St-Catherines-Ward-St-Finbarrs-Hospital-IR-2020

2020 Approved Centre Inspection Report Mental Health Act 2001 Approved Centre Type: Continuing Mental Health Care/Long Stay Psychiatry of Later Life Mental Health Rehabilitation Most Re

2020 Approved Centre Inspection Report (Mental Health Act 2001)

Approved Centre Type:

Continuing Mental Health Care/Long Stay

Psychiatry of Later Life

Mental Health Rehabilitation

Most Recent Registration Date:

Registered Proprietor Nominee:

Mr Kevin Morrison, General Manager, Mental Health Services, Cork Kerry Community Healthcare

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RULES AND PART 4 OF THE MENTAL HEALTH ACT 2001

Compliant Non-Compliant Not applicable

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CHART 1 – COMPARISON OF OVERALL COMPLIANCE RATINGS 2016 – 2020

Compliance ratings across all 39 areas of inspection are summarised in the chart below

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 2016 – 2020

Contents

1.0 Inspector of Mental Health Services – Review of Findings 6

Conditions to registration 6

Responsiveness to residents’ needs 8

2.0 Quality Initiatives 10

3.0 Overview of the Approved Centre 11

3.1 Description of approved centre 11

3.2 Governance 11

3.3 Reporting on the National Clinical Guidelines 15

4.0 Compliance 16

4.1 Non-compliant areas on this inspection 16

4.2 Areas of compliance rated “excellent” on this inspection 16

4.3 Areas that were not applicable on this inspection 16

5.0 Service-user Experience 18

6.0 Feedback Meeting 19

7.0 Inspection Findings – Regulations 20

8.0 Inspection Findings – Rules 65

9.0 Inspection Findings – Mental Health Act 2001 66

10.0 Inspection Findings – Codes of Practice 67

Appendix 1: Corrective and Preventative Action Plan 69

Appendix 2: Background to the inspection process 78

Inspector of Mental Health Services Dr Susan Finnerty

In brief

The approved centre St Catherine’s Ward was located on the grounds of St Finbarr’s Hospital, Douglas Road in Cork city It provided continuing care for people with mental health difficulties All six General Adult teams and both Psychiatry of Later Life clinical teams from South Lee could admit to St Catherine’s Ward Following admission, responsibility for the residents care was usually undertaken by a dedicated Consultant Psychiatrist

The needs of the residents extended between continuing care and rehabilitation although rehabilitation was not directly available to the residents The age ranged from residents in the midspan of life to those in later life

Conditions to registration

There were three conditions attached to the registration of this approved centre at the time of inspection

Condition 1: To ensure adherence to Regulation 15: Individual Care Plan, the approved centre shall audit their individual care plans on a monthly basis The approved centre shall provide a report on the results of the audits to the Mental Health Commission in a form and frequency prescribed by the Commission

Finding on this inspection: The approved centre was not in breach of this condition and was in compliance with Regulation 15: Individual Care Plan

Condition 2: To ensure adherence to Regulation 26(4): Staffing the approved centre shall implement a plan

to ensure all healthcare professionals working in the approved centre are up-to-date in mandatory training areas The approved centre shall provide a progress update on staff training to the Mental Health

Commission in a form and frequency prescribed by the Commission

1.0 Inspector of Mental Health Services – Review of Findings

Finding on this inspection: The approved centre was not in breach of this condition but was non-compliant with Regulation 26: Staffing

Condition 3 : To ensure adherence to Regulation 26: Staffing, the approved centre shall ensure that

residents of the approved centre have access a suitably qualified speech and language therapist, and

dietitian, in accordance with their assessed needs as documented in their individual care plan, by no later than 31 August 2019.

Finding on this inspection: At the time of inspection, the residents in the approved centre had emergency access only to a speech and language therapist and a dietitian

Safety in the approved centre

• Ligature points were minimised to the lowest practicable level within the approved centre

• Medication was ordered and stored in a safe manner

• Hazards were reduced to a minimum

However:

• There were discrepancies in the prescribing and administration of medication

• Cleaning products and dry food products were stored within the same storage room

• Not all healthcare professionals were up to date with the required mandatory training in Basic Life Support, fire safety, the management of violence and aggression and the Mental Health Act 2001

Appropriate care and treatment of residents

• Each resident had a multi-disciplinary Individual Care Plan that reflected the resident’s goals

• There were therapeutic services and programmes that met the needs of the residents

• Each resident had a comprehensive six-monthly general health assessment Residents on antipsychotic medication had an annual assessment of their glucose regulation, blood lipids, and an electrocardiogram Adequate arrangement were in place for residents to access general health services

• A number of staff vacancies exist in relation to an Occupational Therapist, Speech and Language Therapist and a Dietitian However, in the absence of these personnel, a contingency plan for urgent access had been put in place

However:

• The residents whose needs reflected either continuing care or enduring mental health needs for which a specialist rehabilitation team would be appropriate, were all under the care of a general adult consultant

Respect for residents’ privacy, dignity and autonomy

• All bathrooms, showers, and toilets had locks on the inside of the door Bed screening in shared rooms ensured that the residents’ privacy was not compromised All observation panels on doors of treatment rooms and bedrooms were fitted with blinds, curtains, or opaque glass

• Generally, the approved centre was maintained in a good state of repair, and internally the approved centre was clean and hygienic

However:

• Not all residents’ personal property and possessions were sufficiently safeguarded when the approved centre assumed responsibility for them For one resident, the amount recorded in the cash log did not correspond to the amount present in the resident’s wallet in the safe The access to and use of resident monies was not overseen by two members of staff and the resident or their representative Where possible, the resident signed the transaction log with a nurse However, where this was not possible, only one member of staff signed the log

• All residents were required to vacate their bedrooms in the morning The bedroom area was locked during the day and not opened again until around 21:30, when residents went to bed This restrictive practice prevented residents from sleeping or resting during the day in their rooms

• Externally, the courtyard area was littered with numerous cigarette butts and pieces of litter on the ground There was a hole in the wall and chipped paintwork in one of the bedrooms and there was

an area in which there was a smell of cigarette smoke and the floor and a plastic chair displayed burn marks

• There was no programme of general maintenance, decorative maintenance, cleaning, decontamination, and repair of assistive equipment

• There were no curtains in place on the windows in a number of bedrooms

Responsiveness to residents’ needs

• Residents had at least two choices for meals and were provided with a variety of wholesome and nutritious food

• Activities in St Catherine’s Ward included reading books, watching television, and movies, while group activities included: gardening, aqua aerobics, social outings, exercise groups, crossword

groups, walking groups, bingo, therapy dog groups, current affairs sessions, cookery groups and mind groups

• Residents were provided with written and verbal information on diagnosis, medication, and details about the approved centre

Governance of the approved centre

• The approved centre was part of the HSE’s former Community Healthcare Organisation 4 (CHO4) area and spanned counties Cork and Kerry An Executive Management (EMT) teams was in place for each service area, with the Cork Mental Health Area Management Team providing clinical and management oversight of St Catherine’s Ward

• There was an organisational chart to identify the leadership and management structure and lines of authority and accountability in the approved centre

• Feedback from suggestion boxes, complaints and compliments were standing agenda items on the Local Management Team Meeting

• The approved centre had access to the service’s Risk & Patient Safety Advisor who provided a quarterly report to the approved centre The risk register was reviewed monthly at the unit management meeting Risks escalated up to the Area Management Risk Register where indicated

• There was an annual audit schedule in place and key performance indicators were measured centrally Although St Catherine’s had a comprehensive suite of audits, most of which were in reality

checklists, however they served a key function in ensuring practice matches policy

• Heads of discipline had identified strategic aims for their departments and there was clear evidence that changes had occurred since the previous inspection, all of which impacted positively on the approved centre

• Staff have been encouraged to complete mandatory training as a priority over all other training This has greatly contributed to the service almost achieving 100% compliance with mandatory training requirements Support for continuing education programmes was available

The following quality initiatives were identified on this inspection:

1 A Nutrition and Hydration committee comprising representation of a Dietitian and a Speech and Language Therapist has commenced supported by other multi-disciplinary team members

2 The development of Standard Operating Procedures for The Apartment at St Catherine’s has been initiated This will offer a recovery centred practice to bridge the continuum of care from residential support to community living

3 A Risk Register & Quality and Patient Safety (QPS) Oversight Structure has been instigated This has provided a structure to oversee quality and safety appropriately within St Catherine’s

2.0 Quality Initiatives

3.1 Description of approved centre

The approved centre St Catherine’s Ward was located on the grounds of St Finbarr’s Hospital, Douglas Road in Cork city The shared building also provided accommodation alongside a continuing care facility for the elderly: St Stephen’s Situated on two floors, the upper floor which comprised day activities, a dining room and a sitting room had been completely upgraded A phased building refurbishment programme was ongoing in the lower ground floor which comprised all the bedrooms, a night sitting room and an activity therapy kitchen

All six General Adult teams and both Psychiatry of Later Life clinical teams from South Lee could admit to St Catherine’s However, once admitted to St Catherine’s Ward, responsibility for the residents care was undertaken by a dedicated Consultant Psychiatrist (however, there may be exceptions to this on a case by case basis)

The needs of the resident’s extended between continuing care and rehabilitation although rehabilitation was not available for the residents The age ranged from residents in the midspan of life to those in later life

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

Resident Profile

Number of residents in the approved centre for more than 6 months 18

The approved centre was part of the HSE’s former Community Healthcare Organisation 4 (CHO4) area and spanned counties Cork and Kerry An Executive Management (EMT) teams was in place for each service area, with the Cork Mental health Area Management Team providing clinical and management oversight of St Catherine’s Ward

To inform the inspection process regarding clinical governance issues a number of heads of discipline forwarded questionnaires outlining processes for discipline specific governance and also issues of risk or

3.0 Overview of the Approved Centre

specific concern for the particular discipline The Mental Health Commission received completed governance questionnaires from following:

• The Clinical Director

• The Area Director of Nursing

• Area Administrator

• Occupational Therapy Manager

• Principal Clinical Psychologist

• Principal Social Worker

The governance structures included a monthly Area Executive Cork Mental Health Management Team and

a bi-monthly St Catherine’s Local Management Team Meeting A number of members were involved on both committees, including the Occupational Therapy Manager, the Area Administrator and also the Service Risk Advisor The minutes for the previous eight months were provided to the inspection team and they outlined

a well-attended multi-disciplinary grouping who engaged in an active governance process The minutes of meetings for these committees demonstrated that they considered a variety of governance issues including staffing and staff management, risk management, clinical efficiency, together with educational and training matters The minutes adopted a standardised template and format consistent with best practice and also demonstrated an action-oriented focus with clear time lines

Standing items included the Risk Register & Quality and Patient Safety Oversight structure; Policies and Procedures; Incident reviews; service developments and Mental Health Commission regulatory compliance There was an organisational chart to identify the leadership and management structure and lines of authority and accountability in the approved centre Whilst senior management did not attend the approved centre

on a regular basis, there were clear management lines to facilitate communication both upwards and downwards

The management team has also been furnished with strategic priority workbooks to review processes to enhance practice and identify quality improvements

Service user feedback was integral to service responsiveness Feedback from suggestion boxes, complaints and compliments are standing agenda items on the Local Management Team Meeting Where possible, members of the multi-disciplinary team engage in consultation including both the resident cohort and staff through a number of forums to ensure all stakeholders are involved in the design and delivery of any initiatives or changes to programs There was also ongoing routine evaluation through the use of use of pre-post intervention measures with clients participating in some therapeutic services

The approved centre had access to the service’s Risk & Patient Safety Advisor The risk register was reviewed monthly at the unit management meeting in order to discuss if any new risks should be added, and any that require to be escalated to the Area Management Team and to update other existing recorded risks It was planned to undertake a formal audit of the St Catherine’s risk register using a standardised audit tool on an annual

Risks escalated up to the Area Management Risk Register include risks pertaining to premises and access to staff such as an Occupational Therapist, Speech and Language Therapist, Dietitian These risks where similar,

are amalgamated as a risk from a number of centres Actions can be assigned to senior management team members without the risk being escalated to them e.g actions in relation to IR/HR, resources

The approved centre’s receive a quarterly report from the Risk & Patient Safety Advisor from which the approved centre can monitor incidents, observe changes and consider if any incident’s indicate a trend and warrant further controls

The key objectives of clinical audit within St Catherine’s was to achieve compliance through corrective and preventative action plans (CAPAs), in terms of Individual Care Plans (ICPs) and within the Medical Prescription and Administration Records (MPARs) Additionally, audit sought to improve general physical health of residents through monitoring the use of physical health proforma and regular checks as per regulations There was an annual audit schedule in place and KPIs were measured centrally

St Catherine’s ward had representation on a nursing based Judgement Support Framework and Best Practice Guideline (JSF & BPG) committee which was held bi-monthly Although St Catherine’s had a comprehensive suite of audits, most of which were in reality - checklists, however they served a key function in ensuring

practice matches policy One observation noted was that there was some inconsistency in the tabulation of results However, this was rectified during the course of the inspection Staff interviewed felt that it would

be useful to share the task of audit amongst the wider MDT which would give added value to the audits of polices and quality assurance processes Consistent with the membership of the JSF & BPG group, it was felt that there was the opportunity to undertake audit in conjunction with staff in other approved centres as audit practices can risk becoming stale if maintained solely in-house

Ongoing constraints on staff recruitment meant that staff vacancies and the provision of services were the main priorities on the agenda at the local management team meeting The local management team also acknowledged that additional staff in relation to Health Care Assistants would assist in mitigating the risk associated with the restrictive practice where service users are not able to access their own bedrooms during the daytime

Heads of discipline had identified strategic aims for their departments and there was clear evidence that changes had occurred since the previous inspection, all of which impacted positively on the approved centre

A number of staff vacancies exist in relation to an Occupational Therapist, Speech and Language Therapist and a Dietitian However, in the absence of these personnel, a contingency plan for urgent access had been put in place pending fuller access of outstanding positions

Staff have been encouraged to complete mandatory training as a priority over all other training Additionally,

as part of the CAPAs, staff have been prompted to undertake HSE modules on Health and Safety and Record Keeping Any staff member who required training has been provided with a training date This has greatly contributed to the service almost achieving 100% compliance with mandatory training requirements Feedback from staff indicated that there was some difficulty in accessing mandatory training particularly in AED and Fire training Client records management training has also been provided in ensuring medical records will be maintained to the highest standard

Support for continuing education programmes was available One nurse is currently undertaking a Post –Graduate Diploma at UCC Psychology staff are being supported in developing expertise in models of therapy (e.g schema therapy; DBT) This also supports ongoing service research which was conducted on a number

of initiatives within the psychology department (e.g acute unit day therapy programmes; community groups evaluation; schema therapy evaluation)

The MDT met monthly in the approved centre While the Non Consultant Hospital Doctors (NCHDs) were available to the approved centre, they were not based there and did not see the residents on a regular basis The residents whose needs reflected either continuing care or enduring mental health needs- for which a specialist rehabilitation team would be appropriate, were all under the care of a general adult consultant

There was excellent provision of General Practitioner services, however, there was minimal input from social worker attended once a week to facilitate groups and occupational therapy and psychology services were accessed on a referral only basis There was no speech and language therapist or dietitian, despite residents having an assessed need for these services The multi-disciplinary team (MDT) functioned well as many members attended regularly and developed and reviewed care plans The Senior Clinical Psychologist attends the management meetings and participates in the weekly ICP meetings A therapeutic services committee had been established and the ongoing therapeutic groups in the approved centre were viewed with positive outcomes

The Area Principal Psychology Manager provided line management to senior clinical psychologists and conducts an annual performance planning and professional development meeting with staff grade psychologists Their clinical supervisor also participates in these meetings These meetings addressed achievements and challenges in each of the following domains: Service delivery/Client service/Service improvement Initiatives; Line management support/ supervision (What, when, where and how); Learning, growth and development (How you have taken opportunities to develop professionally); Research (Any projects you have been leading or supporting); Setting key priorities for the next 12 months; CPD plan for the next 12 months (including mandatory training) Senior psychologists availed of peer supervision and some senior psychologists also participated in supervision in specialist models of therapy (e.g schema therapy, dialectical behaviour therapy)

Not all departments used a formal appraisal mechanism but it was reported, that this was managed informally through supervision It was noted that there was no formal appraisals of consultant staff however, Basic Specialist Training medical staff (BSTs) have weekly formal supervision and appraisal GP trainees and non-trainee NCHDs had informal weekly appraisal by the supervising consultant in charge of St Catherine’s

Social Work has a line management structure whereby Social Workers meet their team leader approximately once a month for formal supervision Informal supervision occurs often with Team leaders and Principal being available when required Social Workers met once a month for a team meeting whereby relevant issues were discussed/ sharing information was encouraged

At a senior nursing management level, there are monthly review meetings and weekly teleconferencing ADONs have bi-monthly review meeting with Clinical Nurse Managers (CNM2) CNM2s conduct appraisals

of staff nurses in line with HSE policies, as required Individual clinical supervision was provided to Occupational Therapists in-line with the guidelines of their professional body [CORU]

There was an overarching Cork and Kerry Policy Standardisation and Review Group (PSRG) Work was ongoing to standardise applicable policies across the services There was evidence of input from clinical and

managerial staff from within the approved centres to include St Catherine’s ward A number of policies were

in the process of being updated There was evidence from within the approved centre of ongoing audit pertaining mainly to criteria set out in the Mental Health Commission -Judgement Support Framework and the Health Service Executive - Best Practice Guidelines The learning from the audits was disseminated, discussed and analysed at the local management meetings and through the wider JSF & BPG group

There was representation from St Catherine’s staff on the St Finbarr’s Hygiene Committee and the quarterly Health and Safety Committee meeting The approved centre worked towards continual improvement to community integration opportunities for residents including the healthy living group Other working groups included an ICP working Group, Nutrition and Hydration group, Medication Management Working Group and a Therapeutic Services Committee It was also noted that work was ongoing to develop a standard operating procedure (SOP) for the use of the apartment in the grounds of St Catherine’s

3.3 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

4.1 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 between 2016 and 2020 and the relevant risk rating when the service was non-compliant:

Regulation 8: Residents’ Personal Property and

Moderate    X Low

Regulation 23: Ordering, Prescribing, Storing

High   X Low X High

Code of Practice on Admission, Transfer and

Moderate X Moderate X High X Low X High

The approved centre was requested to provide Corrective and Preventative Actions (CAPAs) for areas of compliance These are included in Appendix 1 of the report

non-4.2 Areas of compliance rated “excellent” on this inspection

The following areas were rated excellent on this inspection:

Regulation

Regulation 4: Identification of Residents

Regulation 16: Therapeutic Services and Programmes

Regulation 31: Complaints Procedures

4.3 Areas that were not applicable on this inspection

Regulation/Rule/Code of Practice Details

Regulation 17: Children’s Education As the approved centre did not admit children, this

regulation was not applicable

Regulation 25: Use of Closed Circuit Television As CCTV was not in use in the approved centre, this

regulation was not applicable

4.0 Compliance

Regulation 30: Mental Health Tribunals As no Mental Health Tribunals had been held in the

approved centre since the last inspection, this regulation was not applicable

Rules Governing the Use of Electro-Convulsive

Therapy As the approved centre did not provide an ECT service, this rule was not applicable Rules Governing the Use of Seclusion As the approved centre did not use seclusion, this

rule was not applicable

Rules Governing the Use of Mechanical Means of

Bodily Restraint As no resident had been mechanically restrained since the last inspection, this rule was not

applicable

Part 4 of the Mental Health Act 2001: Consent to

Treatment As there were no patients in the approved centre for more than three months and in continuous

receipt of medication at the time of inspection, Part 4 of the Mental Health Act 2001: Consent to Treatment was not applicable

Code of Practice on the Use of Physical Restraint

in Approved Centres As no resident in the approved centre had been physically restrained since the last inspection, this

code of practice was not applicable

Code of Practice Relating to Admission of

Children Under the Mental Health Act 2001 As the approved centre did not admit children, this code of practice was not applicable Code of Practice on the Use of Electro-Convulsive

Therapy for Voluntary Patients As the approved centre did not provide an ECT service, this code of practice was not applicable

The Inspector gives emphasis to the importance of hearing the service users’ experience of the approved centre To that end, the inspection team engaged with residents in a number of different ways:

• The inspection team informally approached residents and sought their views on the approved centre

• Posters were displayed inviting the residents to talk to the inspection team

• Leaflets were distributed in the approved centre explaining the inspection process and inviting residents to talk to the inspection team

• Set times and a private room were available to talk to residents

• In order to facilitate residents who were reluctant to talk directly with the inspection team, residents were also invited to complete a service user experience questionnaire and give it in confidence to the inspection team This was anonymous and used to inform the inspection process

• The Irish Advocacy Network (IAN) representative was contacted 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

Whilst opportunities to meet with residents individually were organised, the resident’s did not engage in any formal interviews with the inspection team during the inspection Inspectors however, did take

opportunities presented during the course of the inspection to engage with the resident’s in their daily recreational activities and events Condolences were also offered to the resident’s on the recent sad

passing of a resident within St Catherine’s

5.0 Service-user Experience

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:

 Occupational Therapy Manager

 Acting / Clinical Nurse Manager 2

 Senior Clinical Psychologist x 2

 Principal Social Worker

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 <<Enter text here>>

6.0 Feedback Meeting

7.0 Inspection Findings – Regulations

The following regulations are not applicable

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 The policy was last reviewed in January 2019 The policy included all requirements of the Judgement Support Framework

Training and Education: Relevant staff had signed the signature log to indicate 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 there were appropriate resident identifiers on clinical files Documented analysis had been completed to identify opportunities for improving the resident identification process

Evidence of Implementation: A minimum of two resident identifiers, appropriate to the resident group profile and individual residents’ needs, were used Photograph identification was also used with resident consent Identifiers were person-specific and appropriate to the residents’ communication abilities Two appropriate resident identifiers were used when administering medication, undertaking medical investigations, and providing other healthcare, therapeutic services, and programmes A system for identifying residents with the same or similar name was in place

COMPLIANT Quality Rating Excellent

The approved centre was compliant with this regulation The quality assessment was rated excellent because the approved centre met all criteria of the Judgement Support Framework.

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 food and nutrition The policy was last

reviewed in October 2019 The policy included all requirements of the Judgement Support Framework

Training and Education: Relevant staff had signed the signature log to indicate 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 were provided with wholesome and nutritious food in line with their needs Documented analysis had been completed to identify opportunities for improving the processes for food and nutrition

Evidence of Implementation: Menus were approved by a dietitian to ensure nutritional adequacy in accordance with residents’ needs Residents had at least two choices for meals and were provided with a variety of wholesome and nutritious food, including portions from different food groups, as per the Food Pyramid Hot meals were provided on a daily basis and food, including modified consistency diets, was presented in a manner that was attractive and appealing in terms of texture, flavour, and appearance in order to maintain appetite and nutrition Hot and cold drinks were offered to residents regularly and a source of safe, fresh drinking water was available at all times in easily accessible locations in the approved centre

An evidence-based nutrition assessment tool was not used for residents with special dietary requirements Weight charts were implemented, monitored and acted upon for residents, where appropriate Residents, their representatives, family, and next of kin were educated about residents’ diets, where appropriate, specifically in relation to any contraindications with medication Nutritional and dietary needs were assessed, where necessary, and addressed in residents’ individual care plans and the needs of residents identified as having special nutritional requirements were regularly reviewed by a dietitian Intake and output charts were maintained for residents, where appropriate

COMPLIANT Quality Rating Satisfactory

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 evidence of implementation pillar.

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 last reviewed in

October 2019 The policy addressed requirements of the Judgement Support Framework, with the

exception of food preparation, handling, storage, distribution, and disposal controls

Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy Relevant staff interviewed were able to articulate the processes for food safety, as set out in the policy All staff handling food had up-to-date training in food safety commensurate with their role This training was documented, and evidence of certification was available

Monitoring: Food safety audits had been completed periodically Food temperatures were recorded in line with food safety recommendations A food temperature log sheet was maintained and monitored Documented analysis had been completed to identify opportunities to improve food safety processes

Evidence of Implementation: There were proper facilities for the refrigeration, preparation, cooking, and serving of food However, cleaning products and dry food products were stored within the same storage room Food was prepared in the main kitchen of St Finbarr’s campus and was transported to the approved centre Food was prepared in a manner that reduced the risk of contamination, spoilage, and infection There was suitable and sufficient catering equipment in the approved centre Hygiene was maintained to support food safety requirements Residents were provided with crockery and cutlery that was suitable and sufficient to address their specific needs

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 residents’ clothing, which was last

reviewed in October 2019 The policy addressed requirements of the Judgement Support Framework, with

the exception of the responsibility of the approved centre to provide new clothing to residents, where necessary, with consideration of the residents’ preferences, dignity, bodily integrity, and religious and cultural practices

Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy Relevant staff interviewed were able to articulate the processes for residents’ clothing, as set out in the policy

Monitoring: The availability of an emergency supply of clothing for residents was monitored on an ongoing basis. This was documented No residents were wearing nightclothes at the time of inspection

Evidence of Implementation: Residents were supported to keep and use personal clothing Residents’ clothing was clean and appropriate to their needs Emergency clothing was available to residents in the approved centre Residents changed out of nightclothes during the day and all residents had an adequate supply of individualised clothing

COMPLIANT Quality Rating Satisfactory

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 pillar

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 operational policy in relation to residents’ personal property and possessions, which was last reviewed in October 2019 The policy addressed requirements

of the Judgement Support Framework, with the exception of the following:

• The communications with residents and their representatives regarding residents’ entitlement to bring personal property and possessions into the approved centre at admission and on an ongoing basis

• The process to allow residents access to and control over their personal property and possessions, unless this poses a danger to the resident or others, as indicated by an individual risk assessment and the resident’s individual care plan

Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy Relevant staff interviewed were able to articulate the processes for residents’ personal property and possessions, as set out in the policy

Monitoring: Personal property logs were monitored in the approved centre Documented analysis had been completed to identify opportunities for improving the processes relating to residents’ personal property and possessions

Evidence of Implementation: Residents were entitled to bring personal possessions with them to the approved centre, the extent of which was agreed at admission At admission, the approved centre compiled a detailed property checklist with each resident of their personal property and possessions The property checklist was kept separately to the resident’s ICP and was available to the resident Secure

NON-COMPLIANT

Quality Rating Requires Improvement Risk Rating LOW

facilities were provided for the safe-keeping of the resident’s monies, valuables, personal property, and possessions, as necessary A safe was available to residents for the storage of their monies and valuables

Not all resident’s personal property and possessions were sufficiently safeguarded when the approved centre assumed responsibility for them For one resident, the amount recorded in the cash log did not correspond to the amount present in the resident’s wallet in the safe The access to and use of resident monies was not overseen by two members of staff and the resident or their representative Where possible, the resident signed the transaction log with a nurse However, where this was not possible, only one member of staff signed the log

Where money belonging to the resident was handled by staff, signed records of the staff issuing the money was retained Where possible this was counter-signed by the resident or their representative Residents were supported to manage their own property, unless this posed a danger to the resident or others, as indicated in their ICP and in accordance with the approved centre’s policy

The approved centre was non-compliant with this regulation because the registered proprietor did not ensure that an accurate record was maintained of each resident’s money: cash balances did not always correspond with the balance recorded in available records, 8(3)

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 did not have a written policy in relation to the provision of recreational activities

Training and Education: There was no policy for staff to read, understand, or articulate

Monitoring: A record was maintained of the occurrence of planned recreational activities, including a log

of resident uptake and attendance Documented analysis had been completed to identify opportunities for improving the processes relating to recreational activities

Evidence of Implementation: The approved centre provided access to recreational activities appropriate

to the resident group profile on weekdays and at weekends Activities included books, television, and movies, while group activities included, but were not limited to: gardening, aqua aerobics, social outings, exercise groups, crossword groups, walking groups, bingo, therapy dog groups, current affairs sessions, cookery groups, and mind groups Information on activities was provided to residents in an accessible format, which was appropriate to their individual needs and included the types and frequency of appropriate recreational activities available within the approved centre Recreational activities programmes were developed, implemented, and maintained for residents, with resident involvement Individual risk assessments were completed for residents, where deemed appropriate, in relation to the selection of appropriate activities

Resident decisions on whether or not to participate in activities were respected and documented, as appropriate The recreational activities provided by the approved centre were appropriately resourced, opportunities were provided for indoor and outdoor exercise and physical activity, and designated communal areas were suitable for recreational activities Documented records of attendance were retained for recreational activities in group records or within the resident’s clinical file, as appropriate

COMPLIANT Quality Rating Satisfactory

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

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 October 2019 The policy addressed requirements of the Judgement

Support Framework, with the following exceptions:

• The roles and responsibilities in relation to the support of residents’ religious practices

• Respecting religious beliefs during the provision of services, care, and treatment

• Respecting a resident’s religious beliefs and values within the routines of daily living, including resident choice regarding involvement in religious practice

Training and Education: Relevant staff had signed the signature log to indicate 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 to support residents’ religious practices was reviewed to ensure that it reflected the identified needs of residents This was documented

Evidence of Implementation: Residents were facilitated to practice their religion insofar as was practicable Mass was celebrated in the church on the grounds of St Finbarr’s hospital every Sunday and residents could attend independently or with the support of staff Residents had access to multi-faith chaplains The care and services provided in the approved centre were respectful of the residents’ religious beliefs and values Specific religious requirements relating to the provision of services, care, and treatment had been clearly documented Residents were facilitated to observe or abstain from religious practice in accordance with their wishes

COMPLIANT Quality Rating Satisfactory

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 pillar

Processes: The approved centre had a written policy and procedures in relation to visits The policy was

last reviewed in October 2019 The policy and procedures addressed requirements of the Judgement

Support Framework, with the following exceptions:

• The availability of appropriate locations for resident visits

• The arrangements and appropriate facilities for children visiting a resident

• The required visitor identification methods

Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy Relevant staff interviewed were able to articulate the processes for visits, as set out in the policy

Monitoring: Documented analysis had not been completed to identify opportunities for improving visiting processes

Evidence of Implementation: Visiting times were publicly displayed and were reasonable and appropriate

A separate visitors’ room was provided where residents could meet visitors in private, unless there was

an identified risk to the resident, an identified risk to others, or a health and safety risk Appropriate steps were taken to ensure the safety of residents and visitors during visits Children visiting the approved centre were accompanied at all times to ensure their safety, though this was not communicated to all relevant individuals publicly The visiting room was suitable for visiting children

COMPLIANT Quality Rating Satisfactory

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, monitoring, and evidence of implementation pillars

requirements of the Judgement Support Framework, with the following exceptions:

• The roles and responsibilities for resident communication processes

• The assessment of resident communication needs

Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy Relevant staff interviewed were able to articulate the processes for communication, as set out in the policy

Monitoring: Resident communication needs and restrictions on communication were monitored on an ongoing basis Documented analysis had been completed to identify ways of improving communication processes

Evidence of Implementation: Residents had access to mail, fax, e-mail, internet, and telephone unless otherwise risk-assessed with due regard to the residents’ well-being, safety, and health Individual risk assessments were completed for residents, as deemed appropriate, in relation to any risks associated with their external communication and documented in the individual care plan The clinical director or a senior staff member designated by the clinical director only examined incoming and outgoing resident communication if there was reasonable cause to believe the communication may result in harm to the resident or to others

COMPLIANT Quality Rating Satisfactory

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 pillar

(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 operational policy and procedures in relation to the implementation of resident searches The policy was last reviewed in October 2019 The policy and

procedures addressed all requirements of the Judgement Support Framework, including the following:

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

• The consent requirements of a resident regarding searches and the process for carrying out searches in the absence of consent

• The process for dealing with illicit substances uncovered during a search

Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy Relevant staff interviewed were able to articulate the searching processes, as set out in the policy

As no searches had been conducted in the approved centre since the last inspection, Regulation 13: Searches was only inspected against the processes and training and education pillars

COMPLIANT

The approved centre was compliant with this regulation

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 operational policy and protocols in relation to care of the dying The policy was last reviewed in October 2019 The policy and protocols addressed requirements of

the Judgement Support Framework, with the following exceptions:

• Advance directives in relation to end of life care, Do Not Attempt Resuscitation (DNAR) orders, and residents’ religious and cultural end of life preferences

• The process for ensuring that the approved centre is informed in the event of the death of a resident who has been transferred elsewhere (e.g for general health care services)

Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy Relevant staff interviewed were able to articulate the processes for end of life care,

as set out in the policy

As no deaths had occurred in the approved centre since the last inspection, Regulation 14: Care of the Dying was only inspected against the processes and training and education pillars

COMPLIANT

The approved centre was compliant with this regulation

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 October 2019 The policy addressed requirements

of the Judgement Support Framework, with the following exceptions:

• The required content in the set of documentation making up the individual care plan (ICP)

• The time frames for assessment planning, implementation and evaluation of the ICP

Training and Education: All clinical staff had signed the signature log to indicate that they had read and understood the policy All clinical staff interviewed were able to articulate the processes relating to individual care planning, as set out in the policy All multi-disciplinary team (MDT) members had received training in individual care planning

Monitoring: Residents’ ICPs were audited on a quarterly basis to determine compliance with the regulation Documented analysis had been completed to identify ways of improving the individual care planning process

Evidence of Implementation: Ten ICPs were examined during the inspection process and all ten were a composite set of documents Each resident was initially assessed at admission and an ICP was completed

by the admitting clinician to address immediate needs of resident The ICPs included an allocated space for goals, treatment, care, resources required, and reviews The ICPs were stored within the clinical file, were identifiable and uninterrupted, and were not amalgamated with progress notes

An ICP was developed by the MDT following a comprehensive assessment, within seven days of admission The assessment included: medical, psychiatric, and psychosocial history; medication history and current medications; a current physical health assessment; a detailed risk assessment; communication abilities, and; social, interpersonal, and physical environment-related issues, including resilience and strengths Evidence-based assessments were used where possible

The ICP was discussed, agreed where practicable, and drawn up with the participation of the resident and their representative, family, and next of kin, as appropriate The ICPs identified the residents’ assessed needs, appropriate goals, the care and treatment required to meet the goals identified (including the

COMPLIANT Quality Rating Satisfactory

frequency and responsibilities for implementing the care and treatment), and the resources required to provide the care and treatment identified A key worker was also identified in all the ICPs to ensure continuity in their implementation An individual risk management plan and a preliminary discharge plan were also evident in the ICPs examined

ICPs were reviewed by the MDT in consultation with the resident, weekly in an acute setting and at least every six months for residents in a continuing care Each respective ICP was updated following review, as indicated by the resident’s changing needs, condition, circumstances, and goals The resident had access

to the ICP, was kept informed of any changes, and was offered a copy of it, including any reviews, which was documented When a resident declined or refused a copy of their ICP, this was recorded, including the reason, if given

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 pillar

Regulation 16: Therapeutic Services and

Judgement Support Framework

Training and Education: All clinical staff had signed the signature log to indicate that they had read and understood the policy All clinical staff interviewed were able to articulate the processes relating to therapeutic activities and programmes, as set out in the policy

Monitoring: The range of services and programmes provided in the approved centre was monitored on

an ongoing basis to ensure that the assessed needs of residents were met Documented analysis had been completed to identify opportunities for improving the processes relating to therapeutic services and programmes

Evidence of Implementation: The therapeutic services and programmes provided by the approved centre were evidence based, appropriate, and met the assessed needs of the residents, as documented in their individual care plans The therapeutic services and programmes were also directed towards restoring and maintaining optimal levels of physical and psychosocial functioning of residents A list of all therapeutic services and programmes was available to residents

Where a resident required a therapeutic service or programme that was not provided internally, the approved centre arranged for the service to be provided by an approved, qualified health professional in

an appropriate location Adequate and appropriate resources were available and the therapeutic services and programmes were provided in a separate dedicated room containing facilities and space for individual and group therapies A record was maintained of participation and engagement in and outcomes achieved

in therapeutic services or programmes in residents’ individual care plans or clinical files

COMPLIANT Quality Rating Satisfactory

The approved centre was compliant with this regulation The quality assessment was rated

excellent because the approved centre met all criteria of the Judgement Support Framework

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 and procedures in relation to the transfer of residents The policy was last reviewed in October 2019 The policy addressed requirements of the

Judgement Support Framework, with the following exceptions:

• The roles and responsibilities for the resident transfer process, including the responsibility of the multi-disciplinary team and resident’s key worker

• The interagency involvement in transfer process

• The resident assessment requirements prior to transfer from the approved centre, including the individual risk to be assessed

• The process for managing resident medications during transfer from the approved centre

• The resident and/or their representative’s involvement in and consent to the transfer process

• The process for ensuring resident privacy and confidentiality during the transfer process, specifically in relation to the transfer of personal information

• The process for managing resident property during the transfer process

Training and Education: Relevant staff had signed the signature log to indicate that they had read and understood the policy Relevant staff interviewed were able to articulate the processes for the transfer of residents, as set out in the policy

Monitoring: A log of transfers was maintained Each transfer record had not been systematically reviewed

to ensure all relevant information was provided to the receiving facility Documented analysis had not been completed to identify opportunities for improving the provision of information during transfers

Evidence of Implementation: Documents relating to an emergency transfer were examined during the inspection process There was no evidence of documented communication with the receiving facility prior

to the transfer Verbal communication and liaison took place between the approved centre and the receiving facility prior to the transfer taking place, which included the reasons for transfer, the resident’s accompaniment requirements on transfer, and the resident’s care and treatment plan, which itself included needs and risks

Documented consent of the resident to the transfer was available A medical assessment of the resident was completed prior to the transfer; however, a risk assessment was not There was no documentation

NON-COMPLIANT

Quality Rating Requires Improvement

of communication within progress notes and a follow-up letter was not found in either the hard-copy file

or electronic folders A checklist was not completed by approved centre to ensure comprehensive resident records are transferred to the receiving facility

The approved centre was non-compliant with this regulation because it did not ensure that all relevant information about the resident was provided to the receiving facility upon transfer, 18(1)

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 written operational policies and procedures in relation to the provision of general health services and the response to medical emergencies, which were reviewed in

October 2019 The policies and procedures addressed requirements of the Judgement Support

Framework, with the exception of the management of emergency response equipment, including

resuscitation trolley and Automated External Defibrillator (AED)

Training and Education: All clinical staff had signed the signature log to indicate that they had read and understood the policies All clinical staff interviewed were able to articulate the processes relating to the provision of general health services and the response to medical emergencies, as set out in the policies

Monitoring: Residents’ take-up of national screening programmes was recorded and monitored, where applicable A systematic review had been undertaken to ensure that six-monthly general health assessments of residents occurred Analysis had been completed to identify opportunities for improving general health processes

Evidence of Implementation: The approved centre had an emergency trolley and staff had access at all times to an automated external defibrillator (AED), both of which were checked weekly Records were available of any medical emergency within the approved centre and the care provided A registered medical practitioner assessed residents’ general health needs at admission and on an ongoing basis as part of the approved centre’s provision of care Residents received appropriate general health care interventions in line with individual care plans and their general health needs were monitored and assessed as indicated by the residents’ specific needs, but not less than every six months

The six-monthly general health assessment documented a physical examination, family and personal history, blood pressure, dental health, smoking and nutritional status, as well as the resident’s body-mass index (BMI), weight, and waist circumference For residents on antipsychotic medication, there was an annual assessment of their glucose regulation, blood lipids, and an electrocardiogram Adequate arrangement were in place for residents to access general health services and for their referral to other

COMPLIANT Quality Rating Satisfactory

health services as required Records were available demonstrating residents’ completed general health checks and associated results, including records of any clinical testing

Residents could access national screening programmes according to age and gender, including Breast Check, cervical screening, retina check, and bowel screening Information was provided to residents regarding the national screening programmes available through the approved centre Residents had access to smoking-cessation programmes

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 pillar

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 effects

side-(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 written policy and procedures in relation to the provision of information to residents The policy was last reviewed in October 2019 The policy and procedures

addressed requirements of the Judgement Support Framework, with the following exceptions:

• The process for identifying residents’ preferred ways of receiving and giving information

• The methods for providing information to residents with specific communication needs

• The interpreter and translation services available within the approved centre

• The process for managing the provision of information to residents’ representatives, family, and next of kin, as appropriate

• The advocacy arrangements

Training and Education: All staff had signed the signature log to indicate that they had read and understood the policy All staff interviewed were able to articulate the processes relating to the provision

of information to residents, as set out in the policy

Monitoring: The provision of information to residents was monitored on an ongoing basis to ensure it was appropriate and accurate, particularly where information changed Documented analysis had not been completed to identify opportunities for improving the processes relating to the provision of information

to residents

Evidence of Implementation: Required information was provided to residents and their representatives

at admission, including the approved centre’s information booklet that detailed care and services The booklet was available in the required formats to support resident needs and information was clearly and simply written The booklet contained details of the complaints procedure, visiting times and arrangements, residents’ rights, relevant advocacy and voluntary agencies, as well as housekeeping

COMPLIANT Quality Rating Satisfactory