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Report on an unannounced inspection of the Kensington Centre Mental Health Inpatient Unit, Timaru, under the Crimes of Torture Act 1989

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Executive Summary


In 2007, the Ombudsmen were designated one of the National Preventive Mechanisms (NPMs) under the Crimes of Torture Act 1989 (COTA), with responsibility for examining and monitoring the conditions and treatment of people[1] detained in secure units within New Zealand hospitals.

Between 7 and 9 October 2019, Inspectors[2]— whom I have authorised to carry out visits to places of detention under COTA on my behalf — made an unannounced inspection of the Kensington Inpatient Mental Health Unit (the Unit), Timaru.

Summary of findings

My findings are:

  • There was no evidence that any clients had been subject to torture or other cruel, inhuman or degrading treatment or punishment.
  • Clients felt safe on the Unit.
  • Files contained all the necessary legal paperwork to detain and treat clients on the Unit.
  • Seclusion area upgrades had resulted in an improved environment for clients.
  • Unit leave for clients was encouraged and well utilised.
  • Whānau felt included in clients’ care.
  • The complaints process was visible on the Unit.
  • Accommodation was clean and tidy. Clients had their own bedrooms, which they could lock from the inside.
  • The Unit’s kitchen and comfort room[3] were open for clients’ use through the day.
  • Food and drinks were available to clients at any time.
  • Support for whānau was comprehensive.
  • Activities for clients were available on the Unit. Staff adapted activities to suit the client group.
  • Leadership on the Unit was visible and staff felt supported.

The issues that needed addressing are:

  • External window shutters in the seclusion rooms were not operational.
  • The low stimulus area (LSA) courtyard lacked privacy and could be viewed by members of the public.
  • The high care room had no natural light.
  • Seclusion and restraint policies were out of date.
  • Review and recording processes for restraint incidents were not robust.
  • Safe Practice Effective Communication (SPEC) training attendance was not tracked or recorded.
  • The District Inspector’s contact details were not displayed on the Unit.
  • Clients were not invited to multi-disciplinary team (MDT) meetings.
  • Clients were not provided with a copy of their discharge summary letter sent to the client’s GP.
  • There was not a sufficient gender balance among staff.
  • There was little evidence in Māori clients’ care plans of Māori models of care being delivered.


I recommend that:

  1. All seclusion room window shutters are operational.
  2. Privacy screening is installed in the LSA yard.
  3. All client bedrooms have natural light.
  4. The seclusion and restraint policies are updated.
  5. A robust system for accurately reviewing and recording restraint incidents is implemented.
  6. SPEC training attendance for staff is comprehensively monitored and recorded.
  7. The District Inspector’s contact details are displayed on the Unit.
  8. Clients are invited to attend their MDT meetings.
  9. Clients are provided with a copy of their GP discharge summary letter.
  10. The DHB takes a planned approach to recruitment and developing a culturally competent health workforce.

Follow up inspections will be made at future dates to monitor implementation of my recommendations.

Feedback meeting

On completion of the inspection, my Inspectors met with a representative of the Unit’s leadership team, to outline their initial observations.

Further comment

A provisional report was forwarded to the South Canterbury District Health Board (the DHB) for comment as to fact, finding or omission prior to finalisation and distribution. I have carefully considered the comments made by the DHB before finalising my report.  




[1]     The term client is used to describe people receiving treatment in Kensington Inpatient Mental Health Unit, as this is the term the Unit uses to describe individuals in their care.

[2]     When the term Inspectors is used, this refers to the inspection team comprising of the Manager, OPCAT and a Senior Inspector.

[3]     A dedicated room for relaxation and quiet time.

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