Conditions at a Tusla-run secure residential centre posed “a significant risk to children’s safety and protection” and led to some being harmed, a report published on Wednesday finds.
Staff and management at Coovagh House, a special care unit in Limerick for very vulnerable young people, acknowledged to inspectors from the Health Information and Quality Authority (Hiqa), they “no longer had the capacity to safely provide a service” and were at times so unable to manage the violence of some children they “required assistance from An Garda Síochána”.
The watchdog conducted an unannounced inspection of the facility over four days in June and found “the safety and welfare of children could not always be protected and promoted”.
Coovagh House provides secure care to young people with traumatic childhoods who present with risk-taking behaviours, including exploitation by adults/peers, drug and alcohol misuse, non-school attendance, violence and aggression.
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It was found to be non-compliant with all eight regulations examined, including governance and management, protection, and positive behavioural support.
While four children were detained at the centre, two had been moved to a non-registered Tusla accommodation to allow for remedial works and continued to attend the centre during the day.
The children said they felt well cared for in the centre and outside in the company of staff. However, staff, social workers and guardians ad litem said: “there were times when children were not kept safe”.
Later the report says: “Staff responded to incidents in the centre to ensure the immediate safety of children. However, despite this they were not always able to keep children safe, and some children were harmed as a result during incidents.”
The “challenging” behaviour of some children in preceding months had caused serious damage, including broken doors and locks, meaning children could not be kept safe, and led to restrictions.
According to the report, one child told inspectors: “It is not a nice life,” and they felt “punished for the behaviour of others”. The child said that they missed their previous routines in the centre.
“All four children gave negative accounts to inspectors about the impact of these conditions on their lived experience. One child said that ‘the place is a dump’ ... Other comments from children included that ‘the place is a wreck’,” the inspectors said.
Inspectors saw repairs “that needed urgent attention” including “hate symbols engraved on walls”.
Among “significant shortfalls ... in the effective management and oversight of the centre” was the failure to report all serious incidents to relevant authorities.
“The person in charge failed to notify Hiqa of several serious incidents ... relating to the allegations of abuse made by children or serious injuries sustained by children. This did not facilitate the monitoring of the centre by the regulator, as the regulator was not made aware of incidents.”
Nine experienced staff had left in the previous six months, with their posts filled on an interim or temporary contract basis by agency staff and student social care workers.
“Managers and staff could not always manage the behaviours of children effectively as the physical premises was no longer conducive to supporting safe spaces for physical interventions ... This had led to unhelpful and unsafe dynamics within the centre and the staff team required assistance from An Garda Síochána in response to incidents.”
Tusla faced “capacity challenges” at a national level which made implementation of the centre’s emergency plan difficult, the report found. It had not been able to find alternative secure accommodation for two children moved out temporarily. Equally, some children “could not move on from the special care unit when they were ready to do so due to the lack of onward placements available to the provider”.
In a statement Hiqa noted Tusla had “provided assurances in relation to the high-risk non-compliances relating to governance and management, risk management and the notification of incidents. [Tusla] has also submitted a plan outlining how it intends to come into full compliance”.
The report found all four children described feeling well cared for in the centre and had trusting relationships with staff. However, the level of non-compliance was below the expected standard in areas such as governance and management, risk management, and the notification of incidents, it accepted.
Donal McCormack, National Service Director, Children’s Residential Services, Tusla said: “Unfortunately, due to a range of issues and challenges, primarily an escalation in incidents connected to individual young people prior to inspection, the level of compliance with Hiqa’s standards fell short of the standards normally achieved in this centre.”
“We engaged with Hiqa and submitted an action plan outlining how higher levels of compliance will be achieved, while keeping young people safe,” he added.
Key actions taken since the inspection included:
- A review of all incidents of a child protection or welfare concern.
- Complaints have been identified and appropriately notified.
- All young people in the service have an up-to-date individual crisis management plan.
- Additional training has been provided to all relevant staff on Tusla policies and procedures for special care services.
- All new staff to be provided with a comprehensive induction program which includes all mandatory training, mentoring and support.
- Physical deficits in the building are being addressed.
