Two cases of possible physical abuse were identified by inspectors from the Health Information and Quality Authority at the voluntary organisation’s Palmerstown campus in Dublin.
The inspectors, who made an announced visit to the centre last October, found the case relating to two residents was not properly dealt with.
The provider told the inspectors that a committee had been established to address concerns about identifying and reporting abuse allegations.
The inspectors found that staff did not have access to safeguarding plans for residents. There was a mixed level of awareness as to what constituted abuse and what to do if abuse was suspected or witnessed.
A review of staff training records revealed that 67% had not completed mandatory training in safeguarding vulnerable persons.
A copy of the centre’s policy on restrictive practices could not be found on the day of the inspection.
Inspectors found that the residents’ healthcare needs were not being met, particularly in managing seizures.
Staff members told inspectors that there was a support plan for eating, drinking and swallowing for a resident who was at risk of choking but it could not be found and it was later confirmed that it did not exist.
A staff nurse was unable to confirm the expiry dates of medicines for five residents and admitted there was no system in place to deal with this area of medication management.
No staff were employed on night duty in one area of the centre providing accommodation for 10 residents.
Inspectors who made an unannounced inspection of the centre run by Stewarts Care in Lucan, Co Dublin, last September found that some “peer to peer” incidents had not been appropriately identified, reported or investigated as safeguarding concerns.
The centre has 18 residents living in five units and the inspectors found that staff knowledge of safeguarding needed to improve, as well as aspects of behaviour support planning.
The inspectors also found the staff were not consistently supported in their role and issues raised through the line management system were not always acted on.
An announced inspection of another Stewarts Care centre in Lucan where eight people lived revealed safeguarding issues that management had failed to identify and act on.
Safeguarding concerns in one unit were highlighted by a health professional in June last year and through a staff team meeting the following month but failed to be reported or investigated in line with national policy. Some incidents had not been reported to the Health Service Executive safeguarding team as required.
During the inspection in October last year, the provider acknowledged there was “significant deficit” in identifying and reporting safeguarding issues and this was to be investigated “in the near future”.
The inspector found there was a lack of effective management to identify and respond properly and promptly to safeguarding concerns in the centre.
When the inspector expressed concern that the person responsible managed four centres, the provider said there was a plan to have one person in charge of each centre.