The Mental Health Commission (“MHC”), the regulator of mental health services, has recently published a report titled 'a report on physical environments in mental health inpatient units' (the "Report"). The Report has found that the buildings of a significant number of mental health units in Ireland are not appropriate for delivering the highest standard of mental health care and require substantial improvement.
The following are of particular note from the Report:
Non-purpose built buildings
Many mental health facilities were not purpose built and were converted from other longstanding healthcare facilities. The report found that units have struggled to comply with the MHC's regulation on premises (regulation 22) over many years, with 75%, 67% and 69% of centres non-compliant with this regulation in 2017, 2018 and 2019 consecutively.
Commenting on this aspect of the Report, Dr Susan Finnerty, inspector of Mental Health Services said that "because many centres are not purpose built for therapeutic health care, we have facilities with poor lines of sight, long corridors, small sitting rooms, limited outdoor space, and multiple occupancy bedrooms.”
Reduction of Aggression
The Report found that aggressive behaviour by patients in mental health facilities remains a serious problem and that attempts to reduce such behaviours should no longer be confined to security features such as locks, observation windows, violence-proof doors and isolation rooms. Rather, more emphasis should be placed on the design of buildings. “A poorly designed facility that prevents privacy, is noisy, and has other stressful features, can intensify the stress of mental illness and involuntary confinement,” said Dr Finnerty. “This can, therefore, worsen levels of aggression.”
Overcrowding / Single Rooms
The Report cites studies which state that the most important variable for predicting aggressive behaviour is the number of persons per room, otherwise known as 'social density'. Even if a unit reaches 100% occupancy, a ward with single bedrooms, private bathrooms, and several communal spaces - compared to wards with multi-bed rooms, shared bathrooms, and few communal rooms - should make it possible for patients to seek privacy, regulate relationships with others and avoid stressors such as noise and arguments by moving freely between rooms. Acknowledging that Irish inpatient facilities have a limited supply of single, en suite bedrooms, Dr Finnerty states: “single bedrooms with private bathrooms may be the single most important design intervention for facilitating privacy and reducing crowding stress and aggression in inpatient psychiatric wards”
Infection prevention and control
The Report emphasised the fact that inspectors continue to find unclean buildings and/or a poor system of maintenance. Commenting on this aspect of the Report, Chief Executive of the Mental Health Commission, John Farrelly said as follows:
“Every service user has a right to be treated and cared for in a clean, safe environment, but we are finding that during a recent three-year period, approximately one third of Irish mental health units were dirty. This is unacceptable as it shows disrespect for the service user. Lack of governance plays a key role in this failure. Building new units, or significantly altering the design of existing units, may take time but ensuring that they are clean and well-maintained can and should be happening now. That we are still finding dirty rooms and ordering deep cleans is simply not good enough.”
The public health crisis has also shown that while many buildings have been designed to address safety concerns, such as fire, self-harm, and violence, they are not suitable for the facilitation of effective infection prevention and control. “It is important that the physical healthcare infrastructure is fit for purpose in this respect too by providing adequate bed spacing, isolation and single room capacity to minimise the spread of infection," said Mr Farrelly.
The Report found that new units which have opened within the last five years meet the requirements and have single en suite bedrooms with plenty of space internally and externally. Commenting on this aspect of the report, Mr Farrelly stated as follows: “Outside of this report, we already know that centres that were non-compliant with the regulation on premises in 2019, such as the adult mental health unit in Sligo, Aidan’s Residential Unit in Waterford, and Blackwater House in Monaghan, have all since become compliant. This is largely because they have moved into new purpose-built centres and is partly the reason why overall compliance has increased from 20 services out of 65 in 2019, to 36 services in 2020.”
While more facilities are meeting requirements, Dr Finnerty emphasised in the Report that many unsuitable buildings remain and require considerable funding if they are to be replaced or brought up to an acceptable standard. In particular, Dr Finnerty stated as follows:
“Providing a suitable environment involves recognising and respecting the diverse needs, values and circumstances of each patient, including their race, religion, gender, age, sexual orientation, and any disability they may have. Maintaining high standards and continually improving the environment helps improve the experience of service users, staff, and visitors. The environment has a crucial role in supporting the delivery of higher-quality and more cost-effective care. The test of ‘would we ourselves like to be treated or even live in this environment’ is not met in many of our mental health units.”
The full Report can be accessed here.
Written by Eimear Burke and Hannah Unger.
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