Residents at a centre for men with disabilities were not adequately protected and safeguarded and there were concerns about how an incident involving two of them was managed, the healthcare standards watchdog has found.
The Health Information and Quality Authority (Hiqa) carried out an unannounced inspection of Glebe House in Co Louth, run by the St John of God North East Services, in February to follow up on information it received about a safeguarding incident at the centre in 2015.
The inspector found that the incident had not been managed, investigated or responded to appropriately by the provider.
Hiqa’s inspection report said the two residents involved in the incident remained living in bedrooms next to each other with the main control measure implemented being a keypad lock on one resident’s bedroom door to stop the other resident having access to him.
“The inspector queried what other measures were considered following this incident, however no alternatives to the approach taken were highlighted. This did not demonstrate all safeguarding considerations were taken to protect the resident,” it said.
The report said the levels of behaviours of concern and potential risks were of “a very serious nature” in this centre.
“While a number of governance, management and personnel changes had occurred (since this incident), the inspector had concerns regarding a number of the issues reviewed on this inspection,” the report added.
Incident reports
Incident report records could not be found on the day of the inspection and the person in charge of the centre was not appropriately aware of the notification submitted to Hiqa about the incident.
“The inspector found regulatory failings regarding managerial risk oversight and post incident response, protection and safeguarding of residents, their finances, and personal information and the promotion of residents’ rights,” the report said.
The inspector also found that two residents whose finances were checked were down €100 in their cash balances and he was informed that staff must have taken it out for resident activities.
A lot of residents’ personal information and incident reports were kept in an unlocked press on an upstairs corridor of the house, the inspector said.
“This information should be secured for residents privacy and confidentially.”
The report concluded that residents were not adequately protected and safeguarded at the time of the inspection.
In its response, the centre management said it would review risk assessments and there would be specific discussion with staff around the need to remain vigilant around “inappropriate/unwanted interaction between residents”.
The security of personal information would be improved by locked access to the archive room.
Management also said it would make changes to how residents’ cash was accounted for.
Hiqa published 24 inspection reports on centres for people with disabilities on Thursday and found good levels of compliance with regulations in 14 of them.