Severe Issues with Governance, Risk Management and Safeguarding highlighted in HIQA IPAS Inspections

Introduction

HIQA published a further six inspection reports for International Protection Accommodation Services (IPAS) in July 2024. The reports highlight varying levels of non-compliance, but major non-compliances are identified in relation to governance, accountability and leadership, responsive workforce, contingency planning and emergency preparedness, accommodation, safeguarding and response to specialist needs. Some of the common high-risk issues related to ineffective risk management systems and safeguarding measures, a lack of auditing and quality assurance, lack of a dedicated reception officer and issues with Garda vetting of staff.

As an IPAS provider, it is imperative that you review the findings of the latest inspection reports and identify the learnings for your centre. In this article, we provide a summary of the findings under the related Theme of the National Standards for accommodation offered to people in the protection process (2019).

Summary of Major Issues Identified in IPAS Centres

THEME 1: GOVERNANCE, ACCOUNTABILITY AND LEADERSHIP

• The service provider had not yet implemented formal systems for the oversight and monitoring of the quality of care and experience of residents in the centre. There was no annual review, surveys, audits or continual improvement plans developed in consultation with residents.
• There was no residents’ charter in the centre available to residents at the time of inspection. While there was a checklist completed with residents as part of the arrivals process, there was no information for residents describing where services are provided, about staff roles, or how the centre consults with residents regarding their welfare and experience of the service.
• There was a complaints policy in place, however not all complaints received had been recorded or managed in accordance with this policy.
• The provider had arrangements in place to ensure residents received a copy of the charter. At the time of inspection this document had yet to be translated into any other languages.
• Improvement to the provider’s monitoring system was necessary to ensure that clear local audit and evaluation systems were in place.
• There was no formal system of resident consultation in place.
• There were deficits evident due to a limited awareness and understanding of the national standards, legislation and regulations.
• While the management team had completed a self-assessment of their compliance against the standards, this was not comprehensive.
• Improvements were required to ensure that all of the required policies and procedures were in place to guide staff practice and ensure continuity in approach.
• The recording and reporting systems required further development to ensure appropriate management of documentation and oversight by the service provider of incidents, risks, complaints and safeguarding concerns.
• There was an absence of an ongoing auditing or quality assurance programme to assess, evaluate and improve the quality and care and experience of residents living in the centre.
• An annual review of the service provided had not been completed.
• A full suite policies and procedures was required to support the delivery of good quality and safe services and to guide staff in providing appropriate and informed supports to residents. For example, there were no policies on risk management, adult safeguarding and the identification of special reception needs.
• There were no formal quality assurance or reporting systems to ensure the service provider was aware of all risks, incidents and safeguarding concerns.
• The complaints management system was not effective.
• While the service provider had completed an annual review of the service, it was not comprehensive and did not inform a detailed quality improvement plan.
• There was an absence of an ongoing auditing programme to assess, evaluate and improve the quality of care and experience of residents living in the centre.

THEME 2: RESPONSIVE WORKFORCE

• The provider had not obtained a Garda vetting disclosure for two members of staff. Three staff members had not been revetted in the timeframe set out in national policy. Additionally, the provider had not received international police checks for two staff members who had resided outside of Ireland for a period of six months or more.
• Staff had not yet engaged in training in areas specific to residents’ needs or risks in the centre, and not all staff were trained in some key areas.
• The staff and management teams reported that they were well supported in their roles; however, there was an absence of regular, formal and recorded supervision for staff or centre managers as required by the national standards.
• While staff members had received child protection training, none had received training in the safeguarding and protection of vulnerable adults.
• There was a need to undertake a training needs analysis to ensure all the required training as prescribed in the national standards was delivered to the staff team and to inform the training plan going forward.
• Not all staff members had a job description in place or had written references available.
• The oversight measures in place required review to ensure they monitored training that needed to be repeated, such as child protection, to ensure refresher training was provided in an appropriate time frame.
• A performance appraisal system had not been developed.
• Staff members had not completed training in safeguarding vulnerable adults and some staff required training in first aid and fire safety.

THEME 3: CONTINGENCY PLANNING AND EMERGENCY PREPAREDNESS

• The service provider had not developed or implemented an effective risk management framework and policy to guide the staff team in the management of risk.
• there was no risk register and the service provider had not completed a risk analysis or assessment of all risks and hazards that may compromise the safety and wellbeing of residents and the quality of service provision.
• There were no contingency plans to ensure continuity of service in the event of a disaster or unforeseen circumstance.
• The risk management system was not effective and the risk management policy was not sufficiently detailed to guide the staff team in the management of risk.
• The risk register did not contain details of all risks in the service.
• The service provider had not completed a risk analysis or assessment of all risks in the centre.
• There was no overarching risk management policy to guide the staff team in the identification, assessment and management of risk. There was no risk register and not all risks relating to residents had been recorded and assessed.
• While regular fire drills took place, the risk relating to residents not responding to the fire alarm needed to be assessed.

THEME 4: ACCOMMODATION

• The number of washing machines and dryers did not reflect the size of the population residing in the centre.
• There was no after-school or homework club provided in the centre, and there were no study spaces or materials (including computers) available in any communal areas for children.
• The security measures had not been reviewed following a security incident to ensure they were suitable or were effective in minimising the likelihood of a violent incident occurring.
• A centre specific allocation policy was required to direct the allocation of accommodation to ensure a transparent approach was taken and adequate records were maintained.
• Families accommodated in bedrooms did not have adequate living space to ensure children could play and develop.
• The service provider had not ensured that residents had sufficient and appropriate non-food items.
• Residents had to buy their own toiletries and hygiene products in the on-site shop.
• The provider had not assessed the centre’s capacity to accommodate 175 men while prioritising the interests of residents, the best interests of children within the centre, and meeting the needs of residents.
• This inspection found that there were no meeting rooms without CCTV for residents to access for visits or to meet with professionals. The use of CCTV was not subject to periodic review to ensure that it was proportionate and reasonable. In addition, the use of CCTV within the centre was not informed by a policy.

THEME 5: FOOD, CATERING AND COOKING FACILITIES

• The shop had limited opening times and it was not evident that residents were consulted with to determine if this was meeting their needs.

THEME 6: PERSON CENTRED CARE AND SUPPORT

• The right to privacy and dignity was not promoted for some residents due to the nature of the accommodation where they shared accommodation with other residents who were not related.
• The systems in place to formally consult with residents were limited and needed to improve to ensure residents’ views were informing service delivery.
• The staff team did not have access to translators if this service was required.

THEME 8: SAFEGUARDING AND PROTECTION

• There was no policy for adult safeguarding. There was a lack of awareness among the service provider, centre managers, and staff regarding their responsibility to safeguard vulnerable adults in accordance with national policy requirements.
• There were no risk assessment and management policies and procedures in place for dealing with situations where the safety of residents may be compromised.
• Child protection concerns were reported to Tusla in line with Children First but there were no formal arrangements to monitor children while their parents were absent from the centre.
• There was no system to develop a safeguarding plan to ensure children were safe, protected and cared for while their parent was not in the country. While the service provider ensured parents were aware of their responsibilities with regard to the supervision of their children, a policy had not been developed regarding childminding arrangements.  
• Not all staff had received training in adult safeguarding.
• Improvements to the incident management system were required to ensure that all adverse incidents were adequately recorded and that information about incidents was reviewed and evaluated.
• Improvement was required to ensure that all adverse events and incidents were consistently recorded in a manner that allowed them to be reviewed effectively.
• There were no arrangements in place to learn from these incidents as part of continual quality improvement and to reduce the likelihood of reoccurrences.

THEME 9: HEALTH, WELLBEING AND DEVELOPMENT

• The centre did not have a policy or procedure in place regarding substance misuse.

THEME 10: IDENTIFICATION, ASSESSMENT AND RESPONSE TO SPECIAL NEEDS

• At the time of inspection, the provider had not employed a dedicated reception officer with the required qualifications in line with the requirements of the standards.
• The provider had not developed a policy to guide staff on how to identify and address existing and emerging special reception needs, as required by the standards.
• The service provider had not employed a dedicated reception officer with the required qualifications in line with the requirements of the national standards.
• Staff had not received specific training that would support them in identifying or responding to potential special reception needs.
• The staff team received minimal information about residents and they did not have a process to assess the needs of residents on their arrival to the centre.
• A reception officer policy and procedure manual had not been developed at the time of the inspection.

Conclusion

The latest HIQA inspection reports for IPAS centres have identified persistent issues of inadequate governance, risk management, Garda vetting, safeguarding, quality assurance programmes, amongst others. These issues demand urgent attention.

Effective governance and accountability, staff training, robust risk management systems, and improved safeguarding measures are crucial to enhancing the quality of life and safety of residents. Addressing these issues requires a concerted effort from service providers, to implement and monitor corrective actions. Ensuring compliance with national standards and fostering a culture of continuous improvement is vital to transform your IPAS centre into a safe, dignified, and supportive environment for all residents.

To address these deficits, services can leverage HCI’s expertise in quality, safety and regulatory compliance. HCI stands at the forefront, providing essential support to IPAS centres. We provide comprehensive support in developing robust Quality and Safety Management Systems. We conduct quality of care audits, develop essential policies and procedures, provide education and training and develop comprehensive risk management programmes. Partnering with HCI ensures your quality assurance programme is strengthened, key areas of concern are addressed, and residents are safeguarded while achieving full regulatory compliance.

For more information on how HCI can help you achieve regulatory compliance and elevate your service standards, please contact us at info@hci.care or call 01 629 2559.