Some records indicated that residents were receiving very little food or fluids throughout the day. One indicated that the resident had eaten a regular diet "despite the fact that she had chewing and swallowing difficulties". The person in charge indicated this resident would not have been able to eat the food items that were written on the food in-take record.

Other shortcomings highlighted by HIQA included:

- Failure to refer some residents with dental decay for dental treatment.

- A generic care plan rather than individual plans to meet assessed needs.

- Care assistants, most of whom had no training, working unsupervised.

- Concerns over personal items going missing.

- Not all staff files contained evidence of Garda vetting.

- Staff insufficiently trained on the prevention, detection and response to abuse.

On a more positive note, most residents and relatives told inspectors the care was satisfactory; interaction between residents and staff was "pleasant and warm" when the inspection was carried out last November and there was safe practice in relation to the administration and storage of medicines.

In response to HIQA’s findings, the service provider, Patricia McCarthy said any resident that had significant weight loss "did have malnutrition assessments completed". "It appears from the [HIQA] report that no action had taken place, although this was not the case," she said.

She added that one week before the inspection, the person in charge had left the premises, having given one week’s notice. Ms McCarthy also said one registered nurse had been allocated to the management of the residents’ weight.

HIQA carried out an unannounced follow-up inspection at the end of December and was "satisfied with the systems in place to ensure the ongoing management of residents who have weight loss". HIQA said most of the commitments outlined in an action plan from the service provider had been fulfilled. However, they found other areas in need of improvement, including the urinals, which were "stained with stale urine"; the temperature, which was very low in one wing and gaps in recruitment practices. The files of the two most recent staff recruited were reviewed. Although three references were legally required it found there was only one reference on both files.