Concerns highlighted in hospital psych unit report

Residents’ health needs were not being assessed regularly, the garden area was left littered with cigarette butts, and some toilet bowls and sinks were stained and unclean at the Acute Psychiatric Unit at Cavan General Hospital, an inspection report has found.

The announced annual inspection was conducted over a three-day period in October last year, with two areas of ‘High’ risk and three of ‘Moderate’ concern identified within the 25-bed unit, which is located on the ground floor of the local hospital. At the time of the inspection, 19 residents were being accommodated there.

The publication, commissioned by the Mental Health Commission (MHC), is one of seven inpatient psychiatric units examined, including two for children, that, combined, show “common themes of concern” including failing regulations on minimising potential ligature hazards and with the code of practice on the use of restraint.

In total 10 high-risk and 15 moderate-risk non-compliances were highlighted by inspectors in areas such as premises, restrictive practices, therapeutic services and programmes, staffing, general health and risk management.

Cavan had five separate areas of non-compliance listed. However, the facility’s overall percentage ranking rose compared to the last time officials visited - from 83% in 2022 to 85% in 2023, but still lower than the 91% reached in 2021.

While concerns over the premises were deemed ‘Critical’ in 2022, the latest report ranked them as ‘High’ risk. Problems in terms of managing the general health of residents and further listed concerns over staffing, maintaining the register of residents and use of restraint were deemed ‘Moderate’.

No residents availed of the opportunity to meet with the inspection team during the October 2023 inspection, however five completed questionnaires were received from residents during the visit.

Comments on the questionnaires included that the staff were “very attentive” and that residents were happy with the treatment given.

The inspection found, while residents received appropriate general health care in line with individual care plans, there was no evidence to suggest body weight had been checked in two assessments.

For residents on anti-psychotic medication there was no evidence in three files that a fasting glucose had been completed. ‘Blood results had been stored electronically for three of the five residents; no results were available for the other two.

There was no evidence in the clinical files of blood lipid results for two residents.’

Inspectors also found, while residents had access to appropriate personal space and appropriately sized communal rooms were provided, “not all hazards were minimised”, with “hard and sharp” edges observed in the garden and ligature points throughout not minimised “to the lowest practicable level”.

‘Some works had taken place to address the ligature risks identified in the approved centres ligature audit, which included the installation of anti-ligature TV units and window blinds,’ noted the report.

However inspectors found that the unit overall was “not kept in a good state of repair externally and internally”. Some bedrooms required repairs and painting.

The report acknowledged that the unit had a written policy and procedures in place relating to staffing and that the numbers and skill mix of staffing was “sufficient to meet resident needs”.

However, inspectors found that not all staff were trained in Basic Life Support, Fire Safety and the Mental Health Act 2001.

None of the medical staff were trained in the management of violence or aggression, and the unit’s register was “not up to date” in respect of all residents, in that a diagnosis on admission was “not recorded for three residents, and a diagnosis on discharge was not recorded for one resident”.

Though the unit has a written policy on the use of physical restraint, last reviewed in January 2023, a committee, responsible for reviewing all episodes of physical restraint, “did not meet on a quarterly basis, and did not produce a report following each meeting”.

Three episodes of physical restraint were examined on inspection.

Physical restraint was initiated by a registered medical practitioner (RMP) or registered nurse (RN), in accordance with approved policy. The consultant psychiatrist (CP) was notified as soon as was practicable and this was documented in the clinical files.

‘For one episode of physical restraint, a physical examination of the resident was not completed within two hours of the commencement of the episode; the examination was documented as having taken place two days following the episode.’

Orders for physical restraint lasted for a maximum of 10 minutes, and later residents were informed of the reasons for and the circumstances that would lead to its discontinuation.

Mitigating measures

Regarding the concerns highlighted by the MHC led inspection, several actions have been complete, while others are in the process of being addressed.

The unit is currently waiting for ceiling and window replacements, and further informed that legionella, a bacteria that can lead to other health issues, is causing the staining of the toilet bowls.

An annual ligature audit has taken place, and like the planned repairs, is reliant on external contractors to fix, with a deadline date of end of February next year given.

Director of Regulation for the MHC, Gary Kiernan, noted that the use of seclusion and mechanical means of bodily restraint, and a revised code of practice on the use of physical restraint, came into effect at the beginning of 2023.

“While we have seen further positive reductions overall in the use of restrictive practices in recent years, it is, nevertheless, concerning to note that a small number of centres are still receiving high-risk non-compliances in this area.

“We urge all services to adopt a strong human rights focus when reviewing restrictive practices, as required by our national and international human rights instruments and legislation,” he said. Cavan General Hospital, through the RCSI Group and the HSE, have been contacted for comment.