Oireachtas Joint and Select Committees

Thursday, 5 June 2014

Joint Oireachtas Committee on Health and Children

Annual Overview Report on the Regulation of Designated Centres for Older People 2013: HIQA

9:30 am

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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The committee is in public session. I ask members, witnesses and people in the Gallery to ensure their mobile telephones are switched off for the duration of the meeting as they interfere with the broadcasting equipment and with the staff, even when in silent mode.

This meeting has been convened to discuss the Health Information and Quality Authority's annual overview report on the regulation of designated centres for older people for 2013. I welcome Mr. Phelim Quinn, director of regulation, and Mr. Marty Whelan, head of communications and stakeholder engagement, from the Health Information and Quality Authority, HIQA. I also acknowledge the presence in the Gallery of Mr. Paul Hickey, also of HIQA. They are all welcome and at the outset I thank Mr. Whelan for his courtesy and co-operation in the organisation of both this meeting and all the joint committee's meetings with HIQA, as well as for his ongoing co-operation with the joint committee.

If I may, at this point I wish to compliment, congratulate and thank Dr. Tracey Cooper, the former chief executive officer of HIQA, for her unfailing courtesy and co-operation with members, as well as the professionalism she showed to the joint committee. She was a pleasure to deal with and a breath of fresh air. She brought tremendous zeal and professionalism to her job and role, as well as to her dealings with the joint committee. Perhaps the witnesses could convey to Dr. Cooper our thanks and best wishes for her new career and future and that we wish her well.

Mr. Marty Whelan:

I suspect she is probably watching from Wales as we speak.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Very good.

This morning's meeting concerns the first annual overview report on the regulation of designated centres for older people to be discussed. The report summarises the report findings of 697 individual inspection reports published by HIQA during 2013, along with analysing the regulatory activities HIQA undertook as a result of these findings. It provides an overview of the nursing home sector in Ireland and today members will have an opportunity to consider the report in greater detail.

I wish to remind witnesses of the position in regard to privilege. They are protected by absolute privilege in respect of their evidence to the committee. However, if witnesses are directed by the committee to cease giving evidence on a particular matter and they continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice or ruling of the Chair to the effect that where possible, they should not criticise or make charges against any person or persons or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing parliamentary practice or ruling of the Chair to the effect that they should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable.

Before inviting Mr. Phelim Quinn to make his presentation, I wish to notify members and witnesses that there will be a vote in the Dáil at the conclusion of Private Members' business. I again welcome Mr. Quinn and invite him to make his opening remarks.

Mr. Phelim Quinn:

On behalf of the Health Information and Quality Authority, I thank the Oireachtas Joint Committee on Health and Children for giving me the opportunity to discuss our annual overview report for 2013 on our regulatory programme of designated centres for older people. As the Chairman noted, I am joined by Mr. Marty Whelan, our head of communications and stakeholder engagement. We welcome this opportunity to appear again before the joint committee and to engage with members.

The authority, as part of the remit given to it by an Act passed by these Houses, is responsible for setting quality and safety standards in health and social care services in Ireland with the exception of mental health services. Since 2009, HIQA has been responsible for the registration and inspection of designated centres for older and dependent people. All designated centres for older people are required to be registered by HIQA. The purpose of this regulation is to safeguard vulnerable people who are receiving residential care services. Regulation provides an assurance to the public that people living in such designated centres are receiving a service that meets the national quality standards and regulations. This process also seeks to ensure that the health, well-being and lives of people in residential care are promoted and protected. While I will speak a little bit more about this, regulation also has an important role in driving continuous improvement in order that residents have better, safer lives. We endeavour to always publicly share information about the nature and outcomes of our work.

Today, we are here to discuss our annual overview report of our 2013 regulatory programme in centres for older people. This is the first overview report that we have produced and we are eager to listen to members' views about how these services provided across the country meet the needs of the communities they represent. The report describes a national set of residential services that is vastly better and safer since HIQA first engaged with the sector in 2007, following public concern about the Leas Cross nursing home in north County Dublin. Providers of residential services must be commended on the significant improvements we have witnessed in that span of time. The report provides an overview of the regulation of long-term residential care in 2013. As of 31 December 2013, there were 566 designated residential centres for older people in the country. The majority of these, 75%, were privately provided and the remainder were either provided directly by the Health Service Executive, HSE, or in receipt of HSE funding.

In essence, the report captures the findings of the 814 inspections of 565 centres that HIQA carried out last year. Seventy-eight percent of those inspections were carried out on an unannounced basis, while 22% were on an announced basis. There is a value in unannounced inspections as our inspectors then see a service as it is on that particular day. However, I wish to reinforce the fact that announced inspections also have a value in the regulatory process, as they enable providers to show us their service as they would like it to be seen, as well as enabling us to have access to information and documentation to which we would not have access on an unannounced inspection. Good practice in the care of older people was observed in the majority of the centres that we inspected and our inspectors noted improvements in most centres following inspection. The report also makes clear that there are issues where improvements are required. HIQA inspection reports are in a standardised format and contain action plans that are aimed at driving improvement locally. We inspect and report under a maximum of 18 outcomes, each of which is a statement of what we believe is expected under the standards and regulations.

Outcomes are grouped under five themes, namely, governance, leadership and management, safe care and support, effective care and support, person-centred care and support and the workforce involved in the care of individuals. Of the more than 8,000 actions that were required by HIQA for compliance across the country’s suite of residential care centres, 13% of those actions related to issues concerning governance, leadership and management. The sorts of things which we were looking at included issues concerning the statement of purpose, the contract for the provision of services, the suitability of the person in charge and documentation and records kept within the centre. A further 31% of actions were related the theme of safe care and support and the sorts of things at which we were looking there in respect of improvement were safeguarding vulnerable people, health and safety issues, risk management practices, medication management and the statutory notification of incidents, as required under regulations. In addition, 34% of the actions were required for improvements related to effective care and support.

The actions prescribed under this theme dealt with issues of quality and safety of care; how the health and social care needs of residents were being assessed and provided for; and the safety and suitability of premises.
A central issue in the provision of long-term care of older people is the concept of person-centred care and support. With regard to a number of actions, 11% were required to effect improvement in this area. These actions were centred on enabling older people to make informed decisions about their care and enabling them to participate in the day-to-day life of the centre. They also involved issues around the making of complaints and the making of suggestions for improvements in the service. Of all the actions cited in our reports, 11% related to the workforce providing the care. The improvements we required were with regard to staff recruitment practices and ensuring the staff in the centre had the required qualities, skills and experiences.
Shortly after taking up my post as chief inspector and director of regulation, I was keen to ensure that as well as ensuring compliance with standards and regulations, our programme of regulation would place an emphasis on the improvement of services. This overview report also describes the full findings of a pilot programme of thematic inspections which we introduced late in 2013. These were aimed at improving particular aspects of care year to year. The first themes we introduced were aimed at improving some of the most fundamental elements of residential care, including a mechanism for improving end-of-life care and food and nutrition in nursing homes. The pilot programme consisted of conducting the thematic inspections in a selected representative group of 52 nursing homes. This section of the report describes both areas of good practice and areas that require improvement.
In the inspection of the area of food and nutrition, which is a basic and fundamental standard for vulnerable people, over half of the centres were fully compliant with standards relating to food and nutritional care. Examples of good practice were evident in all of the 52 centres visited. In 48 of the 52 centres, inspectors found that residents were being supported to eat and drink, with person-centred approaches used in their care. Our inspectors found that meals were served at times that suited the expressed needs of residents in 42 of the 52 centres that were inspected as part of the pilot programme.
Given the nature of the age and illness profile of residents, all centres should ensure they have the ability to deliver appropriate and dignified care to people at the end of their lives. Typically, staff of residential centres have an understanding of the life-limiting conditions that many residents may have. Overall, we found that residents received appropriate and safe end-of-life care in the 52 centres, with 23 of the 52 centres inspected during the pilot programme being compliant with the relevant standards and regulations. In 51 of the 52 centres, residents, or family, if appropriate, were given timely information in order to make informed choices about future health events. In 33 of the centres, residents were given opportunities to discuss their end-of-life wishes, which is a major comfort to them and their families.Feedback from service providers and the inspection findings both demonstrated the positive impact of the new thematic approach. As a result of this pilot we are applying the same methods to all remaining designated centres in 2014, with a view to identifying further inspection themes for 2015.
The report outlines our evolving approaches to the regulation of services. We regard regulation as a mechanism for improvement and we are always conscious of the burden that regulation can place on providers. We take very seriously our responsibility as a State agency to provide value for taxpayers' money through our programmes of registration and inspection. As a regulator, we aim to reduce the overall burden that is placed on service providers wherever possible while maintaining an emphasis on our objectives for safety and quality improvement. Regulation in the social care sector is intended to help service providers to improve the quality of care for residents, to protect their basic rights and to stop poor or dangerous practice.We ensure we are targeting our resources at areas of greatest need and highest risk. A major part of our programme is the registration of services with a requirement to renew the registration every three years. Renewing a provider's registration is a public confirmation that they have maintained their fitness to carry on the business of running a nursing home. During 2013, we processed 82 registration related applications. Fifty two of these applications were registration renewals.
We recognise the need to ensure our registration process enables the introduction of new beds into the system. To this end, we have a priority system for the registration of new buildings. Providers who plan to apply to register a new designated centre are referred to our registration office, which makes them aware of obligations and requirements in respect of the service they intend to provide. Timelines are shortened to facilitate the swift introduction of quality new beds into the system.
In certain situations a provider may apply to change or remove a condition of registration. Applications to reduce the maximum number of residents accommodated in a centre were granted on two occasions last year to centres, and applications to increase the maximum number of residents accommodated were granted to seven centres. These decisions resulted in an increase of 65 beds in total in 2013.
The authority's approach to regulation of these centres ensures that those providers who are persistently non-compliant with the standards and regulations and who place people at risk of harm are identified quickly and face proportionate and meaningful enforcement action. Formal enforcement procedures were used in respect of one centre last year when a decision to cancel registration of the centre was issued in January 2013. In this case the provider consented to the decision of the authority. It should be noted that this is only one of 565 designated centres which we inspected in the year at less than 0.2% of the total national complement. We remain unequivocal in the appropriate application of our enforcement powers when we believe that vulnerable people are at risk.
The report also describes the findings of a questionnaire we conducted across inspected centres in 2013. Provider feedback is generally positive about the way we conduct our work, with 91% of providers noting that the inspection process led to service improvement and was helpful in identifying gaps in services. I would also like to note the quality of self-assessments that were returned to HIQA in 2013 by providers. Self-assessment is a valuable part of regulation methodology and helps to develop self-awareness of the need for improvement. Our experience in 2013 noted a substantial correlation between the findings on inspection and providers' own self-assessed judgments.
Legislation passed by the Houses of the Oireachtas requires nursing home providers to notify us, without delay, of specified incidents involving residents which occur in nursing homes. The purpose of these notifications is to alert us to potential risks to the health, safety and well-being of residents. The range includes possible incidents and risks, as well as events that occur. In 2013 we received 5,362 of these notifications from nursing home providers. In addition, we also received 355 items of unsolicited information, the majority of which came from residents, relatives of residents and in some instances staff working in the services. These pieces of unsolicited information came from 213 nursing homes. All of this information is risk-assessed by our inspectors. Any risks or other actions required are assessed by our inspectors and applied appropriately. It should be noted that this figure relates to both confirmed and unconfirmed or suspected abuse of vulnerable adults. As mentioned, 31% of actions required to comply with the regulations were related to required improvements under the theme of safe care and support. The safety and interests of vulnerable older people are at the heart of our regulatory and inspection process. In my view, their well-being and interests would be well-served by enhanced legislation that enshrines in law the safeguarding of vulnerable adults in receipt of care services. It is important for our work that a culture exists where staff and providers have the confidence to report such matters to the regulator. HIQA would welcome an opportunity to work with members towards the development of an effective national policy and up-to-date legislation that would address this important issue.
The overall assessment of the authority is that in the four and a half years since the introduction of regulation of nursing homes in Ireland, there has been significant improvement in the quality of care that is provided to residents. The authority is using the findings of this overview report and the outcomes of our inspection work to inform our assessment of risk within the sector and to plan for our ongoing and future regulatory activity, such as the selection of areas of care for our ongoing programme of thematic inspections. Findings on inspections, such as those presented in this report, also inform the guidance we produce which assist providers to improve the quality of their services. All of this activity, along with a commitment to continued improvements in our regulatory approaches, demonstrates HIQA's commitment to ensure the rights and experiences of older persons in residential care are protected and improved. We look forward to continuing this important work and to continuing to work with members of the committee in the interests of improving the quality and safety of care provided to older people who live in residential care in this country.
I thank the members of the Joint Committee on Health and Children for inviting us here today to discuss this report. I look forward to hearing their questions and to learning where they believe we can further improve the process of promoting the quality of life for our older generations living in nursing homes.

9:40 am

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I thank Mr. Quinn for his presentation and analysis.

We all welcome the significant improvement in the quality of care for citizens residing in nursing homes.

9:50 am

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I join the Chairman in welcoming Mr. Quinn and Mr. Whelan, representing the Health Information and Quality Authority. I thank HIQA for its report and the vital role the organisation plays. This acknowledgement is deserved once again. When we recall that HIQA was established as a consequence of the failure of self-regulation and the so-called regulation that applied under the Health Service Executive and previously under the health boards, we can appreciate that this is a very important development and one that needs to be encouraged, resourced and facilitated in full.

Before asking questions, I join the Chairman in extending good wishes to Dr. Tracey Cooper and thanking her for her service as the first chief executive of HIQA in its inaugural years. She has returned to the land of her birth and we wish her every success and happiness there in her new post. Has Dr. Cooper been formally replaced? When will the post of chief executive be filled?

This report is an annual overview. Other colleagues have expressed an interest by asking about X, Y or Z nursing home. This work has already been done and the report is the collected information provided in 565 reports completed by HIQA in 2013. Given that 566 centres were registered last year, the first question that strikes me is which of the nursing homes got away. That is not a serious question. I am simply noting a slight discrepancy in the statistics the witnesses shared with the joint committee.

Mr. Quinn picked up again on the issues of safe care and support. Of the 8,000 actions indicated, 31% were related to required improvements under the theme of safe care and support. Is it too early to indicate the success rate in meeting these requirements across all of the service centres involved? Thirty-four percent of actions refer to effective care and support. Is there any way of carrying out an interim assessment of how these identified actions are being addressed by the service providers involved, whether private for-profit entities or HSE facilities? Must HIQA await the next opportunity to visit these facilities to determine the way in which the various centres have implemented the required, as opposed to recommended, actions? It will be important to ascertain whether these actions are being acted on. I concur with the statement in the report that all of the indications show that they are being acted on, because all of us will be conscious of the significant improvement that has been made across the board. This is indicative of a willingness on the part of centre managers to ensure actions are taken.

The number of beds available is not sufficient to meet needs. I note that HIQA is anxious to facilitate the swift introduction of high-quality beds to the system. This report details that the agency has granted 21 new registrations in 2013. I understand the figure from the report shows there are slightly fewer than 29,000 beds across the system. While this may not be within its remit, has HIQA carried out an assessment to quantify need? In my limited exposure to this matter, I am aware of cases in which people have encountered great difficulty and a long wait in accessing nursing home care. Has HIQA any idea of the optimum position? Perhaps that is not the correct phrase to employ. What encouragement can be offered, given the opportunities that are available in this sector? My home county has only seven such facilities, while County Louth, a neighbouring county, has twice as many, although its population is also much greater. When one examines the profile of the State one finds that some areas have much greater provision, although their populations are much greater. There is certainly scope for the introduction of further facilities or the extension of current facilities, as I have no doubt there is a need. Can the witnesses add anything to their disposition to facilitating the swift introduction of high-quality beds? Does HIQA engage in proactive encouragement of the centres it visits? Is there a focus on extending provision? Even if that is not to be the case, I ask the witnesses to comment.

Will Mr. Quinn to elaborate on the need for what is described in the report as "timely engagement with residents to plan future health events and end-of-life care preferences". What is being proposed in this context?

Again, I thank both witnesses for appearing and commend HIQA on its continuing work.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I acknowledge the presence in the Gallery of Oran Ó Caoláin and thank him for attending to see his party's spokesperson on health in Cavan-Monaghan speaking on his behalf.

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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To clarify, he is not an apprentice.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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We hope he will follow his father's footsteps.

Photo of Séamus HealySéamus Healy (Tipperary South, Workers and Unemployed Action Group)
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I welcome the delegation from HIQA and thank them for their presentation and report. I note from the report that 78% of HIQA visits to care centres were unannounced and 22% were announced. On what basis is the decision taken to make an announced or unannounced visit?

Deputy Ó Caoláin referred to end-of-life care. How is this matter addressed in care homes? On the issue of public versus private facilities, are all facilities dealt with on the same basis or are different approaches taken? Residential care homes in older buildings may provide excellent care but may not be in a position to meet current standards for newly constructed homes. What is the position in this regard?

Photo of Catherine ByrneCatherine Byrne (Dublin South Central, Fine Gael)
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I, too, thank Dr. Tracey Cooper for her work. I found her to be a bubbly, straight-talking person who, more important, was passionate about her job. Since the establishment of HIQA, the authority has raised the bar for those who reside and work in nursing homes and provided an insight into how such homes should be run.

Having read parts of the report, I compliment its authors on its clear layout. As someone who does not read much, I was impressed by its graphics and so on.

I had intended to ask the same question Deputy Healy asked on the reason some visits are announced while others are unannounced.

Why does that happen? Why does HIQA announce that it is turning up? Could they give a broader response on that? On the 2,776 suspected abuse claims, how many of them would prove to be valid? They might be able to fill us in on that.

I also had down what Deputy Seamus Healy asked about older nursing homes. In particular, I refer to one in my area, Cherry Orchard, which is run by the HSE and which provides excellent care. I get many requests from families to have their loved ones put there in long-term care. Some parts of the hospital, although not dilapidated, could do with a general uplift. Sometimes that can put people off when they go to visit these places, particularly if they are going to put a family member in long-term care. I do not know what can be done through HIQA or through the HSE, but the standard of care is excellent. People are happy with the service, but the appearance of some of the wards can be a little off-putting because they date from when there were large dormitories with many beds. Although they probably cannot do anything about it, I would be interested in their comments.

10:00 am

Photo of Robert DowdsRobert Dowds (Dublin Mid West, Labour)
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I welcome both Mr. Quinn and Mr. Whelan and apologise for my late arrival. I pay tribute to the work of Dr. Tracey Cooper, who is a dedicated and committed person. Before returning home, she did the State some service.

I will take a different tack from the others and ask to what extent are nursing homes providing appropriate activities for the residents. In my life, I have visited quite a number of nursing homes, both in Ireland and England, and it would seem that much more is done in England to provide stimulus for the residents. I wonder whether they can make any comment on that. I suppose a related question is to what extent do nursing homes allow some independence for those residents who are still capable of doing things for themselves.

Photo of Ciara ConwayCiara Conway (Waterford, Labour)
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I apologise for my late arrival. I thank HIQA for its report and also wish Dr. Tracey Cooper the very best in her new role in the United Kingdom.

I will focus on the 2,000-plus reports of abuse. Unfortunately, we all are familiar with how the child protection system works in Ireland but we are probably less informed about how the protection of the elderly works. The provision of social workers for the elderly is sporadic. One could not say that there is a consistent service or a consistent approach nationwide in how these are being dealt with. There is now the Child and Family Agency, which is dealing with child protection, but I am not sure there is an equivalent for those who are older. Would they have any comment on that? Is it something on which they should make recommendations in the future?

Photo of Sandra McLellanSandra McLellan (Cork East, Sinn Fein)
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I thank the HIQA representatives for their report and wish Dr. Tracey Cooper the very best in her new role.

Can the witnesses explain the provisions in place regarding enforcement? They indicate that one provider had its registration cancelled. What does that mean? Does it mean that the centre was shut down? If it was shut down, what happened to the residents from that centre? Where did they go?

They also mentioned that the authority's approach to regulation ensures that all of those providers who are persistently non-compliant face proportionate enforcement action. What do they mean by "persistent" and how do they measure proportionate action?

Of the 355 items of unsolicited information, were they all investigated and what were the outcomes?

Mr. Phelim Quinn:

I will try to perform as well as Dr. Tracey Cooper has in respect of this committee.

On Deputy Ó Caoláin's question about Dr. Cooper's replacement, the process for the recruitment of the chief executive is a responsibility of the board of HIQA, but I am aware that the process for her replacement commenced before her departure. It is in train. I am less clear on the timespan within which that will be achieved, but the board is keen to ensure there is a replacement substantive CEO as soon as possible.

There are a number of key issues around the outcome of our inspections. Mention was made of safe care and support. What we can do here is look at safe care and support in relation to a number of the members' questions, specifically the questions on the safeguarding of vulnerable adults. There is a statutory notification process. We are required to receive that notification. In a perverse way, the increased notification of safeguarding issues, whether they are alleged, suspected or confirmed, to us is a good development because it indicates that there is at least an open culture for reporting of those events. However, the number is disturbing when one brings that back down to human level. The key issue here is for us to try to work together to effect improvements within the services.

I was asked whether we can detect improvements. In this instance, we follow up on all actions. The first line by which we follow up is that we require an action plan from every provider on the publication of a report. That action plan is assessed for its adequacy by our inspectors and if there are any inadequacies in a particular action, we go back quickly to the provider to seek further clarification or better actions in respect of those requirements made by ourselves. At times, a follow-up inspection will also be required to ensure that what they have told us is happening on the ground. One will see that there are always more inspections than there are centres. Over the course of the next number of years one will see that number increase. At times, that is linked to the concept of announced and unannounced inspection, because one of the triggers for an unannounced inspection is the need to clarify, for example, whether a specific action that has been claimed has in fact been carried out.

Deputy Conway asked about the issue of safeguarding and its equivalence to some extent with the concept of child protection and welfare. I suppose that is one of the reasons we introduced into this briefing to the committee the concept of wanting to move towards parallel legislation and a parallel national policy that enables such a co-ordinated and multi-agency approach to the concept of the protection of vulnerable adults. At times, as a regulator, we will go in and detect issues that point us in the direction of a series of types of vulnerable adult abuse. That can be physical, it can be neglect, it can be sexual, it can be financial, or it can be verbal. All of those issues of abuse need to be recognised, first and foremost, by those working within the sector, but we also need to have a singular and co-ordinated approach to ensure that allegations of abuse are appropriately investigated. They will be investigated at local level, but they may need to be escalated to another agency and on occasion may require the co-operation of the Garda if the abuse points to some sort of criminal activity. Current policy does not necessarily do that. It does not have the protection of vulnerable adults at its heart. Parallel legislation and a parallel national policy would assist us in our work and would improve the protection of vulnerable adults across the State.

Deputy Conway also asked whether we wait for improvements. We do as I said. We follow-up with the action plan on an administrative basis and then on the ground.

The Deputy also asked about the introduction of new beds. In that regard, one of the questions is whether we have a view on the number of beds within the system.

In our last appearance before the committee I remember Dr. Tracey Cooper talking about the demographic time bomb, to which I have referred in the foreword to the report. The numbers of people aged over 65 years and 85 years in the country are increasing at quite a rate, in some instances at a higher rate than that for our European neighbours. There is a balance to be struck in the nature of care provided within the community. Government policy points us in the direction of providing more care within the community, but it is not always necessarily about residential care. There is absolutely a place for residential care. However, we also need to look at alternatives such as supported living, as well as providing care in a person's own home. We must ensure the care provided in a person's own home is also of a high quality.

10:10 am

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Mr. Quinn referred to a demographic time bomb. Is there a willingness to prepare for this eventuality, given that people, thankfully, are living longer?

Mr. Phelim Quinn:

There is probably a need for an increased focus on our preparedness for the demographics which include morbidity, illness and dependency profiles of our older population. The residential sector is playing an important part in addressing some of the issues involved, in particular end-of-life care issues. For individuals in nursing homes there tends to be a requirement for 24 hour, seven days a week, nursing care. From that perspective, we need to address the various levels of dependency and age profiles across the population.

We tend not to comment on the number of beds within the sector but rather the quality of the operation. However, if we are asked to ensure the facilitation of the entry of new beds into the system, we will do so, as I have outlined.

As I said in the report, there is a place both for announced and unannounced visits. In large part, public confidence calls for increased numbers of unannounced inspections. There is greater public confidence in the concept of unannounced inspections. In these instances, it is about inspectors trying to see services as they are delivered on a day-to-day basis, or, if we have received some unsolicited information, validating a risk. For example, it may be about providing care in the evening with reduced nursing and care staff on the floor. We check this, but there is no point in doing so on an announced basis.

The number of announced inspections we have undertaken this year has, to some extent, been based on the introduction of the thematic programme. The programme is about promoting improvement in the sector, for which we provide information by way of guidance to point them in the direction of best practice. We then follow through on their self-assessment to ascertain how they are achieving the relevant standards and regulations. The announced inspections are about ensuring an improvement in services and working with the sector to achieve that improvement.

Deputy Seamus Healy asked me about the public versus private care issue and whether we treated either category differently. We register at the level of the designated centre. Whether public, private or voluntary, the designated centre is regulated in exactly the same way. We do not treat any sector differently because we are assessing compliance with standards and regulations. Therefore, we deal with them in exactly the same way.

The Deputy also asked about environmental standards. As a regulatory body working alongside care providers, HIQA wants to see progressive realisation of higher standards of care in the environment within which it is provided. A number of targets were included in the original regulations for the achievement of specific environmental standards in the provision of care. Last year HIQA issued a regulatory notice which helped to explain better to providers in all sectors how these standards could be met. The main driver of improved environmental standards is the dignity of, and respect for, residents. In the regulatory notice we have given advice on how this can be achieved within some of the older buildings.

Deputy Catherine Byrne asked about the quality of the environment, in terms of the decor. There is certainly a requirement for providers to maintain a good standard in this regard. For however long someone is there, it is his or her own home. We believe his or her quality of life is influenced by the quality of the environment. Therefore, we have significant standards to be achieved in updating the environment where required.

Deputy Robert Dowds asked about activities within homes. This is a key issue that probably needs a further follow-up concerning the quality of such activities engaged in, including those which are therapeutic, in particular homes. In this and subsequent years we want to focus in our thematic work on areas in which a significant improvement is needed. They include not just areas that involve a high risk but also areas in which activities can be engaged in to enhance the quality of the residents' lives in homes. That is challenging within the residential sector.

The Deputy also asked about the independence of residents. On the person-centred theme, there must be a requirement to address the independence of residents in nursing homes in order that they can go out and engage in social activities in the community. This should be facilitated as part of the person-centred theme in the provision of care.

Photo of Robert DowdsRobert Dowds (Dublin Mid West, Labour)
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To what extent can HIQA exert pressure on homes to do something about this?

Mr. Phelim Quinn:

We can. We need to address the issue through the provision of better guidance for homes on what is a good standard to be achieved in engaging in additional activities to promote independence as part of the person-centred theme. I refer the Deputy to point 5.4.2 in the report which examines the standard for the particular element he described.

Enforcement steps were referred to in the questioning. In 2013 HIQA introduced a new enforcement procedure. The key issue in enforcement is to ensure we identify where there is a significant risk to the safety or welfare of residents, to which we must take a proportionate approach. I have mentioned that residential centres are home to a number of individuals. Therefore, it would be best if we could maintain some level of stability in such centres. In the first instance, our aim is to identify problems as early as possible in order that we can address them with the provider. However, if there is persistent non-compliance and a refusal to work with the concept of our action plans, we will escalate our enforcement activity.

End-of-life care is another theme that emerged from the questions. I have referred to the age, morbidity, illness or dependency profiles of residents in the nursing home sector. One of the key issues in anyone being cared for in a nursing home who is in his or her final months or years of life is to engage with him or her and his or her relatives on how they would like him or her to be cared for. In some instances, we hear how people at the end of their lives are placed in an ambulance, transported to an accident and emergency department and kept on a trolley. In fact, advanced care planning could enable an expression of a person's wish to be cared for within the nursing home with the support of primary care services in the community.

We place a significant importance on how we engage with people at an early stage with regard to assessing their wishes about how they will be cared for. Those are the main focuses we have on end-of-life care, as well as the links and liaisons the nursing home has with the primary carer about a holistic approach to a person's care as the person approaches the end of his or her life.

10:20 am

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Section 4.5 of the report mentions unsolicited information and figure 8 gives the sources of this information, which come from a wide variety of people from whistleblowers to residents. If HIQA receives information, what is its next course of action?

Mr. Phelim Quinn:

We take all information we receive seriously. The information would go to the relevant case holder or inspector for the facility, who makes an assessment of the information and, sometimes, follows through to clarify any issues that need to be clarified regarding it. Then the inspector approaches the facility with the information or triggers an inspection if the information raises concerns about the quality of care in the centre.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Of all such pieces of unsolicited information HIQA has received, how many have been resolved and need no further action? Where do they go beyond HIQA?

Mr. Phelim Quinn:

I do not have the specific information, but every one of them is followed up and has a specific file note on the outcome of our actions.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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If HIQA needs to do more, where does it go?

Mr. Phelim Quinn:

If it requires escalated regulatory action leading to some form of low level or high level enforcement action, we would take it through to that phase. It would be raised internally through the levels of management to me. In some instances in which we believe the information is of specific concern, we have case conferences. We would also contact external agencies if required and appropriate.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Is every case followed up, given a file number and investigated?

Mr. Phelim Quinn:

Absolutely. We have a very specific system that deals not just with notifications but specifically with unsolicited information.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Are those matters accessible under freedom of information or are they private between the individual and HIQA?

Mr. Phelim Quinn:

Given that some of the information we receive is anonymous, there may be issues around our ability to follow through with the specific individual making the allegation. However, we follow through on anonymous information if we believe it is of concern to quality of life.

Mr. Marty Whelan:

A couple of months ago we released information under freedom of information giving a general overview of those points and one of the medical journals wrote a piece on it.

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I thank Mr. Quinn for his comprehensive reply to the questions. However, he missed just one, which is very easy to do. Mr. Quinn referred to "timely engagement with residents to plan future health events and end-of-life care preferences". Could Mr. Quinn elaborate on how that unfolds?

Mr. Phelim Quinn:

One issue is the confidence of staff in nursing homes to engage in such a conversation. It requires a lot of skill on the part of staff. We see it as required depending on the medical or social history of a particular individual. When a person is admitted to a nursing home it may be for specific ill-health reasons that may indicate his or her condition is life-limiting. Early engagement with a resident and his or her family is important because advance care planning is the basis of good end-of-life care. There would be a very early conversation about the person's physical, psychological and spiritual needs so that they are addressed and people in the centre know what the person's wishes are from a very early stage. There have been debates around do-not-resuscitate orders and this is the sort of question that is explored by a resident and his or her family with the GP or any other medical practitioner involved.

Photo of Ciara ConwayCiara Conway (Waterford, Labour)
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I will return to some of the questions the Chairman asked about how unsolicited information is managed. Mr. Quinn said the unsolicited information HIQA received related to the quality and safety of care. If an old person is at physical risk, what does HIQA do? Does it remove the person from the centre to a place of safety? How is it managed, given what happened in an equivalent service where other vulnerable people, namely, children, were left in places they should not have been and came to great harm? Given that there are not enough social workers for the care of the elderly, whose responsibility is it to ensure such a person is safe?

Mr. Phelim Quinn:

In such circumstances, one of our first actions is to assess compliance with standards and regulations, and an issue would be escalated on the basis of the general standard of the home. If there are specific issues we liaise primarily with the HSE about the potential replacement of a care scenario for a particular vulnerable adult. It comes back to the point in my presentation about the requirement for better national policy and legislation that clarifies that. There are times when we feel slightly hamstrung about how we can move some of these issues forward.

Photo of Ciara ConwayCiara Conway (Waterford, Labour)
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Is there a gap in the legislation?

Mr. Phelim Quinn:

Yes, there is a gap in the legislation, and current policy is not sufficiently focused on the resident or service user. It also needs to address the fact that an issue for one service user may impact on other service users living in the centre. The legislation needs to be comprehensive.

Photo of Séamus HealySéamus Healy (Tipperary South, Workers and Unemployed Action Group)
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My question is related to a question Deputy Dowds raised earlier on activities. It has come to my notice in the recent past that residents and their families have received invoices for additional costs for the provision of services. Other Oireachtas Members will also have encountered this. Most of these services were available and covered by the payment on the admission of the patient. There seems to be a move to charge for individual activities provided. Does HIQA have a regulatory function or a view on this? Has HIQA come across this?

Mr. Phelim Quinn:

We have, and it has been raised with us on a number of occasions by concerned residents and their relatives. Our key approach must be through the contracts. I mentioned governance, management and leadership, and one of the core issues is the contract of care. To some extent the provider has the right to levy additional charges, but it must be open and transparent and cannot go beyond the contract agreed nationally or with the individual resident. We approach it from that perspective.

We do not have a remit to consider the reasonableness of those charges, and that is a problem or restriction. Financial abuse comes within the concept of vulnerable adult abuse and, under revised safeguarding legislation, one could technically examine the reasonableness of charges and whether they could be perceived as being abusive.

10:30 am

Photo of Regina DohertyRegina Doherty (Meath East, Fine Gael)
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I apologise for being late, but I read the report and summary last night. I heard a cute phrase last week, attributed to Mr. Eugene Sheehy from one of our banks, to the effect that the best disinfectant is sunlight. This report and its results are a perfect example of the applicability of that cute phrase, and I congratulate those involved. Given that there were few new resources added to the band of merry men and women in HIQA and the amount of work that has gone into this, along with the positivity with which it was received, how has it had an impact on the other work done in HIQA? How did the witnesses find the redistribution of the resources within HIQA? Was there an impact on the delivery of this report and the services provided in this sector? Did it have an impact on the delivery of any other health service?

Mr. Phelim Quinn:

The last time we appeared before the committee we mentioned that over the course of the past year there had been an increase in HIQA's functions in respect of designated centres for people with disabilities. On foot of that enhancement of functions, we received sanction for additional posts, specifically 25 new inspectors. That relates to 1,700 service units for people with a disability.

In the course of the past year we have endeavoured to ensure that we are achieving value for money in the way we apply our inspectorate workforce. We have gone for a skills mix to help us with some elements of our inspection workforce, and that will be introduced in the next couple of months. We are applying performance targets internally to ensure we are achieving what we have set out to do with regard to numbers and nature of inspections being carried out. Our core focus is absolutely on the safety and quality of services and we want to demonstrate to the Irish public value for money in that achievement. The increase in staff numbers in no way reflects the increase in function, but we are determined to maintain a good quality regulatory service through the application of our staff. I am currently confident that we can do that.

Photo of Regina DohertyRegina Doherty (Meath East, Fine Gael)
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Was it just the 25 new inspectors who were responsible for delivering all the inspections?

Mr. Phelim Quinn:

No, they were added to the total. There are now 45 inspectors, with mixed caseloads of older persons and disability centres. They work under the framework of both sets of regulations. The caseloads have significantly increased - almost doubled - since this time last year.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I will ask a question that may seem trivial. The report indicated that in some cases residents had to be woken to get breakfast. Why is that the case in this day and age?

Mr. Phelim Quinn:

Under the concept of person-centred care, breakfast should be offered to an individual - particularly at that time of life - at a time which suits him or her.

I am conscious that we have a time restriction, but I wanted to brief the committee on a couple of forthcoming activities. Tomorrow we will publish a governance review of the University of Limerick hospitals group which relates to our engagement with the hospital group over the course of the past four years and our recent assessment of how the governance structures within that hospital group work. We look forward to engaging with the committee again on any issues it may have arising from that report.

We are continuing our work on the Portlaoise investigation and the expedited review of pre-hospital emergency care. We would also be very happy to engage with the committee when those pieces of work are complete.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Although it will not be discussed today, the authority is also carrying out a review of the ambulance service. When does the authority hope to have its first full report published in that regard?

Mr. Phelim Quinn:

Some reports on the disability sector have been published. It is our intention that there would be an annual overview at the end of 2014.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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That is what I meant. We might come back on the annual overview report and perhaps committee members can reflect on it tomorrow in Limerick. Perhaps the witnesses will return to discuss some of those aspects when we have digested the report.

Mr. Phelim Quinn:

Sure.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I thank Mr. Quinn and Mr. Whelan. I also welcome Mr. Paul Hickey, who has served in these Houses, and I wish him well in his new role with HIQA. I am sure he will bring to that role the same enthusiasm and professionalism as he demonstrated in his role in Leinster House. I thank Oran for staying with us. Deputy Ó Caoláin has a good apprentice and he will certainly be questioned on the way home tonight.

The joint committee adjourned at 10.45 a.m. until 9.30 a.m. on Thursday, 12 June 2014.