The standard of care at the Dhulwa Mental Health Unit is well below expectations, patient and treatment procedures are unclear and dysfunction between staff has contributed to a toxic work culture.
An inquiry into the secure mental health unit has delivered a scathing report into governance at the facility, finding "poor standards of care delivery".
The inquiry found there was dysfunction among staff with unsupportive leadership, poorly managed change, fractured workforce relationships, workforce cliques and poor communication.
It found the model of care at the Symonston facility was unclear and uncertainty about security arrangements had contributed to safety concerns.
Staff reported to the inquiry there was a lack of clarity regarding the "consumer profile" for those admitted to Dhulwa.
"This in turn has created confusion about treatment practice, clinical care delivery and WHS practices to support rehabilitation and treatment," the report said.
"The lack of clarity regarding the services Dhulwa offers and to whom, and how care is to be delivered, creates uncertainty about therapeutic and recovery-oriented practice."
The ACT Human Rights commission has previously been critical of patients not charged or convicted or crimes being transferred to Dhulwa.
The report said clarity needed to be provided about what patients could be admitted to Dhulwa. It said without a clear model of care its policies and procedures were compromised.
Staff at Dhulwa have been forced to work with policies and procedures inappropriate for the needs of patients at the unit.
The review has recommended staffing at the facility should be restructured to provide clear leadership and an "appropriate skills-mix" on every shift.
"The submissions, interviews, meetings, site visits and closed-circuit television footage reviewed by the inquiry show that the standard of care at times provided to consumers at Dhulwa is well below that expected of the unit and contemporary practice," the report said.
The report said findings from other reviews of Dhulwa, including those about certain incidents, had made similar recommendations as the inquiry but no "significant or lasting" improvements had been made.
A majority of staff, in submissions, raised concerns about a toxic work culture. The report said there was distrust between staff and management and there was strong resistance to efforts from managers to enact change.
It said this had resulted in "poorly implemented change practices and over-involvement of the nursing industrial body in day-to-day management of Dhulwa".
The report also said uncertainty about roles and responsibilities at Dhulwa was "permeating all areas of its functioning". There was also a lack of understanding about a clear point of leadership and staff perceived management directions as bullying.
It was recommended a designated clinical leader be appointed to every shift.
Cliques within Dhulwa had emerged and this had contributed to "poor standards of care delivery".
There was also a poor safety culture at Dhulwa as there was a "reactive safety culture" which was driven by a misuse of positions, resulting in bullying and harassment.
There were 25 recommendations made in the review, including the government appoint independent oversight of the implementation of the recommendations.
ACT Minister for Mental Health Emma Davidson said cabinet would consider the recommendations but confirmed the government would ensure there was independent oversight of the implementation of recommendations.
"There's a range of recommendations in this report that could actually be implemented very quickly because they relate directly to how we go about providing care in Dhulwa and how we support staff and those are things we can start working on straight away," Ms Davidson said.
Australian Nursing and Midwifery Federation ACT branch secretary Matthew Daniel said the union was likely to support all 25 recommendations.
"A lot of the issues that our members have raised over a substantial period of time are addressed by the inquiry and we're keen to see the government's response," he said.
The inquiry was led by former Fair Work commissioner Barbara Deegan. There were 68 submissions received as part of the inquiry.
The inquiry was prompted after the Australian Nursing and Midwifery Federation raised concerns about assaults against nurses at the facility. Mr Daniel claimed there were more than 100 physical assaults on nurses over a six-month period.
The report found many of the injuries were as a result of poor work practices but said reports about the number of assaults were inflated.
"While a perception has been created that Dhulwa is a dangerous place to work, only a small minority of the incident reports that were reviewed by the inquiry resulted in the person needing time off work and fewer resulted in serious injury," the report said.
"Of the incidents that resulted in injury few were the direct result of aggression by consumers but appeared to be the result of poorly managed or implemented clinical or work practices."
The inquiry said since Dhulwa had opened there had been 403 incident reports submitted, however, there were multiple reports related to the same incident.
Fewer than 15 had resulted in an injury that required more than one day off work.
"The inflated claims and exaggerated reporting of occupational violence at Dhulwa has damaged its reputation and had far-reaching consequences for both consumers and staff," the report said.
