HIQA has accused a number of long-term staff at a former Camphill Community of causing significant distress to residents by hindering the HSE's efforts to implement appropriate safeguarding practices after taking over the facility last summer.
The watchdog has also criticised the Irish Society for Autism for charging the same fee to all residents of a centre, regardless of whether they lived in shared facilities or in individual apartments.
The facility was run for some 40 years by the Camphill Communities of Ireland, but after HIQA found high levels of risk to the residents, it put the Health Service Executive in charge instead last May.
The report describes HIQA's inspection six weeks after the take-over. It states that the day before the review, the HSE had alerted it to "significant safeguarding breaches" which continued during the two-day inspection.
It states there was evidence of direct obstruction to safeguarding arrangements and that plans being made to address and safeguard residents were being hindered by both the Camphill Communties of Ireland's failure to provide the HSE with necessary information and the actions of some long-term co-workers.
The report states that such situations demonstrate that the current are not sufficient to safeguard the residents' physical or emotional well-being.
'Evidence of direct obstruction to safeguarding arrangements'
The report states that, as residents were already dealing with significant recent changes in the centre, direct contact with them "was limited to minimise further distress".
A resident who spoke with inspectors stated that she was confused and did not know who is coming or going with regard to her previous staff, the report states.
It adds that, while a commitment was made for a smooth transition in the best interests of the residents, this had not occurred in practice.
"Efforts to implement appropriate safeguarding practices were again not supported by a significant number of long-term members of the staff with whom the current provider was in a process of engagement," it continues.
"There was evidence of direct obstruction to safeguarding arrangements which the provider (HSE) needed to address. There was also evidence that plans being made to address and safeguard the long-term well-being of the residents were being hindered by the previous provider's (CCI's) lack of provision of necessary information to the current provider and the actions of some long-term co-workers," the report states.
It says this finding is based on two significant events.
Firstly, HIQA received a notification of a situation which was both physically and psychologically abusive to a resident.
This incident took place after the HSE took over the running of the centre and continued for some hours.
"It is of concern to HIQA that during that time no management in the centre were alerted to the situation by agency or employed staff present at the time in order to protect the resident. It is acknowledged that when the managers were alerted immediate action was taken and the person responsible suspended from duty in accordance with the requirements for the protection of vulnerable adults.
"However, due to the status of the person this matter can only be fully investigated and dealt with by the previous provider (CCI)," the report states.
"In addition to this and of more concern was the deliberate lack of adherence to an interim safeguarding plan and the subsequent significant negative impact this had on residents. Both co-workers living in one unit and two others, who were requested not to enter in the interests of residents' safety, pending full due process investigations and without prejudice, failed to co-operate with this instruction. This action placed residents at potential of serious risk (sic)," the report continues.
The report adds that the HSE had made some positive changes, for example by promptly sourcing advocacy services for all residents in response to the changes and to ensure that, in all future decisions and current circumstances, their views and needs are prioritised and given voice.
It states that this process was ongoing at the time of the early July inspection.
It also notes that a review of financial matters in relation to residents had commenced at the same time.
HIQA's report concludes with an Action Plan which identifies areas where improvements are needed to meet regulatory requirements.
Meath centre criticised over charging system
The independent watchdog has also criticised the Irish Society for Autism for charging the same fee to all residents of a centre in Co Meath, regardless of whether they lived in shared facilities or in individual apartments.
HIQA cancelled the registration of the ISA's centre at Dunfirth Farm in May last year due to major failures to comply with regulations.
Since then it has been run on the HSE's behalf by Gheel Autism Services.
During an unannounced inspection last June, HIQA found that while some improvements had been made over the previous year in the quality and safety of care of the 33 residents, the centre continued to face a number of challenges.
For example, residents' contracts of care required an urgent review as each resident was paying €390 per month for the service, even though some lived in shared facilities while others had individual apartments.
Since the inspection, the new provider has undertaken to review all residents' assessments and to reimburse them where required.
The report also notes that the fees were being transferred from residents' bank accounts to the Irish Society of Autism which then allocated a budget to the centre even though it was no longer providing the service.