John is a long-term 'resident' on the Ground Floor of Carraig Mor 'Treatment Centre'.
Carraig Mór was a two-storey unit in the grounds of the former Our Lady’s Hospital. It was surrounded by extensive grounds and a pitch-and-putt course. The Ground Floor unit functioned as a psychiatric intensive care unit (PICU), and had been open since 2002. It operated a tertiary service, accepting admissions from other catchments in Cork. There were 11 residents in the Ground Floor unit on the day of inspection, six of whom were detained. There was one consultant psychiatrist with a special interest in forensic psychiatry who had clinical responsibility for this unit and an additional consultant psychiatrist. Occupational therapy and social work were shared services from the North Lee Mental Health Services. Upstairs the First Floor unit was a continuing care unit with sessional input from four general adult psychiatrists. The residents in this unit were long stay. There was no rehabilitation input and the unit operated as a continuing care unit.
PROGRESS ON RECOMMENDATIONS IN THE 2008 APPROVED CENTRE REPORT
1.There should be a rehabilitation team appointed to the service. All residents on the First Floor should have needs assessment completed and appropriate accommodation provided in community-based settings.
OUTCOME: THIS HAD NOT BEEN ACHIEVED
2. Funding should be made available to recruit a clinical psychologist.
OUTCOME: NO PSYCHOLOGIST HAD BEEN RECRUITED.
3. Funding should be made available to ensure that ongoing maintenance and refurbishment of the approved centre was undertaken.
OUTCOME: THIS HAD BEEN ACHIEVED.
4. The plans to upgrade safety in relation to the visitors room should proceed without delay and the service needs to consider options in relation to possible future use of seclusion.
OUTCOME: THE VISITORS ROOM WAS NOW ONLY USED FOR VISITORS.
5. Integrated care plans for each resident containing the resident’s multidisciplinary team care plan and where all disciplines can access and record their interventions need to be introduced.
OUTCOME: THIS HAD NOT BEEN ACHIEVED ON THE FIRST FLOOR. RESINDENTS ON THE GROUND FLOOR HAD INTEGRATED CARE PLANS.
First Floor: There was no integrated care plan. There was a nursing care plan. The activity nurse documented in the clinical file. There were regular team meetings.
Ground Floor: Residents had integrated care plans that were reviewed frequently. It was not clear which multidisciplinary team members attended the meetings as there was no attendance record. Most of the plans reviewed had no written input from team members other than medical and nursing staff. There were also comprehensive nursing care plans.
BREACH: ARTICLE 15
First Floor: Although there were therapeutic activities available, these were not linked to an integrated care plan.
Ground Floor: Residents had access to a therapeutic programme which was run by two activities nurses. There did not appear to be a documented link between an individual’s care plan and a therapeutic programme.
BREACH: ARTICLE 16
First Floor: There was a system in place to ensure that six-monthly physical reviews took place. However one resident had had no physical review for over a year.
Ground Floor: Most of the residents in Ground Floor were resident for longer than six months. All the files reviewed indicated that a physical health review had taken place and was in date. There was no mechanism for facilitating national screening programmes as they applied to residents.
BREACH: ARTICLE 19 (1)(b) AND ARTICLE 19 (1)(c).
First Floor: Single rooms were available. There were curtains around beds and the toilets were lockable.
Ground Floor: There were no partition curtains in the male dormitory. This was a temporary situation as the curtains had been sent for alterations following a change in the railings. This was expected to be rectified within a week. Bathrooms did not have locks and a member of staff attended outside the room while residents bathed.
BREACH: ARTICLE 21
First Floor: CCTV was not in operation.
Ground Floor: CCTV cameras were located in the visitors’ room and in the female smoking room. There was no sign announcing its use in the visitors room. The monitor was located in the nurses’ office. Other CCTV cameras were located on the outside of the building.
BREACH: ARTICLE 25 (1)(b)
The service had no psychologist. The social worker, who was on leave, had not been replaced.
BREACH: ARTICLE 26 (2)
First Floor: The records were in good condition and were stored appropriately. There was a policy on the storage of records.
Ground Floor: Records were well maintained. The most recent record of a food inspection was in 2007. Copies of a health and safety inspection and fire inspection were unavailable.
BREACH: ARTICLE 27(3)
First Floor: A complaints policy was available. The complaints procedure was displayed and leaflets available.
Ground Floor: There was no nominated complaints officer in the approved centre. No record of complaints was kept in the approved centre.
BREACH: ARTICLE 31 (4) AND ARTICLE 31 (6).
Ground Floor: Two time-out rooms were used when seclusion was necessary. Access to toilet and washing facilities was through a locked door. The recording of seclusion was of a high standard. There were no policies for staff training in relation to seclusion.
BREACH: SECTION 7.1 AND SECTION 10.1
There was no policy for training in relation to physical restraint training for staff. The recording of physical restraint was to a high standard.
BREACH: SECTION 7.1
Ground Floor: The files of three residents who had been admitted involuntarily for longer than three months and who were in receipt of medication were examined. In each case, Form 17 had been completed as THESE PATIENTS WERE RECEIVING MEDICATION WITHOUT CONSENT.
SERVICE USER INTERVIEWS
The Inspectorate spoke to TWO service users on the First Floor. Both stated that they were happy with the service they received and liked living in Carraig Mór. ONE expressed a preference however to be transferred to another unit.
The First Floor of Carraig Mór was a continuing care unit and many residents were quite disabled. There was no rehabilitation team and while there were some activities available for the residents there were no integrated care plans. THE LACK OF INDIVIDUAL CLOTHING WAS SURPRISING and should be addressed in an imaginative way where there were practical difficulties in the provision of individual clothes. The unit requires one rehabilitation team, an overview of the requirements of the residents and a plan to relocate residents to more appropriate settings.
Residents on the Ground Floor had access to a reasonably full therapeutic programme of activities under the direction of two activities nurses. Residents had integrated care plans that were reviewed frequently, but there was no clear documented link between the care plan and activities. The Ground Floor was well maintained and clean. THE LACK OF A REHABILITATION TEAM WAS REGRETABLE PARTICULARLY IN VIEW OF THE FACT THAT A NUMBER OF RESIDENTS HAD BEEN RESIDENT FOR LONGER THAN SIX MONTHS.
1. Integrated care plans should be put in place immediately on the First Floor.
2. All six-monthly physical reviews should be completed
3. There should be no use of communal clothing. All residents should have individual clothing.
4. Policies for staff training in relation to seclusion and physical restraint must be implemented.
5. The facilities used for seclusion must meet the requirements of the Rules.
6. Therapeutic activities must be linked to the individual care plan. The care plans or clinical files could be enhanced by recording the multidisciplinary team members present at team meetings.
7. The multidisciplinary team should include a psychologist.
8. A rehabilitation team should be appointed.