New HIQA Inspection Reports for IPAS Centres identify critical non-compliance issues in Governance, Risk Management and Safeguarding

Introduction

HIQA published a further eight inspection reports for International Protection Accommodation Services (IPAS) in May 2024. The reports highlight varying levels of non-compliance, but major non-compliances are identified in relation to governance and management, responsive workforce, contingency planning and emergency preparedness, accommodation, person centred care and support, safeguarding and response to special needs.

The common high-risk areas are in relation to governance, risk management and safeguarding, similar to the findings identified in HIQA’s first set of inspection reports for IPAS centres, released in April 2024. It is imperative that you review the findings of these inspection reports and identify the learnings for your service.

In this article, we provide a summary of the high-risk findings under the related Theme of the National Standards for accommodation offered to people in the protection process (2019).

Summary of Major Non-Compliance Findings in IPAS Centres

THEME 1: GOVERNANCE, ACCOUNTABILITY AND LEADERSHIP

• The service provider had not implemented systems to ensure appropriate oversight and monitoring of the quality of care and experience of adults living in the centre. While the provider had developed audit frameworks for quality improvement, these had not been put in practice at the time of the inspection.
• There was an absence of operational policies and procedures essential for the delivery of the service and to guide staff in delivering appropriate supports to residents. For example, there was no policy on adult safeguarding.
• There were no developed governance, accountability and oversight systems to ensure that service delivery was safe and effective. For example, there were no records for meetings with the service provider and staff felt unsupported in their roles.
• There were poor management systems to promote and uphold the rights of residents, and as a result some residents felt unsafe living in the centre.
• There was significant evidence to demonstrate that the service provider did not have the capacity or capability to self-assess in terms of compliance with the national standards or for areas which require improvements. For example, a self-assessment audit was completed in the centre containing a quality improvement plan listing 30 required actions, however, many standards assessed were listed as being much more compliant than the findings of the inspection.
• While a suggestion box was in place in the centre, there were no records to demonstrate that the provider routinely collected feedback from residents to inform practices.
• There was no residents’ charter available to residents at the time of inspection.
• There were no formalised monitoring or review arrangements in place in the centre. Deficits in record keeping limited the potential for the provider to review service provision, or to evidence any previous improvement initiatives they may have implemented.
• The provider had not carried out an annual review of the service.

THEME 2: RESPONSIVE WORKFORCE

• Garda vetting for two staff members was out of date and there were no international police checks available for some staff members employed in the centre who had periods of residence outside Ireland.
• In some files reviewed there was an absence of job descriptions, contracts, references and induction records for their current roles. In many cases, no application forms or work histories were recorded for staff members.
• In addition to the staff members directly employed, there were no Garda vetting records for security staff in the centre or with their contractor company.
• There was no staff recruitment policy in the centre, and no written references for the staff members employed in the centre.
• There was an absence of regular formal supervision for staff members or centre managers as required by the national standards. A formal performance appraisal system was not in in place for staff members at the time of the inspection.
• There were no clear reporting mechanisms for staff, who communicated information on an informal basis. While it was observed that staff were endeavouring to operate the centre as effectively as possible, deficits in staff support and supervision contributed to a lack of clarity regarding roles and responsibilities.
• Staff were recruited before Garda vetting checks were completed and there was no system in place to assess risks which may arise from these checks.
• There was no evidence of Garda vetting for support staff members who were indirectly employed in the centre. In addition, references and photo identification was not available on all staff files as required.
• The provider had not undertaken a training needs analysis to ensure all the required training as prescribed in the national standards was delivered to the staff team. The full staff team had received child protection training but none had received training in the safeguarding and protection of vulnerable adults. Members of the management team had received training in mental health awareness and conflict resolution, however, there was a significant gap in the training requirements as outlined in the national standards. 

THEME 3: CONTINGENCY PLANNING AND EMERGENCY PREPAREDNESS

• While the provider had a risk register in place it was not comprehensive.
• The risk management system in place in the centre was found only to consider some limited health and safety and organisation or corporate-related risks.
• The provider had not completed a risk analysis for the centre to identify, assess, or control risks and hazards that may compromise the safety and wellbeing of residents and the quality of service provision.
• Although a risk assessment system was in place, the inspectors identified risks that were not assessed, recorded or managed appropriately.
• The service provider had not put in place an effective risk management framework and policy.
• While the health and safety statement listed regular fire drills as a control measure, the inspectors found that there were only two records of completed fire drills in the previous five-year period. Multiple residents told inspectors that they had not been informed about evacuation plans in the event of an emergency. Moreover, some residents had additional support needs and would require assistance during evacuations and emergencies, however, there was an absence of comprehensive risk assessments on these matters.
• While there was a register of some potential risks in the centre (such as compliance risks and fire safety risks), these had not been evaluated in any depth and consequently records of control measures contained limited information and were poorly defined. Some potential risks in the centre, in relation to resident safety, had not been identified. Additionally, other known risks in the centre had not been assessed and staff were uncertain as to how they were to manage them.
• The continuity of the service and contingency planning for staffing or an emergency situation had not been addressed in risk assessments reviewed during the inspection.

THEME 4: ACCOMMODATION

• The provider had not ensured that the dignity and safety of residents was protected and promoted. There were examples of limited storage in some of the bedrooms and these spaces, in many cases, did not provide a safe environment or promote the safety and dignity of residents living there.
• There was security supports in place at night time in the centre but the inspectors were not assured that these measures were appropriate and effective.
• The service provider was using bunk beds to accommodate adult residents in rooms although residents had not requested these beds. The floor space in bedrooms was limited. The system used to record maintenance issues in the centre required further development so that the timeline from when the issue arose to the date it was completed was recorded and monitored.
• Residents were not provided with sufficient non-food items such as bedding, linen and toiletries. In addition, there was no engagement or consultation with residents on the types or varieties of non-food provided in the centre.

THEME 6: PERSON CENTRED CARE AND SUPPORT

• There was evidence that complaints were poorly managed and there was no learning from incidents or complaints. Most of the residents who had made complaints to the management team told inspectors that they were not happy with how they were handled or the outcomes of the investigations. Residents did not feel listened to and some told inspectors that some staff members were openly biased and that that there was favouritism displayed on occasion. Some residents spoken to were not aware of the complaints procedure or information in relation to external complaints remedies.

THEME 8: SAFEGUARDING AND PROTECTION

• Incidents of a safeguarding nature that had occurred in the centre were not appropriately managed and reported. While residents felt safe, there was an absence of an adult safeguarding policy and inspectors were not satisfied that the centre had adequate systems in place to identify and respond to adult safeguarding issues. There was an absence of information on display in the centre on how residents could report adult safeguarding concerns.
• The service provider had not ensured that all incidents or adverse events were recorded and there was no system to oversee and monitor concerns relating to the safeguarding of all residents.
• There were also no arrangements in place for information about incidents to inform risk management practices or to learn from these incidents as part of continual quality improvement to enable effective learning and reduce the likelihood of reoccurrences.
• There were no records showing how the management team responded to complaints and incidents raised by residents. However, there were records by management responding to complaints lodged directly to DCEDIY. There were no risk assessments on incidents that had repeatedly occurred in the centre.

THEME 10: IDENTIFICATION, ASSESSMENT AND RESPONSE TO SPECIAL NEEDS

• The provider had not prepared or implemented a policy to identify, communicate and address existing and emerging special reception needs of residents.
• Appropriate support was provided to residents where special reception needs had been identified in a person centred and respectful manner. However, a policy had not been developed to support staff to identify, communicate and address existing and emerging special reception needs of residents, as required by the national standards.
• A system to record the supports and assessments completed by the reception officer with residents needed to be developed.
• The service needed to ensure there was a mechanism in place where the special reception needs of residents was monitored appropriately.

Conclusion

The HIQA inspection reports for IPAS centres have identified persistent issues of inadequate governance, risk management, garda vetting, safeguarding demand and response to special needs, all of which demand urgent attention. Services must undertake a comprehensive review of these findings to identify and address gaps in their systems and processes to ensure compliance with the National Standards and improve the quality and safety of care provided.

To navigate these challenges, services can leverage HCI’s expertise in quality, safety and regulatory compliance. HCI is at the forefront, providing essential support to IPAS centres. We offer comprehensive support in developing robust Quality and Safety Management Systems. We can also conduct quality of care audits, develop policies and procedures, provide education and training and develop comprehensive risk management frameworks. By partnering with HCI, you can enhance your governance structures and address key areas of concern, thereby safeguarding the well-being and dignity of your residents.

For more information on how HCI can assist you in achieving regulatory compliance and safeguarding residents, please contact us at info@hci.care or call 01 629 2559.