Residents of a west Dublin centre for adults with intellectual disabilities were subjected to relentless physical and psychological abuse including being punched, kicked, hit and having their hair pulled, a report from the Health Information and Quality Authority (Hiqa) has found.
Verbal abuse included being cursed and shouted at, while residents had their bedroom doors kicked, leaving them “scared” to leave their rooms, “shaking and sobbing”, and “experiencing a high level of anxiety and stress in their home”.
The abuse was by another resident or residents, and continued despite incidents and concerns being reported by residents, their families and nursing and care staff.
Residents at Liffey Services, operated by the St John of God community services (SJGCS) in Tallaght, were “experiencing potential institutional abuse”, said Hiqa. It found a “failure to protect residents” and this “raised concerns regarding [SJGCS] fitness as a provider”.
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Hiqa conducted an unannounced inspection of one of two community houses at Liffey Services, which had six residents at the time, on November 3rd 2022. The house inspected had three residents.
The inspector recognised “staff members did their utmost to keep residents safe and that they clearly cared about the ongoing conflict in the house”, says the report published on Wednesday.
However, “residents were experiencing considerable stress and fear as a result of ongoing peer-to-peer safeguarding risks as a result of incompatibility of residents. One resident, the inspector spoke with, described the distress living in the house had caused them”.
The impact included “increased incidences of self-injurious behaviours and withdrawing to bedrooms”.
“Safeguarding plans which were in place were ineffective and did not prevent the reoccurrence of psychological and physical abuse,” the report found.
The “persistent and prolonged incompatibility issues between residents [were] compounded [by] staff shortages” and over-reliance on agency staff, it said. “Over a three-month period, 89 shifts were completed by relief staff.”
SJGCS’s own unannounced six-monthly audits of the service in August 2021, February 2022, and August 2022 all “highlighted deficits in complaints management, the safeguarding of residents, the level of risk in the centre and the absence of completed actions from previous visits”, but were not acted on by senior management.
“As a result the safety and wellbeing of residents was being put at risk due to the inaction of the provider,” said Hiqa.
SJGCS failed “to ensure robust admission practices ... to take into account the need to protect residents from abuse”. It also failed “to act on the key concerns highlighted in their own reviews of the centre” and failed to give “meaningful consideration or responsive action” to complaints logged by staff on behalf of the vulnerable residents.
“The inspector found the service was not safe, effective, adequately resourced, monitored, or tailored to meet the needs of the residents, all of which were known, but not addressed by the provider,” the report continued.
“As a result, the service offered did not represent a human rights-based and person-centred approach to the care and support of residents.”
Due to the “high levels of noncompliance” the inspector “took the unusual step of issuing the provider with an urgent compliance plan”. Staff numbers were increased to ensure one-to-one support for each resident.
SJGCS was summoned to Hiqa’s chief inspector “on foot of serious concerns with regards to their fitness as provider”.
“This assessment would form part of the decision making around the next steps of escalation and/or enforcement action that would be taken by the office of the chief inspector,” it said.
In addition, Hiqa referred the findings to the HSE’s national disability safeguarding office which oversees protection of vulnerable adults.
In its compliance plan, detailed at the end of the report, SJGCS said it acknowledged to residents “that the current dynamic within the house is not in line with their will and preferences”. It planned to move one resident to “more suitable accommodation″.
The resident’s family was informed the move “was also to protect all residents” and would allow detailed work with their loved one “to address long standing complex issues they have that are being displayed currently through the behaviours”.
It also said: “With the introduction of additional staffing the residents and their rights are better protected, in particular in relation to safety within their own bedrooms.”
