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Audits identify shortfalls in safeguarding practice at HSE community nursing units

By Catherine Reilly - 02nd Aug 2022

Seven safeguarding concerns were not reported by Sacred Heart Hospital and Care Home in Roscommon over a one-year period, according to a HSE audit of implementation of the adult safeguarding policy for social care.

Sacred Heart Hospital, a HSE community nursing unit, reported one safeguarding concern to its regional adult safeguarding and protection team (SPT) in the period examined (1 September 2020-30 September 2021).  Sixty-three people were resident when the HSE auditors visited the unit, which provides residential, respite, rehabilitation, and palliative care.

HSE audits

In 2022 the HSE initiated audits of a random selection of public community nursing units (stratified according to reporting rates) to assess compliance with key requirements of the Executive’s 2014 adult safeguarding policy, which applies to HSE/HSE-funded disability and older persons services.

According to background information on the audit programme, the HSE National Safeguarding Office (NSO) General Manager had “emphasised the importance” of auditing HSE community nursing units given trends in annual reporting and concerns raised by the Community Healthcare Organisation (CHO) SPTs regarding “low reporting and the understanding of abuse in this sector”. The 2020 NSO annual report “referenced the under-reporting of elder abuse as one of the challenges for adult safeguarding”.

The two other sites audited in quarter one of 2022 were Skibbereen Community Hospital, Co Cork, and Clonskeagh Community Nursing Unit, Dublin (summary findings below).

For all three services, HSE Internal Audit provided a “moderate” level of assurance about the adequacy and effectiveness of the governance, risk management and internal control system in the area reviewed. However, the audit reports also concluded that “appropriate governance arrangements and processes” were in place for the safeguarding of residents

None of the units were aware of the NSO safeguarding self-assessment and audit tool. The CHO inter-agency safeguarding committees in the three regions were also not operational at the time of the audits, which took place earlier this year.  

Sacred Heart Hospital and Care Home, Roscommon (located in Community Healthcare West/CHO 2)

Sacred Heart Hospital and Care Home, Roscommon (SHHR) had demonstrated “low reporting rates” in relation to the HSE adult safeguarding policy, noted the audit report. The auditors reviewed national incident report forms and found three unreported safeguarding concerns. A review of the ward complaints logbooks found a further four unreported safeguarding concerns.  

There were 63 residents at the time of the auditors’ visit in March 2022. There were 138 staff comprising a multidisciplinary team “under the guidance of the acting director of nursing”.

In regard to the seven unreported concerns, SHHR had followed the requirements of stage one of the safeguarding policy, which included assessing the situation and ensuring safety of residents affected. However, it had failed to identify and report the incidents as safeguarding concerns. Implementation of the Trust in Care policy may have been warranted for one incident, according to the audit report.

SHHR management agreed that the senior most accountable person in the service should ensure that all safeguarding concerns were reported and managed in line with the HSE safeguarding policy, according to the report.

The audit report, dated 29 March 2022, noted that safeguarding was not a standing item at SHHR quality and patient safety meetings, but it was discussed “when required”. Management agreed that safeguarding should be added as a standing item for local governance and nursing management team meetings.

A review of a sample of vetting records found all staff members had a valid record.

The auditors met six members of staff and only one resident. All staff met by the auditors were familiar with the safeguarding policy, the definitions of abuse, and the reporting requirements at service level.

The one resident who was consulted “stated they were very happy at the centre, felt safe and were aware of how and to whom to report any concerns or complaints”.

A spokesperson for Community Healthcare West/CHO 2 told the Medical Independent (MI): “The HSE Internal Audit found that while concerns which may have met a safeguarding threshold were not reported to safeguarding, all of them had been followed up and managed appropriately. A HIQA inspection carried out after this audit found the unit fully compliant.”

They continued: “The safeguarding and protection team in Community Healthcare West have worked with older persons services’ managers to establish the needs of community nursing units in terms of improving safeguarding within the units.  As a result of this, additional training has been provided to support existing designated officers.  Additional designated officers have also been identified and trained to further support those already in the role.

“The safeguarding team continues to work with services to meet training needs and to further support the application of safeguarding learning to practice.”

Community Healthcare West/CHO 2 interagency safeguarding committee meetings have “recommenced post-Covid-19 with an initial meeting on 5 May 2022”, added the spokesperson.

The most recent meeting prior to the pandemic was on 14 October 2019. “There were no alternative mechanisms in place during the period when the committee did not meet.  However, the safeguarding and protection team remained in touch with the various members of this committee through the casework and oversight functions of the team throughout the pandemic.”

Skibbereen Community Hospital (located in Cork Kerry Community Healthcare/CHO 4)

At Skibbereen Community Hospital (SCH) there was a serious potential safeguarding and health and safety risk for residents and staff that had not been adequately addressed. The risk was escalated by HSE Internal Audit to the Chief Officer of Cork Kerry Community Healthcare/CHO 4. SCH management outlined the measures in place and stated the risk would be “managed and monitored on a continuous basis”.

SCH, which was noted as having had “medium reporting rates”, provides long-stay, respite, community support and palliative care to the older population in the area. At the time of the auditors’ visit in January 2022, there were 28 residents and the majority were living with a cognitive impairment. The centre is registered to cater to 40 residents and occupancy was reduced due to building works and renovation. There were 52 staff members comprising a multidisciplinary team “under the guidance of the acting director of nursing”.

Eight safeguarding concerns were reported during the period examined (1 September 2020-30 September 2021) and were managed “in line with the safeguarding policy”. However, four were found to be “non-compliant with reporting timelines”. SCH management agreed to ensure that all concerns were reported and managed within the prescribed timeframes, according to the report.

No unreported safeguarding concerns were found in a review of national incident report forms and the complaints logbooks.

A review of a sample of vetting records was found to be valid and safeguarding was a standing item at SCH quality and patient safety and nursing meetings, according to the audit report dated 29 March 2022.

Due to “ongoing Covid-19 restrictions at SCH” it was decided that the audit team would not meet with service users or their family members during the site visit in January 2022.

However the auditors met six staff members and all were familiar with the safeguarding policy, the definitions of abuse, and the reporting requirements at service level.

A spokesperson for Cork Kerry Community Healthcare/CHO 4 said it has taken measures “to ensure full compliance with the safeguarding policy (reporting and practice requirements) in the region”.  These included “all team members” having received “awareness raising training” and all sites having a trained designated officer to oversee and coordinate management of safeguarding concerns.

“Learning for safeguarding concerns are shared during nursing management meetings to inform practice,” added the spokesperson.

Cork Kerry Community Healthcare/CHO 4 will reconvene its safeguarding committee meetings in September 2022.

“It was suspended from Q1 2020 to Q4 2022. Due to competing demands for committee members in working through the Covid-19 pandemic and low availability of members to attend, this committee was suspended.”

There had been “ongoing engagement with the quality and patient safety department and internal policies and procedures in responding to matters that arise. The safeguarding and protection management team remained available to all services to discuss complex cases and escalate any concerns during this time.”

Clonskeagh Community Nursing Unit (located in Community Healthcare East/CHO 6)

A review of a sample of vetting records at Clonskeagh Community Nursing Unit (CCNU) found one staff member did not have a valid vetting record (this has been rectified, according to the CCNU management response). Safeguarding was not a standing item at the CCNU quality and patient safety meetings, but was discussed “when required”. CCNU management stated that safeguarding was now a standing item on the local QSR [quality, safety and risk] community meeting agenda, according to the report dated 30 March 2022.

CCNU, which was noted as having had “medium reporting rates”, provides long-term, respite and day services. Some 80 residents were living at the centre at the time of the auditors’ visit in February 2022. The unit had 125 staff members representing a multidisciplinary team “under the guidance of the director of nursing”, according to the report.

Six safeguarding concerns were reported in the period examined (1 September 2020-30 September 2021) and these were managed “in line with the safeguarding policy”. However, five were found to be “non-compliant with one of the reporting timelines”. No unreported safeguarding concerns were found in a review of national incident report forms and the service’s complaints logbooks.

However, the unit’s standard operational procedure (SOP) for reporting and managing allegations of older persons’ abuse was signed as read and understood by only 58 out of 125 staff. Management at CCNU accepted a recommendation to ensure all staff sign the SOP as being read and understood by 31 May 2022.

During their site visit, the auditors met six staff members and all were familiar with the safeguarding policy, the definitions of abuse and the reporting requirements. They spoke with only one resident during a walkaround, who stated they were “happy at the centre and was aware of how and to whom to report any concerns or complaints”.

According to Community Healthcare East/CHO 6, its older persons services “can confirm that the safeguarding audit conducted in February 2022 did identify that Garda vetting was not in place for a member of staff who worked under supervision in an administrative role in our community nursing unit. Garda vetting was immediately sought and is now in place for this staff member and all staff of the community nursing unit.

“We can also confirm that the item identified as ‘not reported in line with safeguarding timelines’ was in relation to the use of equipment. Following further engagement with HIQA inspectors and local management, it was agreed that improved communications between allied health professionals and nursing would mitigate such issues or perceived delays arising in the future.”

The spokesperson said the last “in-person meeting” of the adult safeguarding committee prior to the pandemic was in Q4 of 2019. The committee “reconvened in-person meetings in March 2022 and further meetings have been scheduled for the remainder of the year on a quarterly basis”.

“While the adult safeguarding committee ceased in-person meetings during the Covid-19 pandemic due to social distancing measures and restrictions on face-to-face meetings, the safeguarding team continued to provide a full service to vulnerable adults at risk of abuse, and services and departments continued to liaise with each other on safeguarding issues via virtual meetings.”


The HSE audit reports noted that HIQA, in its most recent inspections, had been satisfied with the measures in place at these units to safeguard residents and protect them from abuse (HIQA inspected SCH and SHHR in 2021 and CCNU in 2020).

A HIQA spokesperson told MI:“The Chief Inspector takes safeguarding very seriously. Inspections of designated centre assess compliance with the specifics outlined in the regulations and make a judgment on this. The audits conducted by the HSE did not assess a provider’s compliance with the regulations on safeguarding and protection, and as such it would not be appropriate for us to comment on the HSE findings. The Chief Inspector continues to monitor the safety and quality of service in all designated centres.”

According to HIQA, all registered providers of designated centres are required by the regulations relevant to the sector (older persons or disability) to have effective safeguarding and protection policies, procedures and training for staff in place.

“These processes and speaking with residents about their experiences in a centre are key aspects of HIQA’s inspection methodology. In addition, each registered provider is also required to review its own services through audits and quality improvement programmes. These are also reviewed during inspections. It is important to note that the HSE’s policy is not mandatory in any privately-operated centre. HIQA continues to advocate for the implementation of safeguarding legislation.”


A HSE spokesperson told MI: “While the overall number of concerns reported for those over 65 increased in 2021, this is still significantly below what would be expected for both community and residential settings, given an ageing population and the evidence from prevalence studies.

“As noted in previous annual reports, the NSO has highlighted the need for detailed analysis on reporting trends (both community and residential) and how best to build programmes that enhance recognition and response to all forms of elder abuse. In this regard, the internal audit report by the Healthcare Audit Unit is welcomed.”

Asked what steps the NSO has taken to ensure implementation of the safeguarding policy in community nursing units and other settings with low reporting, the spokesperson said: “An awareness training programme on the abuse of vulnerable adults (focusing on the recognition of signs of abuse, the appropriate response when concerns arise, and the need to report any safeguarding concerns) is available as a training programme on HSELanD. All HSE staff working in community nursing units are required to undertake this training. This programme includes an ‘Extend my learning’ section for staff and a ‘Manager’s toolkit’ of resources to assist managers build and maintain a culture of safeguarding in their services.

“The NSO continues to respond to requests for capacity building or practice development support. On World Elder Abuse Awareness Day in June 2022 the NSO communicated with all of the community nursing units and encouraged them to raise awareness of elder abuse. The NSO specifically encouraged the units to promote the theme of ‘Rights don’t get old’ and developed resource materials that were circulated to all nursing units both private and public. 

“These materials included promotional items, a list of suggested activities and a discussion document for resident forums to focus on elder abuse. Feedback to this office was encouraged and this feedback will be highlighted in an upcoming edition of the NSO newsletter. Individual safeguarding and protection teams continue to engage with community nursing units in their area to raise awareness of the issue of elder abuse and the reporting structures available to raise concerns.”

In regard to determining whether service users and their family/advocates were informed of local policies and procedures for safeguarding (and that this was available in accessible formats), the HSE spokesperson said the auditors confirmed the presence of relevant information posters and leaflets during walkarounds at the three units.

“All centres held residents’ meetings and undertook satisfaction surveys or focus groups with residents and/or next of kin where safeguarding was included as a topic.”  The auditors spoke with residents during the walkaround “where possible”, according to the spokesperson.

“In summary, while the auditors made every effort to meet with residents where possible, the auditors were able to achieve this objective of the audit whether or not they met with the residents.”

Meanwhile, the HSE said it “noted” the recommendations around the use of the self-audit tool.

“The NSO has taken feedback on the experiences of those who have used the self-audit tool and are currently working to amend and update the tool. The current version of the self-audit tool is available to all services on the safeguarding page of the HSE website and the amended version will replace this in the near future.”

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