Vulnerable residents in a home for the intellectually disabled ended up hitting and biting each other, almost on a daily basis, a damning inspection report has revealed.
The St John of God-run campus in Drumcar, Co Louth, was so seriously under-staffed that some residents had to be locked alone in a unit, the team from the Health Information and Quality Authority (Hiqa) discovered.
The inspectors received a report last April on an alleged physical assault by a temporary member of staff on one of the 16 residents, none of whom can communicate verbally.
The alleged incident should have been reported to the gardaí earlier.
The inspectors who visited the facility in February and April found ineffective leadership and management, and poor safeguarding practices.
It detailed one poignant episode where one of the residents in a wheelchair was left behind because nobody was available to wheel him to Mass.
"Some time elapsed before the staff member in the house told the resident that he would not be going to Mass by taking off his outdoor coat."
The facility had no private, quiet area. The hallways were so narrow that it was not possible for two people to walk side by side, leading to "altercations" between residents forced to be in such close proximity.
In April, Hiqa found that five of the residents fell more than five times from January to April.
One resident who fell nine times was assessed as at high risk of fracture but "at low risk of falls".
Vulnerable residents were in the sitting room unsupervised on a number of occasions during the day.
The majority of residents in the sitting room or at the dining table had limited or no interaction from staff and no stimulating engagement.
One resident had a communicable infection but shared a room with another person with a wound whose bed was less than a metre away.
Two action plans previously given to Hiqa by St John of God were rejected as inadequate.
It has now submitted another plan detailing corrective action. This includes a new management structure, a review of safeguarding measures and more activities for the residents.
Fine Gael TD for Louth Deputy Fergus O'Dowd said the standards in the home should be deplored. He called for urgent action to protect vulnerable residents.