A resident of a Galway disability centre who was known to be at high risk of absconding jumped from an upstairs bedroom window and fell to the ground, a report from the Health Information and Quality Authority (Hiqa) finds.
There were "unexplained absences" of a resident from the Sylvan Services centre while cases of actual or suspected abuse of residents by other residents had not been notified to the authority as per regulations.
In another centre, Teach Michel, also in Galway, excessive use of chemical restraints and seclusion were used; a resident whose access to food was restricted lost eight kilos (17.6 lbs) in 11 months, and a resident who had been identified as a threat to minors and requiring staff supervision was allowed independent access to the community.
The reports, published on Thursday, are highly critical of the centres operated by Ability West.
Sylvan Services was found non-compliant with eight of the 11 standards examined, while Teach Michel was non-compliant with ten of the 11.
The first centre, home to seven adults with intellectual disabilities, was inspected on October 21st , 2020. It had been given short notice of the inspection.
The inspector found the centre was “not meeting the care and support needs of the residents” and required “significant improvement”.
Insufficient back-up for night staff was highlighted by an emergency situation the night before during which a staff on duty “received no answer to their calls for help, consequently, the staff member had to call the emergency services for support”.
The inspector was told there was no response to the staff’s calls as there was “no actual on call support arrangements in place in Ability West from 5pm to 9am each evening . . . and from Monday evening until Friday morning. This incident showed the lack of governance and oversight,” says the report.
One of the residents in a bedroom upstairs, who “displayed behaviours of concern and had complex medical issues . . . not closely supervised . . . This was a concern, due to the size of the house and the night staff could not observe or hear the resident mobilising upstairs.”
Some residents were not suitability placed in this centre, says Hiqa, and the premises and environment were identified as among “the key issues that were negatively impacting on resident’s behaviour”.
Teach Michel, home to five residents with intellectual disabilities, was inspected on November 4th, 2020. It had been given short notice of Hiqa’s visit.
“Due to the level of risks identified in the centre and the impact these restrictions on residents’ rights and civil liberty, the provider representatives was required to attend a warning meeting to discuss the non-compliances in the centre.”
It found restrictions on residents’ liberties, including physical holds, chemical sedation and seclusion, “over-used”, with use of seclusion increasing 122 per cent from September 2019 to September 2020. Access to food and snacks was restricted without oversight, putting at risk residents’ right to choice and dignity.
The inspector was told one resident’s access was restricted due to concerns about their weight. However, when records were reviewed it emerged “the resident had lost 8kg in weight in the past 11 months and . . . was not over weight”.
Governance and management of risks posed by some residents to staff and minors in the community were “inadequate”.
Action plans to address the non-compliance findings have been agreed between Ability West and Hiqa. The reports were among 22 following inspections of disability centres, published on Thursday.
