Introduction
HCI has conducted a review of 10 HIQA Inspection reports for Nursing Homes, published on 23rd February. Of these 10 reports, 100% of nursing homes were not compliant with Regulation 23: Governance and Management. Furthermore, eight of the ten reports identified non-compliance across four or more regulations, signalling broader systemic weaknesses rather than isolated issues.
A clear pattern emerges from this review. Where governance systems are weak, the impact is rarely confined to one area. Instead, failures in oversight, accountability and risk management create knock-on effects across staffing, safeguarding, incident management, infection prevention and control, training compliance, complaints handling and fire safety assurance.
The evidence is consistent: governance is not simply one regulation among many — it is the regulatory foundation upon which all other areas depend. When governance structures do not function effectively, compliance deteriorates across multiple domains.
Below is a summary of the non-compliant findings under Regulation 23 (Governance and Management), in addition to by poor findings linked to Regulation 16 (Training and Staff Development), Regulation 27 (Infection Control), Regulation 4 (Written Policies and Procedures), and Regulation 34 (Complaints Procedure).
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Regulation 23 — Governance and Management
1) Audit and oversight systems that don’t spot problems or don’t fix them.
A recurring theme under Regulation 23 is that audits may exist, but they aren’t reliably identifying issues, aren’t being completed, or aren’t driving improvement.
- There were inadequate systems of oversight in place to monitor and respond to issues of concern found by the inspectors, particularly in relation to care planning, healthcare, safeguarding, residents rights, the premises, infection prevention and control, and medication management.
- Audit programmes were not consistently adhered to, in some cases audits were incomplete and not signed or dated, and some had not been done since mid-August.
- Disparities between audits results and the inspection findings indicated that there were insufficient assurance mechanisms in place to enable quality improvement.
- The Provider’s maintenance audit completed shortly before inspection reported 100% compliance, but inspectors identified defects during the visit.
- Meetings and audits conducted did not always have documented aligned action plans, resulting in issues identified not being addressed in a timely and appropriate manner.
- Several actions from the provider’s compliance plan were not completed within the agreed time frame, including items relating to a resident directory, fire evacuation maps, fire risk assessment, and maintenance.
- Audits were completed, but they did not identify key trends. Inspectors referenced significant weight loss not being detected through audit review, and there were no quality improvement plans derived from audits.
2) Unclear accountability and escalation
Some reports point to governance structures that don’t clearly define who is accountable for key safety issues, and how concerns escalate to the provider.
- Inspectors found that the specific roles, responsibilities, and accountability of the management team in relation to the supervision and oversight of the service were not clearly defined. The pathway of escalation to the registered provider was unclear.
3) Not enough staff and resources to deliver safe, consistent care
In several reports, inspectors point to resourcing and staffing gaps as a key governance failure, sometimes with direct impacts on oversight and residents’ experience.
- Staffing resources were not maintained in accordance with the statement of purpose, noting multiple vacancies and the resulting impact on oversight and quality.
- Inadequate resourcing was evidenced by the absence of a registered nurse on duty for three separate days.
- Insufficient staffing resources in place to meet the assessed care and supervision needs of the residents, in particular, resident with enhanced supervisory needs.
- One registered provider committed to 4 whole time equivalent (WTE) activities coordinators to provide activities. However, on the day of the inspection there were only 3.2 WTE activities co-ordinators employed, with these post holders redeployed if there was a shortage of HCA’s to deliver direct care to residents.
4) Risk Management, Safeguarding and Incident Oversight Failures
A recurring and serious theme under Regulation 23 relates to weaknesses in how centres identify, investigate, escalate and learn from risk and incidents, including safeguarding concerns.
- A safeguarding incident involving residents had not been investigated, although it had been documented and reported to the person-in-charge.
- The system in place to manage risk was not effectively utilised. Risks in relation to the care environment had not been identified and managed.
- There was a failure to provide a full disclosure of an event resulting in a serious injury of a resident.
5) Fire safety governance: repeat deficits and weak assurance
Fire safety appears repeatedly as a governance and management issue, especially where systems fail to ensure risks are addressed and controls maintained.
- HIQA found that fire safety management systems were not sufficiently robust, noting repeat deficits from a 2021 fire safety risk assessment and examples including issues with fire doors, the alarm system, and staff understanding of panel annotation.
- The fire safety assurance systems were ineffective, and an immediate action was issued regarding insecure oxygen storage.
6) Transparency and records failures
Good governance depends on accurate records and clear reporting, some inspections flagged real concerns around the quality and availability of information.
- The record management systems was not effectively implemented, and not all records set out in Schedule 2 were kept in the designated centre.
- Not all policies in place were in line with legislative requirements. Other policies such as the use of restraints, were found not to be implemented in practice.
- In one centre, not all requested records were available to inspectors.
- Information provided to the Chief Inspector on the day and following the inspection was incorrect and inaccurate.
- An annual review of the quality and safety of care delivered to residents for 2024 was not available in the centre on the day of the inspection, as required by the regulations.
Other Regulations: Poor Findings Highlighted in the Reports
Regulation 16 — Training and Staff Development
Training gaps and weak supervision come through strongly in several reports.
- Action was required to ensure that all staff received refresher mandatory training.
- Staff were not adequately supervised to ensure they implemented local policies and procedures and adhered to best evidence-based practice in respect of upholding residents’ rights and providing safe care and reducing the risk of harm to the residents.
- It was difficult to assess the degree of compliance with training requirements as many staff did not have dates of training completed, other staff were not included in the training matrix so there was no information available regarding their training.
- Training gap identified for kitchen staff relating to dietary requirements and modifications.
Regulation 27 — Infection Control
HIQA repeatedly identified basic IPC controls not being in place or not being followed consistently.
- In once centre inspectors cited issues such as alcohol hand-rub availability, sharps bins were stored incorrectly, yoghurt’s were left on drug trolleys, waste segregation, and housekeeping task-mixing.
- Inspectors found an ARI outbreak was not detected or managed in a timely manner, with gaps in testing, surveillance, and equipment servicing. Failure to respond to the potential outbreak in line with local guidelines impacted effective IPC within the centre.
- Poor adherence to hand hygiene and PPE practices.
- Some areas of one centre (treatment rooms, kitchenettes, sluice rooms, one bathroom) and residents equipment were visibly unclean.
- Deep cleaning records were not consistent with the findings on the day of the inspection.
- Hand hygiene facilities were not in line with best practice guidelines.
- Two bed pan washers were out of order with no sign on the machine to direct staff. Two of the sluice rooms had stained equipment on the clean rack, indicating that contaminated equipment may not have been cleaned properly.
- Clinical waste was not segregated in line with best practice guidelines.
Regulation 4 — Written Policies and Procedures
Policies were flagged where they didn’t match current regulatory requirements.
- Recruitment policy not reflective of Schedule 2 requirements (registration details, references including most recent employer).
- Safeguarding policy had not been updated to reflect the legislative changes implemented at the end of March 2025.
Regulation 34 — Complaints Procedure
Complaints handling was criticised in several centres, often linked to training, timeliness, or policy gaps.
- The nominated complaints officer had not met the complainant to investigate the complaint.
- The registered provider had not ensured that the nominated complaints officer had received suitable training to deal with complaints.
- The registered provider had not ensured complaints were managed in accordance with the timelines set out in the providers policy and regulatory requirements.
- Complaints procedure was not displayed in a prominent position in the designated centre as required by the regulation.
- A number of complaints raised were not being managed in line with the provider’s complaints policy and as required by the regulation.
- Verbal complaints raised by residents and families that had not been resolved at the point of contact and within 48 hours had not been escalated to the complaint officer for formal investigation.
- Complaints procedure was not updated to reflect the amended regulations (from 1 March 2023), including missing review timeline, written response, and nomination of distinct roles complaints/review officers.
Conclusion: What these reports are telling us
Across these inspection reports, HIQA is repeatedly signalling the same core issue: governance systems must function as real assurance mechanisms, not just documentation. When oversight is weak, the problems that follow are predictable – staffing gaps, missed risks, poor infection control, outdated policies, and complaints processes that don’t protect residents properly.
The sharpest takeaway is this: many of these findings are not isolated “one-off” issues. HIQA describes failures of systems, audits that don’t detect problems, action plans that don’t land, and governance structures where accountability and escalation are unclear. When that happens, the same issues return, often across multiple inspection cycles.
If your goal is to move from “inspection response mode” to continuous readiness, tools like Cloda can help services turn inspection themes into trackable actions, supporting governance visibility, audit follow-through, and evidence that improvements are actually embedded in day-to-day practice.
Introducing Cloda: A Smart Digital Assistant for Nursing Home Compliance
For nursing homes looking to strengthen HIQA compliance and support staff utilisation of the best practice policies you have invested in, Cloda is the compliance management system you need.
Cloda is the digital assistant available in staffs’ pocket to provide the answers they need to your policies and procedures — in their own language. In doing so, Cloda helps staff to deliver safer care, aligned with your best practice policies and procedures, and HIQA’s expectations. Because Cloda is mobile-friendly, staff can access her support instantly, when and where they need it.
Cloda helps translate HIQA regulations into day-to-day practice. As the regulatory landscape evolves with updates to standards, new thematic inspections, and revised national guidance, Cloda ensures staff are always working from the most current, organisation-approved policies and procedures. Her instant support allows staff to query information when required, helping confirm that their actions align with up-to-date regulatory expectations. With instant access to procedures, teams reduce variation in practice and improve consistency.
Built-in comprehension quizzes support managers to evidence that staff have read and understood key policies, while centralised training oversight helps streamline mandatory training requirements and highlight gaps before they become inspection findings. With real-time visibility of compliance, risk themes, and policy engagement, Cloda enables providers to move from retrospective inspection preparation to proactive governance — strengthening assurance under Regulation 23 and across the wider regulatory framework.
For more information or a demo of Cloda, contact info@cloda.ai or call 01 629 2559.
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