Hiqa found serious shortcomings at three centres
It accommodates 80 people with intellectual disabilities, many with behavioural challenges, aged from their 30s to their 80s. The HSE operates the services and said that 17 people have moved to community settings this year in accordance with the the policy to move away from large institutional settings.
But the Hiqa reports reveal details of conditions and treatment of residents observed and reported to them during their visits.
An August report on the Oakvale centre found some residents were physically restrained to take bloods, and several residents were chemically restrained, but details were not submitted in quarterly notifications.
Some residents were restrained for excessively long periods because of inadequate staff and poor training on dealing with challenging behaviour.
“As a result of poor governance and oversight of the centres, management had failed to identify... issues for themselves, failed to address them effectively and failed to ensure a safe and good-quality service for residents,” Hiqa reported in relation to one centre.
There were 17 men and women in a dormitory at St Raphael’s Residential Centre, located in a 19th-century building, where inspectors found insufficient screening between beds and high noise levels.
Some residents in the unit with no inhibitions walked around naked, and staff and external suppliers used it as a shortcut to other parts of the centre.
A resident in one centre with a significant wound had no plan of care to inform appropriate dressing or how often to review the wound. There was no daily progress note placed for a resident on antibiotic treatment and wound care to inform staff of the resident’s status, progress or response to treatment.
The end of a resident’s bed was wrapped in foam to protect him from hurting his legs, but this was unsuitable as the partially-wrapped bed end was covered in cling film and secured with twine. This was not assessed for health and safety.
Sash windows were not risk assessed to ensure safety of residents. One resident was seen standing on a chair, opening the sash window and leaning out for fresh air.
Residents had limited access to physiotherapy or psychological services, and a number were at risk of choking but there was no evidence that recommended referrals to speech and language therapist had been made.
Most of these findings have been dealt with to varying degrees by the HSE since being highlighted by Hiqa, but one of the later reports found that moving residents to facilitate refurbishment work was done without consultation. The emergency call bell in a refurbished dormitory was so high over a resident’s bed, it would be difficult for many staff to reach.
