The Acute Mental Health Unit at Cork University Hospital has been found to have the worst level of compliance with rules, regulations and codes of practice, out of a series of reports published by the Mental Health Commission (MHC) in 2024.
Inspector of Mental Health Services, Professor James V Lucey, described the level of critical non-compliance as "unprecedented".
The HSE has been warned that the MHS is considering "further enforcement action".
Prof Lucey said it was also "deeply concerning that the approved centre was found to be in breach of a condition of registration".
The MHC views any breach of a condition of regulation "in the most serious of terms", he said.
Following a four-day unannounced inspection in April 2024, inspectors found the approved inpatient unit at CUH to have a 61% level of compliance.
This compares with a level of 94% at Dublin's Bloomfield Hospital, 83% at University Hospital Limerick's Acute Psychiatric Unit, and 81% at Bantry General Hospital's Centre for Mental Health Care and Recovery.
These were among ten approved inpatient mental health centres across Clare, Cork, Donegal, Dublin and Limerick inspected last year by the MHC.
In all, MHC inspectors identified eight critical risk non-compliances, and four high risk non-compliances at the Acute Mental Health Unit at CUH.
The number of critical risk non-compliant ratings had increased from four in 2023 to eight last year which Prof Lucey, described as "unprecedented".
In his Review of Findings, he said the Mental Health Commission was not assured that "minimum standards of safe, effective, high quality, person-centred care and treatment" were being provided in the purpose-built unit which opened in 2015.
He described the level of critical non-compliance as "unprecedented".
Findings revealed 'deficits'
While acknowledging a slight increase in the overall compliance rate from 2023 of 58%, and that feedback from residents was "largely complimentary", Prof Lucey said the findings revealed "deficits in governance structures, reporting relationships, role definition, allocation of responsibility and accountability" at the approved unit.
The MHC said it issued an Immediate Action Notice to the HSE on 26 April 2024 advising them that the unit was non-compliant with 13 regulations, eight of which were rated as critical risk, and asked them to attend a Regulatory Compliance Meeting the following month.
Today's report says that, at a meeting in May 2024, the HSE accepted it "had failed to meet regulatory requirements", and gave a series of undertakings to improve the service and address all matters highlighted.
Further information was sought by the Mental Health Commission who informed the HSE that it was giving consideration to "further enforcement action".
In a statement, HSE South West said that it was "committed to delivering the highest possible standards of care for patients.
"We take the observations contained in the report seriously and are actively working with the Mental Health Commission in progressing corrective action plans to ensure all requirements are met."
