Watchdog was not told about a number of ‘significant’ assaults in care homes

A residential centre run by the Alzheimer Society of Ireland failed to report a number of “significant and serious” incidents in the first three months of this year.

The Orchard Day and Respite Centre, located in Blackrock in Dublin, was caring for 11 older people when the Health and Information Quality Authority (Hiqa) inspection took place in March.

In its report, Hiqa said that a high number of significant and serious incidents occurred at the centre in the first quarter of 2016. However, none of these were notified to Hiqa as required by the regulations.

Inspectors noted that evidence that a comprehensive review of these incidents, along with measures to prevent or reduce their recurrence, was not available.

These incidences included shouting, threatening and abusive language, grabbing, slapping, pushing, and punching. The assaults included staff and other clients being kicked, punched pushed, and slapped.

One assault resulted in a loss of consciousness, requiring transfer to hospital, while others related to inappropriate kissing, and touching.

Hiqa said that, as all of these incidences had a negative impact on other residents, “it could be determined that they fall within the definition of abuse”.

“Evidence that measures were in place to protect residents from being harmed or suffering abuse was not found,” said the report.

Inspectors also found that the centre was “not visually clean”, with a build-up of grime and stains viewed in some areas. A “strong odour of urine in some of the toilets” was also noted.

Hiqa also found that there was was a lack of adequate clinical governance in the centre, which resulted in poor outcomes for residents.

It said that the management systems in place “did not ensure that services provided are safe, appropriate to residents’ needs, consistent and effectively monitored”.

In total, six out of the nine areas inspected by Hiqa were found to be “major non-compliant”, with only one area deemed to be substantially compliant.

However, a follow-up inspection in June by Hiqa found “evidence of progress in many areas” including governance, staffing levels, and skill mix.

In a separate report of the HSE-run Phoenix Park Community Nursing Units located at St Mary’s Hospital in the Phoenix Park in Dublin, Hiqa noted that although “a good standard of nursing care was being delivered to residents, the care needs of residents at end of life was compromised in the Chapel View unit due to issues related to the premises”.

“Considerable deterioration to the fabric of the Chapel View unit due to a lack of any action to maintain these premises was found,” said the report. “This posed potential risks to the health and safety of residents’ staff and visitors using this building. This unit is not fit for purpose.”

Hiqa inspectors found that a recent reduction in resident numbers was due to the refusal of applicants and/or their relatives to be placed in the unit due to the poor environment and not as part of any formal decision by the provider to reduce the capacity.

In a follow-up inspection in May, Hiqa found the building was in poor condition, with no improvements noted since the previous inspection in March.

It also noted that further improvement would be required to meet regulatory requirements in respect of fire safety.