Women with intellectual disabilities living in a Health Service Executive-run centre had to leave their bungalow to access a suitable bathroom in a separate house on their campus, according to a report by the Health Information and Quality Authority..
The finding by HIQA is among six major failings which led the independent watchdog to conclude that the HSE was not ensuring that the Sligo facility was effectively governed and operated.
HIQA says today's report on last August's unannounced inspection of the Gweedore Services Centre in Sligo town follows the HSE's failure to act on two previous very serious reports.
The centre consists of seven houses which are home to 32 female residents with a primary diagnosis of intellectual disability.
Three of the houses are beside each other while the remainder are dispersed throughout the town.
Residents told inspectors about the support and care they received.
However, some of the women had to leave their bungalow to access a suitable bathroom in a separate house on their campus.
During the summer, residents were assigned new living quarters in other houses in the centre. But this was without consultation and the distress caused is recorded in residents' files.
Two houses were in a poor state of repair and residents complained repeatedly about the challenges they were experiencing due to the size and layout of some of the premises.
For example, the stairs were difficult for residents with mobility issues to manage.
Staff were unable to clearly identify the current person in charge and widespread staff shortages continued to be a problem.
A HSE commitment two months earlier to commission an external review of staffing levels and skill mix had yet to be fulfilled in August.
HIQA and the HSE could not agree all aspects of a proposed action plan to address the report's findings.