The Mental Health Commission has found the inpatient mental health facility at University Hospital Waterford (UHW) has been critically non-compliant with regulations relating to the maintenance of records and the use of seclusion.
Last July, the commission's inspectors found that a dirty and dusty seclusion room was being used at the centre and gave the facility a "high risk" rating for its standards of privacy, premises, staffing and registration, and where the admission of children was concerned.
July's annual inspection of the 44-bed Department of Psychiatry at UHW was unannounced.
The commission's report includes criticism of the management of three randomly chosen voluntary patients who had each been placed once in seclusion.
For example, it says the seclusion room was not cleaned to ensure respect for patients' dignity and that it was dirty and dusty at the time of inspection; and there was a blind spot in the space which meant the residents were not under direct observation by a registered nurse for the first hour of the seclusion.
The report states that in all three episodes, seclusion was only implemented in the resident's best interests, in rare and exceptional circumstances where the resident posed an immediate and serious harm to him or herself or others.
However, in one case, the seclusion was not reviewed by members of the multi-disciplinary team and documented in the clinical file within two working days as required by the Commission.
In none of the three cases was a copy of the seclusion register placed in the clinical files nor was the seclusion register signed in all cases by the responsible consultant psychiatrist or duty consultant psychiatrist within 24 hours.
The report recalls that this was the fourth successive year that the same centre had been found non-compliant with the rule on seclusion.
In general, "clinical files were in very poor order," the report says, citing "potential confidentiality breaches" where files were not stored securely. There was a "lack of logical sequencing in records". Again, this non-compliance was risk rated as "critical".
It recalls that there had been nine child admissions during the previous inspection in October 2017 and that each child was accommodated in a single room with a dedicated staff member. The Child and Adolescent Mental Health Service (CAMHS) consultant psychiatrist had clinical responsibility for each child.
However, age-appropriate facilities and a programme of activities appropriate to age and ability were not available in the centre and child residents did not have access to age-appropriate advocacy services.
Overall, discharge planning and procedures were judged "unsatisfactory, in particular the issuing of discharge letters to GPs".
Residents in hospital for more than six months did not have adequate assessment of their physical health.
In two cases, the registered medical practitioner did not complete a physical examination of each resident within three hours, as required, after the start of an episode of physical restraint," the report states.
In a statement, Inspector of Mental Health Services for the Mental Health Commission Dr Susan Finnerty criticises the failure to give residents of the 14-bed acute unit access to a new communal and dining area despite it being been ready for use since February 2018.
She said they were eating meals by their bedside during July's inspection. The commission says the area concerned was opened some five months later - last December - almost a year later than the commission had said it should have been ready.
Inspection reports at similar centres
Reports on inspections of four other similar centres were also published. They record 31 ratings of "excellent" compliance in them but no similar score at the UHW.
In an accompanying statement on all five reports, the MHC expressed disappointment that in three of them, not all staff had received the required training in basic life support, fire safety, the management of aggression and violence, and on the Mental Health Act 2001.
"On the other hand, it is heartening to see that in two approved centres all the health care professionals had up-to-date, mandatory training completed. This is the high standard we require from approved centres," the statement added.
"Other areas of concern to the Inspectorate are in the area of hygiene, where catering areas and catering and food safety equipment were not appropriately cleaned. These areas of non-compliance do not support food safety requirements."
The Acute Psychiatric Unit in Cavan General Hospital was adjudged "high risk" non-compliant in the areas of food safety, privacy, premises, staffing and ordering, prescribing, storing and administration of medicines.
The Phoenix Care Centre in Dublin had three high-risk non-compliances in the area of premises; use of closed circuit television; and the use of physical restraint.
The same centre also had three compliance areas rated as "excellent".
Dr Finnerty also highlighted that Willow Grove Adolescent Unit in St Patrick's University Hospital in Dublin had the highest compliance rate, being fully compliant in both 2017 and 2018 - with 24 compliances rated as "excellent".
The Owenacurra centre in Midleton, Co Cork was 90% compliant, with three compliance areas rated as "excellent". The report underlined that this score was achieved despite the unit being registered as an approved centre for only three years.
"These compliance rates reflect the work of the commission and the consistent approach of the approved centres year on year," Dr Finnerty added.
MHC Chief Executive John Farrelly said it had used its enforcement powers effectively recently in Kilkenny District Court, acting on the findings of the inspection reports to secure a conviction of the Health Service Executive in respect of its centre in St Luke's Hospital, Kilkenny.
"These reports are crucial to the improvement of the mental health service in this country," Mr Farrelly added.
"Each approved centre is provided with an opportunity to address the findings in the inspection reports and furnish the commission with preventative actions for immediate implementation, which the commission monitors closely.
"Today's five reports show an increasing compliance and a continuous improvement to an excellent standard in some centres. This reflects the commission's work to improve standards and quality of mental health care for patients, which is our responsibility to the human rights of the people who use our mental health services.
"However, standards of service are still not compliant in many cases, and are listed as critical or high-risk in a number of cases. As we have demonstrated in Kilkenny, if service providers repeatedly do not act on our feedback, or are consistently non-compliant, they can expect us to take effective and appropriate action," Mr Farrelly concluded.