Oireachtas Joint and Select Committees

Tuesday, 23 March 2021

Joint Oireachtas Committee on Health

Regulation of Nursing Homes and Development of a New Model of Care for Older People: Discussion

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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I welcome the witnesses from the Department of Health, the Covid-19 nursing home expert panel; the HSE and the Health Information and Quality Authority, HIQA, who will be presenting virtually to the meeting. They will provide us with a briefing on nursing home regulation and the development of a new model of care for older people.

I welcome from the Covid-19 nursing home expert panel, Professor Cecily Kelleher, chair both of the panel and of the reference group and professor of public health medicine and epidemiology at University College Dublin, UCD; from the Department of Health, Dr. Kathleen MacLellan, assistant secretary in the social care division, and Mr. Niall Redmond, principal officer, older person policy development, and Ms Sarah Cooney, principal officer, older person policy reform; from the HSE, Ms Yvonne O'Neill, interim director of community operations; and from HIQA, Mr. Phelim Quinn, CEO, Ms Mary Dunnion, chief inspector and director of regulation, Ms Susan Cliffe, deputy chief inspector for older persons, and Mr. Finbarr Colfer, deputy chief inspector for disability services.

Before we hear the opening statements, I point out to the witnesses that there is uncertainty as to whether parliamentary privilege applies to evidence given from a location outside the parliamentary precincts of Leinster House. If, therefore, witnesses are directed by me to cease giving evidence in respect of a particular matter, they must respect that direction.

I invite Dr. MacLellan to make her opening remarks.

Dr. Kathleen MacLellan:

As outlined, I am accompanied by Professor Cecily Kelleher, Ms Yvonne O'Neill, Mr. Niall Redmond and Ms Sarah Cooney. This is the second year of the Covid-19 pandemic in which, of the more than 120 million cases worldwide, more than 230,000 have been in Ireland. Sadly, more than 2.6 million people have lost their lives, including 4,587 in Ireland, of whom 2,009 have been in nursing homes. The continuing levels of high daily case numbers remain of ongoing concern.

Nationally and internationally, older people and particularly those in nursing homes have been especially impacted. Nursing homes are where more than 30,000 of our citizens call home and residents of nursing homes are vulnerable to Covid-19 for a variety of reasons. Consistent with the learning arising from the pandemic to date, the European Centre for Disease Prevention and Control, ECDC, the expert panel and HIQA highlight that the probability of Covid-19 introduction into these settings depends on the level of Covid-19 circulation in the community. Ireland has put in place a comprehensive set of public health measures, actions and responses that align with each of the ECDC-advised options to help manage and mitigate this risk to residents of long-term residential care.

Sustained communication and interagency co-operation remain central to the response to Covid-19. Guidance, personal protective equipment, PPE, staffing, serial testing, infection prevention and control training, accommodation and financial support have been provided to the nursing home sector, both public and private. In addition, multidisciplinary clinical supports are in place at community healthcare organisation, CHO, level through 23 Covid-19 response teams. Fundamental to this is the continued and determined professional care provided by healthcare workers in nursing homes 24 hours a day. Throughout the pandemic to date, about one third of nursing homes have remained Covid-outbreak free, while many nursing homes that did experience an outbreak managed very well.

While there is much to be hopeful about following the Government prioritisation of vaccination of older people and healthcare workers, the challenges associated with the pandemic will continue for the foreseeable future. A vaccination effect is being seen, however, and the number of open outbreaks in nursing homes now stands at 68, down from 178 on 21 February. In addition, this week sees a significant step in restoring meaningful contact through enhanced visiting guidance for nursing homes, whereby each resident can now have two face-to-face visits a week in light of a high rate of vaccination in the nursing home.

Following the recommendation of the National Public Health Emergency Team, NPHET, in May 2020, a Covid-19 expert panel on nursing homes was established to provide immediate, real-time learnings to the Minister for Health. This panel made a substantial package of 86 recommendations in 15 thematic areas and was published on 19 August. The Minister for Health and the Minister of State with responsibility for mental health and older people committed to progressing these recommendations and established an implementation framework with a priority focus on key short-term public health and protective measures. This framework includes an interagency implementation oversight team and a stakeholder reference group. Early progress on implementation of recommendations is evident and a second progress report has been published. In summary, the areas worth highlighting include assurance of the ongoing HIQA and HSE public health supports and in particular the role of serial testing and Covid response teams, the governance systems put in place by the HSE and HIQA, additional funding for the provision of integrated infection prevention and control measures, the delivery of sustained and intensive education and information campaigns and the establishment and preliminary work of the task force on safe staffing.

A paper reviewing Ireland’s actions in light of the key national options in respect of mitigating and managing Covid-19 in long-term care has aligned well to the November ECDC risk assessment, and this paper was published and discussed by NPHET. In regard to regulation, the Department is in broad agreement with the recommendations of the expert panel and HIQA with regard to the need to enhance the current regulatory frameworks for older people and the need to reform the regulatory model. Over recent months, the Department has sanctioned additional inspectorate staff for HIQA to support a sustained increase in the frequency of inspections. The Minister for Health has approved the development of interim enhancements to the current regulatory framework for nursing homes this year, with a view to commencing a longer-term review of nursing home regulation in 2022, and recently requested that HIQA undertake an up-to-date international evidence review of nursing home regulatory models to support and inform this wider review.

In the meantime, the Department is focused on interim enhancements to the legislation through a bilateral project group supported by HIQA. Detailed work is advancing on legislative proposals that, subject to Government approval, will aim to enhance the enforcement and oversight powers of the chief inspector, including through additional enforcement tools such as compliance notices, obligations for all nursing homes to report key operational data to HIQA and make the data public, exploration of measures to enhance transparency, and increased legal underpinning of infection prevention and control obligations, along with other improvements.

Home care is essential to support older people to live in their homes for as long as possible. Investment in home support services has increased by 66% since 2017 and more than €666 million has been allocated in 2021 to provide 24 million home support hours to 56,000 people. This includes 360,000 hours for intensive home care packages. In addition, the HSE national service plan commits €10 million to the roll-out of the interRAI standard assessment tool and to establish a national home support office. A programme of work to advance the statutory home support scheme is well under way. The Government will soon be asked to approve the principle of moving to introduce a licensing framework for professional home support providers, underpinned by legislation, in line with the programme for Government commitment. Throughout 2021, the Economic and Social Research Institute, ESRI, is conducting research on behalf of the Department on the projected demand for, and cost of, home support provision across a range of models for the financing of the statutory home support scheme.

This work will build on projections for the future demand for home support as set out in various reports, including the Department of Health's Health Service Capacity Review 2018, which forecast that a 120% increase in home support services will be required by 2031 if the health system is fully reformed.

In summary, Covid-19 has highlighted the important need to move to new models of care for older people. This will involve short and long-term reform across government in order to provide new housing models, new home first care models and where long-term care is needed, that it is provided with innovative designs that can meet infection prevention and control requirements and provide a home for those who need this type of care. The HSE’s national service plan also fully recognises pandemic learning and the reform requirements, including commitments to commence planning towards a longer term rebalancing of the public-private nursing home mix. Sláintecare provides the overall framework of right care, right place, right time in order to support older people to continue to live in the community in their own homes for as long as possible, thereby participating to their full potential in economic and social life.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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I invite Mr. Quinn to make his opening remarks.

Mr. Phelim Quinn:

I thank members for the invitation to today’s meeting. We welcome the opportunity to address the Joint Committee on Health. I am joined by my colleagues, Ms Mary Dunnion, chief inspector of social services and director of regulation; Ms Susan Cliffe, deputy chief inspector of social services for older persons; and Mr. Finbarr Colfer, deputy chief inspector of social services for disability services.

As some members will recall, in September 2020, HIQA appeared before a meeting of the Special Committee on Covid-19 Response at which our report on the impact of the pandemic on nursing homes in Ireland was discussed. We are happy to take any questions regarding this and our experience of the regulation of residential services subsequent to its publication.

In respect of my opening statement, I wish to focus on the background and recommendations of HIQA’s report on the need for regulatory reform of the social care sector, published in February of this year. The report, titled The Need for Regulatory Reform, reinforces the insights we have gained while contending with the arrival and impact of the highly infectious coronavirus, Covid-19. In particular, the report highlights the impact on citizens living in residential services and has raised a number of questions as to how we care for vulnerable people. In essence, the practices and models underpinning service provision that were previously acceptable are no longer so. It is important to note that Covid-19 has not in itself signalled the need for regulatory reform; rather, it has shone a spotlight on an issue that was already in need of urgent consideration.

As a consequence of our experience as a regulator in the sector, HIQA has submitted its views to the Government on how regulations and enforcement in the interim of wider regulatory reform could be enhanced with a view to strengthening key areas related to the pandemic, for example, infection prevention and control, staffing, governance and clinical oversight. Therefore, our report on regulatory reform should be seen as contributing to the development of a wider social care strategy and national policy, separate and distinct from any immediate or interim requirements related to Covid-19.

HIQA’s report on the need for regulatory reform recognises that social care in Ireland is changing. The institutional and residential approaches towards the provision of care for older people and people with a disability are being challenged. Although Covid-19 has highlighted deficiencies in the legislation which regulates social care services, many weaknesses have persisted in recent years, due in large part to the evolving nature of service provision.

HIQA’s experience of inspecting centres and assessing compliance with regulations and standards has produced a wealth of knowledge on the quality and safety of services. It has also allowed us to develop insights into how the regulatory framework is serving the interests of people who use and provide services. This report outlines some key regulatory areas which require a dynamic, all-encompassing national health and social care strategy and policy development. These include the reform of the Health Act 2007 to take account of the changing landscape in health and social care services; a comprehensive review of the current regulations pertaining to health and social care services in Ireland, and the establishment of a regular review process; the introduction of regulation into other forms of care that are currently unregulated and whose service users may be vulnerable; consideration of the development of a comprehensive, integrated social care policy that considers social care in its totality; and a framework that makes a clear distinction between the purchaser and provider of services along with clear governance and accountability arrangements.

While there has been a justified focus on how we care for older citizens, it is imperative that there are equitable protections for people with a disability in need of social care and support. Disability service providers continue to explore and develop ways to move citizens currently living in congregated settings into services in the community, in line with national policy. In September of last year, HIQA published its annual overview report on the inspection and regulation of residential services for people with a disability. One key finding was that residents living in congregated settings experience a poorer quality of life compared with those who live and receive care and support in community settings. In developing new residential services, providers have said they want to keep residents within the protection of regulation. However, the current regulations can be overly restrictive when it comes to the development of innovative new models such as partnerships between other service providers and families to develop individual responses to the care and support of those with complex needs.

HIQA welcomes the Government’s intention to make home care available on a statutory basis.

The Sláintecare programme has outlined the roadmap to transform health and social care provision. Regulatory reform is necessary to ensure that the services provided have the capacity and capability to deliver care and support that meet people’s needs in a manner that offers quality, safety and the protection of people’s rights. There is also a strong argument for the development of an overarching social care policy that sets out core objectives, governance and legislative frameworks across the sector at large. The development and implementation of such a policy would help integrate diverse forms of social care and serve to complement Sláintecare objectives.

HIQA very much welcomes the recommendations contained in the final report of the Covid-19 nursing homes expert panel of 2020. It frames clearly the steps which must be taken in order to optimise the response to Covid-19 in care facilities for the elderly. HIQA will continue to share its knowledge and insights of the sector into the implementation oversight team that was created as a result of the panel’s report.

It is HIQA’s view that the provision of health and social services should be subject to a regulatory framework which is fit for purpose, adaptable to changing needs and preferences and responsive to risk and concerns for people’s welfare. This may, in part, be achieved by developing a policy that considers social care in its entirety, given that the principal issues are consistent across all populations who use social care services. HIQA hopes that The Need for Regulatory Reform report forms an integral part of the debate on how we can better care for our citizens into the future.

I thank the committee members for their attention this morning. We look forward to answering any questions they may have.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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As members are also attending the meeting virtually from their offices and cannot see the clock to monitor their speaking time, I will advise them on when they have one minute remaining, if possible. It does not always happen. The first round of questions consists of ten-minute slots. I call Deputy Colm Burke.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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I thank the witnesses for their presentations. I will open with the issue of bringing public nursing homes up to standard, particularly now because of Covid and the challenges that it has posed. I understand that 122 HSE public nursing homes were required to meet a certain standard by 2015 and that an extension was granted for six years, bringing the deadline to December 2021. What is the updated position on those 122 HSE community hospitals or nursing homes? How many of them will be up to standard by December 2021? If they will not be up to standard, what proposals are there for dealing with the issue?

Dr. Kathleen MacLellan:

That is a most important question. Significant progress has been made through the community nursing programme. Timings were affected by Covid-19 last year, so some 30% of those identified to be completed, have been completed. The others are at various stages of development. It should be noted that in addition, the HSE is examining the current nursing units and their bed supply. Some €125 million has been provided in 2021 to fund over 1,250 beds in the community.

The HSE is examining the opportunities for the reconfiguration of a number of beds, taking account of the new model for supporting services in the community and the enhanced level of home care supports this year, amounting to an additional €150 million. It is anticipated, through that pathway, that about 237 users of the long-stay beds will be provided with care within the community instead. Therefore, progress is being made. We can provide a written update on the progress overall if that is helpful.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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It would be helpful if we could have the exact figures for what is expected to be completed by December 2021 and if we knew how it is proposed to deal with people. According to the last set of figures I have seen, there are more than 5,500 people in public nursing homes. I am not sure how many are affected by not having a suitable physical environment for long-stay individuals. Maybe we could have a detailed report on that.

I want to return to an issue I raised in August, or maybe even earlier during the hearings of the Covid committee. It concerned HIQA and the upskilling of staff. I asked specifically for information on what occurred between January 2020 and March 2020. There was an undertaking that I would be given information on preparing staff for dealing with the new challenges. I never got it. The last time I saw such information was when I saw it published in the Irish Mirror. It got the information on foot of a freedom of information request. My question is on training and upskilling regarding infection control. A new challenge arose in December last year. There seems to have been a huge outbreak of Covid in many nursing homes that had not had any outbreak whatsoever in the preceding ten months. What advices were given to nursing homes once it was identified that there was a new variant of Covid? What level of contact was there between HIQA and nursing homes in December 2020 and early January 2021?

Mr. Phelim Quinn:

I thank Deputy Colm Burke. I apologise for any breakdown in communication. As far as I was aware, the information the Deputy had requested in August had been sent on, but I will check that out. I am nearly clear in my belief that it was sent through to the Covid-19 committee, but we can get that checked for the Deputy.

I will hand over to my colleague, Ms Dunnion, who will give the Deputy an update on the preparation and training of staff. She will also respond on the second part of his question.

Ms Mary Dunnion:

I thank Deputy Colm Burke. I reassure the committee that all staff employed as inspectors of social services have qualifications in nursing, medicine, dentistry, pharmacy or social care services. These are the competency requirements at the point of interview. Thereafter, there is a 12-week induction programme for all newly appointed inspectors that covers all the relevant areas, including the legislative framework, the inspection process and the methodologies. As Mr. Quinn said, we will certainly ensure the Deputy gets that information requested if he has not received it already.

In the context of the Covid-19 outbreak, the specific training for our inspection staff that has been very targeted relates to the national guidelines from the Health Protection Surveillance Centre, HPSC, in the context of Covid-19 infection prevention and control. All our staff are trained in that area, and there is ongoing didactic learning and online learning. There is guidance and there is an assessment framework. In addition, we have run many webinars for nursing home providers and disability service providers and their staff. Those webinars covered all aspects of our infection methodology for infection prevention and control. As Dr. MacLellan said, there has been an increase in our number of inspectors. We have increased the number by a total of 12 in respect of the nursing home expert panel, and we are currently at the point of induction for many of those positions. That will increase our inspection activity, with focus on infection control in particular.

To answer the Deputy's question, we have an internal infection-control training programme. It is particularly pertinent to the HPSC guidance. We have had a significant number of webinars, with full attendance from all nursing home providers, on the application of that guidance.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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In December 2020 and January 2021, there were outbreaks in a large number of nursing homes. What level of engagement was there in that period? It is extremely important to address this. We could have a new challenge next week and it would be a case of how fast we could get the information out to the providers.

Ms Mary Dunnion:

What we saw at the time in question was a completely different response landscape. With the HSE, we had a formal escalation pathway for any areas we needed to escalate. We had identified members of the crisis response teams across each CHO area, and we had interaction with all the nursing homes because, as the Deputy knows, reporting of confirmed Covid cases daily is mandated to us. In the third wave, which was at the time to which the Deputy is referring, we saw enhancements in the responses that were being provided across the community through the CHO areas and we actively engaged and participated in that. It was a very responsive situation. We could see that there was significant learning between March 2020 and what happened in December 2020 and onwards.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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On the Department and the proposed licensing concerning home care provision, at what stage are we? I introduced a Private Members' Bill on introducing a regulatory framework for home care. At what stage is the Department on drafting legislation? When are we likely to see draft legislation? What is the timeframe for introducing it and putting it into law if we want to introduce a licensing system?

Dr. Kathleen MacLellan:

We are at a very advanced stage of consideration around planning and progressing, and we intend to bring a memorandum to the Government very shortly. I am going to hand over to my colleague, Ms Sarah Cooney, to provide an update.

Ms Sarah Cooney:

As Dr. MacLellan mentioned, we are at an advanced stage in the development of a regulatory framework for home support providers. We hope to seek Government approval shortly to move forward with this approach to introducing a licensing framework for professional home support providers. We have begun the work on the drafting of the legislation. I am referring to both the primary legislation and the secondary legislation in respect of the regulations that would be needed. We hope to proceed to stakeholder consultation and public consultation on the regulations in the second quarter of this year.

The third element of the regulatory framework is the development of national standards for home supports providers. Our colleagues in HIQA are working with us in regard to that. It will provide the guidance and support for home support providers to enable them to meet their regulatory requirements and to focus on quality improvement in that work. As Dr. MacLellan said, we hope to progress this significantly this year in terms of seeking Government approval to move ahead with the drafting of the heads of Bills, with a view to having them published, undertaking the comprehensive regulatory impact assessment that would be required as part of that process and then bringing the legislation through the Houses of the Oireachtas at the earliest opportunity in 2021.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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Is there a date for when we will see the heads of the Bill?

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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The Deputy is out of time. He may ask just one more question.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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My question was on when might we see the heads of the Bill published.

Ms Sarah Cooney:

We would hope to move forward on that and get Government approval shortly, and then publish the heads as early as possible in quarter 1 or quarter 2 of this year.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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I welcome all the witnesses. I want to use my time as productively as I can. I want to start with Mr. Quinn.

Obviously, if Mr. Quinn needs to refer to his colleagues that is fine but, in terms of a fluid conversation, if Mr. Quinn has the answers, he himself might reply.

I want to focus in on the powers of enforcement and regulation and the area of accountability when it comes to nursing homes and care homes. First, would it be the view of Health Information and Quality Authority, HIQA, that its powers of enforcement are a blunt instrument?

Mr. Phelim Quinn:

Yes, I suppose, is the short answer. What we have determined over the course of the past 12 years is that our powers of enforcement in the main relate to the imposition of conditions on the registration of registered providers and-or up to cancellation of registration. Obviously, part of the enforcement armoury includes prosecution, but used always as a last resort. Within our paper on regulatory reform, we have sought an amendment to the enforcement powers of HIQA to try to bring about some form of graduated approach to improvement within registered providers, for example, that we would be enabled to serve on a non-compliant provider an improvement notice or a non-compliance notice that would provide a staged approach to the enforcement powers that we currently have. Obviously, we work on an ongoing basis with providers at the point of inspection as well, seeking a positive and constructive response to some of the recommendations that would make.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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My time is short and I ask people to be as succinct as they can in responding. Essentially, Mr. Quinn is saying that HIQA would want to have the possibility of improvement notices that HIQA could serve. Would that be similar to what the Health and Safety Authority and the food authority do?

Mr. Phelim Quinn:

Absolutely.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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Is Mr. Quinn talking about similar type notices?

Mr. Phelim Quinn:

Very similar. They would also be similar to a power that we have in terms of our own regulation of services providing ionising radiation or X-rays.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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I want to come back to enforcement. HIQA has the powers of investigation in not only private nursing homes, but all nursing homes. In terms of the private sector, one of the criticisms that has been levelled at the HSE was that the HSE, as a purchaser of services, did not have sufficient knowledge of the private sector. I am looking for Mr. Quinn's view on this as the regulator. Would that be a concern that HIQA would have had?

Mr. Phelim Quinn:

Certainly, in the early stages of the pandemic this became a considerable highlight. The fact is the HSE had a limited knowledge of the privately provided elements of the sector simply because the relationship was through the nursing home support scheme and it was mainly a financial arrangement between the nursing home support scheme on behalf of the HSE and private providers on behalf of residents.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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Is Mr. Quinn's view, as the regulator, that there was not sufficient knowledge of the private sector within the HSE?

Mr. Phelim Quinn:

There was not at the beginning of the pandemic. However, that knowledge and interaction has built up quite considerably since. We believe, through our regulatory reform paper, that now needs to be formalised and accountability should sit as well with the purchaser of services as well as the provider of the service.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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In his opening statement, Mr. Quinn talks about, "a framework that makes a clear distinction between the purchaser and provider of services along with clear governance and accountability arrangements". Would that include looking at such matters as a provider-purchaser agreement and maybe service level agreements to strengthen that level of accountability?

Mr. Phelim Quinn:

Absolutely. It would include a service level agreement which includes an arrangement for clinical oversight of the places commissioned within residential care.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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Can I ask about powers of enforcement for individual complaints? This is something that has come to the fore during the pandemic but it was an issue pre-pandemic as well. I want brief answers if possible; I merely want to establish the facts. Does HIQA have the power to initiate an investigation into individual complaints of abuse or neglect in private nursing homes?

Mr. Phelim Quinn:

No. HIQA is a systems regulator. Therefore, it regulates on the basis of the system or the context within which care is provided and does not have the legislative power to investigate individual complaints.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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If I read Mr. Quinn correctly, HIQA looks at systems, processes and controls but it cannot initiate or investigate an individual complaint.

Mr. Phelim Quinn:

That is correct. However, we use information that we receive about individual complaints to form a framework about a context.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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I understand that, but HIQA does not have that power.

Mr. Phelim Quinn:

That is correct.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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Do adult safeguarding teams or social workers have that power to initiate an investigation in relation to an individual complaint of abuse or neglect in a private nursing home?

Mr. Phelim Quinn:

As the Deputy will be aware, I have appeared before the committee in the past in relation to safeguarding and safeguarding legislation. We believe that there is a requirement for safeguarding legislation.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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What I am asking, if I can establish the facts, is whether at this point in time adult safeguarding teams have the power to initiate an investigation into individual complaints?

Mr. Phelim Quinn:

They do not have the specific power. They can certainly ask for access but they do not have the power.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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That is an extraordinary weakness in the system. Mr. Quinn stated at the start that we shone a spotlight on what happened in nursing homes generally. He quite rightly says that we need a new comprehensive framework of social care and adult safeguarding has to be part of that.

Can I ask the HSE how we have a system where the regulator cannot investigate an individual complaint of abuse or neglect, and where adult safeguarding teams, including social workers, do not have the power to initiate an examination or an investigation? In this committee and indeed in the Special Committee on Covid-19 Response, we dealt with several terrible cases of abuse and neglect. Thankfully, they were small in number. The vast majority of nursing homes provided the highest levels of care but there have been cases of neglect and cases of abuse. It strikes me as extraordinary that we still do not have those powers. Can I ask the HSE why that is the case? Can Dr. MacLellan address that point?

Dr. Kathleen MacLellan:

Ms O'Neill may come in from the HSE as well. On the investigation of individual complaints, as has been outlined by Mr. Quinn, that is not currently within the legislation. It is, however, a priority for the Department, which is examining how those individual complaints can be investigated, and there is already discussion happening between HIQA and the Department on that. The Department is-----

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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I put it to Dr. MacLellan that, in 2013, HIQA called for changes to legislation which included safeguarding vulnerable people, looking to strengthen the statutory remit, and looking for changes in the 2007 Health Act that Mr. Quinn spoke about earlier. It is 2021. Does Dr. MacLellan accept that these were issues for a long number of years pre-pandemic and while Dr. MacLellan is saying we are still looking into this issue, at this point in time neither HIQA nor adult safeguarding teams have the power to investigate complaints of abuse or neglect of individuals? Is that still the case today?

Dr. Kathleen MacLellan:

They do not have legislative powers to investigate but there has been significant investment in building the safeguarding capacity and supports within the HSE, including the role of the safeguarding teams. In addition, it has to be remembered that cases of abuse are criminal matters and also should be subject to reporting to the Garda to be investigated in that way.

The Department is in the process of finalising, and will be going to consultation soon on, a safeguarding policy which will underpin any legislative requirements that are required in relation to legislation for safeguarding teams or for others in the management and assessment of abuse or neglect. One of the key principles there is prevention to educate and to build the supports that are already there. Ms O'Neill may want to respond on the safeguarding office and the work there within the HSE.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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Before Ms O'Neill comes in, I will return to Mr. Quinn for a second. From previous correspondence Mr. Quinn gave to this committee, I understand that, as the regulator, HIQA wrote on several occasions to the Department and the HSE. I mentioned that letter in 2013. Is it correct that, in June 2016, Mr. Quinn wrote to the CMO seeking amendments to the Health Act 2007?

Mr. Phelim Quinn:

That is correct.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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Is it correct that, in March 2017, HIQA developed a number of documents that were sent to the HSE where it was looking at expanding regulation of health and social care services to deal with many of these issues?

Mr. Phelim Quinn:

That is correct.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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In 2017, Mr. Quinn wrote to the director of the national patient safety office providing an update on suggested amendments to the 2007 Act. Mr. Quinn wrote again in 2018 and in 2020.

Is it the case that, from 2013 to 2020, Mr. Quinn, as a regulator, was highlighting, identifying and calling for a strengthening of regulations and powers, including in the area of adult safeguarding, and it simply has not happened to date?

Mr. Phelim Quinn:

That is correct, although I want to fall in behind what my colleagues in the Department have said. There is a very good, constructive engagement taking place at present in respect of the bilateral group, the implementation oversight group, and, as Dr. MacLellan has outlined, work on the investigation of individual incidents in private nursing homes.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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I got a message to say my time might be up, but I have one more question. Obviously, we want to follow up on all these matters. Members of the expert panel are present as well, but I did not have enough time to put a question. I respect the work they have done, but there is a massive amount of work to be done on adult safeguarding, changes to the Health Act 2007 and more powers of enforcement. All these issues are very important and I echo the call that has been made for a new, comprehensive social care model to be developed and for a more hands-on approach in the relationship between the HSE and private nursing homes. The out-of-sight, out-of-mind approach, which has been the case, is no longer acceptable. My last question relates to all nursing homes. Is the HSE considering or supporting the use of antigen testing in nursing homes at present? Can anybody from the HSE answer that question?

Ms Yvonne O'Neill:

I would not want to leave an impression that the safeguarding of adults is not a key priority for the HSE. The safeguarding protective teams in the CHOs respond very proactively to the cases that are made known to us within the legislation and regulation available to us.

On the antigen testing specifically, the guidance on the use of antigen testing is provided to us by NPHET and the antimicrobial resistance and infection control, AMRIC, division. Currently, there is no proposal for the use of antigen testing in nursing homes. A paper is being developed, as far as I am aware, for the purposes of NPHET to advise on the use

of antigen testing, including its pilot use in schools. We will await the outcome of that pilot-----

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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Is Ms O'Neill aware that some nursing homes are using it? I saw a newspaper report about one in Tipperary that is using antigen testing.

Ms Yvonne O'Neill:

No more than the Deputy, we have not been formally notified of that. We work with the guidance we get from NPHET and otherwise, and we will roll it out as we are requested to do within that guidance. The efficacy is the consideration we would watch for and be guided by.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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The next speaker is Deputy Hourigan.

Photo of Neasa HouriganNeasa Hourigan (Dublin Central, Green Party)
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I will stay with the issue of antigen testing now that it has been raised. I understand that NPHET is not necessarily backing it fully at present and that research is taking place, but if a service provider chooses to provide antigen testing, and a number of people have been in contact with me about this, the Covid-19 temporary assistance payment scheme, TAPS, does not cover it. Nursing homes are being asked to exclude those costs from any claims they make to the HSE. Is it the case that we are specifically excluding antigen tests from the allowable costs at present?

Dr. Kathleen MacLellan:

I will respond to that. The allowable costs are related to the current guidance in place, and antigen testing currently is not recommended for use in nursing homes. With regard to the recent visiting guidance, significant research and examination by AMRIC and the HPSC were conducted on the use of antigen testing and the available international evidence. It is being kept under review. Should the guidance change, obviously eligible costs under TAPS will be considered, but at present the eligible costs under TAPS are aligned to the guidance that is available.

My colleague, Mr. Redmond, might wish to add to that.

Mr. Niall Redmond:

That is correct. The scheme has been set up on the basis of following the existing national guidance relating to public health. As it is not recommended under the public health guidance, it is not an eligible item at present. However, if that situation changes, the eligibility of the scheme will be examined.

Photo of Neasa HouriganNeasa Hourigan (Dublin Central, Green Party)
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"If that situation changes" sounds quite loose. Is there a timeline or any expectation regarding when that will be reviewed?

Dr. Kathleen MacLellan:

We understand the matters of antigen testing are kept under constant review by the public health teams and by NPHET. If helpful, we can ask that a paper on that process be provided to the committee. However, it is something that is kept under constant review by NPHET.

Photo of Neasa HouriganNeasa Hourigan (Dublin Central, Green Party)
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I thank Dr. MacLellan. I am glad to hear about the interest in progressing some of the required legislation relating to home care. I read the opening statements and submissions and there is mention by both of legislation for the regulation of home care providers and research by the ESRI on how we would finance an increase in the provision of home care in the long term. I have met a number of advocates for increasing home care services and one of the immediate barriers raised with me is the timely transfer of information and the assessment issues from the service provider, such as the medical facility, nursing homes or the care settings the people are in, to the home care setting. I presume that requires a review of the home and an assessment of supports. That would be particularly relevant for people with disabilities, and I have a particular interest in that. I presume it would need a multidisciplinary team and requires a level of capacity in those settings to carry out that handover moment. While we have heard a little about the required legislation and the possible funding of it, what actions is the HSE taking now to put structures in place? What is the capacity among care providers to facilitate the transfer of service users from one setting to another? It is not the home care setting, but the first step.

Ms Yvonne O'Neill:

I can respond to that. It is a key part of the processes that will support any changes in legislation which drive the policy and practice. It is very important for us in the development of the scheme that we have the supporting assessment process agreed. There is a well developed proposal on that. The Deputy probably will be aware of the interRAI as a common assessment framework that can bring a level of clarity and transparency to how individuals are assessed. In addition, that will be common across the setting where the person could be coming from, perhaps a home, a hospital or a residential rehabilitation or reablement service, and planning to move home. That integrated decision-making process is a core part of the changes that are happening in the home support scheme, and implementation of the common assessment framework is a key part of that. Considerable recruitment is taking place with regard to the number of assessors who will have that dedicated function. It will be an important part of the overall process, an improved process pathway that the Deputy referred to in her question.

Photo of Neasa HouriganNeasa Hourigan (Dublin Central, Green Party)
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To be clear, as I only have a few seconds left, does Ms O'Neill believe we will require a significant number of assessors for the system? What is the position with staffing levels if we are going to provide that service in a timely and effective manner?

Ms Yvonne O'Neill:

As part of the roll-out of interRAI, we will be developing the recruitment and training of about 128 specific interRAI assessors.

It is important to recognise that there are a number of healthcare professionals involved in assessment processes and so there will also be reconfiguration in having a single integrated assessment and decision-making forum around when people move from a setting to home or, equally important, to stay at home.

Photo of Neasa HouriganNeasa Hourigan (Dublin Central, Green Party)
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What will be the required qualifications for an assessor?

Ms Yvonne O'Neill:

I might circulate the job specification following the meeting. I do not have it in front of me, but I certainly can provide it to the Deputy.

Photo of Neasa HouriganNeasa Hourigan (Dublin Central, Green Party)
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That is fine. I thank Ms O'Neill.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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I would like to inform members and witnesses that we are experiencing technical glitches in that cameras appear to be going on and off. Apologies to anyone watching at home and to members. We are trying to sort out the problem, which has been ongoing for a number of weeks. We thought it was fixed, but it is occurring again. The next speaker is Deputy Gino Kenny.

Photo of Gino KennyGino Kenny (Dublin Mid West, People Before Profit Alliance)
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Good morning to our guests. I have a number of questions related to what happened in the nursing homes last year. It makes for sombre reading that 45% of all those who have died in this State of Covid had been in the nursing home setting. My first question relates to Dr. MacLellan's concluding remark in her opening statement that the HSE national service plan fully recognises pandemic learning and reform requirements, including commitments to commence planning towards a longer term rebalancing of public and private nursing home mix. There is a disparate mix in nursing home ownership in that 80% is private and only 20% is public. What does Dr. MacLellan mean in terms of the rebalancing of the public and private mix?

Dr. Kathleen MacLellan:

I thank the Deputy. The HSE is looking at a reform framework for long-term residential care, including opportunities for increasing direct public provision in relation to long-term residential care which will decrease some reliance on the private sector, but also looking at the types of long-term residential care that are being provided. One of the big learnings we would all take on board is that if we can reduce the number of congregated settings for people to live in that would be helpful in terms of protecting them around infection prevention and control. The HSE is looking at ideas such as support villages, own-door services and different types of configurations of long-term residential care. It has committed to that and there has been significant funding put in place to look at new types of intermediate care, rehabilitation beds within the community and expanding home care as well.

Part of the planning around the statutory home care scheme requires that we would look at care of the older person as a new model such that there will be a continuum of care and it is not the case that automatically the decision is made that a person would go to long-term care or receive home care. As described by Ms O'Neill, the decision-making will start with the standard assessment tool, which will look at the needs of older people and, in deciding those needs, look to what supports can be provided within the community, moving towards long-term residential care, as needed. The new home first model is already being tested by the HSE. The goal will be to reduce the number of people within long-term residential care and the length of time that they would spend there such that the admissions would be appropriate and then to look to the broader provision of both by the HSE in terms of publicly provided long-term care.

Photo of Gino KennyGino Kenny (Dublin Mid West, People Before Profit Alliance)
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I thank Dr. MacLellan. In her opinion, was our over-reliance on the private service a factor in the disproportionate number of people who died in this State in nursing homes? I think a public inquiry-type investigation is needed on this issue, during which might come out in the wash the reason for the catastrophic response in terms of nursing home deaths. What can be learned from what happened last year to ensure it never happens again?

Dr. Kathleen MacLellan:

We have significant learning from the nursing home expert panel in regard to the types of causal factors. One of the particular learnings which has been seen through the work of the European Centre for Disease Prevention and Control, ECDC, the Health Information and Quality Authority, HIQA, and the expert panel is that the level of community transmission is significantly important in terms of the level of transmission within nursing homes. There is a piece of work nearing completion. It is a recommendation of the nursing home expert panel that the Health Protection Surveillance Centre, HPSC, with HIQA would examine the risk factors and protective factors in the transfer of Covid-19 into nursing homes. As I said, that work is nearing completion and will be published shortly. That will be significant and supportive in terms of learning going forward.

One of the other learnings, which we have validated through a number of pieces of work, is that the level of transmission and the level of mortality when looked at proportionally are not similar across the private and public nursing homes, but the proportional balance between private and public is leaning towards the private sector. We have to acknowledge the significant supports that have been put in place. The Deputy spoke about the model of care. The nursing home expert panel particularly recommended a stronger integration of both public and private services going forward. The HSE and the panel are fully committed to that and work has commenced on how it can be delivered.

Photo of Gino KennyGino Kenny (Dublin Mid West, People Before Profit Alliance)
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My final question is to the representative from HIQA. In regard to the deaths that took place in nursing homes, what is the breakdown in respect of the private nursing homes and those operated by the HSE? Is a breakdown of deaths in those settings available? There was an issue around staffing levels in private nursing homes in particular, in respect of which I have heard some horror stories that I do not have time to go into now. Is there a breakdown available of the deaths that occurred in private nursing homes and public nursing homes?

Mr. Phelim Quinn:

Before I ask my colleague, Ms Susan Cliffe, to respond to that question, I would like to make one point. The data that is collected as part of statutory notifications from HIQA is around unexpected deaths and so it is not specific to Covid-19. However, there was a pattern that emerged during 2020 and early 2021 which would be indicative of the impact of Covid-19 within the residential care sector. I will hand over to my Ms Cliffe who might be able to give the Deputy some further detail.

Ms Susan Cliffe:

The number of unexpected deaths notified to the chief inspector from March 2020 to date is 2,721. Again, these are unexpected deaths. The HPSC is the definitive data collector with regard to Covid-related deaths. Of the 2,721, 413 occurred in the public facilities and 2,308 occurred in the private facilities. This is broadly similar to the percentage breakdown for private versus public services in the sector.

Photo of Gino KennyGino Kenny (Dublin Mid West, People Before Profit Alliance)
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I thank Ms Cliffe.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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The next speaker is Senator Martin Conway. As Senator Conway is experiencing technical difficulties, we will move to Senator Hoey.

Photo of Annie HoeyAnnie Hoey (Labour)
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I thank the witnesses for being with us this morning. Can any of them offer some insight on the following issue?

Some weeks ago, there was a radio interview about the uptake of the vaccine among staff working in nursing homes. There was discussion around offering prizes and so on to tempt people into taking up the offer. Has there been any improvement or are there still people resisting it? Has the AstraZeneca debacle had any impact? Is there confidence that the vast majority of staff been vaccinated and only a small minority are not?

Dr. Kathleen MacLellan:

On nursing homes, we understand there has been an extremely high level of uptake both among residents and staff. There may be staff who, for medical or other reasons, have not taken up the vaccine but our information is that there has been an extremely high level of uptake. Compared with international rates, our healthcare staff have really stood up to the plate in taking up vaccinations in the interests of the safety of the residents and patients they look after.

Photo of Annie HoeyAnnie Hoey (Labour)
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That is very positive. I recalled hearing that piece which was worrying but it is good to hear there is a high uptake.

Following an earlier question around care of the older person, the new model and needs for older people and support in the community, what would be the ideal timeline for that happening? We keep hearing about reports and so on but how long is reasonable for this sort of shift to happen? The HSE is trialling supports in the home. What is the time line for that and for reducing numbers in homes? Ideally, what number would this be reduced by? It might be pie in the sky thinking but what would be a good measure of its success?

Dr. Kathleen MacLellan:

We have started and are already progressing moving that model forward. The level of investment and commitments made in the service plan for 2021 are already starting that significant shift. We expect the funding provided for significant re-ablement beds and home first would keep around 250 people in the home rather than their being transferred into long-term residential care. If we see that indicator coming through by the end of the year, it will give us a real sense of confidence moving into 2022 about what can be achieved and delivered safely within the system.

I am not in a position to put a percentage reduction on the number admitted to long-term residential care. That is something we need to look at internationally and see what a reasonable approach would be. The average length of stay can be up to three years in long-term residential care. We would really like to see that reduced. In some countries, that stay is around 18 months. I will ask Ms O'Neill to follow up on the HSE commitments and developments.

Ms Yvonne O'Neill:

The year of Covid has slightly complicated what we can interpret from trends. The home support services have increased by about 20% in the levels provided between 2019, 2020 and 2021. As we tilt towards an enhanced availability of services and a more enhanced packages of care for people in the home, we should watch what its impact is for the people choosing. Something we should mention also, in regard to previous discussions here, is that people should have the choice. People will make choices about going into nursing homes. When they do, the law is that the contract is between the resident and the nursing home. How the HSE makes services available and how ourselves and HIQA have oversight is dependent on that law being that the relationship being between the nursing home and the resident. When a person chooses what it is they would like for their next phase of care, what we want to do, as my colleague, Dr. MacLellan, outlined, is provide a level of choice. The trends in applications for nursing home care are complicated by the Covid context so it will probably be next year before we can see how the relationship progresses between the proportion of home support and residential care.

Photo of Annie HoeyAnnie Hoey (Labour)
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I am a big fan of blue sky questions and broad thinking. What is the reality of this shift? There will be a cost to it and the reconfiguration of community supports and structures as well as costs to individuals and homes. There is also something of a culture shift. Ms O'Neill mentioned choice. It is obviously not simply a choice between the individual and the nursing home, hopefully there will also be a whole family structure around the individual. How will people adapt to that? For many, including my own family, it is an ideal to try to keep people in the home but the reality can be very difficult. Will this succeed in reality? It is tied to the commitment from Government because it is an expensive project. It is very important and worthwhile, and one which I am happy to see, but it will require a huge political commitment and investment. What is the likelihood of it really succeeding, either from the Government perspective or bringing people with us?

Dr. Kathleen MacLellan:

I will begin and will then ask my colleague, Ms Cooney, to address some of the issues that have been coming up through the work by the ESRI. The opportunity to hear families' voices and the voices of individuals will be critical in developing good policy. There has already been some consultation on that and there is a broader NGO group which Ms Cooney works with on developing the statutory scheme. That is absolutely critical. Very important research is being undertaken by the ESRI which has a significant wealth of expertise and experience looking at demand and capacity models. It would be useful if Ms Cooney could give a short description of that.

Ms Sarah Cooney:

As Dr. MacLellan mentioned, we have a programme of work with the ESRI this year that will culminate in the publication of three reports this year. The first is on demand for a home care scheme, looking at the parameters that may be involved. The second is using the ESRI SWITCH model to examine the possible cost of a scheme and taking on board full Exchequer funding and various models that may include user contribution. A third report is to come out in the third quarter which will examine the cost of non-acute care in the community, including home care and other elements such as long-term residential care and primary care. That will enable decisions on the financing model. As Dr. MacLellan and Ms O'Neill mentioned, a large piece of work is being done this year around a reformed model of service delivery. As part of that, we are testing what might be included in a statutory home care scheme, in particular looking at the data that comes out of interRAI. As Ms O'Neill said, approximately 130 assessors will be put across the community in the community health networks to get national coverage. We will examine the data that comes out of that and try to map the needs of our population against that and the services they may require. It will also examine broader elements, including the clinical governance and other models that may be needed to support this in the community, and look at areas such as the evaluation and the monitoring of the home first approach. We are also working with our colleagues in Sláintecare around the enhanced community care and the roll-out of the community health networks which will provide the architecture and the primary care team that will be needed to support this broader model of care to support older people and other people with care needs in their homes. A significant amount of work is ongoing this year and we hope to have the evaluation and data throughout this year and moving into 2022.

Photo of Martin ConwayMartin Conway (Fine Gael)
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I have logged out and logged back in so I hope that has resolved it and the committee can hear me.

In response to Deputy Cullinane, it is shocking to think HIQA has been looking for powers to investigate individual complaints in nursing homes going back to 2013 and that has still not been dealt with. There was clearly a breakdown of some sort or a lack of co-operation between HIQA and the Department of Health. That is serious because smooth engagement and synergies are important with that.

I will concentrate on younger people in nursing homes. There are younger people who do not have mental health challenges in nursing homes, which could easily lead to mental health difficulties. A young person with a physical disability of whatever sort in a nursing home with older people because that is the only care that can be identified for that person is not in a good environment. I ask Dr. MacLellan how many people under 65 are in nursing homes. What is the Department doing to eliminate this practice and find more suitable accommodation for these young people?

Dr. Kathleen MacLellan:

On the Senator's first comment, HIQA and the Department have worked closely on the regulatory models over the years and are in a process to address those now.

On under-65s in nursing homes, it is our policy view that the preference of those individuals should be met as much as possible. Those in nursing homes tend to have complex care so there is a need for various levels of support for them. Our understanding of the number of under 65s in nursing homes is, and I may not be fully correct on this, that it is around 1,300. My colleague in the HSE may be able to correct me on that. A number of those placed there are not inappropriately placed. Particular decisions have been made that they are appropriate placements. For those for whom care in the community is considered preferable, there has been consideration within the current service plan and some funding has been provided to start examining this year those under 65 in nursing homes and how they can transition back into the community.

Photo of Martin ConwayMartin Conway (Fine Gael)
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I will filter my question further. What is the number of under-65s in nursing homes who the Department deems to be placed inappropriately?

Dr. Kathleen MacLellan:

I will ask my colleague from the HSE to come in. I am not sure how much detail we can provide on that at this time.

Ms Yvonne O'Neill:

I thank Dr. MacLellan and Senator Conway. Dr. MacLellan is right. We are basing this on the numbers available to us through the nursing homes support scheme because we do not have sight of the numbers who have an arrangement directly with the nursing home not funded through the scheme. There are about 1,330 under-65s. In direct answer to the question, I cannot tell the Senator the numbers who are currently inappropriately placed.

We are working in regard to the funding made available to offer alternatives to those in nursing homes under 65 who are fit to avail of those alternatives. We are working with the profile. There are complex cases. Some 50% of those are over 55 and 85% of the 1,330 are over 50. If we were to go on age, which could be a place to start, we would target the youngest. It is a piece of work that is part of the national service plan, NSP, we have agreed with Government with some funding this year.

Photo of Martin ConwayMartin Conway (Fine Gael)
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Based on those numbers, it would be fair to say there is in excess of 200 people under 50 currently placed in nursing homes. I would describe all of their placement in nursing homes as inappropriate. Is there a specific unit in the HSE or the Department of Health working to eliminate this and come up with more appropriate solutions for, in the first instance, that 200 and, moving forward, those under 65?

Ms Yvonne O'Neill:

In the brief I have in community operations, between our disability and older persons services we take responsibility for reviewing that. The work has started. It is not just an age issue. It is on the basis of complexity of need. We want to be careful that being under 65 is not a criterion by itself. It should be on the basis of need and the care assessment. We have started that work this year with initial investment which will allow us move a number - probably up to 20 people - this year. We will continue that as investment is provided. Obviously, that----

Photo of Martin ConwayMartin Conway (Fine Gael)
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I ask Ms O'Neill to send a note in writing to the committee with the specifics and the targets. I am dealing with a couple of cases of people whose absolute desire is not to be in nursing homes. I agree with them that it is not appropriate they should be there. It is going on for years and is totally wrong. It is destroying them mentally. They feel hopeless, that they do not have any future and that nobody really cares. It needs to be a top priority to take people out of those wrong settings and give them some sort of independent living with the necessary supports.

Ms Yvonne O'Neill:

We agree with the Senator. It is equally important from our point of view. The earlier conversation on how we enhance our home care packages and what can be offered to give people choice and options beyond residential care is part of that.

Photo of Martin ConwayMartin Conway (Fine Gael)
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Would Mr. Quinn from HIQA like to comment on this?

Mr. Phelim Quinn:

HIQA has a specific regulatory framework but I will pass it over to my colleague, Ms Cliffe, who can give more detail on our experience of this.

Ms Susan Cliffe:

We are aware there are some people who are inappropriately placed in nursing homes but the current regulatory framework does not set age as a criterion for who can be accommodated in a nursing home. When we inspect a nursing home, we look to see if the care needs of the resident are being met, including their psychosocial needs. Where incidents are identified or inappropriate placements are brought to our attention, we engage with the registered provider on that. We look to see that person has access to an advocate and a multidisciplinary team, including a social care worker, and we look at what the provider can do to increase the provision made to support the person's needs. They may need access to a personal assistant to assist them to integrate into their community and issues like that. These issues have been made more difficult during Covid but this is an area we remain focused on and are addressing as we go forward through our inspections.

Photo of Martin ConwayMartin Conway (Fine Gael)
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I thank Ms O'Neill.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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Our next speaker is Deputy Cathal Crowe. I cannot hear him so I will come back to him. I call Deputy Durkan.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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I thank our witnesses for coming along. I have a couple of questions I would like to get into. In the response to a previous question, reference was made to the number of patients who died during Covid in private and public nursing homes. Will the witnesses repeat the numbers again?

Mr. Phelim Quinn:

I think we are talking about the figures provided by Ms Cliffe on unexpected deaths.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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Yes.

Mr. Phelim Quinn:

We can certainly do that.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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Covid-related deaths.

Mr. Phelim Quinn:

We would not have a breakdown in respect of Covid.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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Unexpected deaths so. Then could I have the number of patients in the public and private sectors? We got the number of patients who died unexpectedly but we do not know the total number of patients in each sector.

Mr. Phelim Quinn:

I think we can provide that.

Ms Susan Cliffe:

We were notified of 2,721 unexpected deaths in total since the beginning of March 2020. Of this total number, 413 of these unexpected deaths were notified to us from what we describe as public nursing homes. A total of 2,308 unexpected deaths were notified to us from the private nursing homes.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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How many patients were in each of these sectors?

Ms Susan Cliffe:

That would be-----

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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My understanding is that a huge majority of the patients were in the private sector.

Ms Susan Cliffe:

I can give the Deputy the numbers that are there today. There are 574 nursing homes in total registered with the chief inspector. Of these, the number of beds in the private nursing homes, which are not necessarily all occupied today, is 25,581, and the number of beds in the HSE facilities is 5,610. There are also 978 beds in what we call the voluntary facilities. These are funded under section 38 or section 39. Again, just to be clear, these are the numbers of beds in the total 574 centres. They may not necessarily all be occupied at the moment but if they were full, that would be the total number of residents.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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During the Covid debates we got information that corresponds with what Ms Cliffe has just told me, that there is a vast difference between the number of beds available in the private sector for such patients as compared to the public sector. Is this true? There are at least five times as many.

Ms Susan Cliffe:

Yes.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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The point is made.

I want to ask about inspections and referrals where an inspection is carried out in either a public or private nursing home and concern is expressed or issues are raised. What is the normal procedure in the notification process? Does notification take place instantly? Are the concerns of the inspection group brought to the attention of the authorities immediately in the particular nursing homes and to the attention of the health authorities?

Mr. Phelim Quinn:

I will again pass over to Ms Cliffe and she will bring the Deputy through the notification process and numbers.

Ms Susan Cliffe:

Providers are required by law to notify us in respect of specific issues. Depending on what that issue is, it may be required to be notified to us within 72 hours. Some notifications occur on a quarterly basis.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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Suppose the providers do not notify HIQA.

Ms Susan Cliffe:

If we receive information from other quarters to suggest a provider has not notified us we will engage directly with the provider and seek that information. Otherwise when we are out-----

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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Does HIQA have a system whereby it can identify deficiencies in the system without waiting for a referral?

Ms Susan Cliffe:

That is our inspection process.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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Right.

Ms Susan Cliffe:

When we are out on inspection, we are looking for evidence of incidents that should have been notified to us and that may not have been notified to us. This evidence may come from a resident or a relative whom we meet and speak to during the inspection. It may come from information we see in a complaints log. It may come from information we see in a resident's record. It may come from an allied healthcare professional working in the designated centre. There is a good reporting process throughout the sector. This is seen in the almost 15,000 notifications we received in 2020.

Another factor for us can be the absence of notifications. If we have a centre from which we do not receive notifications it might equally be a flag for us and we would go looking for further information about it.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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How often has HIQA done this?

Ms Susan Cliffe:

That would happen during an inspection. In the preparation work for going out on inspection, every inspector will review the information we have regarding a centre. This will include its notifications and any unsolicited information we have received about the centre or any outside information we may have received. If there is an absence, and some centres may not have had any unsolicited information or notifications, then we will explore that with the provider. I could not pull the Deputy a specific report on how often it happens. It is part of our routine preparation for inspection and engagement during inspection.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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How often do inspections take place normally?

Ms Susan Cliffe:

Prior to Covid we aimed to do two inspections in every centre during a three-year regulatory cycle. This was our minimum requirement. In 2016, 2017 and 2018 we were in approximately 80% of centres and in 2019 we were also in approximately 80% of centres. We were doing more than the baseline expectation. Going forward with our newly sanctioned posts, we will see the inspection regime ramping up because, simply put, we will have more boots on the ground. We expect to see the impact of this towards the end of this year.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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Could it be concluded that the number of inspections was totally inadequate to deal with the possibility of difficulties or issues arising that needed action immediately? For instance, a year is an awfully long time to somebody who is in difficulty in a nursing home, whether it be public or private. Does Ms Cliffe agree?

Ms Susan Cliffe:

We have always had a risk-based response to the information we receive. There are some nursing homes where we have had a concern that may have had three, four or five inspections during a given period. If the profile of the nursing home and the information we had regarding that nursing home mandated an increased requirement for inspections then we have provided and undertaken those inspections. I agree with the Deputy that the more inspections we have, and the more often people go into nursing homes to carry out the baseline inspections, the better we will be. This is the position we are moving towards with an increased inspection regime. We have been allocated additional posts and we have already gone through the process of recruitment. Approximately seven have come on board and we expect to have brought all the posts on board by the end of the second quarter of this year.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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For example, in public or private nursing homes where major issues arose, on review does Ms Cliffe think that sufficient inspections were carried out in the run-up to the discovery of the issues of concern? If not, why not?

Ms Susan Cliffe:

The key point is the regulations we were inspecting against, which comes back to the purpose of this meeting and the requirement for regulatory reform. When we were going out, we were inspecting against regulations that we now see had significant shortcomings. It is not so much the frequency of the inspections but the quality of the tools of the legislative framework against which we could inspect. This is why we very much welcome this engagement now and are actively engaging with the Department to drive the process of regulatory reform in order that we have more effective tools available to us to drive the quality of care in nursing homes and to increase the impact of the inspections we carry out in these nursing homes.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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In comparison to what used to be the system, I used to be a member of a visiting committee to a number of hospitals. A small group of people, normally five or six, visited on a fairly regular basis. We were directed by the authorities based on continuous observance of the situation whatever it was, whether it was a public or private institution. We usually made decisions on the spot. In other words, if something needed to be done it was done then or within 24 hours. If it was not done within 24 hours we called on the authorities to close down the facility instantly. My point is that it is fine to say we need more legislation but we did not have legislation and we did it just the same. There was no legislation to allow the offenders, for want of a better description, whether in the public or private sector, to engage in any way and prevent what was required to be done. We went through an awful lot of changes and brought about an awful lot of changes in that period.

Is it possible to act with more alacrity when something comes to the attention of the authorities? To what extent is there an ongoing monitoring of sensitive areas?

Ms Susan Cliffe:

We have what we call immediate action plans and urgent action plans. An immediate action plan is something we identify during the inspection and bring to the attention of the provider. We require the provider to address it immediately. An urgent action plan may take longer and may have a 24, 48 or 72 hour or two-week period, depending on the issue identified. The vast majority of providers will address an issue such as that when it is brought to their attention. We have greater difficulty with some providers in getting the necessary changes we have on the centre. We have to work within the legislative framework available to us when those difficulties arise. We have faced significant challenges to the legislative framework in the last two years and have undergone three judicial reviews of our powers.

It is important to note the vast majority of providers work with the regulator and are anxious to deliver the best possible service. When we bring something to their attention, they address it immediately or as soon as possible. We have to work within our legal framework when there are difficulties.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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During the course of the judicial review-----

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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I will not allow Deputy Durkan to continue. He is way over his time and is cutting into the time of his colleagues.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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I was waiting for the Chairman's voice. I am always glad to hear it.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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My voice is probably too soft. As we cannot heard Deputy Crowe, I will call Senator Kyne if he is ready.

Photo of Seán KyneSeán Kyne (Fine Gael)
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I welcome the witnesses and thank them for their presentation. I have a couple of questions for Dr. MacLellan. She referred to 68 open outbreaks, down from 178. While the decline is welcome, the figure seems somewhat high considering the number of vaccinations that have taken place. Will Dr. MacLellan describe those outbreaks? Are they less severe than previous outbreaks? Are they among residents who have been vaccinated or staff?

Dr. Kathleen MacLellan:

We have been advised that the level of support and severity is much lower and that a number of these outbreaks are coming to a close. Some outbreaks remain of concern and are receiving ongoing support from the Covid-19 response teams, HIQA and across the HSE. We expect the outbreaks will be closed fairly quickly given the length of time some of them have been open. We have seen a quick and dramatic drop in the number of open outbreaks. It is likely due to the vaccination effect and the reduction in numbers of cases in the community.

The other important point to note is that full effect of the vaccination does not come into play until two weeks after the second dose. It is likely some people who have contracted Covid-19 were at a particular place in the vaccination programme.

Photo of Seán KyneSeán Kyne (Fine Gael)
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Can we expect a continuous drop in the level and severity of outbreaks over the coming weeks and months?

Dr. Kathleen MacLellan:

The current trends indicate it will go that way. Hopefully it will but as we have seen, Covid-19 has a level of unpredictability. However, the trends we are seeing indicate we will quickly see a reduction in the number of open outbreaks over the coming weeks.

Photo of Seán KyneSeán Kyne (Fine Gael)
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It is safe to say the majority of people want to be able to stay at home for as long as possible as they get older. One thinks of one's own mortality at 45 and would like to stay at home while it is safe to do so. However, illness, strokes, heart attacks and debilitating illness get in the way.

Could a model of small, single-level, clustered community units with a communal area for residents and support, as required, be considered as a model between full home care and full residential care? Would the Department be interested in such a model or one where people are at home by day and attend such a facility or nursing home by night, with family supervision, if possible? Much of that depends on supports at home. Not all families have children. Could this model be considered? When will a discussion on future models take place and when will decisions be made on a change in approach?

Dr. Kathleen MacLellan:

I assure the committee that the Department is keen. Its current policy is to see a broad opportunity for the types of housing options that could be supported within the community. It is important they are set up with the types of supports needed from the statutory home care scheme and elsewhere.

Early last year, the then Minister for Housing, Planning and Local Government agreed a policy options paper with the then Minister of State with responsibility for mental health and older people, Jim Daly, on housing options. An implementation committee for this is up and running. It is considering joint working across the Department of Housing, Local Government and Heritage and the Department of Health to examine opportunities to work closely on different types of housing options, potentially within in smaller villages and that provide health supports.

My colleague, Mr. Redmond, has worked in this area and has had the opportunity to see some of those internationally. I ask him to describe some of that.

Mr. Niall Redmond:

We are working through a range of support issues in our joint policy with the Department of Housing, Local Government and Heritage. It is not just the bricks and mortar piece but the wraparound supports that are required in the community. We are considering supports such as the support co-ordination services provided through local authorities. I refer to ALONE in particular and a number of other organisations that provide lower level but important support to keep people at home. It ranges from meals on wheels to befriending services to check-ins and other important community based supports.

We are doing significant work on how we can increase the provision of meals on wheels, improve the service and expand support co-ordination. Considerable work has been done on that and the community call in the context of the pandemic and that has given us good insight into the expansion of those services.

We have a programme of work with the Department of Housing, Local Government and Heritage on creating the infrastructure of a middle ground between the person's home and the nursing homes. A pilot project in Inchicore is being developed with a range of stakeholders to find and design a model that will work for the future and to identify how it could be integrated with the home care scheme. A number of different strands are in development. As they evolve further, it will be important to bring them all together into a coherent framework around the model of care and type of service we provide into the future.

Photo of Seán KyneSeán Kyne (Fine Gael)
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That is important. There are many half-acre sites around the country where granny flats could be constructed and support provided by family members who would look after the individual in their own property. This would provide security and help with the housing situation. Many models could be considered in terms of providing supports and the transition between being fully at home and fully in a nursing home setting. That discussion will be important going forward.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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The opening statement noted that one-third of nursing homes remained Covid free.

What lessons can we learn? What were those nursing homes doing differently, do we know?

Dr. Kathleen MacLellan:

The first thing is to go back to the fact that the level of community transmission has been one of the biggest single indicators of the number of nursing home outbreaks that have been seen. We have brought with us the chair of the expert panel, which has provided us with significant learning across the Covid pandemic, and these are the recommendations on moving forward that have been progressing, so it might be useful if Professor Kelleher had the opportunity to speak about those lessons learned.

Professor Cecily Kelleher:

In reviewing this in the first instance, we on the expert panel were very concerned as to what the factors that created risk for development of outbreaks in nursing homes might be. Clearly, our report is centred on all these things. The first point to make is that the incidence in the community is a very important driver to risk. That was true, unfortunately, at the outset of this, when we were dealing with it last spring, and now it has again become very clear that as we have been going through this period, in January and February, community incidence and incidence generally is an important driver. That is one important factor. Dr. MacLellan referred earlier to the fact that a report will be published shortly, we hope, which was undertaken jointly between HIQA and the HSE's HPSE and which will look at protective factors and risk factors based on the data that were available. The international evidence all points us to the fact that this is a very serious, highly contagious infectious disease whose natural history and management were, in the early stages, very important features; that congregated settings are risky environments for a whole variety of reasons related to transmission of risk; and that in the nursing home setting older people and those who have underlying conditions were particularly susceptible. Of course, there is also the big question of preparedness that was so important then and remains so now. There are, therefore, a constellation of factors at play here that are very important. In the first six months of our reviewing preparedness, all the things that required stepping up have been stepped up. It remains the case, more so than ever, that they should be sustained and that we should have long-term supports in place that would maintain that level of preparedness going into the future. It was therefore a mixture of factors: the incidence in the wider, general population, the management of the condition, the degree of preparedness in the setting and the fact that congregated settings are inherently risky environments.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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Regarding knowledge of the sector at the start of the pandemic, would Professor Kelleher say the expert panel is now satisfied with its knowledge of the sector?

Professor Cecily Kelleher:

It is a key piece that has been brought out across the discussions this morning and of which the expert panel was aware. We were very clear in our recommendations that we wanted to see an integrated approach to both the public and private sectors in respect of nursing homes. Our recommendations focused very much on that. They were very clear on the immediate preparedness response, the importance of having the teams in the community that were up and running and supportive and all the things we have been talking about over the course of the morning, moving towards a new integrated model of care that facilitates choice.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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We heard stories from many families and nursing home staff, particularly earlier in the pandemic, that they felt abandoned. There was the lack of PPE and so on. Again we are hearing stories in the media of a possible tsunami of cases, litigation cases and so on. Is the HSE picking up that information? Has there been any discussions in that regard?

Professor Cecily Kelleher:

When we produced our original report, there were many such harrowing cases. We described them in our report, and many of our recommendations were about addressing them. I believe services have been stepped up to respond more appropriately since then. A whole variety of factors need to be addressed, including, for instance, the visitor guidelines, which we have just been made aware of in recent days. It is therefore very important we would have, as I said, a preparedness into the future but it is required immediately also.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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Staff shortages was one of the difficulties highlighted during this. Do the witnesses hear much about long Covid and staff still suffering from long-term symptoms? Is the incidence of this higher within nursing homes than in, say, the hospital setting or is it on a par, do we know?

Professor Cecily Kelleher:

I will pass over to my colleague, Ms Yvonne O'Neill, on that, but a crucial thing to say is that support for staff is very important and a number of key occupational health supports were rolled out. I think the importance of the vaccination programme in supporting both the residents and the staff will be very important.

Ms Yvonne O'Neill:

I thank Professor Kelleher. There would not be a significant variation between the level of Covid staff leave across the hospital and community sectors. One thing we experienced at the height of the third wave, in February, was that, on average, an outbreak could result in about 20 staff being on Covid leave. The good news now in terms of the positive trends that were referred to earlier is that where we have outbreaks, the level and severity, as Dr. MacLellan said, are much lower, so we would be talking about an average of perhaps four staff being on leave. We will all watch across the system for the impact of what has been termed long Covid. Certainly, there is both the psychosocial response to which Professor Kelleher referred and occupational health's wider response in terms of continued symptoms and the health sector overall through the chief clinical office. It is a matter of reviewing what we would envisage is in the response that will be required to that expected long Covid experience. The other thing about staffing levels, to which the Chairman referred, is that one of the other recommendations arising from the expert panel concerns the workforce planning component for the continued models of care. That will be a key part of the ongoing work across all the providers. I just wanted to come back on those two points.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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Regarding that report, my colleague is trying to get back in. Does Deputy Cathal Crowe want to get in again?

Photo of Cathal CroweCathal Crowe (Clare, Fianna Fail)
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Yes.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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We can hear him this time.

Photo of Cathal CroweCathal Crowe (Clare, Fianna Fail)
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I apologise sincerely. I have had a few IT glitches, but the good old mobile phone is picking up where the laptop failed, so all is good. I can hear the Chairman and I have been following the debate so I thank him for allowing me in. I have a few points I wish to put to our panel of witnesses. I join others in welcoming them today.

A big feature of the first wave of Covid was that GPs were not going into private nursing homes. It was simply, in their view, too risky to be going into them, offering a level of GP care and then risking transmitting the virus within the broader community. Of course, there has been a significant ramping up of vaccinations since early January. I wish to ask our witnesses whether that has improved. Are the medical needs of people in private nursing homes now being fully met when a GP locally is required to be on site? Are GPs coming in? Can they come in? Is all that being facilitated on site and off site?

Dr. Kathleen MacLellan:

I might start, if that would be helpful. Obviously, the GP's direct relationship is with the private nursing home, and there is guidance in place on visits of healthcare professionals to nursing homes and their duties. One of the real things we saw during Covid was the additional expert support that was needed for nursing homes to support residents, be that geriatrician support, palliative care support or GP clinical support.

The standing up of the 23 Covid response teams across the CHOs has been a significant game changer in the level of clinical support that has been and continues to be available to nursing homes. One of the recommendations of the expert panel is that we move to put those teams on a permanent footing within the communities as community support teams and we are at a preliminary stage of considering how we can start that transition phase. It will provide that there can be a lot more clinical expertise available on an ongoing basis. That will fit well with the development of the community networks within the community as well. It will become a much more integrated system across the public and private sectors.

Photo of Cathal CroweCathal Crowe (Clare, Fianna Fail)
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There is a huge amount of dialogue about quarantine, particularly with regard to international travel. Is there any quarantining happening in nursing homes? I will be more specific in what I am asking. I know of a number of cases where an individual may have been discharged from hospital in recent weeks but had not yet been vaccinated for Covid. Rather than going home, it was deemed necessary that this person would go to a step-down facility, that is, a private nursing home close to the person's residence. However, the nursing home residents had all been vaccinated. Therefore, an unvaccinated older person went into a nursing home environment without having been vaccinated. How is that being catered for within the sector? That will improve week-on-week as vaccines roll out but are there mechanisms in place to cater for that? This has caused alarm in cases and people are not aware if there are quarantining or other guidelines in place to mitigate that happening.

Dr. Kathleen MacLellan:

I can outline the guidance that is in place and that we would expect to be followed. That guidance is that any person who is transferring from a hospital to a nursing home should be tested in the few days before transfer. We do not use the term "quarantining" within the nursing homes but we would say that even if Covid is not detected on that test and even if that person is also asymptomatic, that person should limit his or her movements within the nursing home for 14 days after arrival and that there would be ongoing and regular monitoring of that person for symptoms. That is the guidance and that has been in place for a period of time, irrespective of and prior to the introduction of vaccination across the nursing homes.

Photo of Cathal CroweCathal Crowe (Clare, Fianna Fail)
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To build on that, I know other colleagues have asked about staffing shortages. Does it concern the private nursing home sector in particular that as we move towards a model of statutory home care, private nursing homes may be pulling from the same pool of people in terms of employment? Are there enough care assistants and home carers in our country or about to be trained up in our country to meet the needs of both systems running concurrently?

Dr. Kathleen MacLellan:

There are workforce challenges and a strategic workforce plan is being developed to look at the needs across the system. I would like to point to the fact that through the chief nursing office in the Department, work on the safe staffing framework has commenced. That task force is in place and it has looked at international models of staffing across nursing homes. It is examining which model is the closest one that would work in this country and it will look to test that out in this country. There are two pieces to this. First is the availability of staff and the strategic workforce planning that is needed there. Second is the type of staffing model that we want and that we should put in place across the country for the future. Safe staffing has worked through phase 1 in acute hospitals, phase 2 in emergency departments and phase 3 is under way within the long-term residential care facilities. It is a welcome development and it will be helpful for the future.

Photo of Cathal CroweCathal Crowe (Clare, Fianna Fail)
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I want to touch on the issue of younger people, that is, those under the age of 65, who are in nursing home environments. I have heard Dr. McLellan outlining earlier in the meeting that somewhere in the region of 1,300 people in that age bracket are accommodated in nursing homes. It was broken down in discourse that some were appropriately accommodated and others were inappropriately accommodated. It is inappropriate for anyone below 65 to be in a nursing home environment and it is injurious to their ongoing mental health needs.

I mention one case in particular which is quite public and has been well flagged in the media and this lady consents to her story being told. The case in question is that of Jennifer Hynes in County Clare. She is only about 18 months older than me and she finds herself in Mowlam Healthcare's Ennis Nursing Home. Ennis Nursing Home is a fine nursing home but it is not fine for her needs. The Minister of State at the Department of Health with responsibility for disability, Deputy Rabbitte, has been engaging and helpful in dealing with Jennifer's advocate and in dealing specifically with this case because it is almost a test case in the country.

The problem as I see it in removing someone from a nursing home environment and putting him or her into a more appropriate setting is that the process seems to be HSE-led rather than building around the needs of the individual. What other barriers does the Department see to unlocking all of this? The fit for each of these 1,300 people has to be bespoke. Their needs are separate, apart and specific. Problems are already showing up in this test case, despite the best efforts of the Minister of State and the staff around her and within the HSE. There has been a huge effort that we appreciate but the process is about what can be provided rather than being centred around Jennifer's needs. Are there other barriers that Dr. McLellan can identify that need to be overcome?

Dr. Kathleen MacLellan:

I would rather not refer to any single or individual case. The Deputy's point is well made that where somebody is moving it has to be a personalised approach that meets the individual needs of that person in the types of care and supports that can be put in place. For some people, their care is being provided in nursing homes because it is significant and complex care that needs to be supported. As we look at the programme of displacement of those with disabilities from congregated settings into the community, it takes a period of time to examine the types of housing and supports that can be put in place that are appropriate and that will meet the needs of individuals as well. Any type of fast fix for individuals will probably not meet their needs. It is important that there is a comprehensive review of those needs and then an examination of what supports can be put in place.

Photo of Cathal CroweCathal Crowe (Clare, Fianna Fail)
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HIQA gets involved with nursing homes when they are opening up their doors to residents and it is involved in the regulatory process. Should it be involved earlier in the process? What I mean by this is that I am aware of a number of nursing homes that have been built and developed perhaps 1 km or 2 km outside of a town or village. Not everyone in these nursing homes is physically incapacitated. Many of them need to walk to the village or local shop to buy a newspaper and they cannot do so. Therefore, they rely on relatives to bring those goods to them and slowly but surely they unintentionally become more institutionalised to that nursing home and they cannot leave its environment because there is no infrastructure to take them to the village. That is being addressed this week for schoolgoing children. There is a plan to have schools that are accessible right to the front door and there needs to be something similar put in place for nursing homes. Is it a deficiency on the part of HIQA that those needs are not identified at the outset when these nursing homes are being developed and planned for and that in many cases they are being developed out of towns and villages where the residents never have a chance of getting to those services that they need to avail of?

Dr. Kathleen MacLellan:

An important part of Sláintecare is that we look at the right care in the right place. There is a significant amount of work under way on population best health needs planning. This seeks to ensure that we can plan for the future in the types of infrastructure needed and where that needs to be located. It also seeks to ensure that we plan for ten or 20 years ahead through the national development plans and through other planning so that we can ensure the locations and the make-ups of nursing homes or the types of housing support models meet the needs of those individuals. I agree that planning for the future and the long-term future is critical.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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I thank all of our witnesses. Some disturbing evidence was heard today about what was happening in nursing homes. The idea of waiting years for powers to investigate neglect and abuse is concerning. I hear what the witnesses are saying in that we are in a process that is dealing with that. There will be recommendations coming from the committee that we need to act on that much more swiftly.

The committee will meet again in public session on Tuesday, 30 March at 9.30 a.m., when it will get a briefing on the administration of the medical card scheme, with officials from the Department of Health and the HSE presenting to the committee.

I apologise again for the glitches and difficulties of a technical nature we have had with the meeting.

The joint committee adjourned at 11.29 a.m. until 9.30 a.m. on Tuesday, 30 March 2021.