The health and safety watchdog had “significant concerns” about the wellbeing of residents in a disability centre in Dublin after it was notified of two incidents of serious injury and unexplained bruising on three residents.
On Tuesday, the Health Information and Quality Authority (Hiqa) published an inspection report on a disability centre in Dublin 6W run by Cheeverstown House. In addition to the serious injuries, it said there were 31 incidents of unexplained bruising to three residents.
The staff at the centre, which had 13 residents when it was inspected in January, demonstrated strong knowledge of residents’ needs and engaged in kind and supportive interactions, the report found.
However, “the findings of this inspection highlighted serious shortcomings in resident safety, compatibility and access to essential services”.
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The provider had submitted 31 notifications to the Office of the Chief Inspector concerning allegations, suspected or confirmed incidents of abuse in relation to three residents in the designated centre.
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During the inspection, management explained that upon reviewing the bruising incidents, it appeared that poor manual handling during personal care or assistance with dressing might have contributed to the injuries.
Inspectors found 11 out of 33 staff were overdue for manual handling training.
Inspectors also said they were “not assured” that appropriate governance systems were in place to ensure the provided service was “safe, consistent and responsive” to the needs of residents.
“Significant gaps in governance and oversight were identified, particularly in relation to risk identification and management, staff training and supervision, provider response to risks and record-keeping practices,” the report said.
According to the inspector, adequate staffing resources were not in place to meet the needs of residents, and there were “gaps and inconsistencies” in the records kept.
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“For example, a bedrail risk assessment for one resident was reviewed, and although it had been in place since July 2021 and reviewed in July 2023, the risk assessment advised that bed rails should not be used due to high risk of injury,” the report said.
“The assessment recommended using a crash mat and sensory alarm instead. However, during the inspection, it was noted that the resident’s bed had bed rails and bumpers in place.”
The inspectors also found the provider had not yet ensured that all residents were in receipt of services that were appropriate to their needs.
Following the inspection, the provider outlined a number of ways in which it could comply with the regulations, including reviewing all residents’ assessment of needs, ensuring all staff undergo the required training and progressing transition plans of residents into more suitable accommodation.
The report was one of 32 published on Tuesday, with inspectors finding a generally good level of compliance with the regulations and standards in 25 centres and noncompliance in seven centres.
