A care facility in Limerick has been heavily criticised by the Health Information and Quality Authority for failing to show it could monitor, identify and respond to allegations of abuse.
The unannounced inspection of Beech Lodge Care Facility in Bruree, Co Limerick took place on 29 May and found there was a failure to protect residents from abuse.
Residents with dementia had been hit by other residents and these incidents had not been recorded or reported as required.
The facility is a long-term care and convalescent home for older adults and has 66 beds.
The inspection report, which was published today, found that there was a failure to address inadequate staffing levels and not record, or properly manage some serious complaints.
It resulted in the issuing of an immediate and urgent action plan in relation to the safeguarding and protection of residents.
The chief inspector at HIQA found that serious complaints were not recorded and the inspector had not been notified of an alleged abuse or that a resident had absconded.
A resident had been missing for an hour before being located in a family member's house. The family member had taken her home from the centre.
Allegations of abuse had not been investigated or notified to the office of the Chief Inspector.
A resident with dementia and associated behaviour challenges had been subject to environmental restraint.
The report said that the person in charge of Beech Lodge had been recently recruited for the role, despite not having the required post registration management qualification.
Staffing levels were not adequate at various times during the day, particularly in the dementia unit in the morning.
Night staff levels were also inadequate, with one nurse and one health care assistant caring for 15 residents with dementia.
Minutes of a staff meeting in February and April this year showed that senior management personnel were not happy with the staffing levels and did not want the centre to reach full capacity of 66 residents.
The inspection report said that care standards had deteriorated and that meal times were particularly problematic, as there were not sufficient staff available to afford proper assistance at meal times.
A number of areas of good practice were found.
Residents' health care needs were generally met with a good standard, according to residents, relatives and documents reviewed.
Residents were seen to be meaningfully occupied during the days of inspection with reading, knitting, card games, visitors and music.
The premises was well decorated, clean and bright and food was plentiful and choice was available.
In a statement, the Beech Lodge Care facility said it treated the issues raised in the report with the upmost seriousness.
It said it had been working at addressing every one of the issues over the preceding weeks.
The facility said it had appointed a new management team, consisting of a new Director of Care, Clinical Nurse Manager and senior staff nurses.
It also said that a comprehensive analysis of staffing levels had been undertaken and extra resources were being delivered.
Beech Lodge said that its previously unblemished inspection record with HIQA showed that its residents were at the heart of the care culture in the home.