Description of Approved Centre
The National Eating Disorder Recovery Centre (NEDRC) is located on the Merrion Road, Ballsbridge. The former Edwardian residence was expertly renovated to accommodate the Eating Disorder Service operated by the Registered Proprietor Linmore Health Limited in the independent healthcare sector. The two-storey premises was well renovated and decorated, delicately achieving the balance between therapeutic and clinical spaces in a homely environment. The service was registered for eight beds and there were six clients receiving care at the time of the inspection. The NEDRC provided inpatient and outpatient eating disorder services. Clients were assessed as they attended the outpatient programme and were offered inpatient treatment if it was clinically indicated. Use of the outpatient programme frequently formed an integral part of the discharge process. The building’s entrance and foyer were bright and welcoming, leading to the waiting area with adjoining Nursing offices. The kitchen and dining areas were near the waiting area. Good sized therapeutic and relaxation rooms were located to the right as you entered the premises. There were secure lockers available for residents to store their personal effects during the day. Clinical areas could be accessed on the first floor via the staircase to the left of the waiting area. The staircase just beyond the lockers led to the client accommodation on the first and second floors, which comprised of well sized single rooms with good storage and two large double rooms. Two separate shower and toilet facilities could be accessed on the first floor and there was an additional shower room and toilet facilities on the second floor. The Registered Proprietor had provided additional sleeping quarters for staff in the event of severe national weather warnings that advise travel restrictions, also located on the second floor. The outdoor garden was designed as a tranquil outdoor space with a water fountain and sheltered seating, offering residents a well-proportioned space to utilise and enjoy. A modern standalone extended building, with an office plus additional communal and therapeutic space, completed the rear garden area. Inspector of Mental Health Services Summary The 2025 annual inspection of the National Eating Disorder Recovery Centre (NEDRC) was unannounced and occurred over a four-day period from the 10 th to 13 th of June. The inspection report reflects the findings over this period only. Located in Ballsbridge, the NEDRC was very well maintained and managed by a team of professionals dedicated to high quality, person centred, recovered orientated care. In 2024 the NEDRC 1.0 Inspector of Mental Health Services –
Annual Inspection Report 2025 Promoting Quality, Safety and Human Rights in Mental Health National Eating Disorders Recovery Centre. NATIONAL EATING DISORDERS RECOVERY CENTRE,62 Merrion Road, Ballsbridge, Dublin 4 Date of Publication: 20 November 2025 ID Number: AC0310 2025 Approved Centre Inspection Report (Mental Health Act 2001) Approved Centre Type: Eating Disorders Treatment Conditions Attached: None Most Recent Registration Date: 18 June 2024, Full inspection report available at www.mhcirl.ie or direct link click here
Inspector of Mental Health Services Professor James V Lucey
Review of Findings
2024 inspection found six non-compliances. As a result, the management of the service implemented corrective and preventative action plans including the regular auditing of Medicines Prescription Administration Records (MPARs) and Individual Carr Plan (ICPs), extensive refurbishment works, addressing ligature points and risk management, following the extensive collaboration with an external risk management consultant. The positive findings of the 2025 inspection were accurately reflected by the quality of the works completed and processes implemented to maintain high standards of care. There had been no restrictive practice since the last inspection. With a clearly defined admission criteria, the NEDRC received referrals from medical professionals nationwide. The NEDRC was an extensively well-resourced centre with Consultant Psychiatrists, Psychologists, Occupational Therapists, Nursing, Peer Support, and Dietetics professionals specializing in eating disorders. The improvements made by the service were not only reflected by the inspection team’s findings but perhaps even more so from some of the clients’ feedback which were received by the 2025 inspection team, such as:
• “I believe in recovery a lot more now”
• “NEDRC has rebuilt my trust in Mental Health Services in Ireland”
• “I truly believe the NEDRC saved my life” The resident profile on the first day of inspection was as follows:
Resident Profile
Number of registered beds 8
Total number of residents 6
Number of detained patients 0
Number of wards of court 0
Number of residents under the Assisted Decision Making Act 0
Number of children 0
Number of residents in the approved centre for more than 6 months 0
Number of patients on Section 26 leave for more than 2 weeks 0
Conditions of registration
There were no conditions attached to the registration of this approved centre at the time of inspection.
Ongoing escalation and enforcement actions at time of inspection None. Escalation and enforcement actions commenced following this inspection None.
The following quality initiatives were identified on this inspection: Please note, the information below in relation to the good practices and quality initiatives are as described by the service and provided to the inspection team.
Regulation 05: Food and Nutrition quality initiatives
The approved centre had processes in place to identify and provide education and training to clients with regard to the nutritional needs. The approved centre had processes in place for the involvement of residents in their nutritional care. Weekly educational sessions were provided by the dietician to residents. The approved centre took into consideration residents’ psychosocial needs by ensuring the food offered was appetising, visually appealing, well- presented, and enjoyable.
Regulation 09: Recreational Activities quality initiatives
The approved centre took into consideration residents’ interests while creating a schedule of recreational activities. Depending on the stage of recovery a client was at and their physical condition, discussions took place with clients at the weekly Community meeting around activities they would like to participate in e.g. visiting the “Dublinia” history experience, with a multi-disciplinary team discussion to ensure safety needs were met. Staff accompanied clients, while some clients may be required to remain on site. However, this was explained to the client, and staff facilitated an activity of the client’s choice on site. Examples of activities include; Pembroke Library, Sandymount Beech, Cinema, Botanic Gardens, Cafes or Restaurants, and taking the DART to Bray, Dun Laoghaire, or Blackrock. Other options included tabletop activities a Bingo night, and a Pamper night. There was a weekly restorative Yoga session with a qualified Yoga Teacher who had a PhD studies, in eating disorders and could adapt the intensity of the Yoga to meet the physical needs of the client. An awareness of cultural differences & minority group was promoted. Staff ensured clients were fully aware of plans in order for the client to make an informed decision on their participation. E.g., a neurodivergent client who was aware of the recreational outing was shown the venue online with their keyworker, to see if the environment would be suited to their sensory needs, therefore making an informed decision.
Regulation 11: Visits quality initiatives
Sensory needs were considered for clients and visitors, and various spaces were provided throughout the centre along with free access to filtered water (room temperature & cold), and various options of teas and coffees. National Eating Disorder Recovery Centre (NEDRC) provided a variety of cups & mugs, not just one standard cup or mug, as each person was individual and had different preferences to which type of mug or cup they like to drink from. 2.0 Quality Initiatives. A schedule of maintenance was in place & weekly environmental checks for A- Safety, B- Comfort, and C- Meeting needs. E.g., a client found great comfort in their pet dog and leaving their dog while coming in for treatment was a source of anxiety. NEDRC facilitated an area for the client’s dog to visit on a regular basis outside of programme times. This reassured the client and alleviated their anxiety.
Regulation 13: Searches quality initiatives
Open dialogue with clients, a clear expectation of what was permitted and not permitted in the centre and rationale why, was provided to clients prior to admission in the NEDRC handbook which is emailed to all clients in advance. Clients were reminded of this on admission and throughout their admission if necessary. It was NEDRC’s goal to maintain a safe environment for all clients and as a result, if there is good reason to believe that a client has intentionally or unintentionally possessed a prohibited item in their possession, two staff discuss this with the client and seek their consent to help remove any such item. Time was given to the client to ensure they understand why a search was required to take place. Materials to explain the search process could be provided in multiple languages, many of the staff spoke several different languages also. The notice of the availability of information was provided in a client’s native language and was located in the main hallway noticeboard.
Regulation 15: Individual Care Planning quality initiatives
The approved centre provided residents with a key worker to facilitate coordination and communication of interventions in line with their individual care plan. Integrating CHIME (Connectedness, Hope, Identity, Meaning & Empowerment) into the Individual Care Plans. There were regular monthly audits of all individual care plans to ensure the minimum standards required of the regulation were achieved.
Regulation 16: Therapeutic Services and Programmes quality initiatives
The approved centre provided access to community based therapeutic services and programmes. Regulation 19: General Health The NEDRC provided leaflets and information regarding health screening, public health information and promotion. These were interlinked with information provided in key working sessions, dietetic sessions (group and individual) and recovery-based peer support worker sessions (group and individual). An example of this, a client who had diabulimia, type 1 diabetes (misuse of their insulin to lose or maintain weight) had a long history of not taking their insulin and as a result was at high risk of physical complications of same- e.g. nerve damage/loss of limbs, deterioration/loss of eyesight. This client had a diabetic team in the Hospital they attended, but had inconsistent attendance with the same. NEDRC’s multi-disciplinary team worked with the client and their hospital diabetes team ensuring a cohesive plan of care that all people involved in this client’s care was aware of. There was ongoing education from the multi-disciplinary team on the impact that illness was having on her overall health and the longer-term effects was challenging at times, but perseverance from the team and trailing of different approaches, including facilitating a checkup with the retinal screening centre resulted in the client developing an understanding of the reality of what was happening within their body. This client attended periodic out-patient appointments and reported for the first time in her life that she takes her insulin as scheduled resulting in a vast improvement in her overall health. • Regulation 20: Provision of Information to Residents Staff were aware of the location of the resource “Healthcare Services Intercultural Guide: Responding to the needs of diverse religious communities & cultures in healthcare settings” HSE booklet and to use this as a reference guide if the need was to arise. Staff had contact numbers for the most local religious organisations.
Regulation 21: Privacy quality initiatives
The approved centre promoted the principles of equity, inclusion, and respect for diversity. staff have completed the dignity in work training, further
o In-house training ensured understanding of the use of peoples’ pronouns and exploring assumptions and stereotyping. The approved centre empowered residents to manage their own lives through stronger social relationships and a sense of purpose.
o The approved centre acknowledged the evolving understanding of human rights and maintained policies and practice in line with current requirements. An example was a client being uncomfortable with night-time checks. While reiterating to the client the rationale for the night-time checks (previously explained on admission), staff risk assessed the client for any concerns previously or current self-harm or suicidal ideation. Staff decided that the risk of continuing to carry out nighttime checks on this resident out-weighed the benefits (positive risk taking) and upheld their concern. Not only did this re-enforce that the team was working for her but with them. This resident quickly began sleeping better (no voicing of poor sleep) and solidified their trust in the team. Regulation 22: Premises The approved centre ensured that the physical environment was designed to achieve the best outcomes for residents. A quality example was the “fluffy room” that could be used with visitors or during the day by residents if they needed quiet time in a low sensory environment. The approved centre provided sensory equipment for clients throughout the building which always received very positive feedback from clients. The rear garden was designed as a tranquil outdoor space with a water fountain and sheltered seating area, offering residents a space to utilise and enjoy.
Regulation 23: Ordering, Prescribing, Storing and Administration of Medicines quality initiatives
Weekly and Quarterly Medication, Prescription, Administration audits were regularly completed. This was a service initiative that the NEDRC had implemented since the 2024 Inspection non-compliance finding. Regulation 26: Staffing Ther approved centre ensured the team felt valued and motivated by positive feedback and incentives. The Registered Proprietor was able to provide emergency accommodation for staff in the event of adverse weather warnings or other unforeseen circumstances. Regulation 27: Maintenance of Records The approved centre has an integrated electronic record management system. Information was readily available such as client food intake on a daily basis which added to the cohesive planning with the Dietitians. Regulation 29: Operating Policies and Procedures The approved centre incorporated feedback from residents, families and carers into its policies, procedures, protocols, guidelines, and education programmes.
The National Eating Disorder Recovery Centre (NEDRC) is owned by Linmore Health Limited the registered proprietor a private healthcare provider. The senior management team comprised the registered proprietor nominee (RPN), director of services (DOS), clinical director (CD) and assistant director of services (ADOS). Following the implementation of recommendations from an independent risk management consultant, governance meetings were increased from monthly to bi-monthly. These meeting included agenda items such as clinical risk register, clinical audits, clients their supporters and staff feedback, complaints, staff training and recruitment, innovation and excellence, safeguarding and regulatory matters. Although bi-
monthly, the small but cohesive senior management were adaptable and responsive to meeting at more regular intervals if required. There were local management meetings held monthly by the DOS, ADOS and Nursing, monitoring the clients plus their supporters feedback and suggestions, the therapeutic services and programmes, admissions and discharges, complaints and any issues raised in the documented weekly client community meetings. The Director of Services had overall responsibility for risk management and was also the approved centre’s complaints manager. NEDRC has a local risk register which is monitored and reviewed regularly. The ‘Eating Disorder Evaluation Questionnaire’ was utilised to review processes and procedures in conjunction with a robust audit system. The ligature audit was up to date and based on the industry recognized HSE risk matrix. The audit reviews and risk register formed a collective mechanism contributing to service quality improvement.
The service used an Electronic Healthcare Record system, EpicCare. This had facilitated the capture and monitoring of all clients’ healthcare provision and needs including individual care plans, assessments and appropriate personal information. The National Eating Disorder Recovery Centre operated a 12-week programme. Clients of the service and their families were encouraged and facilitated to be involved in the development and review of their individual care plans. Head of Discipline governance questionnaires were completed by the registered proprietor, clinical director, director of services, Clinical Psychologist and Dietician. Collectively they all identified similar operational risks such as: clients ‘using online sources for diagnosis and treatment’ pre-admission, ‘Improving the communication skills of residents who have autism spectrum disorder and adapting the programme to their specific needs’, and ‘Sourcing the most relevant and evidenced based Eating Disorder training programmes.’ The approved centre has had to access training in other jurisdictions like the United Kingdom, United States and Australia which can pose time-zone challenges, in the continued pursuit of providing evidenced based quality care interventions for clients, to improve recovery and treatment outcomes.
Therapeutic Services and Programmes
The therapeutic services and programmes provided by the approved centre were appropriate, met the assessed needs of the residents as documented in their individual care plans and were directed towards restoring and maintaining optimal levels of physical and psychosocial functioning of residents. Residents had access to dietetics, occupational therapy, social work and family therapy, psychotherapy
and clinical psychology on an individual basis (one-to-one) as required. Where a resident required a therapeutic service or programme that was not provided internally, the approved centre arranged for the service to be provided by an approved, qualified health professional in an appropriate location. The provision of speech and language therapy and physiotherapy could also be provided if required privately.
Therapy programmes available to residents included nurse led therapeutic groups, psychology led therapeutic groups, peer support worker lead groups, and dietetic led groups. The approved centre was well resourced regarding therapeutic facilities. It had sufficient designated therapeutic spaces including a comfort or quiet room, an activities room, a family therapy room and multiple other rooms which could
be used for therapy.
Nursing staff offered a decider skills group weekly. Dieticians offered a Dietetic Education group weekly,and a breakfast club group every two weeks. The peer support worker offered three groups per week; a recovery tools group, a goal setting group and weekend planning group. Psychology offered two groups per week; Dialectical Behaviour Therapy (DBT) and Cognitive Remediation Therapy. The Social
Worker/Family Therapist (part-time) offered one to one sessions and weekly Individual family therapy with the client and their family. The Psychotherapist and Occupational Therapist also offered one to one sessions.
4.1 Compliant areas on this inspection
Please refer to Appendix 1 for further guidance for compliance in relation to these regulations, rules and
codes of practice.
Regulation/Rule/Act/Code 2025
Regulation 04: Identification of Residents……………………………………………………..Compliant
Regulation 05: Food and Nutrition………………………………………………………………..Compliant
Regulation 06: Food Safety…………………………………………………………………………..Compliant
Regulation 07: Clothing………………………………………………………………………………..Compliant
Regulation 08: Residents’ Personal Property and Possessions………………………….Compliant
Regulation 09: Recreational Activities……………………………………………………………Compliant
Regulation 10: Religion…………………………………………………………………………………Compliant
Regulation 11: Visits……………………………………………………………………………………..Compliant
Regulation 12: Communication……………………………………………………………………..Compliant
Regulation 13: Searches………………………………………………………………………………..Compliant
Regulation 14: Care of the Dying……………………………………………………………………Compliant
Regulation 15: Individual Care Plan……………………………………………………………….Compliant
Regulation 16: Therapeutic Services and Programmes……………………………………..Compliant
Regulation 18: Transfer of Residents………………………………………………………………Compliant
Regulation 19: General Health……………………………………………………………………….Compliant
Regulation 20: Provision of Information to Residents………………………………………Compliant
Regulation 21: Privacy……………………………………………………………………………………Compliant
Regulation 22: Premises…………………………………………………………………………………Compliant
Regulation 23: Ordering, Prescribing, Storing and Administration of Medicines….Compliant
Regulation 24: Health and Safety…………………………………………………………………….Compliant
Regulation 26: Staffing…………………………………………………………………………………..Compliant
Regulation 27: Maintenance of Records…………………………………………………………..Compliant
Regulation 28: Register of Residents……………………………………………………………….Compliant
Regulation 29: Operating Policies and Procedures……………………………………………Compliant
Regulation 31: Complaints Procedures…………………………………………………………….Compliant
Regulation 32: Risk Management Procedures………………………………………………….Compliant
Regulation 33: Insurance……………………………………………………………………………….Compliant
Regulation 34: Certificate of Registration………………………………………………………..Compliant
Code of Practice: Admission, Transfer and Discharge……………………………………….Compliant
4.2 Non-compliant areas on this inspection No areas were non-compliant on this inspection.
4.0 Compliance
4.3 Areas that were not applicable on this inspection Regulation/Rule/Code of Practice Details Regulation 17: Children’s Education As no child with educational needs had been admitted to the approved centre since the last inspection, this regulation was not applicable. Regulation 25: Use of Closed Circuit Television As CCTV was not in use in the approved centre, this regulation was not applicable.
Regulation 30: Mental Health Tribunals As no Mental Health Tribunals had been held in the approved centre since the last inspection, this regulation was not applicable. Rules Governing the Use of Electro-Convulsive Therapy As the approved centre did not provide an ECT service, this rule was not applicable. Rules Governing the Use of Seclusion As the approved centre did not use seclusion, this rule was not applicable. Rules Governing the Use of Mechanical Means of Bodily Restraint As the approved centre did not use mechanical means of bodily restraint, this rule was not applicable. Part 4 of the Mental Health Act 2001: Consent to Treatment As there were no patients in the approved centre for more than three months and in continuous receipt of medication at the time of inspection, Part 4 of the Mental Health Act 2001: Consent to Treatment was not applicable. Code of Practice on the Use of Physical Restraint in Approved Centres As the approved centre did not use physical restraint, this code of practice was not applicable. Code of Practice Relating to Admission of Children Under the Mental Health Act 2001 As no children had been admitted to the approved centre since the last inspection, this code of practice was not applicable. Code of Practice on the Use of Electro-Convulsive Therapy for Voluntary Patients As the approved centre did not provide an ECT service, this code of practice was not applicable.
5.1 Service-user feedback
The Inspector gave emphasis to the importance of hearing the service users’ experience of the approved centre. To that end, the inspection team engage with residents in a number of different ways: • Posters were displayed inviting the residents to talk to the inspection team. • Residents were invited to complete a service user experience questionnaire, which were reviewed by the inspection team in confidence. This was anonymous and used to inform the inspection process. • Set times and a private room were available to talk to residents. • The Peer Advocacy in Mental Health representative was contacted to obtain residents’ feedback about the approved centre. With the residents’ permission, their experience was fed back to the senior management team. The information was used to give a general picture of residents’ experience of the approved centre as outlined below.
Three clients took the opportunity to speak with the inspection team, there comments included
• My privacy is 100% respected by staff. They always knock before entering my room
• On admission staff brought me around and I felt settled in very quickly
• The days go so quick as there is a lot of activities. Groups are beneficial and goal setting is helpful.
• I meet my doctor and the team every week and my keyworker is very helpful and supportive
• I feel staff treat me with a lot of respect
• Being here, I now believe in recovery more Six clients completed the ‘Your Experience’ questionnaires, their responses included:
• Staff always give information about my diagnosis, care and treatment
• I am always involved in setting goals for my individual care plan
• There are enough talking therapies
• I am always able to discuss worries or concerns with a member of staff as soon as I need to.
• I truly believe the NEDRC saved my life
• The Staff always support me in every possible way
• The NEDRC has rebuilt my trust in mental health services in Ireland.
All six questionnaire respondents rated their care experience as 10 out of 10.
5.2 Advocacy
The approved centre had an advocacy service. The inspectors did not receive a report from the Peer Advocacy in Mental Health representative.
5.0 Service-user Experience
Compliance
Regulation 4: Identification of Residents
The registered proprietor shall make arrangements to ensure that each resident is readily identifiable by staff when receiving medication, health care or other services.
Regulation 5: Food and Nutrition
(1) The registered proprietor shall ensure that residents have access to a safe supply of fresh drinking water.
(2) The registered proprietor shall ensure that residents are provided with food and drink in quantities adequate for their needs, which is properly prepared, wholesome and nutritious, involves an element of choice and takes account of any special dietary requirements and is consistent with each resident’s individual care plan.
Regulation 6: Food Safety
(1) The registered proprietor shall ensure:
(a) the provision of suitable and sufficient catering equipment, crockery and cutlery
(b) the provision of proper facilities for the refrigeration, storage, preparation, cooking and serving of food, and
(c) that a high standard of hygiene is maintained in relation to the storage, preparation and disposal of food and related refuse.
(2) This regulation is without prejudice to:
(a) the provisions of the Health Act 1947 and any regulations made thereunder in respect of food standards (including labelling) and safety;
(b) any regulations made pursuant to the European Communities Act 1972 in respect of food standards (including labelling) and safety; and
(c) the Food Safety Authority of Ireland Act 1998.
Regulation 7: Clothing
The registered proprietor shall ensure that:
(1) when a resident does not have an adequate supply of their own clothing the resident is provided with an adequate supply of appropriate individualised clothing with due regard to his or her dignity and bodily integrity at all times;
(2) night clothes are not worn by residents during the day, unless specified in a resident’s individual care plan.
Regulation 8: Residents’ Personal Property and Possessions
(1) For the purpose of this regulation “personal property and possessions” means the belongings and personal effects that a resident brings into an approved centre; items purchased by or on behalf of a resident during his or her stay in an approved centre; and items and monies received by the resident during his or her stay in an approved centre.
(2) The registered proprietor shall ensure that the approved centre has written operational policies and procedures relating to residents’ personal property and possessions.
(3) The registered proprietor shall ensure that a record is maintained of each resident’s personal property and possessions and is available to the resident in accordance with the approved centre’s written policy.
(4) The registered proprietor shall ensure that records relating to a resident’s personal property and possessions are kept separately from the resident’s individual care plan.
(5) The registered proprietor shall ensure that each resident retains control of his or her personal property and possessions except under circumstances where this poses a danger to the resident or others as indicated by the resident’s individual care plan.
(6) The registered proprietor shall ensure that provision is made for the safe-keeping of all personal property and possessions.
Regulation 9: Recreational Activities
The registered proprietor shall ensure that an approved centre, insofar as is practicable, provides access for residents to appropriate recreational activities.
Regulation 10: Religion
The registered proprietor shall ensure that residents are facilitated, insofar as is reasonably practicable, in the practice of their religion.
Regulation 11: Visits
(1) The registered proprietor shall ensure that appropriate arrangements are made for residents to receive visitors having regard to the nature and purpose of the visit and the needs of the resident.
(2) The registered proprietor shall ensure that reasonable times are identified during which a resident may receive visits.
(3) The registered proprietor shall take all reasonable steps to ensure the safety of residents and visitors.
(4) The registered proprietor shall ensure that the freedom of a resident to receive visits and the privacy of a resident during visits are respected, in so far as is practicable, unless indicated otherwise in the resident’s individual care plan.
(5) The registered proprietor shall ensure that appropriate arrangements and facilities are in place for children visiting a resident.
(6) The registered proprietor shall ensure that an approved centre has written operational policies and procedures for visits.
Regulation 12: Communication
(1) Subject to subsections (2) and (3), the registered proprietor and the clinical director shall ensure that the resident is free to communicate at all times, having due regard to his or her wellbeing, safety and health.
(2) The clinical director, or a senior member of staff designated by the clinical director, may only examine incoming and outgoing communication if there is reasonable cause to believe that the communication may result in harm to the resident or to others.
(3) The registered proprietor shall ensure that the approved centre has written operational policies and procedures on communication.
(4) For the purposes of this regulation “communication” means the use of mail, fax, email, internet, telephone or any device for the purposes of sending or receiving messages or goods.
Regulation 13: Searches
(1) The registered proprietor shall ensure that the approved centre has written operational policies and procedures on the searching of a resident, his or her belongings and the environment in which he or she is accommodated.
(2) The registered proprietor shall ensure that searches are only carried out for the purpose of creating and maintaining a safe and therapeutic environment for the residents and staff of the approved centre.
(3) The registered proprietor shall ensure that the approved centre has written operational policies and procedures for carrying out searches with the consent of a resident and carrying out searches in the absence of consent.
(4) Without prejudice to subsection (3) the registered proprietor shall ensure that the consent of the resident is always sought.
(5) The registered proprietor shall ensure that residents and staff are aware of the policy and procedures on searching.
(6) The registered proprietor shall ensure that there is a minimum of two appropriately qualified staff in attendance at all times when searches are being conducted.
(7) The registered proprietor shall ensure that all searches are undertaken with due regard to the resident’s dignity, privacy and gender.
(8) The registered proprietor shall ensure that the resident being searched is informed of what is happening and why.
(9) The registered proprietor shall ensure that a written record of every search is made, which includes the reason for the search.
(10) The registered proprietor shall ensure that the approved centre has written operational policies and procedures in relation to the finding of illicit substances.
Regulation 14: Care of the Dying
(1) The registered proprietor shall ensure that the approved centre has written operational policies and protocols for care of residents who are dying.
(2) The registered proprietor shall ensure that when a resident is dying:
(a) appropriate care and comfort are given to a resident to address his or her physical, emotional, psychological and spiritual needs;
(b) in so far as practicable, his or her religious and cultural practices are respected;
(c) the resident’s death is handled with dignity and propriety, and;
(d) in so far as is practicable, the needs of the resident’s family, next-of-kin and friends are accommodated.
(3) The registered proprietor shall ensure that when the sudden death of a resident occurs:
(a) in so far as practicable, his or her religious and cultural practices are respected;
(b) the resident’s death is handled with dignity and propriety, and;
(c) in so far as is practicable, the needs of the resident’s family, next-of-kin and friends are accommodated.
(4) The registered proprietor shall ensure that the Mental Health Commission is notified in writing of the death of any resident of the approved centre, as soon as is practicable and in any event, no later than within 48 hours of the death occurring.
(5) This Regulation is without prejudice to the provisions of the Coroners Act 1962 and the Coroners (Amendment) Act 2005.
Regulation 15: Individual Care Plan
The registered proprietor shall ensure that each resident has an individual care plan. [Definition of an individual care plan:“… a documented set of goals developed, regularly reviewed and updated by the resident’s multi-disciplinary team, so far as practicable in consultation with each resident. The individual care plan shall specify the treatment and care required which shall be in accordance with best practice, shall identify necessary resources and shall specify appropriate goals for the resident. For a resident who is a child, his or her individual care plan shall include education requirements. The individual care plan shall be recorded in the one composite set of documentation”.]
Regulation 16: Therapeutic Services and Programmes
(1) The registered proprietor shall ensure that each resident has access to an appropriate range of therapeutic services and programmes in accordance with his or her individual care plan.
(2) The registered proprietor shall ensure that programmes and services provided shall be directed towards restoring and maintaining optimal levels of physical and psychosocial functioning of a resident.
Regulation 17: Children’s Education
The registered proprietor shall ensure that each resident who is a child is provided with appropriate educational services in accordance with his or her needs and age as indicated by his or her individual care plan.
Regulation 18: Transfer of Residents
(1) When a resident is transferred from an approved centre for treatment to another approved centre, hospital or other place, the registered proprietor of the approved centre from which the resident is being transferred shall ensure that all relevant information about the resident is provided to the receiving approved centre, hospital or other place.
(2) The registered proprietor shall ensure that the approved centre has a written policy and procedures on the transfer of residents.
Regulation 19: General Health
(1) The registered proprietor shall ensure that:
(a) adequate arrangements are in place for access by residents to general health services and for their referral to other health services as required;
(b) each resident’s general health needs are assessed regularly as indicated by his or her individual care plan and in any event not less than every six months, and;
(c) each resident has access to national screening programmes where available and applicable to the resident.
(2) The registered proprietor shall ensure that the approved centre has written operational policies and procedures for responding to medical emergencies.
Regulation 20: Provision of Information to Residents
(1) Without prejudice to any provisions in the Act the registered proprietor shall ensure that the following information is provided to each resident in an understandable form and language:
(a) details of the resident’s multi-disciplinary team;
(b) housekeeping practices, including arrangements for personal property, mealtimes, visiting times and visiting arrangements;
(c) verbal and written information on the resident’s diagnosis and suitable written information relevant to the resident’s diagnosis unless in the resident’s psychiatrist’s view the provision of such information might be prejudicial to the resident’s physical or mental health, well-being or emotional condition;
(d) details of relevant advocacy and voluntary agencies;
(e) information on indications for use of all medications to be administered to the resident, including any possible side-effects.
(2) The registered proprietor shall ensure that an approved centre has written operational policies and procedures for the provision of information to residents.
Regulation 21: Privacy
The registered proprietor shall ensure that the resident’s privacy and dignity is appropriately respected at all times.
Regulation 22: Premises
(1) The registered proprietor shall ensure that:
(a) premises are clean and maintained in good structural and decorative condition;
(b) premises are adequately lit, heated and ventilated;
(c) a programme of routine maintenance and renewal of the fabric and decoration of the premises is developed and implemented and records of such programme are maintained.
(2) The registered proprietor shall ensure that an approved centre has adequate and suitable furnishings having regard to the number and mix of residents in the approved centre.
(3) The registered proprietor shall ensure that the condition of the physical structure and the overall approved centre environment is developed and maintained with due regard to the specific needs of residents and patients and the safety and well-being of residents, staff and visitors.
(4) Any premises in which the care and treatment of persons with a mental disorder or mental illness is begun after the commencement of these regulations shall be designed and developed or redeveloped specifically and solely for this purpose in so far as it practicable and in accordance with best contemporary practice.
(5) Any approved centre in which the care and treatment of persons with a mental disorder or mental illness is begun after the commencement of these regulations shall ensure that the buildings are, as far as practicable, accessible to persons with disabilities.
(6) This regulation is without prejudice to the provisions of the Building Control Act 1990, the Building Regulations 1997 and 2001, Part M of the Building Regulations 1997, the Disability Act 2005 and the Planning and Development Act 2000. Regulation 23: Ordering, Prescribing, Storing and Administration of Medicines
(1) The registered proprietor shall ensure that an approved centre has appropriate and suitable practices and written operational policies relating to the ordering, prescribing, storing and administration of medicines to residents.
(2) This Regulation is without prejudice to the Irish Medicines Board Act 1995 (as amended), the Misuse of Drugs Acts 1977, 1984 and 1993, the Misuse of Drugs Regulations 1998 (S.I. No. 338 of 1998) and 1993 (S.I. No. 338 of 1993 and S.I. No. 342 of 1993) and S.I. No. 540 of 2003, Medicinal Products (Prescription and control of Supply) Regulations 2003 (as amended).
Regulation 24: Health and Safety
(1) The registered proprietor shall ensure that an approved centre has written operational policies and procedures relating to the health and safety of residents, staff and visitors.
(2) This regulation is without prejudice to the provisions of Health and Safety Act 1989, the Health and Safety at Work Act 2005 and any regulations made thereunder.
Regulation 25: Use of Closed Circuit Television
(1) The registered proprietor shall ensure that in the event of the use of closed circuit television or other such monitoring device for resident observation the following conditions will apply:
(a) it shall be used solely for the purposes of observing a resident by a health professional who is responsible for the welfare of that resident, and solely for the purposes of ensuring the health and welfare of that resident;
(b) it shall be clearly labelled and be evident;
(c) the approved centre shall have clear written policy and protocols articulating its function, in relation to the observation of a resident;
(d) it shall be incapable of recording or storing a resident’s image on a tape, disc, hard drive, or in any other form and be incapable of transmitting images other than to the monitoring station being viewed by the health professional responsible for the health and welfare of the resident;
(e) it must not be used if a resident starts to act in a way which compromises his or her dignity.
(2) The registered proprietor shall ensure that the existence and usage of closed circuit television or other monitoring device is disclosed to the resident and/or his or her representative.
(3) The registered proprietor shall ensure that existence and usage of closed circuit television or other monitoring device is disclosed to the Inspector of Mental Health Services and/or Mental Health Commission during the inspection of the approved centre or at any time on request.
Regulation 26: Staffing
(1) The registered proprietor shall ensure that the approved centre has written policies and procedures relating to the recruitment, selection and vetting of staff.
(2) The registered proprietor shall ensure that the numbers of staff and skill mix of staff are appropriate to the assessed needs of residents, the size and layout of the approved centre.
(3) The registered proprietor shall ensure that there is an appropriately qualified staff member on duty and in charge of the approved centre at all times and a record thereof maintained in the approved centre.
(4) The registered proprietor shall ensure that staff have access to education and training to enable them to provide care and treatment in accordance with best contemporary practice.
(5) The registered proprietor shall ensure that all staff members are made aware of the provisions of the Act and all regulations and rules made thereunder, commensurate with their role.
(6) The registered proprietor shall ensure that a copy of the Act and any regulations and rules made thereunder are to be made available to all staff in the approved centre.
Regulation 27: Maintenance of Records
(1) The registered proprietor shall ensure that records and reports shall be maintained in a manner so as to ensure completeness, accuracy and ease of retrieval. All records shall be kept up-to-date and in good order in a safe and secure place.
(2) The registered proprietor shall ensure that the approved centre has written policies and procedures relating to the creation of, access to, retention of and destruction of records.
(3) The registered proprietor shall ensure that all documentation of inspections relating to food safety, health and safety and fire inspections is maintained in the approved centre.
(4) This Regulation is without prejudice to the provisions of the Data Protection Acts 1988 and 2003 and the Freedom of Information Acts 1997 and 2003.
Note: Actual assessment of food safety, health and safety and fire risk records is outside the scope of this Regulation, which refers only to maintenance of records pertaining to these areas.
Regulation 28: Register of Residents
(1) The registered proprietor shall ensure that an up-to-date register shall be established and maintained in relation to every resident in an approved centre in a format determined by the Commission and shall make available such information to the Commission as and when requested by the Commission.
(2) The registered proprietor shall ensure that the register includes the information specified in Schedule 1 to these Regulations.
Regulation 29: Operating Policies and Procedures
The registered proprietor shall ensure that all written operational policies and procedures of an approved centre are reviewed on the recommendation of the Inspector or the Commission and at least every 3 years having due regard to any recommendations made by the Inspector or the Commission.
Regulation 30: Mental Health Tribunals
(1) The registered proprietor shall ensure that an approved centre will co-operate fully with Mental Health Tribunals.
(2) In circumstances where a patient’s condition is such that he or she requires assistance from staff of the approved centre to attend, or during, a sitting of a mental health tribunal of which he or she is the subject, the registered proprietor shall ensure that appropriate assistance is provided by the staff of the approved centre.
Regulation 31: Complaints Procedures
(1) The registered proprietor shall ensure that an approved centre has written operational policies and procedures relating to the making, handling and investigating complaints from any person about any aspects of service, care and treatment provided in, or on behalf of an approved centre.
(2) The registered proprietor shall ensure that each resident is made aware of the complaints procedure as soon as is practicable after admission.
(3) The registered proprietor shall ensure that the complaints procedure is displayed in a prominent position in the approved centre.
(4) The registered proprietor shall ensure that a nominated person is available in an approved centre to deal with all complaints.
(5) The registered proprietor shall ensure that all complaints are investigated promptly.
(6) The registered proprietor shall ensure that the nominated person maintains a record of all complaints relating to the approved centre.
(7) The registered proprietor shall ensure that all complaints and the results of any investigations into the matters complained and any actions taken on foot of a complaint are fully and properly recorded and that such records shall be in addition to and distinct from a resident’s individual care plan.
(8) The registered proprietor shall ensure that any resident who has made a complaint is not adversely affected by reason of the complaint having been made.
(9) This Regulation is without prejudice to Part 9 of the Health Act 2004 and any regulations made thereunder.
Regulation 32: Risk Management Procedures
(1) The registered proprietor shall ensure that an approved centre has a comprehensive written risk management policy in place and that it is implemented throughout the approved centre.
(2) The registered proprietor shall ensure that risk management policy covers, but is not limited to, the following:
(a) The identification and assessment of risks throughout the approved centre;
(b) The precautions in place to control the risks identified;
(c) The precautions in place to control the following specified risks:
(i) resident absent without leave,
(ii) suicide and self harm,
(iii) assault,
(iv) accidental injury to residents or staff;
(d) Arrangements for the identification, recording, investigation and learning from serious or untoward incidents or adverse events involving residents;
(e) Arrangements for responding to emergencies;
(f) Arrangements for the protection of children and vulnerable adults from abuse.
(3) The registered proprietor shall ensure that an approved centre shall maintain a record of all incidents and notify the Mental Health Commission of incidents occurring in the approved centre with due regard to any relevant codes of practice issued by the Mental Health Commission from time to time which have been notified to the approved centre.
Regulation 33: Insurance
The registered proprietor of an approved centre shall ensure that the unit is adequately insured against accidents or injury to residents.
Regulation 34: Certificate of Registration
The registered proprietor shall ensure that the approved centre’s current certificate of registration issued pursuant to Section 64(3)(c) of the Act is displayed in a prominent position in the approved centre.
RULES UNDER MENTAL HEALTH ACT 2001 SECTION 52(d)
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