Jerry Buttimer (Cork South Central, Fine Gael)
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The second half of the meeting is on the response from the HSE to the issues raised by the RTE investigations unit broadcast on the Mayo care centre. I apologise to Mr. Healy, Mr. O'Brien, Ms Meany and Dr. Crowley for the lateness of the start to the meeting. Parliamentary democracy means that votes take place and we must attend them. I hope we have not inconvenienced the witnesses too much. On behalf of the committee, I note our appreciation that they have taken the time to be here tonight.

I welcome formally to the meeting Mr. Tony O'Brien, director general of the HSE, Mr. Pat Healy, HSE director of social care, Ms Marion Meany, and Dr. Philip Crowley, all of whom are very welcome. The purpose of the meeting is to receive a response from the witnesses to the programme on RTE on 8 December entitled "Inside Bungalow 3". The programme included very serious allegations of abuse and mistreatment of residents in a specific care setting. Accordingly, the committee at its meeting last Thursday asked as a first step that we would have this meeting tonight. We will focus on some of the broader issues regarding congregated settings, residential care settings and the treatment of people with intellectual disability. The HIQA report on Redwood has also been published and tonight's meeting is an opportune one. I ask Mr. Tony O'Brien to make his opening remarks.

Mr. Tony O'Brien:

I thank the committee for the invitation to attend this evening. I am joined by my colleagues, Mr. Pat Healy, national director for social care; Dr. Philip Crowley, national director for quality improvement, and Ms. Marion Meany, head of operations and service improvements for disabilities within the social care division.
Áras Attracta, which is located on a 13 acre site in Swinford, County Mayo, is a residential respite and day service for adults with an intellectual disability. It currently provides 100 residential places, 95 for residents and five respite places. Áras Attracta was the subject of a HIQA investigation and report in February 2014. This followed on from information received by HIQA, including information on the death of a resident at the centre. On foot of the report, HIQA made 59 recommendations. All of the recommendations have been implemented, including a significant programme of training and development for staff. There have been 423 hours of training to date in 2014, including over 100 hours in bungalow 3, which was at the centre of the "Prime Time" report. Training in relevant topics, including amongst many others adult protection, crisis prevention and intervention management, care planning and trust in care, has been implemented in the facility by the HSE. The facility received positive reports from the regulator on subsequent unannounced visits in May 2014, who clearly stated that:

[I]nspectors found the provider and person in charge with the support of staff had significantly improved practice in relation to these areas and the specific issues identified on the last inspection had been addressed. The inspectors also found that in response to a required action from the previous inspection, the provider had put in place an effective management system and this had resulted in a significant improvement in the provision of quality and safe care for residents.

A total of 13 staff have been put off duty. An Garda Síochána and HIQA were notified. Mr. Christy Lynch, CEO of KARE has been appointed as independent chairman to conduct a full and thorough investigation into the matter. Practice co-ordinators have been assigned to bungalow three to supervise practice and implementation of care plans and to provide assurance to management. External expert advice from Scotland, originally engaged following the first HIQA inspection, has now been re-engaged to support the service at Áras Attracta, responding to the needs of the residents at bungalow three.

At the second level, a full assurance review has also been commissioned of all of the units in the Áras Attracta facility under the independent chairmanship of Dr. Kevin McCoy, assisted by three independent experts within the field. This group will review the programme of work already implemented on foot of the reports from HIQA and HSE audits to establish their effectiveness, identify the gaps that arose and make recommendations for further improvements for each unit at Áras Attracta.

In addition, the output from the review team will help to inform a system-wide programme of improvement and assurance for all residential centres, including a mechanism for input from service users and their families and staff at all levels throughout the sector and academia will be involved.

At the third level, the HSE has initiated a system-wide programme of measures to assure that the quality and safety of services delivered by 90 providers in the 908 designated residential centres for people with disabilities is in line with the requirements of the regulations and standards as inspected by HIQA. In this regard, a six-step programme will be implemented and monitored by a national implementation task force for disability residential services, led by Pat Healy.

The national implementation task force will drive the implementation of the programme and development of long-term sustainable and evidence-based safeguarding practices and training programmes specific to residential settings.

Implementation of safeguarding vulnerable persons at risk of abuse - national policy and procedures - is the policy which is for all HSE and HSE-funded services and it builds on and incorporates existing policies in HSE disability and elder abuse services and in a range of other disability service providers. It will provide a consistent approach to safeguard and protect people with disabilities and older people from abuse and neglect. The policy defines the types of abuse and who is at risk of experiencing such abuse. It gives direction in the area of recognising abuse and how complaints can be made as well as the procedures to be followed to investigate any claims of abuse. A dedicated office for the implementation of the policy has been established, building on previous work undertaken in the area of elder abuse.

In terms of advocacy, the HSE will work in partnership with key internal and external stakeholders, families and service users to develop and implement a volunteer advocacy programme, similar to the model being developed for older persons and drawing on experience of other models of advocacy currently in use by disability groups. The HSE will support the development of service user-family councils that will concern themselves with the welfare of all residents and will seek to protect residents' rights and to enable them to participate in matters that affect their daily lives. These councils will be independently chaired and will empower service users and their families and will focus on quality development based on service user needs.

In terms of evaluation and practice improvement, this will involve undertaking an evaluation on the transfer of standards of care into practice in services provided by the 90 service providers which deliver residential services in designated residential centres regulated by HIQA. In collaboration with service users, staff, locally and nationally, will devise a quality improvement plan to support the sustainability of good practice throughout disability services around the country. The team has extensive knowledge and competencies in the area of intellectual disability and provision has been made to expand the team in 2015.

The recommendations of the McCoy review in respect of Áras Attracta and the broader system wide programme of improvement and assurance will be implemented. A national summit held today, which both I and the Minister of State, Deputy Kathleen Lynch, addressed, had participation not only from the HSE and the Department of Health but also from HIQA, the National Disability Authority, national advocacy services, the CEOs and senior management from the 90 providers, voluntary sector representatives and advocacy groups. The output from the summit will inform the work of the national implementation task force which held it’s first meeting this afternoon, following the summit. The system-wide reform programme will be included in the operational plan for the social care division in 2015 and further summits to review progress are scheduled March and June of 2015. The membership of the national implementation task force, the investigation team, chaired by Mr. Christy Lynch, and the assurance review team, chaired by Dr. Kevin McCoy, are available for the information of members.

Steps are also being taken for the appointment of confidential recipient for staff in HSE and HSE-funded services for vulnerable persons. I am pleased to announce that Leigh Gath has agreed to take up this important role. The role, of which the finer details have yet to be finalised, involves acting as a confidential recipient for whistleblowers, including staff and clients and their relatives and friends, in relation to safeguarding concerns and issues of alleged abuse, negligence or other mistreatment. Leigh Gath has been an objective critic of the HSE on disability matters over the past years. Both staff and clients can be reassured that she will be an important champion for people who may be concerned for various reasons when they make complaints. The terms of reference for the role are currently being agreed.

As director general of the HSE, I wish to put on record again that what was viewed on the RTE "Prime Time" programme falls well below the standards that we expect in the health services and displayed an absence of dignity, respect and human kindness for the most vulnerable citizens for whom we care. Such standards should not and will not be tolerated in the health service or the HSE. At the centre of many of these examples of poor practice is the individual responsibility of staff members. I urge all members of staff of the HSE, without fear or favour, to blow the whistle on any instance of misconduct, disrespect or abuse towards residents, clients, patients or any service user should they ever witness it. On behalf of the HSE, I again wish to apologise unreservedly to the residents concerned, to their families and to society more generally for the distress experienced at any time in relation to poor standards of care provided to them in bungalow three. This concludes my opening statement and together with my colleagues, we will endeavour to answer all questions members may have.

Billy Kelleher (Cork North Central, Fianna Fail)
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I thank Mr. O'Brien for his contribution. The "Prime Time" programme was very disturbing for people who watched it. It goes without saying that it clearly indicated appalling treatment of very vulnerable people and everybody would condemn such activities. We must ask what can we do to ensure it does not happen again. Clearly, it is a matter for the Garda Síochána to investigate but as legislators and policy-makers, we have an obligation to hold people to account - that includes people in the HSE and others - in terms of ensuring we come forward with solutions to address concerns. The concerns are that this could be happening elsewhere. I do not think any of us can rule that out.

What actions is the HSE taking in the short term in regard to residential units in which physically and intellectually disabled people are being cared for in a congregated setting? The HIQA report and recommendations and the McCoy report and recommendations will have to be implemented.

This is just an observation-criticism but HIQA has reported many times and published many recommendations in key areas of health and the HSE has not always covered itself in glory in responding to, and implementing, those recommendations. I have instanced the whole area of maternity services. Very often resourcing is the issue but sometimes the recommendations made by HIQA are not always implemented in the manner it would have envisaged or in the manner we, and sometimes the HSE, would have liked because of lack of resources. However, in this case, we cannot leave anything to chance because the people being cared for deserve our full protection.

In this case, the student was an undercover person who worked in Áras Attracta between September and November.

There was a report on a death in Áras Attracta made previously to HIQA where HIQA carried out an investigation. The key question is, were there other reports brought to the HSE's attention. One must be asked why "Prime Time" picked Áras Attracta, specifically bungalow 3. Were there reports of abuse, ill treatment, lack of oversight, basic lack of humanity shown to other persons? Were such reports ever brought to the attention of the HSE by anybody working in Áras Attracta or by those resident in Áras Attracta or their family members because it is hard to believe that somebody would merely arrive with a camera and start working in an undercover manner without having some knowledge? I wonder had the HSE any similar knowledge in that context.

There are 90 providers and over 900 residential units. As I asked in my opening statement, what measures can the HSE put in place? Clearly, HIQA carries out inspections. It is now legally charged with that responsibility. However, often the inspections are box-ticking exercises - I do not mean that in any condescending way - in that they involve a template looking at physical aspects such as the square footage, the number of staff per patient and fire exits. Is there a need for us to broaden the remit of HIQA or is HIQA even capable of ensuring that patients, the advocates of patients and family members are also spoken to so that in the context of visiting these residential units, not only are the obvious physical environment and surroundings inspected but there would be discussions with staff and, as importantly, residents?

Mr. O'Brien spoke about a confidential recipient line and Ms Leigh Gath being appointed, and I welcome that. He stated the terms of reference must be drafted and the basic infrastructure around the confidential recipient must be put in place, but that must be done quickly. All staff in these residential care units should be informed that not only will the confidential recipient be in an office, but that there will be a strong promotional aspect throughout all of these residential centres, that all families members and residents will be informed of same in a meaningful and forthright manner that this confidential recipient is there to help and protect, and that the confidential recipient will be given adequate resources.

On the broader issue, while HIQA is statutorily charged with overseeing and inspecting these centres, the HSE is responsible ultimately for what happens in such centres, not only the ones for which the HSE provides directly but also those that it funds. Has the HSE adequate resources? Has the HSE the capability and expertise to investigate itself when complaints are made? That is the key issue. We have seen it in other areas, such as An Garda Síochána where we had to go to the Garda Inspectorate and the Garda Síochána Ombudsman Commission. One always has concerns about an organisation investigating itself. While there is HIQA and other outside bodies which are statutorily charged, there is a strong obligation on the HSE to ensure that it has within its ranks staff who, if such breaches should happen again, are not afraid to act or hold persons to account.

While we are talking about Áras Attracta only, there is concern for those who are cared for in the home environment. I published a Bill on the matter and other Members published Bills in the past. We must accept that while the vast majority of those who care for the vulnerable, be they the elderly or persons with physical or intellectual disabilities, do so for all the right reasons. If this kind of abuse can happen in a congregated setting where professionals are the carers I would be amazed if there were not forms of abuse carried out in the home setting and I wonder is it time for us to put an inspectorate in place for those funded to care for persons in the home setting, for instance, through the carer's allowance, to inspect that environment as well. For example, in my constituency I have come across one or two cases where I was concerned about the individual who was being cared for by persons in receipt of carer's allowance. There is no inspection pathway available other than that of a public health nurse who one could contact to ask to call. I wonder, in the broader context, bearing in mind that a large amount of people are cared for in the home environment, whether we should put in place quickly a statutory inspectorate to address that genuine concern. Senator Colm Burke spoke last week about publishing a Bill. I published one in 2012. It is time we act on this as well.

Jerry Buttimer (Cork South Central, Fine Gael)
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I apologise for the absence of Deputy Ó Caoláin, who is due to speak in the Dáil on a Private Members' motion. Deputy Kelleher will leave us as well. I apologise for Deputy Ó Caoláin's absence. He was here earlier for the meeting.

Billy Kelleher (Cork North Central, Fianna Fail)
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I will try to stay for as long as possible.

Jerry Buttimer (Cork South Central, Fine Gael)
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I also want to convey the apology of Deputy Kelleher who must go to the Dáil. I call Deputy McLellan, an able replacement for Deputy Ó Caoláin.

Sandra McLellan (Cork East, Sinn Fein)
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Last week's "Prime Time" programme was shocking and disturbing to everybody across the island of Ireland. We need to ensure that the correct measures are put in place so that something like this does not happen again, even though, when I say "does not happen again", we are not sure whether it is happening now in other homes because the HIQA report on another care facility in County Meath for adults with an intellectual disability showed that there was over-restraint and poor practice, even when it was an announced visit.

It is also disturbing that there was a HIQA investigation report in February last where it made 59 recommendations, all of those recommendations were implemented, and it was visited again in May when everything seemed to be of good practice. HIQA got that one very wrong.

I welcome the appointment of Ms Leigh Gath as confidential recipient for whistleblowers in HSE funded services. I note she has been an outspoken advocate on behalf of those with disabilities. I wonder to whom the confidential recipient report. Will it be the Garda, the HSE, HIQA or this newly announced audit team? My party is of the view that there is need for a root and branch review of the care system for the intellectually challenged and the address of staffing must start with management. Oversight, with empathy and compassion across the board, must be guaranteed.

We need more detail on the audit team. What specific and distinct role will this team have? Considering it will have 900 units across the country to visit, will it be properly resourced? When will it be in place? Was HIQA not put in place to prevent poor care and abuse like this happening again? How will this audit team function differently to HIQA and root out and expose practices such as those seen on "Prime Time"? Will the visits be announced or will they be undercover? I will leave it at that for now.

Ciara Conway (Waterford, Labour)
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I thank Mr. O'Brien for his opening remarks.

Here we are again on foot of a "Prime Time" investigation programme. Nobody who watched the programme the other night did not draw parallels between what we saw carried out in Áras Attracta and what we saw in the child care setting. The similarity is that those in receipt of the service are non-verbal, exposed to danger and vulnerable. We as a society must do much better than we are doing for those vulnerable groups.

What concerned me most is when we saw the person who was a management position go in and physically sit on a woman who has brittle bones, and that the staff stood by and thought this was fun.

The woman's name was Ivy and she was humiliated further by being asked to apologise to staff and people thought that was acceptable.

What concerns me is that all the HIQA reports in the world are not going to root out that kind of behaviour. We need a focus on the kind of people and relationships they have with the people they are looking after. We have to turn this whole thing on its head in terms of how we are operating services. First, the camera was there for however many weeks, but the only time I saw the manager - granted in the excerpts I saw - come into the building was when he came in to sit on that woman. Who was in there looking to see what quality of service was being provided? We saw some very tender moments. One saw a care staff member putting some lipstick on a person and brushing her hair. Those are the kinds of things people who are carers and nursing staff should do. They are the kinds of things we would do for our children or vulnerable aunts, uncles, brothers or sisters as if it is their home.

Jerry Buttimer (Cork South Central, Fine Gael)
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There is a vote in the Dáil according to the monitor.

Ciara Conway (Waterford, Labour)
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How is the HSE as a service provider and funder of other organisations going to ensure that there is a quality relationship? We have seen now that all the HIQA reports in the world will not make a blind bit of difference for the residents. It is alarming for parents and relatives not just in respect of bungalow 3, but across the country. It is alarming for parents of children who have to look into the future and decide what is best for their children. They will not have confidence that their children will be happy and well looked after in years to come. I want to know what we are going to do.

I have a specific question for Dr. Crowley. HIQA went in on foot of somebody dying and Dr. Crowley's role is in regard to patient safety. What was his response as head of patient safety when he heard that a patient and a client of the HSE had died in care?

Jerry Buttimer (Cork South Central, Fine Gael)
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We have another eight minutes for the vote. I will take the next speaker, who is Senator Colm Burke. If he could conclude within three minutes, I would be appreciative.

Colm Burke (Fine Gael)
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I apologise for not being here for the opening statement, which I have read, however. I had to launch a document on mental health, which is the reason I stepped out of the committee. I had given a commitment.

On nursing homes, there is a perception currently that HIQA only inspects by giving notice. In fairness, HIQA also carries out inspections without giving notice at a large number of nursing homes and it is important to ensure that information is publicised. In regard to this facility, I do not understand something about the lack of checks and balances. For instance, some of the information we got from the "Prime Time" report indicates that if there were a medical review of patients, the average GP would have been able to identify a patient in a more distressed state if it was something that happened suddenly. If it was not suddenly happening and had not occurred over a short period of time, that means it was going on for a long period of time. Where was the failure here? In every system in the health care sector, there are checks and balances and we do not always need HIQA to identify issues. What else do we need to put in place outside HIQA and the appointment of a confidential recipient? The patients themselves will not be able to get the number of the confidential recipient. From a medical and nursing care perspective what else do we need to do in terms of checks and balances to ensure we do not have a repeat of this or, if it is happening in other facilities, to ensure we can identify it at an early stage and deal with it? What is the response of the witnesses to that?

Jerry Buttimer (Cork South Central, Fine Gael)
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We will suspend until after the Dáil vote has concluded. I apologise to witnesses for having to interrupt again.

Billy Kelleher (Cork North Central, Fianna Fail)
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There is a health debate in the Dáil and those of us who are spokespersons may not return to the meeting. I apologise for that. We will have other people here who will be willing to listen to the answers.

Jerry Buttimer (Cork South Central, Fine Gael)
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I sincerely apologise to the delegates, staff and the Members of the Seanad for the delay. We will hear first from Mr. O'Brien.

Mr. Tony O'Brien:

There was a common theme running through the questions posed by members in respect of the thought process we employed. We have to recognise collectively that all of the things we have had in place - as a system - did not achieve the desired result at Áras Attracta. As Deputy Billy Kelleher indicated, it is true the HSE has a somewhat patchy record in terms of the implementation of HIQA reports. However, that is not the case in respect of Áras Attracta. All of the recommendations were being implemented, yet there is clear evidence from the video shot - over 200 hours of filming was undertaken - of what happened in bungalow 3. The central question that arises relates to the additional steps we need to take, but I do not think it is an issue of HIQA being in some way defective. Regulation can only take us so far. Cultural change is required in the context of some of the other actions we need to take. There is a realisation that, regardless of whether it is in a community or non-congregated setting, in a place such as bungalow 3 or a private home, once the doors are closed, we cannot see what the particular subset of people behind them are doing.

This is what RTE, in its efforts, has demonstrated to us and is one of the reasons we are focusing very strongly on empowering whistleblowing in the health service and making it easier for people who have concerns. We saw in the film that some people did not appear to be taking part directly in any of the abusive practices, but did not appear to be doing anything to stop them. We want to empower these individuals to blow the whistle more easily.
We also intend, as I have mentioned elsewhere, to undertake undercover investigations using the same techniques as RTE. We have also published a European prior information notice, which is part of the procurement process, to seek the specialist advice and services we would require for the use of CCTV in vulnerable care settings on an overt basis, that is in an open and transparent manner, but also, where there may be a prima faciecase for doing so subject to us being able to make this legal, decent and honourable, also using on occasion covert filming in various settings. It is apparent that the measures one would have expected to have an appropriate outcome did not have the desired outcome in this instance. There is no basis upon which we can assume this is an isolated incident. We need to provide assurance throughout the sector, and this was essentially the focus of today's summit with all of the providers, regulators and other groups.
Mr. Healy will address some of the specifics with regard to what we are doing at present, and Dr. Crowley was asked a specific question which he will answer. There is a realisation that the measures we put in place which we believed would be sufficient are not, and therefore we must do more and do things in different ways. I do not say this in any sense to be critical of the role of the regulator in this instance. Regulators can only do so much. HIQA has been discharging its responsibilities in line with its legislation and procedures.

Mr. Pat Healy:

We are implementing a six-step programme of system-wide reform. The opening statement of the director general outlined three courses of action we will take. These are with regard to the unit in question; Áras Attracta, with regard to the McCoy review and its potential to translate elsewhere; and a specific six-step programme. Key elements of this include the national policy for safeguarding vulnerable persons at risk of abuse. To answer Deputy Kelleher's question, while our particular focus and that of the task force we have established is specifically on residential care, the policy applies to all services. The definition of what is intended is in respect of individuals in receipt of a care service, whether in their own homes, in the community or as residents of a centre. This is the approach which has been in place with regard to the elderly and we have expanded it to all social care.

With regard to the initiatives we are taking, expanding on the implementation of the policy to safeguard teens in each of the new community health care organisations, each team will have four or five members of staff who will lead awareness, development and education, which some members have discussed and which is very important. This will mean there will be awareness in wider society as well as among staff and those working in the system.

Other important aspects are the audit, or evaluation quality improvement programme. Today three people qualified in auditing and who have expertise in this area are in Áras Attracta working with the teams there, particularly in unit 3, to develop programmes and examining how practice can be improved. The intention is to expand this throughout the system in 2015 and we will prioritise its implementation. The intention is these members of staff will visit the 90 providers during 2015. Some of these visits will be unannounced. The programme will be implemented, and all of the policies will be checked with regard to vulnerable adults. Our service arrangements with voluntary sector providers will form part of this. Most importantly, these staff members will examine and assess practice. They will support its implementation but challenge where it is not being implemented. Any deficiencies in this regard will be identified so the services can continually improve. Separate to this, the regulator will discharge its responsibility.

An important aspect discussed in great detail at the national summit today is the development of a national volunteer advocacy programme. We have examined how the existing arrangements which have been developed in services for older people can be expanded to the disability sector. This will involve the development of residential councils in each residential centre whereby parents, family members or interested members of the community will be trained as volunteers. They will have a role, and will be able to visit, support, engage and identify areas where they feel there may be deficiencies. We will work with the sector to examine how this can be tailored to the disability sector.

The McCoy review has two key components. Much of the focus has been on the investigation and disciplinary issues, but the work of the McCoy review is probably more fundamental with regard to the learning which can transfer throughout the system and make a difference. We have put in place many programmes and training. We have also made many changes. However this did not have the desired impact with regard to unit 3. We want to learn from the McCoy review what exactly happened and where the gaps occurred, and address this specifically in Áras Attracta in the first instance so each of the nine units there will have a specific plan. We also want to translate the learning from this throughout the system. Since this issue arose we have had significant interest from academics and staff, and Dr. McCoy has agreed to facilitate this so the learning can be incorporated and it will form part of the report. We have also agreed with him that we will not wait for the full report to be concluded but will have another summit in March at which any initial learning will be encompassed. Another summit will be held in June and any additional learning at this stage will also be encompassed. We will learn as we go and will publish the final report when it is concluded.

Jerry Buttimer (Cork South Central, Fine Gael)
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To go back to Deputy Conway's point on members of management being accomplices or party to reprehensible behaviour, many parents who have made contact with me and, I am sure, other committee members, are seeking accountability and action. I do not want to prejudice anything with regard to the alleged offences. I assume the HSE is awaiting the Garda investigation in this regard.

Mr. Tony O'Brien:

I had intended to deal with two points raised by Deputies McLellan and Conway. I will address this specific point now and will come back to the others.

Jerry Buttimer (Cork South Central, Fine Gael)
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I apologise for interrupting Mr. Healy.

Mr. Tony O'Brien:

It is an important point. As the Chairman stated, a criminal law investigation is being pursued, under the leadership of a senior officer of An Garda Síochána. As a result we have been asked to pause, and have done so, three aspects of our own investigative process in order not to in any way interfere with the Garda process. The 13 members of staff to whom I referred are not suspended but are off duty. Suspension is an outcome of a disciplinary process and not something one does in anticipation.

Not wishing to prejudice those individuals in any way, it is important to say that of the 13, two hold positions of responsibility. In other words, they have managerial roles. The Deputy has cited one specific example; another individual who may or may not have been seen on the film that was broadcast has also been put off duty and also has a position of responsibility. That adds to the concerns about the nature of the culture and the inter-relationships and length of time a particular team had been together, for example, which are feeding into the overall process of engagement about what service providers might do immediately to deal with this issue in advance of the full outcome of the reviews. All of those individuals are subject to investigation both in the context of any potential criminality and in the context of breaches of duty and discipline relating to their employment. Those who are unable to adequately account for themselves will be subject to the rigours of the disciplinary process, as I am sure they will be to any action the Garda Síochána may take.

Jerry Buttimer (Cork South Central, Fine Gael)
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Have those staff been replaced temporarily in their positions?

Mr. Tony O'Brien:

All of the staff have been replaced. There are about 170 staff in total at Áras Attracta against 100 clients. Having to appropriately remove 13 of them in this case is a significant challenge for a unit in a relatively remote location. With the assistance of other service providers within the HSE and funded agencies and through some direct recruitment, we have at this point been in a position to maintain staffing in the facility. I am always conscious when referring to this that there is tonight a significant number of staff who are not implicated in this issue, who are working and providing much-needed care in that facility and in many others around the country.

Mr. Pat Healy:

They are the specific actions we are taking as part of this system-wide reform piece. We have also established a national implementation task force to oversee the implementation of all of that, to take account of any learning that emerges in the context of the McCoy review and to look at other issues. We had the first meeting of the national implementation task force today following the national summit. It was a very useful meeting and they will take on board much of the feedback which has been received. There was 300 people at the summit so we will take that on board and a further meeting of the task force has been established for early January. We will be ensuring then that we progress this programme in a systematic way. The key elements I have just outlined will be incorporated in the social care division operational plan for 2015 and will be resourced in that context.

As we progress and as input emerges from the academics, staff and service users, it is intended that we will continue to progress and develop this programme as we proceed. There was a very strong commitment today from within the room regarding the leadership of the sector. There is recognition that while more may and will be done in 2015, there is a real necessity to be vigilant today. All of the providers and all those working in the service are committed to ensuring that this issue receives very serious attention immediately. People will be reviewing the position in each of their locations, including issues around encouraging staff feedback, whistleblowing, and listening to service users and their families in a way that perhaps has not happened. A question was asked about complaints that may have been made and they have been asked to check those and review them to make sure that where families, individuals or staff have been making complaints, they will be looked at. Together with the initiative on the confidential recipient and the national policy and so on, there are now a number of other mechanisms by which complaints, perspectives and views of inappropriate activity or abuse can be brought to notice. It is for us to ensure that this stays very high as a priority throughout 2015.

Dr. Philip Crowley:

I was asked for my response as national director for quality and patient safety. I have worked very closely with the social care division to ensure that the initial set of recommendations that arose from the death of a person who had been staying at Áras Attracta were fully implemented, particularly with a focus on the area of nutrition. Dietetic advice was brought into the centre and other allied health staff were brought in to try to ensure that care became more individualised. We have carried out an audit of practice and policy in the unit since then and made recommendations and worked with the unit and the social care division to ensure that all the recommendations are and have been implemented.

I was as shocked as everybody else by the programme. I was personally completely unaware that such a level of care was being delivered in the centre. All I can say is that we must redouble our efforts to work with the social care division to ensure that we all work in a very coordinated fashion and devote all of our energies to ensuring that the kind of actions that Mr. Healy has laid out today have the desired effect. We must try to ensure that this very poor level of care is eradicated.

Mr. Tony O'Brien:

To come back initially to some of the observations from Deputy Conway, myself and Mr. Healy travelled to Áras Attracta the Thursday before last, after we had become aware of the allegations, after staff had been put off duty and in advance of the broadcast of the programme. We walked the grounds and were in bungalow 3 and, in a respectful way, given her particular concerns around men, we met with Ms Ivy McGinty, Ms Mary Garvin and Ms Mary Maloney. They are non-verbal but they are not non-communicative. They are in my opinion very gentle souls and I would not say that we witnessed anything that could be called challenging behaviour by any manner or means. We also met with other residents in other parts of the facility and with the staff who are currently providing care. It was appropriate that we should visit but if anything, it made it all the more difficult to see the way those individuals had been treated because there was absolute disrespect for their basic humanity and for their rights as citizens of this country.

On this issue of the confidential recipient, which has been mentioned a couple of times, discussions with Ms Leigh Gath about taking that role were only concluded in the past 24 hours. We wanted to be able to identify both the process and name of the individual for the purposes of engaging in a discussion with participants in the summit today about aspects they felt were important in the context of that role. We had that discussion. She will be provided with office facilities and all that is required and will be based in Limerick. We will bring in staff to work with her who have had no prior engagement with the health service and who have relevant skills. Under the terms of the 2004 Act, she will be in receipt of a formal legal delegation from me giving her authority throughout the health service under the powers that are vested in me as - effectively - chief executive officer of the HSE. She will have access to legal counsel.

Ms Gath will be in a position to decide herself what she will do with each complaint. The majority, I expect, will be referred for action by the social care division and then she will be in a position to monitor the action that occurs. Where she thinks appropriate, she may refer to HIQA, the Garda Síochána or, dependent on the elements of the complaint - whether it has been partially dealt with before or whatever - she may seek to say that the complaint qualifies for consideration by the Ombudsman. The specific type of whistleblowing we are asking to be directed to her is on issues of abuse, neglect, mistreatment or failures in the safeguarding of vulnerable persons.

We are going to leave open the definition of "vulnerable persons". We do not want to create a context in which every possible complaint about every aspect of the health service lands on her desk because that would just make it more complicated for us to ensure the serious ones, in which we are most interested and in which whistleblowing is of key importance, would be dealt with; therefore, we will be directing people to the existing mechanisms for complaining about things generally. It is a large, complex service and there are many things about which people have legitimate complaints.

The confidential recipient will be assuming duties on Monday and arrangements will have been completed by then. We will communicate broadly about the establishment of the post of confidential recipient, how to connect with her and draw complaints to her attention. The key emphasis will be on the word "confidential". This is intended to remove the barrier, of which we are all aware, which sometimes prevents people from stepping forward, namely, the fear of identification, recrimination and retaliation. She will be able to ensure confidentiality. That is true not just for staff but also for service users who are in a position to express their views more clearly and others who may be in a position to make representations on behalf of clients - service users, citizens or whatever language we care to use throughout the system.

Jerry Buttimer (Cork South Central, Fine Gael)
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How does the position co-exist with the role of HIQA?

Mr. Tony O'Brien:

HIQA has a prescribed set of obligations. It is in the regulatory and inspection space and carries out reviews and makes recommendations. It is not seeking to occupy the position of confidential recipient. Essentially, we are seeking to provide an additional channel for people to do the right thing if they feel they can do so. At one level, we can talk about bringing in undercover investigators. There are 12,000 staff working in the social care sector. I want the vast majority of them to be our undercover investigators, empowered without fear of a comeback and report anything they believe requires further investigation. We could then use the techniques about which I spoke, whether it be placing other staff or using surveillance techniques in accordance with the law and carrying out the appropriate investigations, in order that we could do two things. One is to create a very simple realisation: there can no longer be an assumption that once the door is closed, it is safe to do things people know they should not be doing and that there is a very real prospect of being caught, which will have a deterrence effect. The notion that other staff have been more empowered to challenge, even if they must do so through a confidential informant, will change behaviour. These are interim measures; we are really seeking to change culture, but we know that this takes time. The culture appears to be part of the legacy of the way we used to do certain things in having institutions with high walls and so on. It will not be easy or quick to eradicate these thought processes from the minds of some; therefore, we will have to do some things that typically one would not want to do in order to provide additional surety. That is what this process is about. The audit team mentioned will have such resources as are necessary and the summits are helping us to shape what level of resources it requires.

Regina Doherty (Meath East, Fine Gael)
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I thank the HSE for what has been presented so far, but it does not fill me with much confidence and I do not say that lightly. The programme broadcast last week was, to say the least, absolutely shocking, but rather than focusing on individual issues within Áras Attracta, I concur with the comments made by Ms Lorraine Dempsey when interviewed for that programme: that the buck on this issue and any and all other patient safety issues stops at the top of the HSE. The six-step programme Mr. O'Brien has just announced is welcome, notwithstanding the fact that we have a patients' charter which was so wonderfully lauded last year in terms of its objectives and all of the improvements it was going to bring. Not to be trite, however, I do not see any difference at the end of 2014 arising from these objectives which were issued at the beginning of the year.

I wish to ask some specific questions about the quality and patient safety division. How many individuals, specifically in St. Stephen's House, not just involved in social care across the country, are responsible for ensuring quality and patient safety? What exactly, arising from the patients' charter, has the quality and patient safety division done this year, notwithstanding what Dr. Crowley has said about responding to particular instances involving nutrition or other issues in Áras Attracta or other venues?

I want to ask about patient safety advocates, not just in the 90 facilities with which the HSE has met. Are there registered, known, named patient safety advocates in each of these 90 facilities? Are there patient safety advocates in each of the acute hospitals? In any service offered on behalf of the State to citizens are there patient safety advocates who are known to patients? Is there a patient safety charter process in all of these facilities which known to patients in order that they know that if they have an issue or a complaint, they know where they should go, what they should do and how they should make their complaint?

I want to ask specifically about the first three items in the patient safety charter. The first is a "commitment to supporting the development of an open and transparent culture with defined accountability for quality and safety". Obviously, that is not working, as people are not whistleblowing; they are leaving. It is great that a confidential recipient is being announced today and I wish her well, although we have a history with confidential recipients who have not worked in other areas. What are we going to do in all of the other services which could be in exactly the same position with regard to whistleblowing? Is there a concern that the confidential recipient is going to work under the umbrella of the organisation on which she is to report? Would there not have been merit in making the confidential recipient independent? Strengthening the HIQA legislation and allowing the person concerned to work for it might have given more strength and perhaps more credence to the position.

The second part of the patient safety charter is that there will be "clear governance and accountability for quality and safety at all levels of the Health Service and Divisions". We have seriously failed on that level in every single aspect. Notwithstanding what happened in Áras Attracta and Redwood this week, we know what happened in Galway last year and Portlaoise again this year. There are too many instances that highlight the fact that, as a national organisation, we do not have a real patient-led service. With respect, I was one of the people who often defended the service plan last year, particularly when we talked about the provision of money and patient-led services, because it was said so many times, even in the prologue to the plan, that the service was totally patient-centred. It is very clear that it is not.

One of the commitments in the patients' charter is that we are going to "support quality improvements throughout the health service [and] improve outcomes" by interacting with patients to find out what their experiences are of the services being offered. When was the last time a patient experience survey was actually conducted in any section of HSE? What did we do to inform and change the processes of the system arising from the recommendations made?

I also need to ask - Dr. Crowley will know from where I am coming - about the two independent organisations which had their funding removed. They were the only ones which were engaging independently with patients on behalf of the two private organisations and the HSE. Why was it seen fit to stop that funding? If there was an issue with money, why did we not start to conduct patient surveys on behalf of the HSE, although I do not agree with this?

Peter Fitzpatrick (Louth, Fine Gael)
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I offer my deepest sympathy to the victims and their families. What happened should never have happened. There will be no excuses for the HSE if this disgraceful abuse happens again.

Some 59 recommendations were made by HIQA in its first report of February 2014. It proposed that staff training should be undertaken and that the staff of bungalow 3 would be required to undertake 100 hours training from the total of 423 training hours recommended. HIQA made an unannounced visit in May 2014, and found a significant improvement in the practice of the management.

I am concerned that it took a person - an undercover RTE reporter - on work experience for ten weeks to find out what was going wrong. Why did this RTE reporter go to work in Áras Attracta? Was he tipped off about a problem in Áras Attracta?

There are more than 900 designated residential centres regulated by HIQA. Are there more such incidents happening in these centres? Of the 13 staff involved in the incident in Áras Attract, has any one of these staff been disciplined before? Has any staff member come to the attention of the Garda Síochána before? Have all staff got Garda clearance? Are they properly trained? Have the staff involved apologised to the victims and their families? Has the HSE contacted all the other 908 residential centres? Reference was made to the National Implementation Task Force led by Mr. Pat Healy. How many residential centres have been contacted since the "Prime Time" programme on Áras Attracta was aired by RTE? Families are very concerned and it is very important that we get it right first time.

Fergus O'Dowd (Louth, Fine Gael)
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I concur with everything that Deputy Doherty said in her contribution. I think, if this has not been already said, there is an absolute systems failure in the HSE to protect the most vulnerable people under its care. No matter how many summits take place or improvements are made, the glaring fact is that the HSE has failed to protect those in residential care at present.

It is a fact that HIQA has received information from 930 individual whistleblowers who have made complaints about HSE institutions and also private nursing homes. I do not know how many of the nursing homes are HSE run or homes for people with disabilities. Does the HSE know or has it tried to find out how many of these complaints refer to institutions under its control? What contact have the witnesses had with the 160 individual complaints about homes for people with disability or residential services? How many of the 27 fully redacted complaints - and we cannot even get the date - involved HSE institutions?

In my view the HSE is not doing its job and there is a total failure of care. HIQA was established in 2013 and the complaints go back to that date. Deputy Conway asked HIQA at a committee meeting on 5 June 2014 what needed to change for it to deal with the unsolicited information it was receiving. In response, the HIQA representative referred to gaps in the legislation and said "The legislation needs to be comprehensive." Today the HSE representative said that HIQA was not seeking anything. That is not what Mr. Phelim Quinn said on the record.

Mr. Tony O'Brien:

I never spoke on behalf of HIQA.

Fergus O'Dowd (Louth, Fine Gael)
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With respect, Mr. O'Brien said that HIQA had a job to do and that was that. HIQA looked for a greater role when it appeared before this committee. Mr. O'Brien may not be aware of that.

Mr. Tony O'Brien:

Yes, I know.

Fergus O'Dowd (Louth, Fine Gael)
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I am not a member of this committee. I think Mr. O'Brien needs to explain things much better. I think he needs to take accountability and responsibility right up the line. I do not know who is in charge of disability services in the HSE, and if that person is here, I am not being personal but I am deeply unhappy about the outcome of the efforts of the HSE.

The HSE spoke about protecting whistleblowers. Practically every one of those 930 individual complaints that are on the record speak about the fear of the person who made the complaint. If they are working for the HSE, they are in fear that they will lose their jobs, if they are resident in the institution or if a member of their family is in the institution, they are fearful that the resident will be kicked out of the institution and in some cases, when a complaint was made, the resident has been put on notice to leave.

It has been stated that the HSE will pay more attention to complaints and will have designated officers who will accept complaints, but at present the HSE is the body accountable to take complaints. I may have misunderstood but I understood Mr. Healy to say that we will have to check if the complaints have been looked at. I see no sense of urgency and commitment or a sense that the HSE is demanding change from what has been said today.

Are the officials aware of other investigations into HSE facilities? I have a further point, and I thank the Chairman for giving me leeway. Will there be another meeting about Áras Attracta and related issues so that we get answers to these questions? Complaints have been made about physical, sexual, psychological and financial abuse - all cases of appalling abuse - and that nothing has changed. Let me stress that I do not know the different institutions, but they all have been inspected by HIQA. It goes back to the case at Leas Cross. There has been no real change. I am very concerned and I would like the HSE to address those issues.

Jerry Buttimer (Cork South Central, Fine Gael)
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For the information of Deputy O'Dowd, this is the first of a series of meetings we are to hold as a committee on the issue of congregated setting, home care setting for people with intellectual disabilities.

I have allocated four minutes to each speaker who is not a party spokesperson.

Mary Moran (Labour)
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I concur with Deputy Regina Doherty. I am not convinced and nothing I have heard here tonight has relieved my fear. I am a mother of a child who uses a respite unit and I am appalled, sickened and shocked by what went on in Áras Attracta and nothing that I have heard has eased my fears. I have nothing against the unit where my son attends.

I have noted there will be a Garda inquiry, HIQA and HSE inquiries, and a confidential recipient. A new task force has been set up. We could talk for ever and ever. What we need is positive action and not more reports and more meetings.

I was delighted when Mr. O'Brien referred eventually to the actual people who were most wounded in that report, namely, the residents. What exactly has been done for them since this report came out?

Deputy O'Dowd raised the issue of those who make complaints or whistleblowers who will contact the confidential recipient. The designation of a confidential recipient is welcome but from my study of the reports that HIQA has done on institutions all over the country, one can see that it has had to report on major non-compliance when it has made a second visit.

In the course of the "Prime Time" programme, we heard a reference that "she's gone" about the person who appeared to have made complaints about what was going on in Áras Attracta and that nothing was done about the complaints. I have been contacted by several people in the past year about their concerns about what was happening in residential units, people who tried to make complaints about different places but got nowhere and felt they would be bullied out of their job if they complained too loudly.

Although I could keep going all night, I only have four minutes in which to ask specific questions of the witnesses. I seek an answer this evening as to whether the HSE can state categorically that each person in any of its services, be it provided directly or privately funded, has a person-centred plan in place that is meaningful, monitored, reviewed and actually is carried out. Can the witnesses confirm for the joint committee this evening that everybody in the HSE's services, both funded and provided, has a full and comfortable life? I am sorry but I have no doubt but that it will not ring true. Can the witnesses confirm that those who cannot communicate are supported in decision-making and have their needs met? There must be fundamental reform of how the services are designed and delivered. One should consider the money that will go into all of these measures, as I reiterate my welcome for the confidential recipient. I absolutely do not like the job she must do or the amount of work that will be in front of her. However, the supports must be put in place in all the other places nationwide given the existing levels of care. I have a question regarding the 13 people who currently have stepped down from their work. Were they all qualified nurses or what was the breakdown in this regard? Were they permanent staff? Were there any agency staff involved and if so, what specific measures can be taken with agency staff? While I have many more questions, perhaps I can come back in.

Mary Ann O'Brien (Independent)
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To my eyes, the "Prime Time" programme unveiled a desperately cruel and unsafe culture. I will focus on the word "culture" because an organisation should have shared values from the very top management all the way down through the management levels below right down to the front-line staff. Culture is a very difficult word and is an invisible thing in companies and in health services. While I acknowledge Mr. O'Brien has mentioned culture to members this evening, how does he motivate and train his staff to be patient, caring, loving, careful, safe, compassionate and sensitive along with paying incredible attention to detail in respect of their incredibly vulnerable clients? Culture is something that companies value when they have good ones and it is a long task to change a culture. All members are frightened sitting here because they all know it is not just Áras Attracta, as there are 900 other homes.

Mary Moran (Labour)
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If one includes residential homes, there actually are a lot more.

Mary Ann O'Brien (Independent)
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Moreover, it is not just the HSE services as there also are the private nursing care companies the HSE uses. As the leader of the organisation, does Mr. O'Brien conduct a culture survey each year among the entirety of the HSE, such as the world-renowned Denison culture survey? Does Mr. O'Brien ask the direct provision providers or the private nursing providers to conduct culture surveys? As I stated, it is an invisible but important word.

I support the comments of Senator Moran and immediate positive action is needed. Christmas is coming and while members will be leaving Leinster House on Friday, they will be leaving a highly vulnerable situation and have a crisis on their hands. I acknowledge the Minister of State, Deputy Kathleen Lynch, agreed quietly with me the other night but ethical issues and the rights of patients must be considered in this regard. For the present, are cameras needed in all these homes? Will it be necessary to keep a watchful eye because audits do not do it for me? As for the Health Information and Quality Authority, HIQA, I have a client who is a 17-year-old child and whose parents wrote to the authority for fear of the child's safety. However, as all members are aware, HIQA cannot deal with individual complaints and one should put HIQA aside because audits mean nothing to me. Audits are box-ticking and anyone can open a door and be charming and perfect. I ask Mr. O'Brien to outline to members the HSE's short-term crisis control plan to allow everyone go home for Christmas. He should outline how something immediate will happen to protect these people and to stop the worry of all the families nationwide.

Mr. Tony O'Brien:

First, I will deal with the issue of the specific questions about the individual staff members who are off-duty. With respect to Deputy Fitzpatrick, I cannot tell him or disclose information about previous disciplinary records or previous Garda issues. Were that information available, it would be improper to so do because it would be prejudicial to the current investigations and I hope the Deputy will bear with me on that one. As for the split of staff, there are 13 people who were on duty and who no longer are on duty. Eleven of them were directly employed, six of whom were nursing staff and five of whom were non-nursing health care staff. Two were agency personnel, one nursing and one non-nursing. The engagement of the two agency personnel has simply been ceased.

Jerry Buttimer (Cork South Central, Fine Gael)
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Sorry, can Mr. O'Brien say that again?

Mr. Tony O'Brien:

The engagement of the agency personnel involved simply has been ceased. We are not under any obligations to go through disciplinary processes or anything like that.

Mary Moran (Labour)
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I find that-----

Mr. Tony O'Brien:

I am sorry but does the Senator think we should keep them on?

Mary Moran (Labour)
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No, I wish to ascertain whether that report will go on.

Mr. Tony O'Brien:

They remain subject to investigation by An Garda Síochána and with regard to the person who is a member of a regulated profession, information is shared with the regulator.

Mary Moran (Labour)
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Okay.

Mr. Tony O'Brien:

The professional regulator, as distinct from HIQA, will be kept fully informed.

Jerry Buttimer (Cork South Central, Fine Gael)
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What is the position in the case of the agency staff?

Mr. Tony O'Brien:

One of them was a member of a regulated profession and the regulator has a role in respect of that person.

Jerry Buttimer (Cork South Central, Fine Gael)
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Did they come via a recruitment agency or have there been other checks and balances in respect of that agency?

Mr. Tony O'Brien:

Yes, they would be subject to all the usual checks and balances. However, the fact is that they were engaged on an agency basis, as opposed to a direct employment basis and therefore, they are not put off duty in the sense that they will never be capable of returning. They simply are no longer retained.

Jerry Buttimer (Cork South Central, Fine Gael)
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I will ask a stupid question, if I may. Were these people to go to the south or eastern regions, would they be red-flagged as being under investigation or whatever term, without prejudice to the other case?

Mr. Tony O'Brien:

Until such time as the investigative processes are completed, none of these 13 individuals will be engaged in the health service. Obviously, we cannot speak to what else they might do elsewhere. However, the people who were directly employed during the period when they were put off duty still are subject to their employment contracts and should not be engaged in alternative employment. In addition, they are not permitted anywhere near Áras Attracta during this period. In view of the duty of ongoing care we have towards them, the human resource function remains in contact with them as is appropriate to the circumstances.

On the issue of culture, we have just completed the first employee engagement survey, which is the term that is used for cultural measurement. While these have been embedded in other health systems - such as the one in our nearest neighbour across the channel that has been in place for more than a decade at this point - this is the first one we have completed. It is a baseline study, the results of which we do not yet have as it still is being analysed. The overall level of participation was modest as compared with more established surveys but it is not out of line with where they started and consequently, it is a beginning. As the Senator correctly identifies, there are fundamental issues of culture. The organisation - I refer to the HSE - does not have a homogenous culture.

The manner of its creation did not facilitate this at the time nor since. We are also very conscious that there can be some pockets where culture is an issue, which appears to have been a factor in this instance. The process in which we are engaged is about wider service delivery in the community that the HSE directs, as well as by by bodies that we fund. One of the key themes was how we should begin the process of establishing a common culture - the right common culture - which would be focused very much, as one of the advocate representatives put it, on emphasising the service provided.

In regard to the specific actions taken, I ask Mr. Healy to speak about them. On the specific questions about resourcing in terms of quality and patient safety, I will ask Dr. Crowley to respond to them.

Mr. Pat Healy:

There were a number of questions related to residential centres. All residential centres were written to in the week commencing 1 December when we became aware of this specific issue to remind them of their responsibilities to address it in a significant way. It is important to say that, prior to the emergence of this issue, arising from HIQA's report and so on, a learning summit was held during the year for all providers, in addition to the learning that had been identified in the original HIQA report and all that had flowed from it which had been communicated across the system. We had taken action in translating what had been learned. Particularly on the concerns people had, I may not have communicated the point well. The point I was making was that, in addition to the very specific actions we were taking, there were specific programmes we were going to implement. We have started to implement the valuation and audit-type programme in Áras Attracta, with three practice co-ordinators already working on the ground. The intention is to roll it out in 2015. This is not a policy or something we are planning to implement; rather, these are specific programmes we will be implementing and which will be included in the operational plan for 2015.

In the context of assuring standards and practices in residential centres today, focusing particularly on the units with our most vulnerable residents, the point was made clearly by Senator Mary Moran - "we are going home for Christmas" - that there was a necessity for all providers to ensure the matter was addressed urgently. I may not have got that point across. As Deputy Fergus O'Dowd said, it was made clear that, while it would be important that significant changes be planned for 2015 and to have new programmes implemented, the matter needed to be addressed urgently. All providers have committed to doing this. It will obviously be followed up in writing and communicated again before Christmas. Again, the matter was discussed at some length by the national task force following the summit. It was not in the context of complaints; rather, it was to restate the point that complaints needed to be dealt with seriously. In the context of the summit, we received feedback from advocates, voluntary representatives and so on that it was an issue which required attention. That is the reason it was emphasised during the course of the summit.

I hope that clarifies the point about the HSE taking all complaints made seriously. Our intention is to make sure all providers follow this up. We will be taking it on board in the context of implementation of the programme.

Dr. Philip Crowley:

In reference to the quality and patient safety division and the decisions being made on the funding of organisations, I accept that some hard decisions were made on the funding of a number of organisations. However, we continue to fund national patient advocacy independent groups. We have increased funding in the area of advocacy to support the commitments being made to enhance advocacy in the disability sector and also in the acute hospitals sector. We have also worked with a group of people who have either personally or whose families have experienced harm as a result of their experiences of health care provision in Ireland. We have tried to support the Patient Safety Champions Network which is independent of us. We try to facilitate its work in order that it can generate its agenda from its experiences in order that we can listen to what it considers we should be doing to deal with the harm that, unfortunately, is caused in health care settings. We are also trying to support the measurement of quality and safety measures. We measure a great deal, but we need to measure more. This is directly relevant to what a patient experiences, the outcomes he or she experiences and his or her care. We have more measures in the service plan this year than ever before and I hope we will continue to expand the picture our performance report gives the committee and the public of the quality of care we provide and seek to provide.

Regina Doherty (Meath East, Fine Gael)
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I ask Dr. Crowley to qualify what he has said by giving the committee "a who, where, what, when and how" as what he has outlined is very broad? We need raw data or reports to look at.

Dr. Philip Crowley:

I will do my very best in seeking to meet the Deputy's need for information. If there are gaps, I will certainly forward information afterwards.

We have discussed the culture on a number of occasions in the light of the deep-seated cultural problems exposed. Work we have been doing has been focused on the issue of open disclosure. When we investigate the harm caused when things go wrong - we have felt this for some time - the health care system can sometimes compound it by how it responds to families or individuals by either being secretive or not apologising. We have run more than 100 workshops with front-line staff to promote the new policy of open disclosure which was launched by the Minister. We have also conducted a patient safety culture survey, initially in the acute hospitals division, which we will seek to make available across the service. We need to take stock of what we have learned from it and how effective it is as a tool. I note the tool recommended by the Senator.

Issues around governance were raised. We have been working hard on our delivery system to develop models of governance that will ensure that the delivery system will have at the heart of decision making consideration of the impact of any decision on the quality of care for service users and patients. We have new quality patient safety committees at all levels of all organisations and are promoting the message that they analyse all available data on safety and quality of care and use them to ensure the leaderships of all organisations properly focus on the issue above all else.

We also have an audit function whereby we have a group of people who check to see if we are doing what we said we would do. We assess and evaluate the implementation of recommendations to which we have committed and all of the audit findings are to be found on our website. We have worked on the issue of leadership which is central to having an improved and more person-citizen focused culture, one entirely focused on quality of care. We have developed guidance for the entire system promoted on new forms of leadership. In many cases we want the leadership shown across the system to be standardised in order that the leadership of the health care system is engaged fully with front-line staff, patients and service users and listens and responds to them.

In terms of measuring patient experience, we have developed a new survey tool which we are promoting throughout the health care system for post-discharge surveys of patients. We have also been working with the health care system to develop patient and family groups so that we properly listen to people, perhaps in a more qualitative way, which sometimes can be richer. We are also examining options to see if we can find cost effective methods to develop more real-time feedback from patients and service users so that we respond in a very agile fashion.

We also have formed partnerships with some of the training bodies and others to try to build capacity around quality improvement. We do not believe that simply telling people to change things or promulgating guidance on something in the hurly-burly of front-line care will always get everybody to change the practice in the way that we would like it to so do. We are utilising proven methodologies of quality improvement, training people in it and training our clinical leaders and others in this methodology to try to embed within our system a commitment to not just go into work every day to do our job but to go in every day to do our job and to improve that job.

We have also worked with the Royal College of Surgeons to develop a number of national audits to ensure we examine critical areas of practice such as ICU care, trauma management and the management of hip fractures, to name but three, and others are in development, to nationally examine the issues and to explore and ensure that we know if there are variations in practice. What we seek to promote in all of this work is standardisation of practice. Variation is the enemy of quality and we seek to eradicate it. The approach is based on the adoption of practice that is not best evidence based. To carry out that programme of work we have 40 people working in the quality and patient safety division. Importantly, with an overall staff of 90,000 to 100,000 people we do not pretend that the team will work in isolation. We will not be able to assume all of those responsibilities without forming partnerships with other bodies, and most particularly working with the line divisions who all have been developing consistently a capacity for quality improvement and safety management in the period since they have been formed.

Members will see from the service plan this year and last year a very clear commitment that quality and patient safety cannot just be the responsibility of a team or a number of individuals, that we are really committing as an organisation that the entire organisation needs to focus on this because we are mindful of the challenge that has been laid down to us. We are acutely aware of the times that we fail patients and we work extremely hard to try to minimise that risk into the future.

Mr. Tony O'Brien:

I will return to the specific questions raised by Deputy O'Dowd on the referral of complaints from HIQA. We know that HIQA has in place a process whereby on the basis of judgments it makes, that it refers-----

Fergus O'Dowd (Louth, Fine Gael)
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I apologise but I cannot hear Mr. O’Brien very clearly.

Mr. Tony O'Brien:

My apologies. I have a slight head cold as well so between us we are probably not great. I am aware that HIQA has a policy in place whereby it determines which of the complaints should be referred where, and that it does refer a number of complaints directly to the HSE. When they are received they are progressed as though the complaints have been made directly to us. I do not have visibility of how the numbers sit against the numbers Deputy O’Dowd has outlined to me this evening.

Fergus O'Dowd (Louth, Fine Gael)
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If it is helpful, a total of 160 complaints related to residential care units.

Mr. Tony O'Brien:

We can probably come back to the Deputy and say how many complaints we have had referred to us from HIQA that relate to residential care.

Fergus O'Dowd (Louth, Fine Gael)
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And how many the HSE has within its system as well as how the HSE has dealt with them, which would be very important.

Mr. Tony O'Brien:

I do not have visibility in terms of the numbers Deputy O’Dowd has presented, but what we can do is present the number we have in terms of complaints HIQA has referred to us. Clearly, HIQA will take a view as to where it should refer the complaints based on the fact that the 930 cases Deputy O’Dowd referenced are about the totality of the health system-----

Fergus O'Dowd (Louth, Fine Gael)
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No, they relate purely to residential care facilities.

Mr. Tony O'Brien:

When I say “the totality” I mean cases that do not just relate to the HSE.

Fergus O'Dowd (Louth, Fine Gael)
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Of course. Private service providers are included. Cases relating to the HSE are in the minority because it is responsible for a smaller number of homes.

Mr. Tony O'Brien:

We will have a look to see what our records tell us. We will examine the matter and come back to the Deputy, as is the norm for questions looking for specific detail that we do not have with us. We will come back with the relevant information.

To return to the issue of whistleblowing, of course there could be other ways of approaching the situation but I do not have the luxury of waiting for other people to make that decision. As members have correctly identified, I am the executive head of an agency that has a king size problem, a very substantial problem. We know from what has been reported back to us that there is reticence about blowing the whistle, probably borne of past negative experience. I am taking the step of appointing someone who has been an excellent critic of the HSE and a fearless advocate across two continents, who has even been arrested for her trouble, in the hopes that will give people confidence to come forward and say to her things they may not in present circumstances say to the manager of their facility, a national director, to me or even a regulator. We need that intelligence. I know from the feedback I have had since I communicated with the system the day before the programme was produced that there are many people out there who want that channel and will use that channel.

Jerry Buttimer (Cork South Central, Fine Gael)
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I have one question based on what Mr. O’Brien just said and on the appointment. Anecdotally, we have all got complaints, either in the meeting with the ambulance service which I will not go over now, and in other areas of the health service. I applaud what Mr. O’Brien is doing but it goes back to Senator O’Brien’s point about the culture. Is Mr. O’Brien confident that we can eliminate that culture where for argument’s sake, a manager, line manager or whoever can receive a complaint or engage properly with a person who makes a complaint? In some parts of the health service that does not happen and there is a culture of avoidance or even of bullying, if I can use that term without being derogatory to anyone.

Mr. Tony O'Brien:

Let us be completely open and honest with each other. The last seven years have seen a number of people elevated into managerial positions for which they did not receive training or support in order to fill gaps as people left on the various exit programmes. That is fact 1.

Fact 2 is that there are many thousands fewer people operating in the health service than there were before. People may feel over-stretched and they may not have the skills necessary to respond to issues as they arise. We have been addressing that in the last while by supported training, management development and in bringing eminent speakers to speak to a cross-section of the leadership of the health service about this very issue of culture – culture being defined very simply as what we do around here. We have a rebuilding job to do. We are fortunate that with the beginnings of the economic recovery, some of the particular challenges the health sector has had to face because of the necessary reduction in staff numbers and in resources means that we no longer have to ask our manager to focus disproportionately on one part of the balance score card, that being the financial process, which has been the lens through which the health service has been judged for far too long.

Deputy Regina Doherty correctly referenced – I am very conscious of the support that she gave at the time – the emphasis that has been placed in this year’s service plan and in previous service plans on communicating internally to our organisation that the balance must switch decisively towards a greater and balanced focus on other things. Clearly, we have much more work to do. I say these things not in any sense to excuse anything, because that is not the business I am in, but to tell the committee honestly as I started out, the business of changing a culture is a long-term process. I think we all know that. The whistleblowing element of it, and the ability of people to respond in a constructive as opposed to a defensive way to complaints is something that takes time. I hope the emphasis on whistleblowing is a relatively short-term measure. I hope that we can get to a position where there is less and less requirement to have recourse to whistleblowing and more and more confidence in using the normal process of complaint and improvement. That is where I was going with those comments and observations.

Nobody who runs any large, complex system, be it a health system or any other, with services in more than 3,000 locations and deploying more than 140,000 staff directly and indirectly through agencies would ever, with any degree of credibility, come into any forum and say he could give complete assurance that everybody is doing what they should do when they should do it and in the way they should do it. I am not going to do that. It is easy for me to say doing so would be complete rubbish. That is why we are going through the processes to put in place a series of measures designed to take shorter, medium and longer-term steps that can bring us to a place of much greater assurance.

Mary Moran (Labour)
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Mr. O'Brien mentioned that there are thousands fewer staff in the HSE. What we saw in Áras Attracta was not a question of resources or staffing. There were plenty of staff there. Dr. Crowley mentioned training hours. We noted that there were more than 100 additional hours since the first HIQA report into Áras Attracta, yet we saw what we got. Irrespective of whether an inspection is announced or not, one will not get the true story of what is actually occurring in a facility because people put on their best face when inspectors visit. There were people in Áras Attracta who had not been taken out for weeks. They had not been outside the door and were left sitting in chairs. We have to be able to state categorically what is happening. The buck stops with Mr. Tony O'Brien, as leader of the HSE. He has to be able to say everything is being done that should be done for our most vulnerable.

Fergus O'Dowd (Louth, Fine Gael)
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I asked whether Mr. O'Brien is aware of any of the 160 complaints HIQA has received about institutions, be they institutions of the HSE or private service providers. There are 27 ongoing inquiries into some of these cases. Is Mr. O'Brien aware of any of the complaints pertaining to his institutions?

Mr. Tony O'Brien:

We certainly are but we do not know what category they are in because we do not see the categorisation.

Fergus O'Dowd (Louth, Fine Gael)
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Let me put a different question in that case. How many locations are being investigated as a result of complaints of which Mr. O'Brien is aware right now?

Mr. Tony O'Brien:

As I said, we will come back to the committee with the detail on referrals from HIQA. I will ask Mr. Pat Healy to elaborate as he has more information.

Mr. Pat Healy:

Investigations have taken place into and complaints have been and are made regularly about many services. There are always complaints in process across the system. I do not have the specific number in the system at present. There are investigations under way in regard to a number of them. We can come back to the committee with specifics.

Regina Doherty (Meath East, Fine Gael)
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Arising from what Dr. Crowley said to me, could he provide to committee members the result of the post-discharge surveys based on the tool purchased from the United Kingdom? What is the trend arising from the data collected and the consequent recommendations? Could he provide us with information on his engagement with and support of the patient safety and quality agenda group? How has the interaction with it worked?

Since I have every confidence in Mr. O'Brien, I ask him to consider re-engaging with the service users and patients. We stopped doing so in a meaningful way a number of years ago. Mr. O'Brien should start talking to the people who are using the service as opposed to waiting for people to blow the whistle on what is wrong. If we actually engaged with service users, we would find their valuable information would prove unending. Let us learn from what we are doing right and wrong.

Mary Moran (Labour)
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May I be furnished with the information?

Jerry Buttimer (Cork South Central, Fine Gael)
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It will come to the secretariat.

Mr. Tony O'Brien:

As the Chairman stated, any follow-up information will come through the committee and all members will have access to it. I am in complete agreement with Senator Mary Moran in that none of the comments I made was intended or could be construed to suggest any of the behaviour witnessed on the television programme was the result of a lack of staff or resources in bungalow 3. Certainly, there is no excuse of that kind that could be presented. The unit was well staffed. To put it frankly, if people had enough time to abuse patients, they certainly had enough time to look after them. We all saw that with our own eyes.

I thank Deputy Doherty for her expression of confidence. We certainly intend to apply throughout the health service the lessons learned from this instance and to engage in an entirely new way. Part of this is the process that started today. We will keep the committee posted on how that develops. We intend to do this in a very public and transparent way.

One of the well-known disability advocates, Mr. Martin Naughton, who was with us today, used a very telling expression that we embraced. He said he would seek to keep our feet to the fire in relation to his monitoring of this. We said we hoped he would.

Jerry Buttimer (Cork South Central, Fine Gael)
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I have a couple of questions for Mr. Pat Healy on the congregated settings and the policy in that respect. We all welcome the HIQA inspections but, from talking to service providers, we realise there is a financial cost to meeting HIQA standards. In many cases, the service provider has not been resourced. I know of one organisation that has spent close to €700,000 trying to comply with HIQA standards, regulations and requests. Is any cognisance taken of this when providing resources to organisations to meet the HIQA standard? If not, how do organisations attain the standard?

My next point is in the context of Mr. O'Brien's remarks on the 13 staff who have been put off duty and replaced - perhaps they have not all been replaced - and in the context of the moratorium, particularly in the area of disability and intellectual disability. I appreciate that Mr. O'Brien is going to give me a standard answer on there being a blunt instrument. We are talking in this case about people who are the most vulnerable and who require the services of the State. An organisation with staff going on both maternity and sick leave could have up to 30 members of staff absent in a calendar year without replacing any.

With regard to congregated settings and the strategy for community inclusion, I refer to recommendations 1 and 3. As the delegation knows, I have a particular interest in disability. I am a member of the COPE Foundation. While I am not on the board and have no executive duties, I have a family related interest that dates from my childhood. What is the position on the movement of congregated settings and particularly on recommendations 1 and 3?

Mr. Pat Healy:

The project manager for the congregated settings report was Christy Lynch. The report was adopted and published in 2011. An indicative timeline of seven years, between 2012 and 2019, was established in which to implement the recommendations. As stated in the Oireachtas recently in regard to the report, the downturn in the economy had a bearing on the capital resource required. At the time in question, one of the indications from the review was that if one were to reconfigure or transform and release the resource tied up in institutional care, it would go a very long way, if not all the way, towards meeting the needs of people in a different way from within the revenue resource. However, there is, significantly, a capital resource required to release and fully implement the programme. That is related to the point the Chairman made. HIQA is now regulating. In this context, we are seeing a requirement for that to be funded. In comments this morning, the Minister of State, Deputy Kathleen Lynch, mentioned she was engaged with colleagues in considering this matter. The challenge has featured in the current year and we hope to address it in 2015.

Even in the Chairman's area, the south, more than 200 projects are under way currently in which specific person-centred, community-based models of service are being implemented.

It is not the case that nothing is happening. As was stated in our plan last year, the pace of change is slower than was originally anticipated. That is something we would like to see progressed. Progressive and creative models are being implemented from within the same level of resources and they are better able to meet the needs of people in a more community-based and person-centred model. The congregated settings plan is one we are very focused on implementing.

Jerry Buttimer (Cork South Central, Fine Gael)
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Who is the HSE person in charge of that?

Mr. Pat Healy:

Pat Healy.

Jerry Buttimer (Cork South Central, Fine Gael)
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You are in charge of that.

Mr. Pat Healy:

That is right. We have with the Department a very comprehensive implementation framework that was signed off by Government. It is up and running since this year and our intention is to make significant progress across all aspects of that, including the congregated settings, in 2015 and beyond.

Mr. Tony O'Brien:

A few months ago I might have given the Chairman a stock answer about the moratorium and it being a blunt instrument and so on, all of which would have been right at the time. On budget day things changed a little in that we are now moving into an environment which we are calling the funded workforce plan. There is less of a preoccupation with numbers and more of a preoccupation with value in that sense. The moratorium, as we knew it, does not exist. We can employ such and so many staff in the categories that we need to do so up to the level of staff that we can afford. This is not particularly relevant to Áras Attracta, but we have previously had an excessive dependence upon agency personnel at greater cost in order to sustain services while remaining within an overall cap. We are no longer in that environment.

In terms of the staffing requirement at Áras Attracta right now, some of that is being met through the good offices of some of the funded service provider agencies that we fund who have effectively loaned to us and rallied around to provide us with their qualified and appropriately regulated and registered staff while at the same time we have been recruiting additional staff. The latest figure is that we have successfully recruited nine additional staff. I am not sure if all those staff have been deployed but all the required slots are filled currently by different means. We have not allowed other considerations to get in the way of that.

On the Chairman's direct question on the impact of regulation, this particular sector has only been regulated for a little more than a year. It is not yet a mature regulatory process. It will mature and get stronger and better. In the context of the private sector, not the private health sector but the private commercial sector generally, there is a process around a regulatory impact assessment. That process does not apply in the same way in the public sector. For example, as appropriate regulation is introduced in order to improve services, particularly environmental and quality of service issues, it has a cost and that is not always taken into account. We have not hitherto been in a position to provide sufficient capital or revenue funding to some of the service providers to enable them to rapidly meet the emerging standards. This has been a feature in the care of the elderly in community nursing units, where there are a number of nursing units for which we do not have the capital funds to enable them to qualify and be registered. We need more capital funding if that is to be achieved. Similar issues apply in regard to the implementation of what is colloquially called the Christy report from 2011 around congregated settings and the registration requirements of the some of the existing facilities, even the ones in the community where there is work required to bring them up to full scratch. There is a challenge in that area, of which the Minister of State, Deputy Lynch, is very much aware on which she is working.

Jerry Buttimer (Cork South Central, Fine Gael)
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I got a phone call from a citizen today whose mother was in one of these care homes. In the context of the sensitivity and privacy of the citizens we are talking about, would it be the norm that a male would assist a male and a female would assist a female with bathing, washing and cleaning? In the case of an elderly woman, would a woman rather than a man look after her?

Mr. Pat Healy:

Nurses are nurses. A nurse is a trained nurse.

Jerry Buttimer (Cork South Central, Fine Gael)
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There was a stress that this person's mother was being taken care of by a male.

Mr. Pat Healy:

What we are emphasising and what is important is the issue of dignity, respect, behaviour, having an appropriate attitude and seeing the person before one. Whether it is a male or a female nurse, what is at issue is the quality of the engagement and relationship, as was mentioned earlier. The important point is that dignity and respect is the culture that resides.

Colm Burke (Fine Gael)
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It is important at the end of this meeting that we acknowledge the huge commitment made by nursing staff and people in the health care sector. It is important also that we identify the problems that are there and ensure they are weeded out but we must acknowledge the vast majority of people in the health care sector are extremely dedicated, committed and provide a very good service across the whole area of health care.

Jerry Buttimer (Cork South Central, Fine Gael)
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I will do that. This has been a very useful and necessary first step in our committee's journey. It is about the respect and dignity of our people who are citizens of our Republic and who, in many cases, are vulnerable and require the State to look after and take care of them. It is important that we recognise the value of a very committed workforce who have provided huge service, compassion and care and go far and beyond the call of duty in looking after many people we all know of in these situations. I acknowledge that we have and that we should have honest conversations with the family, the parents and the service users - the people themselves - who require the support of many organisations across the country. It is important today that we acknowledge there is a great deal of work being done and that there are deficits that we must fix.

I thank Pat Healy, Tony O'Brien, Marion Healy and Dr. Phillip Crowley for being here this evening. I thank the staff to my left who have been here since 5.30 p.m. and I also thank the men and women behind the glass for their service who have also been here since 5.30 p.m. I also thank the committee members and non-members for being here and members of the media who have stuck with us.

I remind members that we will be back at 10.30 a.m. tomorrow in the Audio Visual Room to launch a report on concussion in sport. I thank all the HSE staff and wish all the delegates and their staff and families a very happy and peaceful Christmas and a prosperous new year. They do trojan work. We appreciate there being here this evening as a voice and representative of the staff.