Report of the Inspector of Mental Health Services 2010

Transcription

1 Report of the Inspector of Mental Health Services 2010 EECUTIVE CATCHMENT AREA HSE AREA CATCHMENT AREA MENTAL HEALTH SERVICE APPROVED CENTRE Limerick, North Tipperary and Clare West Limerick West Tearmann Ward and Curragour Ward St. Camillus Hospital NUMBER OF WARDS 2 NAMES OF UNITS OR WARDS INSPECTED Tearmann Ward and Curragour Ward TOTAL NUMBER OF BEDS CONDITIONS ATTACHED TO REGISTRATION Medical No TYPE OF INSPECTION Unannounced DATE OF INSPECTION 24 March 2010 Page 1 of 48

2 PART ONE: QUALITY OF CARE AND TREATMENT SECTION 51 (1) (b) (i) MENTAL HEALTH ACT 2001 INTRODUCTION In 2010, the Inspectorate paid particular attention to Articles 15 to 22 and 26 of the Mental Health Act 2001 (Approved Centres) Regulations 2006 and all areas of non- with the Regulations in 2009 and any other Article where applicable. The Inspectorate was keen to highlight s and initiatives carried out in the past year and track progress on the implementation of recommendations made in Information was gathered from self-assessments, service user interviews, staff interviews and photographic evidence collected on the day of the inspection. DESCRIPTION Tearmann Ward and Curragour Ward were situated in the campus of St. Camillus Hospital in Limerick City. It was a single storey building and had 22 residents who required an intensive level of input from nursing staff and a number had physical disabilities. The age range was from 67 years to 90 years. Curragour Ward was an assessment ward that also provided respite care. Tearmann Ward provided continuing care for its residents. On the day of inspection there was one detained patient in the approved centre. DETAILS OF WARDS IN THE APPROVED CENTRE WARD NUMBER OF BEDS NUMBER OF RESIDENTS TEAM RESPONSIBLE Tearmann Ward Medical Beds Medical Patients Psychiatry of Old Age Curragour Ward 10 9 Psychiatry of Old Age QUALITY INITIATIVES The bathroom facilities were refurbished to a high standard in A total of nine beds had been removed from the wards to create extra space within all the bedrooms. The premises had been redecorated to a high standard and were much brighter than previously. Page 2 of 48

3 PROGRESS ON RECOMMENDATIONS IN THE 2009 APPROVED CENTRE REPORT 1. Individual multidisciplinary care plans should be developed for each resident. Outcome: Some work had commenced on the development of an individual multidisciplinary care plan. 2. An appropriate skill mix should be available to implement therapeutic services. Outcome: This had not been achieved. 3. There should be a greater level of activation, linked to individual care plans, on the wards. Outcome: This had not been achieved. 4. All policies should be reviewed to ensure they are specific to the approved centre and that implementation and review dates are correct. Outcome: This had not been achieved. 5. Policies relating to seclusion, ECT and physical restraint should be developed, simply stating that these were not used in the approved centre. Outcome: This had not been achieved. 6. The placement of medical patients in this approved centre should cease, and the medical patients currently in the approved centre should be accommodated in a general medical facility. Outcome: This had not been achieved. 7. Consideration should be given to creating extra space and improving privacy by removing some of the beds. Outcome: Nine beds had been removed to create extra space on the wards. 8. All staff should receive sufficient training on the Mental Health Act (2001), particularly in view of the predominance of staff from a general nursing background. Outcome: This had not been achieved. 9. The level of decor was poor and faded and should be improved. Outcome: The unit was clean, bright and recently refurbished. 10. The one small multipurpose room available should be adequately furnished. Outcome: This had not been achieved. Page 3 of 48

4 PART TWO: EVIDENCE OF COMPLIANCE WITH REGULATIONS, RULES AND CODES OF PRACTICE, AND SECTION 60, MHA EVIDENCE OF COMPLIANCE WITH REGULATIONS UNDER MENTAL HEALTH ACT 2001 SECTION 52 (d) Article 4: Identification of Residents but Page 4 of 48

5 Article 5: Food and Nutrition but Page 5 of 48

6 Article 6 (1-2): Food Safety but Justification for this rating: There was an up-to-date food safety report available on the day of inspection. Page 6 of 48

7 Article 7: Clothing but Page 7 of 48

8 Article 8: Residents Personal Property and Possessions but Justification for this rating: The approved centre had an up-to-date policy on personal property and possessions. Page 8 of 48

9 Article 9: Recreational Activities but Justification for this rating: An activities person was available for one morning per week. However, on the day of inspection there were limited signs of any recreational activities available for residents on the wards. Many of the residents were either sitting or wandering around the wards aimlessly. Nursing staff on both wards reported that a lack of staff and space made implementation of this Article very difficult. An Art therapist attended the ward two days a week and music therapists were available to the approved centre. Breach: 9 Page 9 of 48

10 Article 10: Religion but Page 10 of 48

11 Article 11 (1-6): Visits but Justification for this rating: The visitor s room was currently being redecorated. The approved centre had up-to-date written operational policies and procedures for visiting. Page 11 of 48

12 Article 12 (1-4): Communication but Justification for this rating: The approved centre had up-to-date written operational policies and procedures for communication. Page 12 of 48

13 Article 13: Searches but Page 13 of 48

14 Article 14 (1-5): Care of the Dying but Page 14 of 48

15 Article 15: Individual Care Plan but Justification for this rating: Transition to a new integrated individual care plan was taking place. Residents did not sign their individual care plans nor did they receive copies of their individual care plans. There were regular team meetings. Family meetings occurred between staff and the multidisciplinary team on a six-monthly basis and they were kept informed of any changes in care and treatment of their relative on a regular basis. Breach: 15 Page 15 of 48

16 Article 16: Therapeutic Services and Programmes but Justification for this rating: No psychiatric occupational therapist attended the wards. The residents did not have access to appropriate therapeutic services and programmes in accordance with his or her individual care plan. The approved centre did not ensure that programmes and services provided were directed at restoring and maintaining optimal levels of physical and psychosocial functioning of a resident. The approved centre reported that they were in the process of updating each resident s profile and linking activities to patients interests and hobbies. Breach: 16 (1) (2) Page 16 of 48

17 Article 17: Children s Education This was not applicable in this approved centre. Page 17 of 48

18 Article 18: Transfer of Residents but Justification for this rating: There were up-to-date policies on the transfer of residents. A letter of referral and staff member accompanied the resident on transfer to another unit or service. Page 18 of 48

19 Article 19 (1-2): General Health but Justification for this rating: There was some confusion over the person responsible for undertaking general health checks and as a result, several six monthly physical reviews were not completed. Neither ward had an emergency trolley. There were up-to-date written operational policies and procedures for responding to medical emergencies. Breach: 19 (1) (b) Page 19 of 48

20 Article 20 (1-2): Provision of Information to Residents but Justification for this rating: There was a new information booklet for the approved centre and operational policies and procedures for the provision of information to residents were available. Page 20 of 48

21 Article 21: Privacy but Justification for this rating: There was no screening on the glass panels on the dormitory doors. The approved centre was in the process of installing new screening on all glass panels. Breach: 21 Page 21 of 48

22 Article 22: Premises but Justification for this rating: The bathroom in the wards had been renovated to a high standard. Several beds had been removed from Tearmann Ward to create extra space which was visible on inspection. On Curragour Ward there were ten beds and the area was very cramped and claustrophobic. There was little space for walking, or activities of daily living. The main entrance to the ward opened directly into the resident s bedroom and the layout of this ward must be re-examined. There was access to a lovely well kept garden area. The smoking room on Tearmann Ward did not have an extractor fan in situ which resulted in all residents being supervised when smoking to avoid any injuries or accidents. Nursing staff were therefore required to stay in the smoking room with patients exposing them to passive smoking. Breach: 22 (3) Page 22 of 48

23 Article 23 (1-2): Ordering, Prescribing, Storing and Administration of Medicines but Page 23 of 48

24 Article 24 (1-2): Health and Safety but Page 24 of 48

25 Article 25: Use of Closed Circuit Television (CCTV) but Page 25 of 48

26 Article 26: Staffing WARD OR UNIT STAFF TYPE DAY NIGHT Tearmann Ward CNM2 1 0 CNM1 / Staff nurses 2 x 0730h to 1330h 2 x 2000h to 0030h 2 x 1330h to 2030h 1 x 0030h to 0730h Multi Task Attendant Psychologist On request 0 Social worker On request 0 Curragour Ward CNM2 0 0 CNM1 0 0 Staff nurses 2 1 Multi Task Attendant 2 2 Psychologist On request 0 Social worker On request 0 but Page 26 of 48

27 Justification for this rating: Residents were under the care of two consultants in psychiatry of old age, with the exception of two medical patients who were under the care of the physicians of geriatric medicine. A general practitioner attended the ward each morning. Residents had no access to a psychiatric occupational therapist. The nursing staff were predominately general trained nurses and not all staff had received training in the Mental Health Act (2001). Breach: 26 (2) (3) Page 27 of 48

28 Article 27: Maintenance of Records but Justification for this rating: The approved centre had one composite clinical file for each resident. The approved centre did not have a fire inspection certificate available on the day of inspection. Breach: 27 (3) Page 28 of 48

29 Article 28: Register of Residents but Justification for this rating: The register of residents contained all the required details. Page 29 of 48

30 Article 29: Operating policies and procedures but Page 30 of 48

31 Article 30: Mental Health Tribunals but Page 31 of 48

32 Article 31: Complaint Procedures but Page 32 of 48

33 Article 32: Risk Management Procedures but Justification for this rating: On the day of inspection the risk management policy did not refer to Tearmann Ward and Curragour Ward by name, neither did it refer to precautions in place relating to risk of suicide and self-harm. Breach: 32 (1), 32 (2) Page 33 of 48

34 Article 33: Insurance but Justification for this rating: A copy of the insurance was shown to the Inspectorate on the day of inspection. Page 34 of 48

35 Article 34: Certificate of Registration but Page 35 of 48

36 2.3 EVIDENCE OF COMPLIANCE WITH RULES MENTAL HEALTH ACT 2001 SECTION 52 (d) SECLUSION Use: The approved centre did not use seclusion. ECT (DETAINED PATIENTS) Use: The approved centre did not use ECT. MECHANICAL RESTRAINT The approved centre did not use mechanical restraint. 2.4 EVIDENCE OF COMPLIANCE WITH CODES OF PRACTICE MENTAL HEALTH ACT 2001 SECTION 51 (iii) PHYSICAL RESTRAINT Use: At the time of inspection, no resident had been restrained in ADMISSION OF CHILDREN Description: The approved centre did not admit children. Page 36 of 48

37 NOTIFICATION OF DEATHS AND INCIDENT REPORTING Description: At the time of inspection, no deaths had occurred at the approved centre in SECTION DESCRIPTION FULLY COMPLIANT SUBSTANTIALLY COMPLIANT COMPLIANCE INITIATED NOT COMPLIANT 2 Notification of deaths NOT APPLICABLE 3 Incident reporting 4 Clinical governance Justification for this rating: The approved centre reported all incidents. Incidents were reviewed on the unit. Serious incidents were reported to the Mental Health Commission. Page 37 of 48

38 ECT FOR VOLUNTARY PATIENTS The approved centre did not use ECT. Page 38 of 48

39 ADMISSION, TRANSFER AND DISCHARGE Part 2 Enabling Good Practice through Effective Governance The following aspects were considered: 4. policies and protocols, 5. privacy confidentiality and consent, 6. staff roles and responsibility, 7.risk management, 8. information transfer, 9. staff information and training. Level of : FULLY COMPLIANT SUBSTANTIALLY COMPLIANT COMPLIANCE INITIATED NOT COMPLIANT Justification for this rating: There was a policy on admissions. Information was transferred with the resident. A risk assessment was carried out as part of the initial assessment. There were no up-to-date policies on the transfer of residents. Breach: 4.1 Page 39 of 48

40 Part 3 Admission Process The following aspects were considered: 10. pre-admission process, 11. unplanned referral to an Approved Centre, 12. admission criteria, 13. decision to admit, 14. decision not to admit, 15. assessment following admission, 16. rights and information,17. individual care and treatment plan, 18. resident and family/carer/advocate involvement, 19. multidisciplinary team involvement, 20. key-worker, 21. collaboration with primary health care community mental health services, relevant outside agencies and information transfer, 22. record-keeping and documentation, 23. day of admission, 24. specific groups. Level of : FULLY COMPLIANT SUBSTANTIALLY COMPLIANT COMPLIANCE INITIATED NOT COMPLIANT Justification for this rating: All admissions were discussed at team meetings. The service user was invited to view the approved centre and talk to staff. Family were involved where possible. Page 40 of 48

41 Part 4 Transfer Process The following aspects were considered: 25. Transfer criteria, 26. decision to transfer, 27. assessment before transfer, 28. resident involvement, 29. multi-disciplinary team involvement, 30. communication between Approved Centre and receiving facility and information transfer, 31. record-keeping and documentation, 32. day of transfer. Level of : FULLY COMPLIANT SUBSTANTIALLY COMPLIANT COMPLIANCE INITIATED NOT COMPLIANT Justification for this rating: There were up-to-date policies on the transfer of residents. All transfers were accompanied by relevant information and a staff member accompanied the resident to their destination. Page 41 of 48

42 Part 5 Discharge Process The following aspects were considered: 33. Decision to discharge, 34. discharge planning, 35. predischarge assessment, 36. multi-disciplinary team involvement, 37. key-worker, 38. collaboration with primary health care, community mental health services, relevant outside agencies and information transfer, 39. resident and family/carer/advocate involvement and information provision, 40. notice of discharge, 41. follow-up and aftercare, 42. record-keeping and documentation, 43. day of discharge, 44. specific groups. Level of : FULLY COMPLIANT SUBSTANTIALLY COMPLIANT COMPLIANCE INITIATED NOT COMPLIANT Justification for this rating: The discharge plan was part of the individual care plan. All decisions to discharge were made through the multidisciplinary team meetings. The resident s General Practitioner was informed as was the community mental health nurse. Page 42 of 48

43 HOW MENTAL HEALTH SERVICES SHOULD WORK WITH PEOPLE WITH AN INTELLECTUAL DISABILITY AND MENTAL ILLNESS The following aspects were considered: 5. policies, 6. education and training, 7. inter-agency collaboration, 8. individual care and treatment plan, 9. communication issues, 10. environmental considerations, 11. considering the use of restrictive practices, 12. main recommendations, 13. assessing capacity. Level of : FULLY COMPLIANT SUBSTANTIALLY COMPLIANT COMPLIANCE INITIATED NOT COMPLIANT Justification for this rating: There were a small number of residents with intellectual disability and mental illness in the unit. There was no policy for people on intellectual disability and mental illness. The staff had not received any specific training. Breach: 5, 6, 8, 9 Page 43 of 48

44 2.5 EVIDENCE OF COMPLIANCE WITH SECTIONS 60/61 MENTAL HEALTH ACT (MEDICATION) SECTION 60 ADMINISTRATION OF MEDICINE Description: There was one detained patient in the approved centre. This patient did not consent to treatment, but there was an up-to-date Form 17 in the chart. SECTION FULLY COMPLIANT SUBSTANTIALLY COMPLIANT COMPLIANCE INITIATED NOT COMPLIANT Section 60 (a) NOT APPLICABLE Section 60 (b)(i) Section 60 (b)(ii) Page 44 of 48

45 SECTION 61 TREATMENT OF CHILDREN WITH SECTION 25 ORDER IN FORCE Description: No children were admitted to the approved centre. Page 45 of 48

46 SECTION THREE: OTHER ASPECTS OF THE APPROVED CENTRE SERVICE USER INTERVIEWS The residents were greeted by the Inspectorate on both wards. No resident wished to talk individually with the Inspectorate. MEDICATION The medication sheets were untidy, difficult to read, not properly signed in some cases and other signatures were illegible. MEDICATION LONG STAY NUMBER OF PRESCRIPTIONS: 22 Number on benzodiazepines 14 (64%) Number on more than one benzodiazepine 1 (5%) Number on regular benzodiazepines 13 (59%) Number on PRN benzodiazepines 6 (27%) Number on hypnotics 12 (55%) Number on Non benzodiazepine hypnotics 12 (55%) Number on antipsychotic medication 19 (86%) Number on high dose antipsychotic medication 0 Number on more than one antipsychotic medication 0 Number on PRN antipsychotic medication 2 (9%) Page 46 of 48

47 Number on antidepressant medication 16 (73%) Number on more than one antidepressant 5 (23%) Number on antiepileptic medication 6 (27%) Number on Lithium 0 OVERALL CONCLUSIONS This was the second inspection of Tearmann and Curragour Wards, St. Camillus Hospital, since it had been registered as an approved centre. The service was introducing individual multidisciplinary care plans to the wards but without them and an occupational therapist, therapeutic services and programmes could not be individually directed to the needs of the residents. Residents had very little to occupy themselves with during the day and there continued to be a lack of space on Curragour Ward. Nine beds had been removed from Tearmann Ward which had created extra space which was welcome for the residents. The renovation of the bathroom areas had been of a high standard. The majority of the nursing staff on both wards were of general nursing background and upon speaking with staff members, it was clear to the Inspectorate that there was uncertainty among staff as to the statutory requirements involved in managing an approved centre. All nursing staff on the wards reported to the Director of Nursing for the general hospital and it appeared that there was little input into the wider mental health services. It remains of particular concern to the Inspectorate that the continuing placement of medical patients in the approved centre is unsafe for both staff and residents. The practice of placing medical patients onto a psychiatric unit in order to ameliorate operational difficulties including where there are staff shortages must cease immediately. It was evident throughout the inspection that there were positive working relationships between the nursing staff and the residents of this service. Page 47 of 48

48 RECOMMENDATIONS The individual multidisciplinary care plan should be finalised and each resident should have access to their fully completed individual care plan. 2. A system should be developed to ensure that each resident has a six monthly physical review. 3. A system should be developed to ensure that all residents receive information on their clinical team, medication and diagnosis. 4. The approved centre must ensure privacy in all bedrooms. 5. The service should develop and implement policies regarding how staff should work with people with mental illness and an intellectual disability. 6. The psychiatry of old age team should be staffed with a full complement of multidisciplinary members to implement therapeutic services and programmes. 7. The placement of medical patients in this approved centre should cease, and the medical patients currently in the approved centre should be accommodated in the general medical facility. 8. There should be a greater level of activation, linked to individual care plans on the ward. 9. All policies should be reviewed to ensure they are specific to the approved centre and that implementation and review dates are correct. 10. All staff should receive sufficient training on the Mental Health Act (2001), particularly in view of the predominance of staff from a general nursing background. 11. The one small multipurpose room available should be adequately furnished. 12. All residents should have one composite clinical file and the practice of maintaining two clinical files on some residents, one for psychiatric care and one for medical care should cease. 13. The standard of prescriptions should be improved. 14. A review of the use of benzodiazepines should take place. Page 48 of 48