Residents at a designated centre for people with disabilities were found to be living in "fear and stress" when the Health Information and Quality Authority conducted an inspection of their accommodation late last year.
The unannounced inspection took place in November at a centre run by St John of God's after HIQA received information regarding an ongoing incompatibility issue in one of the houses that made up the centre, resulting in peer-to-peer safeguarding incidents.
It resulted in the watchdog issuing the provider with an urgent plan to ensure the safeguarding and protection of residents living in the centre.
One resident told the inspector about the unhappiness and distress they felt of not feeling safe in their own home.
The resident was angry and frustrated about having to remain in their bedroom a lot of the time, saying "I always get threatened". The resident said the staff were very nice and tried to help, but the incidents kept occurring.
The inspector also spoke to a family member who discussed their concerns and the complaints they had made regarding the incompatibility of the resident group.
While one complaint was under investigation, the inspector could not find documented evidence that all complaints had been investigated in line with the provider's complaints policy.
HIQA said staff had also advocated on behalf of residents - in particular those without natural supports or independent advocates - through the complaints process.
One staff complaint said residents felt "scared" in the house. The complaint noted that one resident could not leave their bedroom for long periods of time, and there were incidents of peer-to-peer intimidation and threatening behaviour towards residents.
According to HIQA, the response to the complaint did not bring about improvements in the centre or "considered action" by the provider given that it was lodged in November 2021 and the inspection that occurred 12-months later found matters ongoing.
The inspection report published by HIQA this morning shows staff were "hyper-vigilant" during the inspection to residents' emotional presentations and the location of residents at all times.
A preliminary screening form reviewed by the inspector, which outlined daily presentations of residents and the types of incidents that were happening, noted some residents as appearing nervous and fearful when leaving their bedroom.
When they returned from day services, some would ring staff to ask them to open the house door so they could enter and move safely to their bedroom.
The report concluded that the psychological wellbeing of some residents had been compromised, and said the risk of physical and verbal abuse was ongoing.
Incident reports for the centre, read by the inspector, outlined examples of institutional abuse experienced by residents, one of whom "appeared frightened and was shaking and sobbing''.
Incident reports also detailed physical assaults such as being punched, kicked, hit and hair being pulled. Verbal abusive incidents such as being cursed and shouted at also had an impact on residents.
The impact according to HIQA was increased incidences of self-injurious behaviours and withdrawing to bedrooms as residents did not feel safe in communal areas.
The inspectors' report found that staff had escalated safeguarding concerns to the best of their abilities.
However, given the significant safeguarding issues identified, the inspector was not assured that the governance arrangements were effective in being able to ensure the safety and wellbeing of residents.
The inspector took the "unusual step" of issuing the provider with an urgent compliance plan requiring it to put immediate and urgent actions in place to ensure the safeguarding and protection of residents living in the centre.
The provider responded by increasing staffing levels to ensure each resident had one-to-one support in an effort to mitigate safeguarding incidents from occurring.
The provider was invited to attend a fitness assessment with the Office of the Chief Inspector on foot of serious concerns.
The Office of the Chief Inspector also referred the matters to the National Disability Safeguarding Office, raising concerns in relation to the safeguarding incidents, potential institutional abuse occurring and the lack of evidence to demonstrate the consistent and effective implementation of National Safeguarding Vulnerable Adults policies and procedures.
'We apologise unequivocally to our residents and their families'
Saint John of God Community Service has noted and accepted the findings of the HIQA report into one of its designated centres based in west Dublin.
In a statement, it accepted the seriousness of the issues raised and confirmed that a series of measures were immediately put in place following the inspection to improve the safeguarding and welfare of the residents in the short term.
It added that a more permanent solution is being explored.
The situation has been under continuous review according to St John of God Community Service and further measures have been put in place in recent days to address additional risks that have been identified until a permanent solution is implemented.
"We apologise unequivocally to our residents and their families and acknowledge the distress and worry that this situation has imposed on them. We also acknowledge and commend the work of staff members at the Centre in both seeking to protect and support the residents and their efforts to find a solution to the ongoing problems for some time," it said.
St John of God Community Service concluded the statement by noting that it takes its responsibilities seriously and will do all in its power to "restore stability in this situation and deliver a sustainable outcome for those availing of its supports".
It also confirmed that a full internal review into the circumstances that led to the issues identified in the report is under way.