29 May 2022

Compliance jumps by 43% at DOP in St Luke's Hospital in Kilkenny

Compliance jumps by 43% at Kilkenny mental health centre

The Mental Health Commission (MHC) has today published inspection reports on two inpatient mental health centres in the south-east of the country that have significantly improved their overall compliance with rules, regulations, and codes of practice.

One of the centres – the Department of Psychiatry at St Luke’s Hospital in Kilkenny – achieved an overall score of 94% compliance, a 21% improvement since the previous inspection in 2019, and a 43% improvement on the inspection prior to that in November 2018.

Following the 2018 inspection, which identified a series of critical risks, the MHC initiated legal proceedings against the HSE as the registered proprietor of the centre. The HSE pled guilty to several charges in February 2019 at Kilkenny District Court.

“The improvements that have occurred at St Luke’s since 2018 clearly demonstrate that our decision to initiate legal proceedings was undoubtedly the right call to make,” said the Chief Executive of the Mental Health Commission, John Farrelly.

From a position of 18 non-compliances following the inspection of November 2018 – which included three critical risks and 11 high risks - inspectors found just two non-compliances during the latest inspection in July 2020. One of these non-compliances related to the admission, transfer and discharge of patients and was rated as a high-risk.

“While we will always seek to urge and support centres to eliminate all non-compliances, we must recognise that this is an extraordinary improvement by the centre in a period of 18 months and management and staff deserve to be congratulated for their efforts,” added Mr Farrelly.

The Inspector of Mental Health Services, Dr Susan Finnerty, stated in her report that the centre was found to be clean, bright, and well-maintained and that resident areas appeared pleasant and comfortable.

“It should also be noted that the service had a dedicated Mental Health Commission Compliance Officer who, together with the unit’s senior management team, had greatly contributed to a cohesive and co-ordinated culture of implementing quality improvement,” said Dr Finnerty.

Although the centre had three conditions attached to its registration relating to individual care plans, general health, and staffing, it was not in breach of any of these conditions at the time of inspection.

The second inspection report published today also saw significant improvements at the Department of Psychiatry at University Hospital Waterford, which achieved an overall compliance rating of 86%, representing a 29% increase from their previous inspection in 2019.

“The approved centre was clean, hygienic and kept in a good state of repair externally and internally,” said Dr Finnerty. “There was a programme of general maintenance, decorative maintenance, cleaning, decontamination, and repair of assistive equipment.”

The report also noted that the centre had introduced a daily bed management meeting to deal with issues of overcapacity, which was proving to be very beneficial at the time of inspection.

There was one high risk non-compliance in relation to individual care plans (ICP) following a review of five ICPs upon inspection. This showed that one plan was not developed by relevant members of the multi-disciplinary team; two plans were not reviewed by relevant members of the multi-disciplinary team; three did not identify appropriate goals for residents; three did not identify appropriate care and treatment for each resident; and three did not identify appropriate resources to provide care and treatment.

The centre also scored a high-risk non-compliance with the code of practice on the admission of children because age-appropriate facilities and a programme of activities appropriate to age and ability were not provided.

The centre had one condition attached to its registration relating to staffing and was not in breach of this condition at the time of inspection.

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