Intervention report concerning Orchidée 1 and 2, intermediate resources | Protecteur du Citoyen
June 30, 2016

Intervention report concerning Orchidée 1 and 2, intermediate resources


Two intermediate resources, Orchidée 1 and Orchidée 2, located in the Montréal region, are residences for a client population with severe mental impairments. Some users also have a physical disability, need a wheelchair or are non-verbal.

Further to a report describing failings in the quality of care and services to residents at Orchidée 2, the Québec Ombudsman decided to intervene and broaden its investigation to Orchidée 1.

The investigation revealed similarities in how services are organized at both resources. The Québec Ombudsman observed the following in particular:

  • deficient risk management for a highly vulnerable client population;
  • given the complexity of the users’ needs, an insufficient number of employees available for all of the obligations that must be met;
  • substantial flaws in the satisfaction of users’ needs and respect of users’ rights.

As a result, the Québec Ombudsman made four recommendations to CIUSSS du Centre-Sud-de-l’île-de-Montréal, the institution responsible for both resources. They concerned staff training, the assessment of users and establishing a fire evacuation plan.

Further to the investigation, the CIUSSS committed to the measures required for implementing the recommendations.

N.B. Recently the CIUSSS decided to close Orchidée 2 and to only maintain contractual ties with Orchidée 1.