A "chaotic" private nursing home in Kerry was slated by health inspectors for its poor hygiene in the midst of a Covid-19 outbreak, with rooms not being cleaned and staff failing to recognise symptoms of the virus in elderly residents.
Oaklands Nursing Home in Listowel, which repeatedly failed to meet nursing home standards in recent months, struggled to contain an escalating outbreak of Covid-19 that ultimately claimed the lives of nine residents and left most of its staff out sick or isolating.
The Health Service Executive (HSE) was ordered by the court to take over the nursing home in November after the nursing homes regulator gave evidence of residents wandering unsupervised and those with Covid-19 mingling with others.
Records released by the nursing homes regulator, the Health Information and Quality Authority (Hiqa), reveal new insights into Oaklands, with claims that rooms were not properly cleaned during the Covid-19 outbreak.
Cleaning products being used in the home were "not appropriate" to keep the home safe. One staff member was "instructed" not to clean a resident's room who had been transferred to hospital, inspectors noted. The resident was transferred back into the still uncleaned room on November 4, the records state. By then the facility was in the grip of a Covid-19 outbreak.
Staff failed to recognise Covid-19 symptoms in residents. The IT system, with all the residents' symptoms and care records, failed over three days during the outbreak and there was no back-up.
The records also show the disquiet that followed the HSE's decision to pull out of Oaklands 12 days after sending in a crisis team to manage the escalating outbreak.
The HSE took charge of the nursing home on November 4 as cases multiplied.
By November 11, 30 residents and 13 staff had the virus, according to an internal Hiqa email.
"The situation has deteriorated considerably over the last 24 hours," the email from Hiqa's chief inspector Mary Dunnion said.
The HSE pulled out five days later, saying it had stabilised the situation, but promising ongoing support for the nursing home.
Hiqa appeared to question the HSE's decision. An internal email noted that the nursing home operators "do not have the capacity or capability to manage this centre".
The general manager of Oaklands had expected the HSE to remain in charge for four weeks, and pleaded with the HSE to return because it was still "in crisis" and unable to manage.
In an email to the HSE, she pointed out that six of her nine nurses were off work because of Covid-19 and they needed a "clinical nurse manager" as "a matter of extreme urgency".
Hiqa asked the court days later to cancel the nursing home's registration and ordered the HSE to resume control of the centre. The HSE closed the nursing home on December 9 and transferred residents to other facilities.
The records chart Hiqa's repeated interventions with the nursing home before finally seeking a court order to cancel its registration.
In an email in July, Hiqa raised "urgent concerns" that staff were not wearing face masks, and that residents transferred to the centre were not placed first in a single room, in line with guidelines.
The nursing home was also asked to account for unsolicited reports it received that a staff member returned to work after a foreign holiday, apparently without self- isolating.
By September, management at Oaklands asked the regulator to lift a ban on admitting new residents, claiming that it had sufficient staff.
However, the following month the nursing home was hit by the second wave of the coronavirus, with the first case detected on October 22, the records show.
In a Zoom meeting with Hiqa on August 16, Michael O'Donoghue, a director of Oaklands, admitted that it could not comply with regulations and had "run out of options" in addressing clinical governance and staff numbers.
The meeting also noted that he was not present at the centre as he lived in the UK while the general manager also had to self-isolate.
Local families have questioned how the outbreak occurred at a time when the nursing home was under such scrutiny from Hiqa.
Families of residents have asked the HSE to preserve patient records and CCTV from Oaklands for a potential future inquiry.
Many families wanted the HSE to continue to operate the nursing home. The HSE has said it did not own the premises and it could not offer residents certainty about their future care.
When the coronavirus claimed its first victim in Northern Ireland on March 19, First Minister Arlene Foster said the pandemic required "a united response" while Sinn Féin's Michelle O'Neill said there was a "collective responsibility" to look after each other.