Isolated and institutionalised: the reality of life for many mentally ill patients in community care

Cypress Lodge, a community residence for people with mental health problems, is not exceptional. However conditions there help to explain why care in the community isn't always what it seems.

The 17-bed unit in rural Co Sligo was opened more than 20 years ago by the Health Service Executive in what was regarded as a progressive move to accommodate pa- tients being discharged from an outdated mental hospital.

Inspectors who visited the centre unannounced last year found it was grubby and malodorous in places and isolated from the wider community, while there was evidence that patients’ money was being used without receipts or adequate records being kept.

“Many of the residents had been in the house since it opened 22 years ago. Some residents attended therapeutic activities elsewhere, but for those that did not, there were few activities of any kind provided,” it found.

Services blueprint

In 1984, a blueprint for modernising our mental health services recommended the development of high-support hostels like these for patients who could be relocated from outdated psychiatric hospitals.

Today there are more than 100 of these 24-hour supervised residences run by the HSE.

However, a report from Dr Susan Finnerty, assistant inspector of mental health services, has found many residences are little more than "mini-institutions" in the community. Many are isolated in rural areas, away from the wider community or in the grounds of a psychiatric hospital from which patients were discharged.

“It is difficult to see these residences as anything but wards in the community with all the disadvantages of institutional care,” Dr Finnerty wrote.

While the HSE estimates there are 102 “high-support residences”, inspectors estimate there are 115. That means there are in the region of 1,500 residents – although no one knows for sure.

Under the current mental health policy, A Vision for Change, it is recommended that these residences should have a maximum of 10 places to foster a "non-institutional environment". Almost three- quarters of those inspected over recent years have more than the maximum recommended number. In fact, some have in excess of 25 beds.

Another alarming finding relates to financial transparency. Under health regulations which came into effect in 2005, charges may be imposed on people in long-stay public care. Rents though varied dramatically and did not appear to be dependent on location, size or staffing of the residences, with fees ranging between €50 a week to more than €150 a week.

Inspectors found some encouraging evidence, though. Multidisciplinary individual care plans were implemented in two-thirds of residences, in some centres staff had a good knowledge of residents’ needs and preferences and interaction between staff and residents was “warm and lively”.

There were also gaps though: only half had access to psychology services, while just 58 per cent had access to occupational therapy.