The Policy Gap in IPAS Centres: What HIQA’s Latest IPAS Inspection Reports Reveal

Summary of Findings

Across the inspection reports, HIQA identified a number of policy-related weaknesses. These included missing policies, policies that were not aligned with national requirements, procedures that lacked practical guidance, and policies that had been developed but were not being implemented consistently.

Key findings included:

Theme 1: Missing policies

In one centre, HIQA found that there was no local policy to guide staff on the issuing of verbal or written warnings to residents. This created a gap in procedural fairness and consistency, particularly in an environment where decisions affecting residents should be transparent, proportionate and clearly documented.

Where policies are absent, staff may be left to rely on individual judgement rather than agreed organisational procedures. This increases the risk of inconsistent practice and makes it harder for providers to evidence fair decision-making.

Theme 2: Policies not aligned with national requirements

Several reports identified policies that did not fully reflect national requirements or sector-specific expectations.

For example, HIQA found that a recruitment policy did not align with the IPAS child protection policy, particularly in relation to the requirement to obtain three references for new staff. In another centre, recruitment practices were also found to be inconsistent with relevant vetting and child protection expectations.

This is a significant issue. Recruitment policies in IPAS services must do more than describe a general HR process. They need to reflect the safeguarding responsibilities of services that accommodate children, vulnerable adults and people who may have experienced trauma, displacement or exploitation.

Where policies are not aligned with national guidance, providers may unintentionally create gaps in safeguarding, accountability and regulatory compliance.

3. Policies lacking sufficient practical guidance

HIQA also found examples of policies that existed but did not provide enough practical guidance for staff.

In one centre, safeguarding statements and policies did not provide robust guidance on how staff should respond to adult safeguarding or child protection concerns. The policy for managing allegations against staff also lacked clear detail on how such allegations would be managed by the provider.

This highlights an important distinction: having a policy is not the same as having an effective policy.

For policies to support safe practice, they must be clear, practical and usable. Staff need to know:

• what to do
• when to escalate
• who to report to
• what records to complete
• what timelines apply
• how concerns will be reviewed and followed up

Without this level of clarity, even well-intentioned staff may respond inconsistently to serious issues.

Theme 4: Policies not implemented in practice

A recurring concern across the reports was the gap between written policy and actual practice.

HIQA found examples where centres had policies, procedures or commitments in place, but these were not fully implemented. For example:

• The centre had committed to using a standardised meeting agenda covering key areas such as safeguarding, risk, fire and incidents, but this had not been implemented.
• Fire drills had not been completed in line with local policy.
• The risk management policy did not guide staff on regular review of ongoing risks, meaning all risks had the same annual review period regardless of severity.
• The supervision policy had not been implemented, with formal structured supervision not taking place for almost a year.
• The risk escalation procedures were not followed in relation to known fire and structural risks.
• The centre had developed a supervision policy, but it was not yet fully implemented for all staff.

These findings show that compliance depends not only on policy development, but on implementation, monitoring and assurance. A policy that is not understood, accessed or followed in practice will not protect residents, support staff or satisfy regulatory expectations.

Theme 5: Policies requiring consolidation or development

HIQA also identified areas where policies required further development or consolidation.

In one centre, there were multiple policies relating to reception and vulnerability assessment that required consolidation. This created a risk of confusion and inconsistency in how residents’ needs were identified, recorded and followed up.

Another centre had not yet developed a supporting guidance document for the Reception Officer role. This is important because the Reception Officer role is central to helping identify and respond to residents’ needs, including special reception needs and vulnerabilities.

Where multiple overlapping policies exist, or where role-specific guidance is missing, staff may not have a clear operational framework for carrying out their responsibilities.

The Overall Policy Message from HIQA

Across the five reports, HIQA’s concern was often not simply that policies were missing. The broader issue was that policies were sometimes:

• incomplete
• inconsistent with national requirements
• lacking practical detail
• not accessible enough to guide daily practice
• not embedded through supervision, training and governance
• not monitored for implementation

This points to a wider policy implementation gap.

In IPAS services, policies and procedures must be living tools. They should support staff at the point of need, guide consistent decision-making, and provide providers with assurance that standards are being applied in practice.