Lois Bridges
Lois Bridges inspection Report 21 – 24 March 2017
Mental Health Commission summary of finding of Lois Bridges
There were numerous ligature anchor points throughout Lois Bridges, which constituted a high risk to residents. Medication management was not safe and also was rated high risk. Despite Lois Bridges being a specialist eating disorder unit, there was not always a psychiatric nurse on duty. The approved centre did not have input from a medical specialist or from a medical facility. The Inspector was concerned about the safety of two residents who had been admitted to Lois Bridges. The layout of the approved centre and skills and expertise of staffing were not adequate for the care and treatment of a resident with severe mental illness. There was no admission criteria to ensure that residents were not admitted if too physically or mentally ill to be treated in Lois Bridges
Appropriate care and treatment of residents
Residents were not always transferred to appropriate facilities based on their physical or mental health needs. Where transfers took place, the process was adequate. General health needs were provided by a GP but there was no input from specialist medical staff. As outlined above in the case of two residents, appropriate care and treatment was not provided in line with their assessed needs.
Responsiveness to residents’ needs
While there was a booklet with information about Lois Bridges and the services provided, this was not given to residents but sent to carers. There was no information displayed as to how to make a complaint and complaints were not investigated promptly.
Governance of the Lois Bridges Eating disorder clinic
Lois Bridges was independently run and the management team comprised the registered proprietor, the clinical director, and the director of services. The management team met quarterly. There was only one consultant psychiatrist (who was also the clinical director) who was available twenty-four hours a day and seven days a week, with cover for planned leave. This was neither a safe practice for residents nor the consultant psychiatrist. Staff supervision was not facilitated in a structured, formalised manner. The clinical director and the director of services identified strategic aims for the Lois Bridges and discussed potential operational risks with their departments including difficulties in recruiting and retaining registered psychiatric nurses. There were no established mechanisms in place for performance appraisal within Lois Bridges.
Regulation 20: Provision of Information to Residents: NON-COMPLIANT
Information was provided in the form of a booklet. Information booklets were not routinely given to residents, as required by the regulation, but were e-mailed to residents’ representatives/parents. Staff were unaware of how to source the booklet, which was not available to the inspectors until a copy was printed out by the director of services. The booklet did not reflect senior managerial staff at the time of the inspection. The booklet contained information on the complaints procedure and relevant advocacy and voluntary agencies but did not include details of arrangements for personal property or residents’ rights. Information was provided to residents regarding housekeeping practices, including arrangements for mealtimes, visiting times and visiting arrangements. Three of four residents interviewed stated that they had not received information on the following at admission: visiting arrangements, search policy, and procedures around the locking of rooms. Residents stated that they would have preferred to receive pertinent information upfront rather than gradually learning how Lois Bridges operated. Residents were provided with the details of their multi-disciplinary team. Residents were provided with written and verbal information on their diagnosis, unless the provision of such information might be prejudicial to their physical or mental health, well-being, or emotional condition.
Lois Bridges was non-compliant with this regulation because residents were not provided with information regarding arrangements for personal property, as required under 20(1)(b).
Regulation 22: Premises: NON-COMPLIANT
Risk Rating: High
There were numerous ligature anchor points throughout the Lois Bridges these had not been effectively mitigated.
Lois Bridges was non-compliant with this regulation because the premises was not maintained with due regard to the safety and well-being of residents, given the presence of ligature anchor points, 22(3).
Regulation 23: Lois Bridges Ordering, Prescribing, Storing and Administration of Medicines: NON-COMPLIANT
Risk Rating: High
The MPARs did not contain a dedicated space for recording once-off or as-required medications. In one MPAR there was no stop date recorded for a medication. The inspection team observed medication being prepared in advance of its administration, a practice that could lead to potential errors in administration The MPARs contained 18 omissions relating to the documentation of the administration of medication in three residents MPARS. Medication was stored in the environment indicated on the label or as advised by the pharmacist. Medication storage areas were incorporated into the cleaning and housekeeping schedules. During the inspection, the freezer door of the fridge was broken. There was excess water in the medication fridge. A daily log of medication fridge temperatures was not maintained. One medication past its expiry date was found in the medication cupboard. Medication was stored in a locked cupboard in a disorganised manner. A party paper cup was used to store loose medication. A system of stock rotation was in place and an inventory of medications was conducted weekly, but this was not documented.
Lois Bridges was not compliant with this regulation for the following reasons:
- a) There were 18 omissions in the documentation of administration in three MPARs, an unsuitable administering practice under 23(1).
- b) Medication was not appropriately stored: 23 (1) The medication fridge contained evidence of damp, Medication past its expiry date was observed in the medication cupboard, Medication was stored in a party paper cup, A daily log of medication fridge temperatures was not maintained.
- c) Medication was prepared in advance of administration, an unsuitable administration practice under 23(1).
Regulation 26: Staffing: NON-COMPLIANT
Risk Rating: Critical
The number and skill mix of staffing did not meet resident needs because an appropriately qualified staff member was not on duty and in charge at all times. According to the roster, for 25% of the time, a registered psychiatric nurse (RPN) was not in charge during daytime hours and night time hours. This issue was identified in last year’s inspection report.
The inspection team noted that there were incidences where 1:1 nursing/health care assistant (HCA) observation was in place. This was provided by the one of the complement of two nursing/HCA staff on duty, leaving only one staff member for all other tasks. This was insufficient.
The clinical director provided on call 24/7 to Lois Bridges. There was no formal arrangements for a consultant on call rota. There were also no formal arrangements for cover in the event of annual leave, sick leave or unforeseen absences. It was not considered safe practice to have only one consultant psychiatrist on continuous duty. A written staffing plan for the approved centre was not available to the inspection team.
Annual staff training plans had been developed for all staff, and orientation and induction training was completed. All staff had received training in the Mental Health Act (MHA) 2001. All staff were trained in Children First. Staff training was documented and records indicated that efforts had been made to achieve compliance with this part of the regulation. Not all staff were up-to-date with required training: 13 of the 26 staff did not have up-to-date Fire Safety training, 11 staff did not have up-to-date training in Basic Life Support (BLS), and 8 staff did not have upto-date training in the Therapeutic Management of Aggression and Violence (TMAV)
Lois Bridges was non-compliant with this regulation for the following reasons:
- a) An appropriately qualified staff member was not on duty and in charge at all times, as per 26(3).
- b) Not all staff had up-to-date training in Fire Safety, BLS, or TMAV, as per 26(4).
Due to the critical risk rating, an immediate action notice was forwarded to Lois Bridges after the inspection, requesting immediate actions to be taken to address the areas of non-compliance
Regulation 27: Maintenance of Records: NON-COMPLIANT
Entries noted the date but were not always timed. Records were retained or destroyed in accordance with legislative requirements and Lois Bridges policy. Documentation relating to food safety, health and safety, and fire inspections was maintained in the approved centre.
Lois Bridges was not compliant with this regulation because the approved centre did not have written policies and procedures relating to the creation of records, 27(2).
Regulation 32: Lois Bridges Risk Management Procedures: NON-COMPLIANT
Risk Rating: Critical
Numerous ligature anchor points remained throughout Lois Bridges; these had not been effectively mitigated. Risk assessments of residents were completed at admission to identify individual risk factors. Incidents were not consistently recorded and risk-rated using a standardised format. One incident had been recorded since the date of the last inspection. An incident form was used, and the incident was risk rated in a standardised format. An episode of self-harm was reviewed. Risk was mitigated for this incident however this episode was not recorded as an incident or risk-rated as such. The Mental Health Commission was not notified of this incident. The incident was reviewed by the MDT at its regular meeting, and a record was maintained of the review and of recommended actions. The individual responsible for risk management in Lois Bridges reviewed incidents for any trends or patterns occurring in the services, and six-monthly summary reports of incidents were forwarded to the Mental Health Commission (MHC). The approved centre did not have an emergency plan that included evacuation procedures. The only emergency plan available dealt specifically with fire. The Inspector was concerned about the safety of two residents who had been admitted to Lois Bridges. There was no admission criteria to ensure that residents were not admitted if too physically or mentally ill to be treated in Lois Bridges. Lois Bridges was solely an approved centre for eating disorders. The risk was rated as critical and referred to the Regulatory Committee as a Serious Concern for followup.
The Lois Bridges was non-compliant with this regulation for the following reasons:
- a) The risk management policy did not cover the approved centre’s arrangements for identifying, recording, investigating, and learning from serious or untoward incidents or adverse events involving residents, 32(2)(d).
- b) The approved centre did not record and risk-rate all incidents and notify the MHC of all incidents occurring in the approved centre, 32(3).
- c) Care and treatment of two residents constituted a risk to their safety 32(1).
Notification of Deaths and Incident Reporting: NON-COMPLIANT
Lois Bridges Admission, Transfer and Discharge: NON-COMPLIANT
In one of the clinical files examined, the admission assessment did not include family history, medical history, details of current and past medication, social history, or a mental state examination. In one file, there was no evidence that a family/advocate/carer was involved in the admission process. In one of the four files a resident was identified as having significant risks associated with their physical health, however a full physical examination was not completed until two days after admission. One resident was not admitted to the unit most appropriate to their needs. Lois Bridges did not follow their own policies in relation to the admission of this resident. The approved centre’s admission process was compliant with
Regulation 7: Clothing,
Regulation 8: Residents’ Personal Property and Possessions,
Regulation 15: Individual Care Plan.
Regulation 20: Provision of Information to Residents,
Regulation 27: Maintenance of Records,
Regulation 32: Risk Management Procedures.
Discharge: The clinical file of one resident who had been discharged from Lois Bridges was examined. There was no evidence that the discharge was coordinated by the relevant key worker, and efforts to inform primary care or community mental health of the discharge within 24 hours were not documented.
Lois Bridges was non-compliant with this code of practice for the following reasons:
- a) The admission process did not comply with Regulation 20: Provision of Information to Residents (22.5), Regulation 27: Maintenance of Records (22.6), and Regulation 32: Risk Management Procedures (7.2).
- b) The transfer policies did not include procedures for emergency transfers or transfers abroad or a protocol for ensuring the safety of residents and staff during transfers (4.13).
- c) There was no evidence that the discharge was coordinated by the relevant key worker (37.1).
- d) Efforts to inform primary care or community mental health of the discharge within 24 hours were not documented (38.2).
