A residential service for people with intellectual disabilities was found to have restrictive practices, poor management of safeguarding incidents, poor staffing arrangements and poor behavioural support for residents when it was inspected last year.
The Health Information and Quality Authority (HIQA) found that Sunbeam House Services had not put effective governance and management systems in place to protect residents from the risk of abuse.
In the two years up to July last year, 482 safeguarding notifications were submitted to HIQA's chief inspector about the service - 375 of them related to ten centres.
The notifications primarily related to Sunbeam’s failure in managing peer-to-peer incompatibility and conflict and its impact on the safety and welfare of residents.
Such was the level of concern, HIQA inspectors undertook a regulatory programme of 34 inspections across 28 centres.
It found that some residents were not being adequately safeguarded.
Some told inspectors that they were upset and wanted to move out of their homes or live on their own due to the ongoing aggressive behaviours of other residents.
Others said they did not feel safe in their homes and while they had made complaints about their concerns, those concerns had not been resolved.
One resident explained they had engaged in self-injurious behaviour due to being upset and stressed about their living circumstances.
There were recurring examples across a range of centres where the provider’s own policy on restrictive practices was not being implemented.
In one centre, the flush button on a toilet had been removed to prevent a resident from flushing it after use.
This had not been reported to the provider’s human rights committee to ensure that any impact on the resident’s right to privacy and dignity had been assessed.
In another example, regular night-checks of residents were being carried out where staff were going into the bedrooms of residents while they slept.
Reliance on agency staff
HIQA found that this was a historical practice, that there was no clear rationale for it and staff were not clear about why these checks were taking place.
The practice had not been identified as a potential rights and privacy restriction that required a rationale for its implementation according to the report.
A huge reliance on agency staff also affected residents profoundly.
During a two-week period last summer, 12 different agency staff supported one resident.
Another resident told inspectors they did not know all staff supporting them, and their family had complained to the provider on their behalf.
During another inspection, a resident referred to night-time staff as 'strangers' and explained that they did not want to let unfamiliar staff into their home.
The resident’s behaviour support plan stated that it was a requirement for the wellbeing of this resident to have familiar staff working with them.
However, the staffing arrangements were continuously not in line with the recommendations made by the behaviour support expert and with the residents' own preferences.
Due to the frequent changes of staff, another resident did not have an opportunity to build trust them.
The report notes a number of incidents to show how matters highlighted in previous inspections had not been addressed.
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Resident sustained regular bruising due to lack of space
In one designated centre, a resident was sustaining regular bruising from banging their limbs because there was not enough space for them to manoeuvre in the premises.
The matter had also been found during inspections of the centre in 2021 and 2023.
An occupational therapy assessment in 2020 made recommendations to address the accessibility issues.
In 2024, the inspectors found that the recommendations had not been implemented, and the resident could still not freely access areas of their home.
In another centre, inspectors found that a request to the provider’s maintenance team to fit handrails to support residents at risk of falling had been made in 2021.
Health and safety reports and the provider’s own audits of the centre had also highlighted this requirement.
In 2024, the provider submitted notifications to the chief inspector that residents were experiencing falls in the centre.
However, despite this, at the time of the inspection the provider had still not installed the handrails.
HIQA examined the governance of Sunbeam House Services as part of its evaluation and spoke to members of the board as well as senior management.
Inspectors found that there was a disconnect between the board’s oversight and what was happening in the centres.
The board expressed concern about poor inspection findings, but explained that they did not always have a clear understanding of the complex needs of residents or the services.
Management structures within the organisation were not effective in ensuring good quality support for residents and in identifying and responding when issues arise that impact on the safety and quality of life of residents according to HIQA.
Senior service manager responsible for 15 locations
Senior service managers spoke about the challenges they encountered and how difficult it was, stressful and hard at times to fulfil all of their responsibilities.
One senior service manager was responsible for 15 locations which comprised of seven residential services, day services and self-directed living services.
Since 2022 due to ongoing non-compliance, HIQA’s chief inspector issued notices of proposed decision to cancel the registration of six of Sunbeam centres, two of which were then issued with notices of a decision to cancel the registration.
The HSE has taken over the operation of one of those centres.
Cancellation of registrations can cause upset and distress for residents, which means such an action is only taken as a last resort where a provider has repeatedly failed to improve the quality of support and safety for residents.
In response to the report, Sunbeam House Services submitted a compliance improvement plan on how they intend to strengthen their oversight of centres, and how they will drive improvements in the lived experience of residents.
HIQA’s chief inspector is monitoring its implementation and inspections will be undertaken to verify whether the actions are being implemented.
History repeating itself - Inclusion Ireland
Inclusion Ireland has described the HIQA report on safeguarding and governance at Sunbeam House Services as history repeating itself with institutionalised practices and human rights denied.
In the two years up to July last year, almost 500 safeguarding notifications were submitted to HIQA's chief inspector about the service, which is primarily located in the East of the Country.
The notifications primarily related to Sunbeam's failure in managing peer-to-peer incompatibility and conflict and its impact on the safety and welfare of residents.
The CEO of Inclusion Ireland Derval McDonagh described the findings as "deeply concerning" and called for supports for all those affected including representative advocacy support and counselling.
She has also called for evidence that people will be moved out of any home where they do not feel safe and into a home of their own.
HIQA Inspectors found that Sunbeam House Services failed to protect people who lived in the houses from aggressive behaviour from other people they lived with.
In eight houses, people who did not get along were living together in the same home, and that led to incidents of aggression and harassment.
Ms McDonagh said: "Where you remove choice and freedom about where you live, who you live with and how you live your life, you create the conditions for poor practice and in extreme circumstances abuse.
"Unfortunately, that's what we're seeing here today - people with no choice about where they live or who they live with, asking for help and not receiving help.
"This is far below what we should expect in 2025 in Ireland’".
Inclusion Ireland has called for swift and immediate action by pointing out that no one should have to live their life feeling scared and unheard as it amounts to inhumane and degrading treatment.
