Lois Bridges Eating Disorders

2017 Lois bridges an eating disorder clinic Focused Inspection Report (Mental Health Act 2001)

An Inspector of Mental Health Services, provided a summary of findings from the focused inspection of Lois Bridges eating disorder clinic.  The focused inspection was carried out as there had been serious concerns following the annual inspection in March 2017, regarding safety of the residents and staffing of Lois Bridges. Non-compliance in risk management procedures and staffing were risk rated as critical. In particular, the inspectors were concerned about the number of ligature anchor points in Lois Bridges and the lack of registered psychiatric nurses on duty and in charge at all times. It was determined that a focused inspection should be undertaken to gather further information in relation to these areas and to ascertain whether appropriate actions had been taken to address the risks identified. During this focused inspection, the inspectors found that the ligatures and ligature anchor points remained. Although the inspectors were informed that these would be rectified imminently, no work had commenced. Despite the fact that Lois Bridges an eating disorder clinic was a specialist Eating Disorder clinic, there was no arrangement for specialist medical input. Lois Bridges relied on a GP and the emergency department of general hospitals.

 

The non-compliance with Regulation 32: Risk Management was again risk rated as critical.

A registered psychiatric nurse was not on duty and in charge of Lois Bridges at all times and the skill mix of staff was not appropriate to the assessed needs of residents.

The clinical director was on duty 24 hours a day, seven days a week and also in another full-time post in another approved centre. Not all staff had up-to-date, mandatory training in Basic Life Support and fire safety.

 

Non-compliance with Regulation 26 Staffing was again risk-rated as critical.

 

Lois Bridges an eating disorder clinic was again non-compliant with Regulation 23: Ordering, Prescribing, Storage and Administration of Medicines and this was risk-rated as high.

There were numerous deficits in the admission, transfer and discharge processes. On the previous inspection there had been no admission criteria; on this inspection admission criteria were in place.

2.0 Inspector of Mental Health Services – Summary of Findings

3.1 Description of Lois Bridges 

Lois Bridges was a private eating disorder clinic unit for adults located in Sutton Co. Dublin. It was located in a residential area. Lois Bridges provided care and treatment for up to seven adults with eating disorders. The majority of admissions were planned and voluntary. Residents were generally funded by private health insurance, the HSE, or self-funded. Lois bridges comprised a five-bedroom, two-storey house. There were six residents in Lois Bridges at the time of the inspection. The treatment programme featured group and individual therapies provided by a range of therapists who were contracted for services provided. There was no specialist medical input or adjacent medical facility. A GP assessed the residents and provided medical interventions. The only access to specialist medical assessment and treatment was to be sent as an emergency referral to an emergency department of a general hospital. The clinical director, who was a consultant psychiatrist, provided a service to the approved centre 24 hours a day and seven days a week. This psychiatrist also had a full-time position in another approved centre at the same time, providing acute psychiatric care. The senior registrar did not provide clinical input for the approved centre and there was no other registered medical practitioner in the approved centre. The resident profile on the first day of inspection was as follows:

Resident Profile

Number of registered beds 7

Total number of residents 6

Number of detained patients 0

Number of Wards of Court 0

Number of children 0

Number of residents in the approved centre for more than 6 months 0

 

4.1 Reason for focused inspection

The previous inspection of the approved centre on 21 – 24 March 2017 identified the following areas of concern:

Regulation/Rule/Act/Code Risk Rating

Regulation 20: Provision of Information to Residents Moderate

Regulation 22: Premises High

Regulation 23: Ordering, Prescribing, Storing and Administration of Medicines High

Regulation 26: Staffing Critical

Regulation 27: Maintenance of Records Low

Regulation 32: Risk Management Procedures Critical Code of Practice for Mental Health Services on Notification of Deaths and Incident Reporting Moderate

Code of Practice on Admission, Transfer and Discharge to and from an Approved Centre High

 

In view of the critical risk rating for the non-compliance with Regulation 26: Staffing and Regulation 32: Risk Management Procedures, an Immediate Action Notice was issued to the registered proprietor. It was determined that a focused inspection should be undertaken to gather further information in relation to these areas to ascertain whether appropriate actions had been taken to address the risks identified.

4.2 Focus of inspection

The focus of the inspection was as follows:

• To determine whether the medical and nursing care in Lois Bridges was appropriate.
• To determine whether the care and treatment provided was safe.
• To determine whether the admission and discharge processes to Lois Bridges were appropriate. Specific legislative requirements, or parts thereof, inspected as part of the focused inspection were as follows:

Regulation/Rule/Act/Code Part (or full regulation)

Regulation 23: Ordering, Prescribing, Storing and Administration of Medicines Full

Regulation 26: Staffing Full

Regulation 32: Risk Management Procedures Full

Code of Practice on Admission, Transfer and Discharge to and from an Approved Centre Full

 

A feedback meeting was facilitated prior to the conclusion of the inspection. This was attended by the inspection team and the following representatives of eating disorder clinic:

Ø Clinical Director

Ø Registered Proprietor nominee

Ø Clinical Nurse Manager 2

 

INSPECTION FINDINGS

NON-COMPLIANT

Quality Rating Requires Improvement Risk Rating

 

The MPARS did not contain dedicated space for recording once-off or as-required medications. Two of the MPARS examined did not include the Medical Council Registration Number of every medical practitioner prescribing medication to the resident. Two prescriptions were not signed by the medical practitioner/nurse prescriber. Where there was an alteration in the medication order, the medical practitioner rewrote the prescription. All medicines were administered by a registered nurse or registered medical practitioner. Medicinal products were not always administered in accordance with the directions of the prescriber. Sixteen separate administration records were not signed within the six MPARs inspected, and there was no record of whether residents had received or refused medication or whether medication had been withheld. Medication arriving from the pharmacy was verified against the order and stored in the appropriate environment. The medication cabinet was locked and secured, and a system of stock rotation was implemented. A daily log of medication fridge temperatures was not available to the inspectors, and the thermometer in the fridge was reading 11°C. Food was observed in the medication fridge.

 

Lois Bridges was non-compliant with section 1 of this regulation for the following reasons:

1. a) The policy did not include the requirements relating to: codes of practice, external reporting of medication errors and/or adverse incidents and the processes for medication: ordering, selfadministration,

management on transfer and discharge, reconciliation and review.

1. b) The MPARs did not contain dedicated space for recording once-off or as-required medications.
2. c) Two of the MPARs examined did not include the Medical Council Registration Number of the prescribing medical practitioner.
3. d) Two prescriptions were not signed by the medical practitioner/nurse prescriber.
4. e) Sixteen separate administration records were not signed within the six MPARs inspected and there was no record of whether the residents had received or refused medication or whether medication had been withheld.
5. f) Medication was inappropriately stored: The thermometer in the medication fridge was reading 11°C, there was no evidence of regular monitoring of fridge temperatures, and food was stored in the medication fridge.

 

Regulation 26: Staffing

(1) The registered proprietor shall ensure that lois bridges has written policies and procedures relating to the

recruitment, selection and vetting of staff.

(2) The registered proprietor shall ensure that the numbers of staff and skill mix of staff are appropriate to the assessed needs

of residents, the size and layout of lois bridges.

(3) The registered proprietor shall ensure that there is an appropriately qualified staff member on duty and in charge of Lois Bridges at all times and a record thereof maintained in the approved centre.

(4) The registered proprietor shall ensure that staff have access to education and training to enable them to provide care and

treatment in accordance with best contemporary practice.

(5) The registered proprietor shall ensure that all staff members are made aware of the provisions of the Act and all regulations

and rules made thereunder, commensurate with their role.

(6) The registered proprietor shall ensure that a copy of the Act and any regulations and rules made thereunder are to be made

available to all staff in Lois bridges.

 

INSPECTION FINDINGS

NON-COMPLIANT

Quality Rating Requires Improvement

Risk Rating

Evidence of Implementation: The approved centre eating disorder clinic had an organisational chart to identify the leadership and management structure and lines of authority and accountability of staff. The skill mix of staff did not meet resident needs, as at times there was no registered psychiatric nurse on duty and, therefore, an appropriately qualified staff member was not on duty and in charge at all times. One nurse in charge was an intellectual disability nurse, not a registered psychiatric nurse. The clinical director, who was a consultant psychiatrist, provided a service to the approved centre 24 hours a day and seven days a week. This psychiatrist also had a full-time position in another acute approved centre at the same time. The senior registrar did not provide clinical input for Lois Bridges and there was no other registered medical practitioner in Lois Bridges. A written staffing plan for Lois bridges was not available to the inspection team. Orientation and induction training was completed for all staff, and at least one staff member had Children First training. There was training in manual handling, infection control, mental health care for people with an intellectual disability, Dialectical Behaviour Therapy, and incident reporting. Not all staff had up-to-date, mandatory training in Basic Life Support and fire safety. Resources were available to staff for further training and education, and in-service training was delivered. The Mental Health Act 2001, the associated regulation, Mental Health Commission rules and codes, and all other documentation and guidance were available to staff throughout Lois bridges.

 

Lois Bridges an eating disorder clinic was non-compliant with this regulation for the following reasons:

1. a) The skill mix of staff was not appropriate to the assessed needs of residents, 26(2).
2. b) An appropriately qualified staff member was not on duty and in charge at all times, 26(3).
3. c) Not all staff had up-to-date, mandatory training in fire safety or Basic Life Support, 26(4).

Ward or Unit Staff Grade Day Night

(1) The registered proprietor shall ensure that Lois Bridges has a comprehensive written risk management policy in

place and that it is implemented throughout the approved centre.

(2) The registered proprietor shall ensure that risk management policy covers, but is not limited to, the following:

(a) The identification and assessment of risks throughout the approved centre;

(b) The of children and vulnerable adults from abuse.

(3) The registered proprietor shall ensure that an approved centre shall maintain a record of all incidents and notify the Mental

Health Commission of incidents occurring in the approved centre with due regard to any relevant codes of practice issued by

 

NON-COMPLIANT

Quality Rating Requires Improvement

Risk Rating

Evidence of Implementation:. Risk management procedures did not actively reduce identified risks to the lowest level of risk, as evidenced by the presence of ligature points. Numerous potential ligatures and ligature anchor points had been identified but had not been effectively mitigated, including cables in bedrooms, bannisters, taps, handles and rails in the toilet, and shower rails. Clinical, corporate, and health and safety risks were identified, assessed, treated, reported, monitored, and documented in the risk register. Structural risks were not removed or mitigated. Risk assessments of residents were completed at admission to identify individual risk factors. Each resident’s clinical file contained a risk assessment and management plan developed at admission. The requirements for the protection of children and vulnerable adults were appropriate and implemented as necessary. Incidents were recorded and risk-rated in a standardised format, and the individual responsible for risk management in Lois Bridges reviewed incidents for any trends or patterns occurring in the service. Six-monthly summary reports of incidents were forwarded to the Mental Health Commission. Lois Bridges had an emergency plan that included evacuation procedures. There was no specialist medical input or adjacent medical facility. A GP assessed the residents and provided medical interventions. The only access to specialist medical assessment and treatment is to be sent as an emergency to an emergency department of a general hospital.

Lois Bridges was non-compliant with this regulation for the following reasons:

1. a) The risk management policy was not implemented throughout the approved centre in that numerous ligatures and ligature anchor points had not been mitigated or removed, 32(1).

1. b) The risk management policy did not specify the processes for recording, investigating, and learning from serious or untoward incidents or adverse events involving residents, 32(2)(d).

1. c) The only access to specialist medical assessment and treatment is to be sent as an emergency to an emergency department of a general hospital, which constituted a risk to residents. Admission, Transfer and Discharge

Please refer to the Mental Health Commission Code of Practice on Admission, Transfer and Discharge to and from an Approved Centre, for further guidance for compliance in relation to this practice.

 

INSPECTION FINDINGS

NON-COMPLIANT

Risk Rating

Evidence of Implementation: Lois Bridges did not comply with Regulation 32: Risk Management Procedures, which is associated with this code of practice. The admissions, transfers, and discharges inspected pertained to the period after the last inspection.

Admission: The clinical files of three residents admitted to Lois Bridges were examined. These indicated that there was a key worker system in place and the entire multi-disciplinary team record was contained in a single clinical file. Each admission was made on the basis of a mental illness or disorder, and the decision to admit was taken by a registered medical practitioner (RMP). An admission assessment was completed, and details of all assessments and examinations were included in the clinical files. Admission assessments included a history of presenting problems, the previous psychiatric history, family history, medical history, details of current and past medication, social history, a mental state examination, and a full physical examination. A family/advocate/carer was involved in the admission process in two cases; the third resident did not consent to family involvement.

 

Transfer: The clinical files of two residents who were transferred to another medical facility for specialised treatment were examined. Both transfers were emergencies. In one case, while the decision to transfer was made by the RMP, this was not documented. In each case, efforts were made to respect the residents’ wishes and obtain consent to the transfers, and this was documented. A family member was involved in one of the transfers; the second resident did not consent to family involvement in the transfer. A copy of the referral letter was not retained in one resident’s file.

 

Discharge: The clinical files of three residents who had been discharged from Lois Bridges were examined. In each case, the decision to discharge was made by an RMP. None of the residents had a documented discharge plan in place as part of their individual care plans. In two cases, a discharge meeting involving the resident, key worker, relevant members of the MDT, and a family member/carer/advocate did not take place. There was no documentary evidence that a comprehensive assessment of the residents took place prior to discharge. In one of the files examined, there was no evidence that the discharge was coordinated by the key worker. In one file, there was no evidence of family/carer/advocate involvement in the discharge process. There was no documentary evidence that efforts were made to inform the primary care/community mental health care team of the discharge within 24 hours. In three cases, there was no record that a preliminary discharge summary was sent to the primary care/community mental health team within three days or was followed by a comprehensive discharge summary within two weeks. One summary was not sent until 41 days after a discharge against medical advice, while two other summaries were not dated. None of the discharge summaries referenced prognosis, follow-up arrangements, contact information for key people for follow-up, or risk issues. One discharge summary did not record the resident’s medication, and one did not address the resident’s outstanding health or social issues.

 

Lois Bridges an eating disorder clinic was non-compliant with this code of practice for the following reasons:

4. a) The policy in relation to admission did not address the roles and responsibilities of the MDT in relation to post-admission assessment, 4.7.
5. b) The policy in relation to transfer did not address the following:

– The discharge of involuntary patients, 4.2.

– Prescriptions and supply of medication on discharge, 4.10.

– Transfer abroad or the safety of residents and staff during a transfer, 4.13.

1. c) The post-discharge follow-up policy did not reference relapse prevention strategies, crisis management plans, or a way of following up and managing missed appointments, 4.14.

1. d) There was no documented evidence to indicate that all staff had read and understood the policies in relation to admission, transfer, and discharge, 9.1.

26. e) In one file examined in relation to transfer, the decision to transfer was not documented by the RMP, 26.1.
27. f) A copy of the referral letter was not retained in one resident’s clinical file following a transfer, 31.2.
28. g) Residents did not have a discharge plan in place as part of their individual care plans, 34.1, 34.2, and 42.1.
29. h) In two files examined in relation to discharge, a discharge meeting attended by the resident, key worker, relevant members of the MDT, and a family member/carer/advocate was not held, 34.4 and 42.1.
30. i) There was no documentary evidence that residents received a comprehensive assessment prior to discharge, 35.1.
31. j) In one case, there was no evidence that the discharge was coordinated by the relevant key worker, 37.1.

1. k) There was no documentary evidence that efforts were made to inform the primary care/community mental health care team of the discharge within 24 hours, 38.2.

1. l) There was no record that a preliminary discharge summary was sent to the primary care/community mental health team within three days or was followed by a comprehensive discharge summary within two weeks, 38.3.

1. m) None of the discharge summaries referenced prognosis, follow-up arrangements, contact information for key people for follow-up, or risk issues, 38.4.

38. n) One discharge summary did not record the resident’s medication, and one did not address the resident’s outstanding health or social issues, 38.4.
39. o) In one file, there was no evidence of family/carer/advocate involvement in the discharge process, 39.1.

7. p) The approved eating disorder centre did not comply with Regulation 32: Risk Management Procedures, which is related to this code of practice, 7.1.

The Irish Times describes Lois Bridges as an unsafe: 

There are “ongoing concerns” about the safety of residents, risk management and staffing at the Lois Bridges centre, particularly in relation to seriously physically ill residents with anorexia nervosa

Private eating disorders treatment centre told not to admit ill residents