Health inspectors did not visit a scandal-hit care home for six months despite it having been threatened with closure over concerns for residents' safety.
The Regulation and Quality Improvement Authority (RQIA) visited Clifton Nursing Home on June 24 last year to ensure it was meeting minimum standards, just weeks after serious concerns about conditions in the home had been raised.
It has now emerged that the watchdog did not carry out another inspection until five weeks ago, on January 7.
The results of that inspection have yet to be made public.
In May last year, the Belfast Trust took the unprecedented decision to move all residents from the home. It came after there were nine Covid-related deaths of residents, one resident sustained an unexplained fatal head injury and a nurse working there was left fighting for her life after falling ill with coronavirus.
Julieann McNally, from CHASNI (Care Home Advice and Support NI), criticised the gap between inspections by the RQIA in light of the long-standing serious issues at the home.
"We are very concerned that the RQIA has taken six months to return to Clifton Nursing Home, given the serious failings identified by the RQIA and the Belfast Trust at the start of the pandemic," she said.
"We would expect the RQIA to have conducted monthly visits to Clifton throughout 2020 to ensure the residents were all safe.
"This has been going on for seven years now without any sustained improvement.
"This means our system of regulation is not fit for purpose. We need urgent change."
Clifton Nursing Home has repeatedly appeared in news headlines over the years for a litany of distressing failings.
Health inspectors raised concerns about infection control failings in the 12 months leading up the pandemic, while the Belfast Trust had been supporting the home for 18 months.
The RQIA then uncovered scenes of chaos inside the facility during inspections on May 15 and 21 last year.
Among the findings, the manager of the home was wearing her personal protective equipment inappropriately, equipment such as stethoscopes and thermometers were either not available or were faulty, some communal areas required a deep clean and a nurse was observed to be upset and overwhelmed.
The findings of the inspection, which took place after the Belfast Trust raised concerns, were so serious that a meeting was called with management.
Reassurances were provided that failings would be addressed. However, concerns were subsequently raised by the Belfast Trust, the Public Health Agency and the Department of Health.
Following a further inspection on May 21, the home was considered so dangerous that health bosses took the decision to move residents for their own safety.
This was avoided when a new care home provider stepped in to manage the home on a temporary basis. The RQIA then returned to the facility in June and found it was compliant.
An RQIA spokesman said that as a result of the June inspection, it was "assured the necessary actions had been taken to address" concerns. He added the watchdog had continued to monitor the home since, with inspections playing part of this process.