A residential centre for people with learning disabilities in Co Louth had no dedicated person in charge of it for three months resulting in negative outcomes for residents, according to a HIQA report.
The inspection also found that the St John of God Service, which owns the centre, failed to investigate an unexplained injury to a resident.
The Bliain Orga centre has 22 residents with learning disabilities and is comprised of four units on a campus in Drumcar.
The HIQA report published today said that 12 months ago the regulator was notified by management that the person in charge of the centre would be absent until 30 March and that a staff member had been nominated as a replacement.
But when HIQA began its unannounced inspection on the 31 March the post was still vacant, there was no person in charge in the centre and no replacement had been identified by the St John of God Services.
There was also an absence of frontline management due to staff absences.
Staff reported that although the temporary person in charge had been as available as they could be, their commitments within the wider organisation dictated that "their presence was not always regular".
HIQA said this resulted in frontline staff completing management duties such as rostering in good faith and that "this deficit in a robust management structure was evident throughout the inspection".
Accidents and incidents had been documented but not reviewed by management. Complaints were not reviewed and followed up on and the recording of residents' information was inadequate.
Inspectors found that management had failed to investigate an unexplained injury to a resident. They ordered an internal probe which revealed that the appropriate healthcare professional had not reviewed the injury and that there was no continuity of care.
The inspection also revealed "significant failings" in respect of risk management, the fire management systems and the premises and it concluded that "the cumulative findings demonstrated that there was an absence of governance which fundamentally resulted in negative outcomes for residents".
Twenty-seven failings were identified, 17 of them being the responsibility of St John of God Community Services (SJGCS) and ten being attributable to the unfilled person-in-charge post.
In the action plan published by the SJGCS as part of the HIQA report, the provider said a new full-time person in charge began work at the centre on 22 June last.
A clinical nurse manager, who is trained as a positive-behaviour support specialist was appointed the same week.
Meanwhile, a separate HIQA report on a similar centre in Co Wexford has found that under-staffing was impacting on the quality and safety of care.
An inspection last October of the HSE-run Summerhill House in Enniscorthy also found that residents' privacy and dignity was compromised by the use of twin bedrooms.
The centre is a large detached house within the community and most of the 11 residents have severe to profound intellectual disabilities.
Inspectors said they had to walk through one double bedroom to access another resident's room.
The inspectors found that staffing levels were inadequate to meet the activation needs and goals of residents.
They said that during a three-week period last October, 135 nursing hours were utilised with agency nursing staff.
"This does not promote continuity of care for residents," the report stated.
