A Sligo residential centre for people with intellectual disabilities run by the Health Service Executive has failed to comply with all but one of 14 statutory standards reviewed by the social services watchdog HIQA.
The Glenbow Centre in Co Sligo was charging residents the maximum rate, pegged to their income, for round-the-clock nursing care despite the fact that none of them had been assessed as requiring 24-hour nursing.
At the time of the Health Information and Quality Authority's unannounced inspection last August, the four central units on the Glenbow campus were home to 42 adult residents who had intellectual disabilities.
Five months earlier, HIQA had taken the unusual step of issuing a formal warning letter after finding that the residents had a poor quality of life and were not always safe.
Today's report on the August inspection states that most remedial actions agreed after the previous inspection had not been implemented and those that had been had failed to impact positively on the residents' quality of life.
Inspectors found that the holder of the Person-in-Charge post had been absent for over 28 days yet the HSE had failed in its duty to inform the watchdog.
"There was an absence of identified responsibilities for all areas of service provision," the report states.
Residents, for the most part, led passive lives with minimal interaction with their local community and surrounding areas and they spent most of their time on campus, leaving it only weekly or fortnightly.
Some had not engaged in an activity for four to five days and staff interactions with residents, were in the main, based around direct care.
The report says that, during the previous five months, the HSE had notified HIQA of a number of allegations and suspicions of abuse at Glenbow and that, in the main, appropriate action had been taken once they were reported to management.
However, a review of one resident's files revealed that he/she had sustained a laceration to the head and that the HSE had failed in its duty to inform HIQA of this.
The watchdog found that some residents' bedrooms were directly opposite the main entrance and anyone entering the large building - including visitors and administration staff - had access to those bedrooms.
During the day of the inspection, one resident was occupying a bed in a communal area surrounded by a screen, an arrangement the inspectors say compromised the person's dignity.
Five months earlier, the watchdog had identified the need for significant fire safety work and it was due to start the day before the unannounced inspection. However, the deadline had been missed.
Inspectors discovered that fire doors were held open with furniture and bedroom doors were left open while residents were sleeping.
Residents had not taken part in any fire drills and staff had not received training in the protection of vulnerable adults.
The HSE has been required to undertake a comprehensive set of remedial time-bound actions agreed with HIQA.
This afternoon the HSE issued a statement saying it accepts all findings within the report.
It said the report "highlighted that residents who chose to engage with inspectors, expressed satisfaction with the service they received and staff engaged with residents in a caring manner.
"The report also acknowledged that the provider had taken some action since recent inspections".
It went on to point out that in relation to leadership, governance and management, "a series of changes have been made.
"Since the inspection the governance and management has been strengthened."
Chief Officer for Health Services in the region John Hayes said: "I am working closely with management and staff at the centre to ensure that all of the concerns identified by HIQA and the HSE’s own Quality Improvement Team are being addressed."