Serious concerns following inspection at CUH adult mental health unit

Several serious concerns were noted in the Adult Mental Health Unit at Cork University Hospital by the Mental Health Commission (MHC), with a high level of critical non-compliances and risk of further enforcement measures.

The MHC conducted an unannounced inspection in April 2024 and found that while individual feedback from residents was largely complimentary, issues were identified of access to therapeutic services, care planning, general health, staffing, staff training, and risk management.

There was a slight increase in the overall compliance rate of 58% from the 2023 inspection, to 61%, but the number of critical non-compliances had doubled, from four to eight, and the MHC said: “This level of critical non-compliance is unprecedented.”

Deeply concerning

It said it was also “deeply concerning” that the centre was found to be in breach of a condition of registration, which it views “in the most serious of terms”.

The front door to the centre was locked, with no risk assessment analysing the need for the locked door, nor any evidence that this was discussed, decided, or reviewed.

Regular fire drills and personal evacuation plans were identified as control measures, but no drills had taken place since the last inspection and no resident had such a plan documented in their file. Some fire doors were not fit for purpose as they could not adequately contain smoke.

Two serious reportable events were notified to the MHC since the last inspection, however five events that met the criteria for notification had occurred, meaning three were not reported. There were also staffing shortages, with two consultant psychiatrist vacancies and no dedicated occupational therapist.

Despite previous assurances that access to a dietician through CUH was in place, inspectors found that a private dietetic assessment had to be procured through a business case, and residents requiring assessment had not been referred. 

Training

Not all staff had completed mandatory training in the five courses required, and the MHC noted that of particular concern was the number without up-to-date training in acts which bestow significant powers on medical staff, including the right to detain a person in hospital.

There was no overall training co-ordinator for the service and no training plan provided to the inspection team.

There were also deficits identified in the implementation of the new code of practice on physical restraint, including one instance where no medical exam was conducted of the person post-restraint, one instance where no debrief was conducted, and one instance where no review of the episode was conducted with the resident.

Change required

Overall, inspectors said, a change in organisational culture and extra resources were required. 

The centre was told to develop and implement a costed, funded, and timebound plan to address ligature risk and a quality improvement plan “to comprehensively address continuous areas of non-compliance”.

The MHC noted that the HSE “accepted that they had failed to meet regulatory requirements”, and were informed that the MHC was “giving consideration to further enforcement action”.