consistently by persons working in the mental health services. A failure to implement or follow this Code could be referred to during the course of legal proceedings. Please refer to the Mental Health Commission Codes of Practice, for further guidance for compliance in relation to each code.

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Use of Physical Restraint

Please refer to the Mental Health Commission Code of Practice on the Use of Physical Restraint in Approved Centres, for further guidance for compliance in relation to this practice.

INSPECTION FINDINGS Processes: The approved centre had a written policy on the use of physical restraint. The policy, which had been reviewed annually, included details of the following:

The provision of information to residents regarding the use of physical restraint.

The individuals authorised to initiate and implement physical restraint.

The training requirements relating to physical restraint. Training and Education: Not all staff involved in physical restraint had signed a log, indicating that they had read and understood the policy. Staff interviewed were able to articulate the process of physical restraint as outlined in the policy. A staff training plan was in place, which specified who should receive training, areas to be addressed during training, frequency of training, the identification of appropriately qualified individuals to deliver training, and the mandatory nature of training. A record of attendance at training was maintained. As no episode of physical restraint had been recorded in the approved centre since 2015, the monitoring and evidence of implementation pillars for this code of practice were not inspected against.

The approved centre was compliant with this code of practice.

COMPLIANT

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Admission of Children

Please refer to the Mental Health Commission Code of Practice Relating to the Admission of Children under the Mental Health Act 2001 and the Mental Health Commission Code of Practice Relating to Admission of Children under the Mental Act 2001 Addendum, for further guidance for compliance in relation to this practice.

INSPECTION FINDINGS As children were not admitted to the approved centre, this code of practice was not applicable.

NOT APPLICABLE

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Notification of Deaths and Incident Reporting

Please refer to the Mental Health Commission Code of Practice for Mental Health Services on Notification of Deaths and Incident Reporting, for further guidance for compliance in relation to this practice.

INSPECTION FINDINGS Processes: The approved centre’s risk management policy, dated April 2017, addressed the reporting of incidents and deaths to the Mental Health Commission (MHC). Its care of the dying policy, dated April 2017, also covered the reporting of deaths. The policies specified the risk manager and outlined the roles and responsibilities of staff in relation to the following:

The reporting of deaths and incidents.

The completing of death notification forms.

The submission of forms to the MHC.

The policies did not reference the roles and responsibilities in relation to the completion of six-monthly incident summary reports. Monitoring: Deaths and incidents were reviewed to identify and correct any problems as they arose and to improve quality. Evidence of Implementation: The approved centre was not compliant with Regulation 32: Risk Management Procedures. It used the National Incident Management System to report incidents, and the incident report forms were available to the inspector. A six-monthly summary of all incidents was sent to the MHC. There had been five deaths of residents of the approved centre since the last inspection, and these had been notified to the MHC within the required 48-hour time frame. The approved centre was not compliant with this code of practice for the following reasons:

a) It was not compliant with Regulation 32: Risk Management Procedures, 3.1. b) The policies did not reference the roles and responsibilities in relation to the completion of six-

monthly incident summary reports, 4.3.

NON-COMPLIANT Risk Rating

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Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities

Please refer to the Mental Health Commission Code of Practice Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities, for further guidance for compliance in relation to this practice.

INSPECTION FINDINGS As the approved centre did not admit residents who had been diagnosed with an intellectual disability, this code of practice was not applicable.

NOT APPLICABLE

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Use of Electro-Convulsive Therapy (ECT) for Voluntary Patients

Please refer to the Mental Health Commission Code of Practice on the Use of Electro-Convulsive Therapy for Voluntary Patients, for further guidance for compliance in relation to this practice.

INSPECTION FINDINGS As the approved centre did not use Electro-Convulsive Therapy, this code of practice was not applicable.

NOT APPLICABLE

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Admission, Transfer and Discharge

Please refer to the Mental Health Commission Code of Practice on Admission, Transfer and Discharge to and from an Approved Centre, for further guidance for compliance in relation to this practice.

INSPECTION FINDINGS Processes: The approved centre had separate policies in relation to admission, transfer, and discharge, all dated April 2017. Admission: The admission policy included all of the criteria of this code of practice, including a protocol for planned admission with reference to pre-admission assessments, eligibility for admission, and referral letters. It detailed the roles and responsibilities of multi-disciplinary team (MDT) members in relation to post-admission assessment. It contained protocols for urgent referrals, self-presenting individuals, and timely communication with primary care teams. There was also a policy on confidentiality, privacy, and consent. Transfer: The transfer policy detailed how a transfer was arranged and outlined the roles and responsibilities of staff in relation to the transfer of residents. It included procedures for involuntary transfer and transfer abroad. It did not include provisions for an emergency transfer or for ensuring the safety of the resident and staff during a resident transfer. Discharge: The discharge policy referenced prescriptions and supply of medication on discharge, and it included procedures for managing the discharge of involuntary patients. It did not include protocols for discharging homeless people, older people, or people with an intellectual disability, nor did it contain a process for managing discharge against medical advice. The policy did not contain follow-up procedures. Training and Education: There was no documented evidence that all staff had read and understood the policies on admission, transfer, and discharge. Monitoring: There was no documented evidence that audits had been completed on the implementation of and adherence to the admission policy. As there had been no discharges from the approved centre since the last inspection, the monitoring pillar for discharge was not inspected against. Evidence of Implementation: Admission: One clinical file was inspected in relation to admission. The approved centre had a key worker system in place and the entire MDT record was contained in a single clinical file. Admission was made on the basis of mental illness or disorder, and the decision to admit was taken by the registered medical practitioner (RMP). An admission assessment was completed and documented in the clinical file. Family members/carers were involved in the admission process. Residents were admitted to the unit most appropriate to their needs. The approved centre’s admissions process was compliant under the following regulations associated with this code of practice: Regulation 7: Clothing, Regulation 8: Residents’ Personal Property and Possessions, Regulation 15: Individual Care Plan, Regulation 20: Provision of Information to Residents, and Regulation 27: Maintenance of Records.

NON-COMPLIANT Risk Rating

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Transfer: The approved centre was compliant with Regulation 18: Transfer of Residents. The files of two residents who had been transferred to another health care facility in emergency circumstances were inspected. The decision to transfer was made by the RMP and a pre-transfer assessment was undertaken. Family members/carers/advocates were involved in the transfer process, as were members of the MDT. Referral letters were sent to the receiving facility. A copy of the referral letter was not retained in the clinical file of one of the residents. Discharge: As there had been no discharges from the approved centre since the last inspection, the evidence of implementation pillar for discharge was not inspected against. The admission, transfer, and discharge processes were not compliant because the approved centre did not comply with Regulation 32: Risk Management Procedures. The approved centre was not complaint with this code of practice for the following reasons:

a) The transfer policy did not include provisions for an emergency transfer or for ensuring the safety of the resident and staff during a transfer, 4.13.

b) The discharge policy did not include a protocol for discharging homeless people, 4.12. c) The discharge policy did not include follow-up procedures, 4.14. d) The discharge policy did not include procedures for managing discharge against medical advice,

4.15. e) The discharge policy did not include protocols for discharging people with an intellectual

disability, 4.16, or older persons, 4.17. f) There was no documentary evidence that all staff had read and understood the policies on

admission, transfer, and discharge, 9.1. g) There was no documentary evidence that an audit had been completed on the implementation

of and adherence to the admission policy, 4.19. h) One of the clinical files inspected in relation to transfers did not contain a copy of the referral

letter, 31.2. i) The approved centre was not compliant with Regulation 32: Risk Management Procedures, 7.1.

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Appendix 1: Corrective and Preventative Action Plan

Regulation 16: Therapeutic Services and Programmes Report reference: Page 33-34

Area(s) of non-compliance Plan required Specific Measureable Achievable / Realistic Time-bound

Taken from the inspection

report

Reoccurring1 or

New2 area of

non-compliance

New plan; plan carried over

from 2016; or monitored as

per Condition3

Provide corrective and

preventative action(s) to address

the area of non-compliance

Provide the method of

monitoring the implementation

of the action(s)

Provide details of any barriers

to the implementation of the

action(s)

Provide the timeframe

of the completion of the

action(s)

1. Residents did not

have access to an

appropriate range of

therapeutic services

and programmes.

New Plan required Corrective Action(s):

1. Access to Therapeutic

Service and Programme will

be available, following MDT

review.

Post-Holder(s) responsible:

Senior Management Team

Self-assessment (MDT and service user) through best practice guidance.

Barriers to the implementation of the action(s)

Funding approval for

recruiting additional

health and social care

professionals.

Demographic / geographic issues with recruitments of new staff.

December 2017

Preventative Action(s):

Identify and recruit the most

appropriate health and

social care professionals for

therapeutic services and

programmes.

Post-Holder(s) responsible:

Heads of the Discipline

Overseen by ECD / CD Funding approval for

recruiting additional

health and social care

professionals

Demographic / geographic issues with recruitments of new staff

March 2018

1 Area of non-compliance reoccurring from 2016 2 Area of non-compliance not reoccurring from 2016 3 Not applicable

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2. Therapeutic

programmes and

services were not

directed towards

restoring and

maintaining optimal

levels of physical and

psychosocial

functioning of

residents.

New Plan required Corrective Action(s):

1. To establish recovery and

rehabilitation care pathway

for meeting the needs of

residents with enduring

mental illness.

2. Multidisciplinary Team to

review therapeutic services

directed towards restoring

and maintaining optimal

levels of physical and

psychosocial functioning of

residents.

3. Plan and implement

therapeutic services

following review.

Post-Holder(s) responsible:

Heads of Disciple

On going Barriers to the implementation of the action(s):

Funding approval for

recruiting additional

health and social care

professionals.

Demographic / geographic

issues with recruitments

of new staff.

December 2017

Preventative Action(s):

Identify and recruit the most

appropriate additional

health and social care

professionals for therapeutic

services and programmes.

Post-Holder(s) responsible:

Heads of Disciple and

Consultant

Overseen by ECD / CD Barriers to the implementation of the action(s):

Funding approval for

recruiting additional

health and social care

professionals

Demographic / geographic

issues with recruitments

of new staff

Governances and IR issues

March 2018

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Regulation 19: General Health

Report reference: Page 37-38

Area(s) of non-compliance Plan required Specific Measureable Achievable / Realistic Time-bound

Taken from the inspection

report

Reoccurring or

New area of non-

compliance

New plan; plan carried over

from 2016; or monitored as

per Condition

Provide corrective and

preventative action(s) to address

the area of non-compliance

Provide the method of

monitoring the implementation

of the action(s)

Provide details of any barriers

to the implementation of the

action(s)

Provide the timeframe

of the completion of the

action(s)

3. Not all residents had

received a complete

general health needs

review within the last

six months.

New Plan required Corrective Action(s):

All general health needs reviews completed at present.

Post-Holder(s) responsible:

Consultant lead MDT

6 Monthly Audit cycle

of checklist to measure

compliance

Achievable / Realistic Completed

Preventative Action(s):

To amended the site specific

policy on general health to

reflect ,If residents refuse

general health review ,

reschedule health review for

two weeks, family meeting

to be organised if third

refusal.

Post-Holder(s) responsible:

Consultant lead MDT

Commenced 12th

September 2017

Achievable On going

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Regulation 21: Privacy

Report reference: Page 40

Area(s) of non-compliance Plan required Specific Measureable Achievable / Realistic Time-bound

Taken from the inspection

report

Reoccurring or

New area of non-

compliance

New plan; plan carried over

from 2016; or monitored as

per Condition

Provide corrective and

preventative action(s) to address

the area of non-compliance

Provide the method of

monitoring the implementation

of the action(s)

Provide details of any barriers

to the implementation of the

action(s)

Provide the timeframe

of the completion of the

action(s)

4. The full names of

residents were

displayed on a

noticeboard that

could be viewed by

visitors.

New Plan required Corrective Action(s):

Visibility of residents full name on the notice board has been removed

Post-Holder(s) responsible:

CNM 2

1. Visible correction. 2. Annual audits.

Achieved 28th July 2017.

Preventative Action(s):

Privacy Audit to be carried out

Post-Holder(s) responsible:

Audit Group

On an annual basis

Achievable

To commence

December 2017

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Regulation 22: Premises Report reference: Page 40

Area(s) of non-compliance Plan required Specific Measureable Achievable / Realistic Time-bound

Taken from the inspection

report

Reoccurring or

New area of non-

compliance

New plan; plan carried over

from 2016; or monitored as

per Condition

Provide corrective and

preventative action(s) to address

the area of non-compliance

Provide the method of monitoring

the implementation of the

action(s)

Provide details of any barriers

to the implementation of the

action(s)

Provide the timeframe

of the completion of the

action(s)

5. The premises were

not maintained in

good decorative

condition.

New Plan required Corrective Action(s):

1.A detailed programme for flooring and painting submitted to the maintenance department.

Post-Holder(s) responsible:

General Manager

Maintenance department.

Ongoine liaison with HSE Estates.

Subject to HSE Estates processes

December 2017

Preventative Action(s):

1.Programme of maintenance in place for minor decorative issues. 2.Monthly monitoring of maintenance programme.

Post-Holder(s) responsible:

General Manager

Maintenance department.

ADON, CNM2

Programme developed

identifying priority

maintenance works

Dependant on minor

funding allocation

December 2017

6. Heating could not be

controlled to

adequately heat the

approved centre.

Required changes had

New Plan required Corrective Action(s):

Refer matter to HSE ESatates in order for a solution to be identified.

Post-Holder(s) responsible:

Maintenance department,

Ongoing liaison with HSE

Estates

Depending on funding March 2018

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to be responded to by

maintenance. ADON and CNM2

Preventative Action(s):

Regular and ongoing monitoring of heating system. Timely reporting and rectification.

Post-Holder(s) responsible:

General Manager

Maintenance department,

ADON and CNM2

On going Achievable On going

7. There was no ongoing

programme of

decorative

maintenance.

New Plan required Corrective Action(s):

1. CNM2 in association with Maintenance department to review the premises and compiled a programme of decorative maintenances required to be included in CHO Minor Capital register.

Post-Holder(s) responsible:

CNM2, General manager,

Maintenance department

CHO Minor Capital Register to include works identified through local review.

Achievable

November 2017

Preventative Action(s):

1.On-going monitoring by management including maintenance team.

Post-Holder(s) responsible:

Maintenance department, ADON & CNM2

Ongoing identification of

priority maintenance works.

Subject to minor capital

funding allocation

Ongoing

8. The physical structure

and the overall Reoccurring Plan required Corrective Action(s):

Through Operational Planning process

Budget approval for renovation works

April 2018

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approved centre

environment was not

developed and

maintained with due

regard to the specific

needs of residents

and patients and the

safety and well-being

of residents, staff,

and visitors.

1.Executive management team to develop a plan to realign unit to meet the specific needs of patient. 2. MDT input into the design phase of the agreed unit.

Post-Holder(s) responsible:

Executive Management Team

commencing on 16th October 2017.

Preventative Action(s):

On going programme to

evaluate patient needs to

Identify appropriate

facilities

Post-Holder(s) responsible:

Consultant lead MDT

Through 3 monthly

review of ICP

Realistic

Ongoing

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Regulation 26: Staffing

Report reference: Page 47-48

Area(s) of non-compliance Plan required Specific Measureable Achievable / Realistic Time-bound

Taken from the inspection

report

Reoccurring or

New area of non-

compliance

New plan; plan carried over

from 2016; or monitored as

per Condition

Provide corrective and

preventative action(s) to address

the area of non-compliance

Provide the method of

monitoring the implementation

of the action(s)

Provide details of any barriers to

the implementation of the

action(s)

Provide the timeframe

of the completion of

the action(s)

9. The numbers and

skill mix of staff

were not

appropriate to the

assessed needs of

residents.

New Plan required Corrective Action(s):

1. Heads of discipline to

review the therapeutic

services and programmes

and the needs of residents

to determine the allocation

of the most appropriate

allied health care

professionals accordingly

Post-Holder(s) responsible:

Senior Management Team

2. Establish recovery and

rehabilitation care pathway

for meeting the needs of

residents with enduring

mental illness

Post-Holder(s) responsible:

Senior Management Team

Through Operational Planning process commencing on 16th October 2017.

Barriers to the implementation of the action(s)

Funding approval for

recruiting additional health

and social care professionals

Demographic / geographic issues with recruitments of new staff

January 2018

Preventative Action(s):

Annual work force planning

Post-Holder(s) responsible:

Senior management team

Overseen by Senior

management team

Achievable Complete

December 2017

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Area(s) of non-compliance Plan required Specific Measureable Achievable / Realistic Time-bound

Taken from the inspection

report

Reoccurring or

New area of non-

compliance

New plan; plan carried over

from 2016; or monitored as

per Condition

Provide corrective and

preventative action(s) to address

the area of non-compliance

Provide the method of

monitoring the implementation

of the action(s)

Provide details of any barriers to

the implementation of the

action(s)

Provide the timeframe

of the completion of

the action(s)

10. Not all staff had up-

to-date mandatory

training in BLS, fire

safety, PMAV, and

the MHA 2001.

Reoccurring Plan carried over from

2016. Please:

Provide the expected

date of completion in

the time-bound

column,

Revise the plans as

necessary, and/or

Provide an update on

the plans.

Corrective action(s):

Staff Training ongoing.

New Training Database

already implemented for

nursing staff to capture and

monitor training needs and

up to date status.

Line managers of other MDT

members to monitor activity

in the training needs of the

staff.

Post-holder(s):

All line mangers to monitor

their staff and source

appropriate training as laid

out in Regulation 26

Training continues in these

four areas

Achievable and Realistic December 2017

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Area(s) of non-compliance Plan required Specific Measureable Achievable / Realistic Time-bound

Taken from the inspection

report

Reoccurring or

New area of non-

compliance

New plan; plan carried over

from 2016; or monitored as

per Condition

Provide corrective and

preventative action(s) to address

the area of non-compliance

Provide the method of

monitoring the implementation

of the action(s)

Provide details of any barriers to

the implementation of the

action(s)

Provide the timeframe

of the completion of

the action(s)

Preventative action(s):

Training plans to be agreed

by Senior Management

Team for roll out of

appropriate training.

Post-holder(s):

Senior Management Team to

identify Training Needs of

staff and implement

appropriate measure to

facilitate compliance with

this Regulation 26

All line mangers to monitor

their staff and source

appropriate training as laid

out in Regulation 26

Training Database in situ

for nursing staff

Training database in situ for

nursing staff. Other MDT

line mangers to monitor

staff training.

Update:

ECD to review medical sytem

of recording training.

MDT review of current

systems in place across all

disciplines.

Central communication point

for disseminating

information on scheduled

mandatory training dates

Training database for all

disciplines

Quarterly review of

training database

For discussion at QPS

Committee

Realistic

December 2017

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Regulation 32: Risk Management Procedures Report reference: Page 56-57

Area(s) of non-compliance Plan required Specific Measureable Achievable / Realistic Time-bound

Taken from the inspection

report

Reoccurring or

New area of non-

compliance

New plan; plan carried over

from 2016; or monitored as

per Condition

Provide corrective and

preventative action(s) to address

the area of non-compliance

Provide the method of

monitoring the implementation

of the action(s)

Provide details of any barriers

to the implementation of the

action(s)

Provide the timeframe

of the completion of the

action(s)

11. The risk management

policy was not being

fully implemented, as

evidenced by the

presence of

significant structural

ligature risks

throughout the

premises.

Reoccurring

since 2016

New plan required Corrective Action(s):

1.Individual risk assessment

completed on each residents

and updated as required.

2.Ligature audit completed

to identify and to prioritise

mitigation and elimination of

ligature point throughout

premises

3.Prioritise structural

ligature risks and mitigate risk associated with ligature

Post-Holder(s) responsible:

General Manager, HSE

Estates, ADON, CNM 2.

1. Annual Ligature Audit 2. Systematic Analysis of

risk register. 3. Analysis of Incidents/

NIMS.

Depending on funding approval

December 2017

Preventative Action(s):

Ongoing review and to

repeat ligature audit every 6

months

Post-Holder(s) responsible:

To commence 1st October

2017

Reliable

On going

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Maintenance Dept,CNM 2,

ADON

12. The environment did

not provide sufficient

controls to prevent

accidental injury to

residents.

New Plan required Corrective Action(s):

1.MDT Falls Risk Assessment on admission. 2.For residents identified as being at low risk of falls, standard fall risk reduction interventions are put in place to ensure the person’s safety is maintained. 3.For residents identified as being at medium or high risk of falls, a falls risk reduction care plan is initiated by the MDT. All interventions are evaluated and outcomes documented after discussing with residents and or their representative.

Post-Holder(s) responsible:

Key worker

1. Analysis of incident occurred / NIMS.

2. Risk register audit

Achievable / Realistic On going process

Preventative Action(s):

Monthly fall incidents analysis and review to identify environmental factors contributing to fall / injuries

Post-Holder(s) responsible:

Audit Group

Overseen by Consultant

Local QPS Committee

Realistic Completed

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13. Staff were not aware

of evacuation

procedures.

New Plan required Corrective Action(s):

All residents integrated care

plans are incorporated with

personal emergency

evacuation plans (PEEP).

All staff can articulate this

evacuation processes as set

out in PEEP.

Copies of Current Fire Safety Management Policy and Safety Statement complete with fire records. Delegation of staff responsibilities in the prevention of Fires and in the event of an outbreak of fire in their area of responsibility during the morning daily ward meeting

Post-Holder(s) responsible:

General Manager, Fire

officer, CNM2

1. Regular evacuation

drills. 2. Regular Fire Training

records

Achievable / Realistic

Complete

Preventative Action(s):

1.Regular fire drill programme 2.Monitoring staff awareness on Fire Safety Management

Post-Holder(s) responsible:

Fire training coordinator,

ADON, CNM2

On going Realistic Completed

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Code of Practice: Notification of Deaths and Incident Reporting Report reference: Page 69

Area(s) of non-compliance Plan required Specific Measureable Achievable / Realistic Time-bound

Taken from the inspection

report

Reoccurring or

New area of non-

compliance

New plan; plan carried over

from 2016; or monitored as

per Condition

Provide corrective and

preventative action(s) to address

the area of non-compliance

Provide the method of

monitoring the implementation

of the action(s)

Provide details of any barriers

to the implementation of the

action(s)

Provide the timeframe

of the completion of the

action(s)

14. The policies did not

reference the roles

and responsibilities in

relation to the

completion of six-

monthly incident

summary reports.

Reoccurring

since 2016

New plan required Corrective Action(s):

Currently reviewing the

policy on Risk management

to incorporate 6th monthly

review of incidents

Establishment of Patient safety and quality group to review six-monthly incident summary reports . Policy on I Risk management will be reviewed within the recommended time frame

Post-Holder(s) responsible:

Policy Review Group

6 monthly audit

Achievable /

Realistic

Dec 2017

Preventative Action(s):

Regular monitoring of incidents by local managers and report finding to senior managers.

Post-Holder(s) responsible:

ADON,CNM2

On going Realistic Completed

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Code of Practice: Admission, Transfer and Discharge

Report reference: Page 72-73

Area(s) of non-compliance Plan required Specific Measureable Achievable / Realistic Time-bound

Taken from the inspection report Reoccurring or

New area of non-

compliance

New plan; plan carried over

from 2016; or monitored as

per Condition

Provide corrective and

preventative action(s) to address

the area of non-compliance

Provide the method of

monitoring the implementation

of the action(s)

Provide details of any barriers

to the implementation of the

action(s)

Provide the timeframe

of the completion of

the action(s)

15. The transfer and

discharge policies did not

meet all the

requirements of the code

of practice.

Reoccurring

[for transfer

policy]

Plan required Corrective Action(s):

The transfer and discharge policy will be reviewed within the timeframe Post-Holder(s) responsible:

Policy Review Group

Hard copy of revised polices will be available for inspection.

Achievable / Realistic November 2017

Preventative Action(s):

Policy update every three

years unless otherwise

indicated by either

legislation, change in

practices or

recommendations from the

Mental Health Commission

Inspectorate

Post-Holder(s) responsible:

Policy Review Group

Ongoing Realistic Ongoing

16. There was no

documentary evidence

that all staff had read and

understood the policies

New Plan required Corrective Action(s):

Head of Discipline/CNM 2/

PIC to organising policy

dissemination session with

in the centre.

Monitoring of PPPG signature register

Achievable / Realistic October 2017

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on admission, transfer,

and discharge.

Implemented PPPG

signature log register as an

evidence to read and under

the policy.

Post-Holder(s) responsible:

Headsof discipline

Preventative Action(s):

All Heads of Discipline and Mental Health Services Management to ensure staff have read and understand the policies.

Post-Holder(s) responsible:

Heads of Discipline

Overseen by Head of

discipline

Achievable

Complete Dec

2017

17. There was no

documentary evidence

that an audit had been

completed on the

implementation of and

adherence to the

admission policy.

New Plan required Corrective Action(s):

To re-establish Audit Group. Complete Audit on admission process

Post-Holder(s) responsible:

Audit Group

Annual audit Achievable / Realistic December 2017

Preventative Action(s):

Audit Schedule in place.

Post-Holder(s) responsible:

Audit Group

Completed Achieved 2ND Aug 2017

18. One of the clinical files

inspected in relation to

transfers did not contain

a copy of the referral

letter.

New Plan required Corrective Action(s):

CNM2/ PIC to ensure a copy

of transfer letter is enclosed

in the integrated case note,

following resident transfer

Analysis is completed to identify opportunities to improve information provision during transfers.

Achievable / Realistic October 2017

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to another healthcare

facilities

Post-Holder(s) responsible:

CNM2 /Person In charge

Preventative Action(s):

Regular monitoring of transferring process and procedure.

Post-Holder(s) responsible:

CNM2 /Person In charge

Completed Achieved 12 Sep 2017