Hiqa inspection found medication management issues at Cork Horizons centre
The centre was found not compliant in seven areas and substantially compliant in one, with issues around staffing, the complaints procedure and the premises itself being noted by inspectors.
A HIQA inspection into the Cork City South 1 centre for adults with disabilities, operated by Horizons, identified several issues to do with the management of medications.
The centre was found not compliant in seven areas and substantially compliant in one, with issues around staffing, the complaints procedure and the premises itself being noted by inspectors.
The inspection into one particular house in the centre was undertaken after the chief inspector of Social Services received information which raised concerns, particularly relating to medicines management practices.
As a result, the provider was issued with a provider assurance report (PAR) in July 2025.
While the PAR response given by the provider contained a lot of information, some of the specific questions asked were not fully answered, hence it was decided to conduct an inspection.
During the inspection it was indicated that a medicines audit had not taken place since early 2024. Communication received after the inspection indicated that there was meant to be twice yearly medicines audits but that due to an error, they had been taken out of the schedule.
In the PAR issued, the provider was asked if there had been any instance identified or alleged of a staff member administering medicines but signing the name of a different staff member. The PAR response said that no clear evidence had been found to suggest this had occurred, but did not address if it had been alleged.
In light of this, it was queried during the inspection if there was any allegation of a staff member administering medicines but signing the name of a different staff member, and it was suggested that there had been no such allegation.
However, when confirmation of this was requested in writing, communication was received after the inspection which confirmed that there had been three such allegations raised between September 2024 and August 2025 - none of them had been notified to the chief inspector though regulations state that issues of this nature should be reported within three days.
In the response to the PAR submitted by the provider, it was identified that a number of medicine errors had been identified for one resident such as the resident receiving one medicine from staff who were not trained to administer it, and not receiving another prescribed medicine.
The PAR response from the provider assured that a specific protocol in relation to medicines administration for the resident involved had been introduced.
The inspector also found that a medicine that had expired in April 2025 was still being administered.
Horizons said after the inspection that the out of date medicine was a multivitamin which had been received from the person’s family members and transferred into the old container, which resulted in the inspector misunderstanding that it had expired when this was not the case.
They added that a review of all medicine management in the centre had been carried out, and actions and measures will be implemented to prevent any reoccurrence of issues raised.
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