Delivery of high-quality mental health care impaired by old and unsuitable buildings25 February 2021
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, according to a new report we have published today.
Authored by the Inspector of Mental Health Services, Dr Susan Finnerty, the report, entitled ‘Physical Environments in Mental Health Inpatient Units’ states that buildings have suffered from years of neglect. Existing issues of concern and unsuitability largely stem from the fact that the many buildings were not purpose built but have been converted from other longstanding healthcare facilities.
The report also points out that units have struggled to comply with the regulation on premises over many years, with 75%, 67% and 69% of centres non-compliant with this regulation in 2017, 2018 and 2019 consecutively. And while some of the reasons for non-compliance are due to lack of cleanliness, and poor decorative and maintenance standards, others - such as the presence of ligature anchor points, poor ventilation, and insufficient or unsuitable furniture - are down to the nature and design of the building itself.
“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,” said Dr Finnerty. “One centre has a nine-bed dormitory. Others have bedrooms that are cramped, with little space between the beds, resulting in lack of privacy and dignity. Some units have only limited access to an outdoor area, with service users at one Cork unit dependent on staff to take them to a nearby green area as the centre has no outdoor space.”
The report states that aggressive behaviour by patients in psychiatric facilities remains a serious and worldwide problem and that attempts to reduce this type of hostility should no longer be limited to security features such as locks, observation windows, violence-proof doors and isolation rooms. Rather, more focus 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,” explained Dr Finnerty. “This can, therefore, worsen levels of aggression.”
The report cites studies showing that the most consistently important variable for predicting aggressive behaviour is the number of persons per room, otherwise known as social density. Even if occupancy of a unit reaches 100%, 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.
Highlighting the fact that Irish inpatient facilities have a limited supply of single, en suite bedrooms, the Inspector 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”.
Apart from providing more space for service users, the report identifies other factors that it says should be considered when designing inpatient facilities. These include the avoidance of excessively large and high spaces that are likely to be noisy and distressing; safe external areas; a covered space for shade and patient use in bad weather; and that all fixtures and fittings should be anti-ligature, robust and able to withstand sustained attack. The report also recommended that service users should have an early and continuing opportunity to contribute to the new service design and participate in the planning process.
While many of the non-compliances on the regulation for premises relate to the design of the building, the report also emphasised the fact that inspectors continue to find unclean buildings and/or a poor system of maintenance.
“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,” said the Chief Executive of the Mental Health Commission, John Farrelly. “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 COVID-19 pandemic has also demonstrated 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, not just for COVID-19, but in the context of illnesses which people in congregated mental health facilities are more vulnerable to.
“It is paramount that mental health services prevent transmission of COVID-19 and other contagious illnesses in inpatient settings, as well as preventing the spread in the community,” said Mr Farrelly. “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.”
The report noted that new units which have opened within the last five years are meeting requirements and have single en suite bedrooms with plenty of space internally and externally.
“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,” said Mr Farrelly. “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 units are meeting requirements, Dr Finnerty stressed 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.
“The function of a mental health inpatient unit is to provide safe care in the least restrictive environment,” she said. “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 read here.