The government-run Transition to Home service was established in 2020 to allow people with disability to be moved from hospitals into more home-like accommodation while awaiting suitable long-term housing. It operates across two sites, providing up to 53 beds.
Issues with the service were first raised after the 2021 case of a man who was left in soiled clothes with an infected pressure wound, prompting a complaint from ambulance officers who also believed he was malnourished.
The new Labor state government ordered a review of the service earlier this year and the report released on Tuesday revealed poor hygiene, poor wound care, inappropriate admissions and a lack of proper clinical assessments.
It said an internal audit detailed more than 1800 incidents in the 12 months to the end of April including assaults, injuries, care concerns, behavioural problems and medication errors.
The review found the service had not met, or only partially met, a number of recommendations from a previous investigation by the Health and Community Services Complaints Commissioner.
It also raised concerns about the length of stay for most people. While it was anticipated clients would spend up to 90 days at the facility, the average stay was now 207 with the longest 536.
The service caters to people who do not require acute medical care.
The facilities themselves lacked privacy, were sparsely furnished and offered limited access to outdoor areas, the review said.
Human Services Minister Nat Cook said the government would act on the review's findings by employing more staff, delivering ongoing worker training, and by improving risk assessment and monitoring.
She said the facilities would also be subject to both scheduled and spot checks.
"I've long held concerns about aspects of Transition to Home. Complaints brought to my attention before and after coming to government showed we need to do better," Ms Cook said.
"I am working towards an ambitious future where there is no need for a step-down service for NDIS participants leaving hospital, because they will be discharged straight to their home with suitable NDIS supports in place."
The minister said support workers in the Transition to Home service dealt with highly complex circumstances every day and the independent review noted that they were committed to the people they support.
"I'm confident that the actions we're taking to address the review's findings will better support staff to provide a consistent quality service," she said.
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