Why Internal Audits Are Central to Governance and Management Failure in Nursing Homes

Introduction

Internal audits are intended to be one of the strongest safeguards within a nursing home’s governance framework. They are designed to identify risk early, provide assurance to providers, and drive continuous improvement. Yet, recent HIQA inspections tell a very different story.

HCI’s review of 25 HIQA inspection reports found a recurring and concerning pattern: internal audits frequently indicated compliance, while inspectors identified serious risks on the day of inspection. This disconnect sits at the heart of Regulation 23 – Governance and Management failures and is a key driver of repeat non-compliance and regulatory escalation.

Regulation 23 and the Role of Audit in Governance

Regulation 23 of S.I. No. 415/2013 – Health Act 2007, requires providers to ensure that their service is well governed, effectively managed, and subject to ongoing monitoring and review — and internal audits are one of the key mechanisms through which this assurance should be demonstrated. This expectation is further reinforced under Theme 5: Leadership, Governance and Management of the National Standards for Residential Care Settings for Older People in Ireland, where Standard 5.4 states that the quality of care and residents’ experience must be monitored, reviewed and improved on an ongoing basis. In practice, this means audits must do more than confirm policies exist — they must systematically test real practice, identify emerging risk before incidents occurs, and ensure findings are reported, implemented, and actively monitored to drive continuous improvement across the service.

When audits fail to fulfil this role, governance is weakened. Inspectors do not view audits as a “nice to have” — they view them as a fundamental control. Where audits are ineffective, Regulation 23 is unlikely to be met.

What HIQA Is Actually Finding In Relation To Audits

Across the inspections reviewed, HIQA identified significant weaknesses in audit effectiveness. Inspectors found a misalignment between audit results and actual practice. In several cases, audits reported compliance, yet inspectors observed unsafe care, environmental risks, or poor staff practice during inspection. This was particularly evident in high-risk areas such as fire safety and infection prevention and control.

Audit programmes often failed to include key areas of risk. Fire safety risks — including damaged fire doors, unsafe storage and incorrect signage — were missed by internal audits. IPC audits did not identify unsafe practices, such as inappropriate chemical preparation or storage trollets in contaminated areas. In one centre, wound care audits identified inconsistencies, but no follow-up occurred for over two months.

Inspectors also noted challenges in accessing and using audit data, particularly where electronic audit systems were in place but not effectively utilised. Audit findings did not consistently translate into clear quality improvement plans, nor was there evidence that improvements had been sustained.

HIQA’s message is consistent: the issue is not the absence of audits, but the absence of assurance.

Why Traditional Audit Models Are Failing Providers

Many audits remain checklist-driven, focusing on whether documentation exists rather than whether care is delivered safely and consistently. This approach may confirm that a policy is in place, but it does not test whether staff understand it, follow it, or can apply it under pressure.

Audits are often completed in isolation, without sufficient linkage to governance oversight. Findings may be recorded, but ownership is unclear, escalation is limited, and follow-up is inconsistent. Action plans are closed without verification that risk has actually reduced.

There may be a tendency to audit what is easiest to measure, rather than what poses the greatest risk. High-risk, complex areas such as out-of-hours escalation, evacuation capability, or staff decision-making are less frequently tested, despite being central to inspection outcomes.

The result is a high volume of audit activity with limited impact.

What HIQA Expects an Effective Audit System to Demonstrate

The inspection findings provide a clear indication of what HIQA expects from audit systems in practice.

Effective audits:

• Test real practice, not just documentation
• Include observation, staff knowledge and resident experience
• Focus on high-risk areas aligned to inspection priorities
• Lead to timely, proportionate action
• Are reviewed and challenged at governance level
• Demonstrate that actions taken have reduced risk

Inspectors look for evidence that audits are used as a tool for learning and improvement, not simply as a record of compliance.

How HCI Supports Effective Audit and Assurance

HCI supports nursing homes by delivering a tailored Independent Quality of Care Audit Programme, providing objective oversight and assurance that care is aligned with HIQA requirements and best practice.

Our specialists carry out thorough assessments against the relevant regulations and National Standards through a structured approach that includes offsite documentation review, onsite audits, staff interviews, and observation of practice, resulting in evidence-based findings and clear, actionable recommendations.

Each audit delivers a detailed report outlining areas of good practice alongside a line listing of opportunities for improvement, supported by a Quality Improvement Plan that gives Registered Providers a practical roadmap to strengthen governance, reduce risk, and demonstrate a clear commitment to continuous quality and safety improvement.

Conclusion

Internal audits should be one of the strongest protections a nursing home has. When they fail to identify risk, governance fails with them.

If your audit never makes you uncomfortable, it may not be asking the right questions.

The recent HIQA findings provide a clear opportunity for providers to reflect, reset, and strengthen assurance — before inspection, rather than because of it.

If your nursing home requires regulatory, quality or resident safety support then contact HCI at +353 (0)1 6292559 or info@hci.care to find out how we can help you.