HIQA has found that the person in charge of a residential centre for people with disabilities in south Dublin could not ensure that it was effectively managed because he or she was responsible for six other centres operated by their employer.
The watchdog also found that the facility, which is run by the St John of God services, did not have enough staff to meet the assessed needs of residents and had failed to train staff to support highly dependent residents.
The centre in Islandbridge is home to 14 residents, both male and female, with varying degrees of intellectual disabilities, some of whom have significant medical needs and challenging behaviour.
Last May's inspection was unannounced and followed the receipt by the Health Information and Quality Authority of notifications and unsolicited information in relation to safeguarding issues.
Residents' prescription sheets revealed deficiencies which in two cases required immediate attention as they risked compromising the safety of residents.
Healthcare plans were either not developed, did not contain the appropriate information to guide safe practice, or were not updated to reflect changes in circumstances.
The inspectors also found that necessary fluid intake monitoring was not consistently recorded where required.
Inspectors concluded that significant improvements were required in the facility's governance and management structures so as to ensure a safe quality service.
They ruled that the person in charge could not ensure that it was effectively managed because he or she was responsible for six other centres operated by the St John of God services - as a person in charge in two and as a programme manager with responsibility for another four.
"The person in charge could not ensure the effective governance, operational management and administration of the designated centre concerned given the areas of responsibility they were assigned," the inspection report states.
The review also found that improvements were required in both the supervision of staff and staffing numbers in the Islandbridge centre.
Training records revealed that improvements agreed with HIQA six months earlier had not been implemented and that staff had not been trained to attend to some of the assessed needs of residents.
Some staff had not been trained in the use of restrictive practices used in the centre and employees told inspectors that there was no formal supervision in place for staff.
Staff reported that they felt concerns that had been raised with management were not addressed.
One staff member who inspectors were informed was being mentored by another staff member had received no formal mentoring since the process was due to commence a number of months earlier.
Staff also reported that the use of agency staff made it difficult to provide consistency of care to residents given their complex needs and the requirement for specific staff training to support some of those in their care.
Rosters revealed that there were times of the day when not enough staff were on duty to meet the assessed needs of residents.
For example, in the late morning/mid afternoon, five staff were on duty. However three of them were supporting residents who required intensive supervision.
And "there were times during this period where four staff were required to meet the residents' needs as per their personal plans," the report states.
Inspectors found what they call "significant failings" in the centre's overall governance and management systems.
For example, of the 17 remedial actions identified at the previous inspection six months earlier, only one had been satisfactorily completed. In addition, major non-compliances with regulations were found in nine of the 12 areas inspected and none of the other three areas was compliant.
Areas of the centre were unclean and poorly maintained but the large residential unit accommodating all but one of the residents was generally well maintained.
A resident in an outlying apartment told inspectors that the water in one shower was too hot and staff confirmed this, but no action had been taken to rectify the problem.
There was no review of the large number of incidents occurring in the centre to guide future practice despite a previous inspection requiring this reform. A synopsis of the previous six months' incidents was unavailable.
No plan or guidance was in place for a resident with challenging behaviour who was subjected to a restrictive practice which had not been notified to HIQA.
The conditions for the use of restriction on another resident required that it be reviewed by a multidisciplinary team every month. However, the last review had taken place four months previously and there was no plan for a further review.