A new report has found the Department of Psychiatry at Letterkenny University Hospital fell short of compliance standards last year.
Overall compliance dropped to 74% in 2023, down from 78% in 2022.
An inspection by the Mental Health Commission (MHC) found six high risk non-compliances in areas including individual care planning, staffing, risk management procedures, the code of practice on the use of physical restraint, with the regulation on the maintenance of records, and with rules governing the use of seclusion.
While improvements like a calming room and staff training were noted, concerns included unclean areas, lack of mandatory staff training, and disorganised patient records.
An inspection in August 2023 found improvements for user well-being: a calming room, device charging stations, a revamped activity room, a garden, and staff safeguarding training.
The report found it was “not clean everywhere” as external walls and windowsills in the courtyard, and external walls in the Acute Assessment Unit were dirty while some toilet walls were damaged and in need of repair.
The Department of Psychiatry is an approved centre adjacent to Letterkenny University Hospital and is connected to the General Hospital via a corridor. Built in 2011, the approved centre has been undergoing extensive upgrading. The centre was registered for 34 beds and at the time of the inspection accommodated 27 residents.
On the maintenance of records, the inspector noted that clinical files were not all in good order. “In one clinical file not all of the resident records were located in a logical sequence or in the correct resident’s file. Secondly, not all resident records were physically stored together,” the report said.
There were also issues with the assessment and management of risks. “A risk assessment of a resident documented a diagnosis which did not match other clinical notes: this posed a risk to individual residents during the delivery of individualised care,” the inspector reported.
At the time of inspection, the centre used physical restraint and had commenced integrating the revised code of practice, but the report noted the centre was not compliant with the Code of Practice on physical restraint for eight different reasons and not compliant with the Rule Governing Seclusion for nine different reasons.
The Mental Health Commission requires corrective and preventive action plans (CAPAs) from all services where non-compliances are identified. The MHC monitors the implementation of these CAPAs on an ongoing basis and requests further information and action as necessary.
The full report is available to view here: Department of Psychiatry, Letterkenny University
