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.