Serious shortcomings at a residential centre for people with disabilities in Co Kerry were identified by inspectors from the State's health services watchdog during an unannounced inspection.
The centre in Rathmore operated by Kerry Parents and Friends Association comprises of three separate houses that are close to each other in the rural village.
Throughout the two-day visit, last April inspectors met 14 of the 15 residents.
There was a good atmosphere in each house and inspectors saw there was equitable engagement between residents and staff.
However, inspectors found that governance arrangments were not ensuring that the care and support provided for residents was always safe.
Shortcomings were identified in risk management, fire precautions, individual assessment, personal plans and positive behavioural support.
While the provider had made changes to strengthen governance and staffing levels the inspectors were not assured enough had been done.
In particular, there were inconsistent and at times concerning and inadequate arrangments for the management and review of incidents involving residents.
After identifying one serious incident the inspector reviewed 50 accidents and incidents and found that the way four were recorded meant that management was not alerted about their occurrence.
Another unannounced inspection of Damien House in Clonmel, Co Tipperary, operated by the HSE found that a “significant safeguarding matter” had not been reported to Hiqa's chief inspector.
Damien House provides full-time long term care to 12 adults and comprises of three houses and an apartment.
The inspection was to follow-up on action taken by the health authority since a previous inspection in November 2018 that identified a lack of adequate management and oversight.
The overall state of repair of the premises and decor remained poor in two of the houses, with unsuitable bathroom facilities.
The environment in one house was described as “stark and un-homely”, which was not entirely due to the need for a secure environment.
Another HSE-run centre – Beechgrove/Acorns that consists of two bungalows on the outskirts of a large town in Co Westmeath, had no person in charge in place on the day of the inspection.
There were eight residents in the centre when inspectors made an unannounced visit in March and staff in the centre were not aware of who was in charge.
Not all resident's rights were upheld and not all steps agreed following a previous inspection in September 2018 had been taken.
There was insufficient evidence that residents were supported to have a meaningful day and the premises were not maintained to an acceptable standard.
Following the inspection, a newly appointed person in charge was appointed by the HSE.
The inspection reports on residential homes for people with disabilities were among 29 published by the Hiqa on Wednesday.
Inspectors found a good level of compliance with the regulations and standards in 23 inspections, including in centres operated by the HSE.
Inspections of 15 centres operated by the HSE found that 12 were complying with regulations and standards but noncompliance was identified in three centres.
A Hiqa report into a residential home for people with disabilities found money was missing from the account of one of its residents.
It was one of 29 reports from a number of similar homes carried out by the health watchdog in the last few months, with most found to be compliant.
The inspection at Damien House in Tipperary noted the HSE's auditors had been aware of cash missing from the resident's account for 'some time'.
However there was no evidence of an investigation or money being transferred back into the account.
The inspection also found the facility had a bathroom which was unsuitable for use, with an alternative still had broken shower doors from a previous inspection.
It was noted that overall there was a lack of direction of care review strategies and risk and incident management.
However a separate inspection at the Beechgrove/Acorns home in Westmeath found that it was not adequately managed or governed, with staff unaware of who was in charge on the day.
It also noted that the premises were not maintained to an acceptable standard, while there was no evidence of staff meetings to address a previous inspection report at the home.
Overall, 23 of the 29 centres inspected were found to have a good level of compliance.
- Additional reporting Digital Desk