Sunday 16 June 2019

‘Poor design’ of mental health unit a factor in high level of physical restraints

Jessica Farry

A serious lack of risk management procedures at the Sligo/Leitrim Mental Health In-patient Unit in Ballytivnan was highlighted as a major concern in a Mental Health Commission report, published last week.

Sligo/Leitrim Mental Health In-patient Unit is a 32-bed unit, on the outskirts of Sligo.

At the time of the inspection there were 22 residents.

The building dates from the 1930s, but plans are progressing for the development of a new acute unit on the campus of Sligo University Hospital with an opening target date of the first quarter 2021.

There has been a marked improvement in compliance with regulations since 2016, going from 51% in 2016, to 79% on this inspection in 2018. The centre had one critical risk rating of non-compliance in the area of risk management procedures and five high risk ratings. Twelve compliances were rated as excellent.

The report highlighted 'a concerning lack of risk management procedures in place', and this was rated by the inspectors as critical risk.

There was no risk advisor at the time of the inspection and all staff were responsible for risk management.

There was no clinical governance/business group in place in the approved centre, and there was no clear documentation of how risks were managed. The process to escalate risks to the service risk register was unclear.

Residents who were assessed as high risk were only observed every two hours when they returned to the ward from the high dependency unit.

This was not in line with the observation policy that was sent to the Mental Health Commission following concerns being raised previously.

The report stated that residents who had assaulted staff were not managed in a manner that ensured the safety of residents and staff.

Incident management forms indicated that there had been two fires in the approved centre since the last inspection.

One was where a bin was set alight and the other a toilet roll was set on fire.

Only seven nurses and no medical staff had up-to-date fire safety training.

There was no emergency plan in place that specified responses by the approved centre staff in relation to possible emergencies and/or evacuation.

The individual care plan was reviewed weekly but this review was often completed by medical and nursing staff and not the by the multi-disciplinary team. While residents had access to their individual care plans, not all care plans were reviewed in consultation with the resident. The report stated that 'these deficiencies are unacceptable and demonstrate a lack of recovery and person-centred care'.

Female residents who required seclusion were escorted to the seclusion room via the male admission ward, which was a gross invasion of privacy.

All bedrooms on the female unit were without bedside lights or night-lights.

Residents in shared dormitories could not control the lighting or turn on a bedside light if they wished to read in bed.

New fitted wardrobes had no doors and were not conducive to resident dignity or privacy.

As part of a risk management programme, a seclusion and physical restraint group was established.

One of the aims was to minimise behavioural hazards. There were 38 seclusion episodes since the last inspection and 37 episodes of physical restraint. The poor design of the premises was a factor in the high number of seclusions and restraints as there were no areas of outdoor space and no quiet room.

The service highlighted that contracts had been signed for a new purpose built centre and undertook to manage the risks until this new approved centre was commissioned.

The Commission issued an Immediate Action Notice to address areas of non-compliance identified by the Inspector and has been monitoring this issue.

Anti-ligature wardrobes had been fitted, and new anti-ligature windows had been installed. Other ligatures were evident; however, a programme to minimise ligatures was underway at the time of the inspection.

Maintenance and contract workers were committed to 16 hours of work per week to minimise ligatures and the priority was to eliminate high-risk ligature points.

Actions were in place for all outstanding works.

The ordering, prescribing, storage and administration of medication was done in a safe manner.

Not all healthcare professionals were up-to-date with Basic Life Support (BLS), fire safety, Mental Health Act 2001 and Therapeutic Management of Aggression and Violence training.

Only seven nurses and no medical staff had up-to-date fire safety training.

The provision of written information about the approved centre and residents' diagnoses and medication was excellent.

The six-bed dormitory on the male side was cramped and did not offer access to personal space.

There was a garden beside the approved centre.

Light switches for each of the dormitories were positioned on the wall outside the room and so residents had to get out of bed to turn them off.

Sufficient spaces were not provided for residents including outdoor spaces.

New anti-ligature windows had been installed and these had improved ventilation.

The approved centre was not kept in a good state of repair externally and internally. This was an old building and despite a programme of decorative maintenance and repair there were many areas that were badly worn including floors and the entrance area to the building.

A cleaning schedule was implemented until 6pm but there were no cleaners after this time, which impacted on cleanliness. The inspection team noted that there was a smell of cigarette smoke in a number of rooms throughout the inspection.

The following quality initiatives were identified on this inspection:

1. A seclusion and physical restraint reduction group was established.

2.As part of a refurbishment plan, some new furniture was purchased and parts of the approved centre have been painted.

3. A new policy portal was introduced and all policies are available on-line.

4. A new individual care plan template had been introduced.

5.A sensory room had been established in the female unit and one was planned for the male unit.

Areas of compliance that were rated as 'excellent' during the inspection were as follows:

- Identification of residents

- Food and nutrition

- Food safety

- Clothing

- Residents' Personal Property & Possessions

- Religion

- Care of the dying

- Provision of information to residents

- Use of CCTV

- Maintenance of records

- Operating Policies & Procedures

- Mental Health Tribunals.

The inspection team met with residents. They were complimentary about the service and all knew their respective multi-disciplinary teams. It was reported that there were times when there was not enough staff on the ward. Activities were held upstairs and there was a good programme of both therapeutic services and recreational activities.

Eight residents returned questionnaires to the inspectors. Seven indicated that the residents understood their care plan and seven knew who their keyworker was.

Seven residents also indicated that their privacy and dignity was respected. On a scale of 1-10, with 1 being poor and 10 being excellent, two rated 10 out of 10 for overall experience of care and treatment, five rated between 5 and 7 and one did not indicate a rating.

Sligo Champion