Oireachtas Joint and Select Committees
Thursday, 17 July 2025
Public Accounts Committee
Financial Statements 2023: Health Information and Quality Authority
2:00 am
Paul McAuliffe (Dublin North-West, Fianna Fail)
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This morning, we engage with the Health Information and Quality Authority to discuss its 2023 financial statements. From the authority, I welcome Ms Fitzgerald, Mr. Finbarr Colfer, chief inspector designate, Mr. Sean Angland, chief operating officer, Mr. Sean Egan, director of healthcare regulation and Ms Susan Cliffe, deputy chief inspector with responsibility for older persons services. From the Department of Health, I welcome Mr. Patrick Dolan, principal officer in patient safety policy and governance and Mr. Niall Sinnott, principal officer in ehealth and health information systems. From the Health Service Executive, I welcome Ms Patricia Whelehan, assistant national director of services for older people - access and integration, Ms Amanda Casey, chief social worker, and Mr. Pat Healy, national director of national services and schemes. We are joined by officials from the Office of the Comptroller and Auditor General, including the Comptroller and Auditor General, Mr. Seamus McCarthy, who is a permanent witness to the committee, and Mr. Mark Brady, deputy director of audit. You are all very welcome.
I will explain some limitations to parliamentary privilege and the practice of the Houses as regards reference witnesses may make to other persons in their evidence. The evidence of witnesses physically present or who give evidence from within the parliamentary precincts is protected pursuant to the Constitution and statute by absolute privilege. This means they have an absolute defence against any defamation action for anything they say at the meeting. However, they are expected not to abuse this privilege and it is my duty as Leas-Chathaoirleach to ensure this privilege is not abused. Therefore, if their statements are potentially defamatory with regard to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction. Witnesses are also reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that may be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory regarding an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.
I ask Mr. Seamus McCarthy, the Comptroller and Auditor General, to make his opening remarks.
Mr. Seamus McCarthy:
Gabhaim buíochas leis an Leas-Chathaoirleach. The Health Information and Quality Authority was established in 2007. Its primary functions are to set standards and regulate health and social care services, and to advise on the collection and sharing of information across healthcare services. Much of the authority’s work is focused on inspections across the disability, older people’s and children’s sectors. Designated residential care centres must formally register with the authority.
The authority’s financial statements, like some others in the broader health sector, are presented with separate income and expenditure accounts, covering current and capital spending. The income and expenditure account on the current side records total income in 2023 of €38.5 million. Of this, €7.4 million, or around 19%, was received from registration and annual fees paid by regulated residential centres. Most of the remaining income in 2023 was received from the Vote for health. Some €1.1 million was received form the Vote for children, equality, disability, integration and youth. The latter was provided in respect of the authority’s role in monitoring the International Protection Accommodation Services' residential facilities.
The authority’s recurrent expenditure in 2023 was €38.3 million, of which 75% related to staff costs. In 2023, the authority’s average headcount was 351, with 80% of those staff employed in regulation functions. The authority recognised capital funding of €5.8 million in 2023, including €4.78 million from the Vote for health, as reflected in the capital income and expenditure account. Total capital expenditure was also €5.8 million, €2.3 million of which was spent on what is referred to as "software in the cloud". This expenditure relates mainly to the costs of a major ongoing ICT project for the development of new regulatory software systems for the authority, to be hosted by an external service provider under a multi-year service contract. The ICT software development costs are a charge on the authority’s capital income and expenditure account, but under accounting standards, they do not result in the creation of a related intangible asset on the authority’s statement of financial position.
I issued a qualified audit opinion in respect of the authority’s financial statements for 2023. The qualification is only in relation to the authority’s accounting treatment for pensions. As provided for by law, the Minister for Health has elected to direct certain health sector bodies, including the authority, to account for staff pensions as they are paid. Generally accepted accounting practice requires recognition of pension liabilities as they accrue.
Other than that, I am satisfied that the financial statements give a true and fair view of the authority’s financial position at the year's end and of the transactions for the year.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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I thank Mr. McCarthy. We move to our other witnesses. As the officials can imagine, there was significant concern from members about what was portrayed in the "RTÉ Investigates" programme and they intend to ask questions about that. We hope the officials will be able to provide reassurance but also deal with other questions that have been raised by the Comptroller and Auditor General.
We will now hear the opening statements of our other witnesses. I ask Ms Fitzgerald to make the opening statement for HIQA.
Ms Angela Fitzgerald:
I thank the Leas-Chathaoirleach. I wish everyone a good morning. I thank the committee for inviting us to discuss HIQA's financial statements. We will of course be happy to address the questions the Leas-Chathaoirleach raised.
As was already said, HIQA was established in 2007 as the independent regulatory authority. Our role is to enable the best possible outcomes for people using health and social services. Our legal remit includes setting standards, regulating public, voluntary and private health and social services and providing evidence to inform and support Government policy decisions. Protecting the safety and welfare of people using health and social care services is at the heart of what we do. Regulation seeks to provide independent oversight of the quality and safety of care and support and aims to drive continuous improvement. To put our role into context, the chief inspector regulates over 2,000 nursing homes and disability services. He also has a role in relation to specific aspects of children's services. In healthcare, we monitor the quality and safety of public and private healthcare services. We also have a role in relation to permanent IPAS centres.
It has to be said the primary responsibility for day-to-day quality and safety must rest with the service provider. Our role as the regulator is to ensure providers have systems and processes that are effective to assure themselves in the first instance that people using their services are getting the support they need and deserve. This is why governance and management are central parts of our inspections. This seeks to allow us to help providers move beyond simple regulatory compliance towards continuous improvement.
What have we done and how have we had an impact? It is fair to say that, in the lifetime of HIQA, we have driven a move from a medical to a social model of care in the area of social care and, in particular, a focus on a person-centred and human rights-based approach.
Often, the improvements achieved for people are things that we in society take for granted. For example, they mean that people living in nursing homes can exercise choice and autonomy in their daily lives and can enjoy privacy and dignity. In the context of disability, we have seen a significant move out of congregated settings into community. People tell us every day about the impact this has had on their lives. In children’s services, we have driven improved oversight and improved delivery of safety for those children who are most at risk. We also know that, as the regulator, we have much more to do. As the regulatory landscape changes, we have to adapt and change.
Other areas we are involved include setting national standards. National standards in regulation set the bar for driving continuous improvement. We also provide advice to the Minister and the HSE on the clinical effectiveness and cost-effectiveness of health policies and in respect of vaccination and screening programmes. One example was that during Covid, our team played a pivotal role in providing the evidence to support Government in making rapid decisions on public health issues. We work collaboratively with the Department of Health on informing national health information policy and digital health policies. We are currently developing an ethical framework for AI, which is rapidly coming into health and social care.
Listening and responding to people, taking the Leas-Chathaoirleach’s point, has to be part of what we do every day. We listen to residents, patients, families and inspections but we also try to use our voice to advocate for policy or regulatory change, and we can talk about that today. One other way that may not necessarily be associated with HIQA is the national care experience programme. This is a unique national collaboration between HIQA, the HSE, the Department of Health and patient advocacy groups. The findings give us clear insights as to what matters to patients and their families and allow us to help service providers drive those improvements. We also work with the Department to try to look at structural or other issues that might improve the experience of residents.
Our organisation is 18 years old. Our chair often describes us as a teenager organisation. Our remit has grown significantly under successive Governments. In the past two years alone, as evidence of that rapid expansion, we are now moving into monitoring private hospitals. We have a role in relation to international protection, we were asked by Government to review the mid-west in terms of urgent and emergency services. We have contributed significantly to the work of the Department and the Law Reform Commission in the area of adult safeguarding. We drafted standards for home support services that will be the bedrock of the regulatory framework that is coming. We recently assumed responsibility for the national immunisation advisory committee. As mentioned earlier, we published a review on the use of non-CE springs in children. We have also been asked to take on a role with regard to critical entities resilience, which is how we protect the State against external shocks.
On the matter at hand today, namely financial resources, the C and AG has already mentioned some of the areas involved. As a result, I will be brief. It is important to note that we have strong internal controls, overseen by our board, to ensure that our spend is fully aligned with the allocations we get. We are committed to ensuring high standards of corporate governance and compliance, and we have secured and retained our ISO accreditation. We have effective and constructive engagement with the Department of Health to ensure our resources are appropriate for our remit and are used appropriately. Our budget increased by 11% on the previous year. That is a clear reflection of our expanding remit and of the constructive relationship we have with the Department.
The C and AG referenced our spend. Like other organisations, 75% of our spend goes on staff costs. We always operate within our approved allocation and all new positions are sanctioned by the Department. Our staff are committed to making a difference to everyone we serve. As CEO, I am proud and I am struck every day by the strong sense of unity of purpose, shared values and passion among our staff. We invest significantly in our people to ensure that we maintain that sense of purpose as we grow and diversify. Critically, we must continue to attract, develop, promote and retain high-calibre staff.
One of the big enablers for us as a growing organisation is digital solutions, and this is very much aligned with Government policy. We have committed to move to digital platforms to allow us to take on new functions, to optimise our research capability and to make sure that, in the regulatory space, we have real-time access to data analytics, which will inform our regulatory approach but also will allow us, between inspections, to look at surveillance of services. We all know about the threat of cyberattacks. For us, as a regulator, protecting our systems and our people against external attack is critically important. Therefore, we have invested in the development of a multi-annual digital strategy, which we hope will ensure that we are an agile, fit-for-purpose and secure organisation.
As the Leas-Chathaoirleach stated, we must be always open to improving and learning. What was broadcast on the “RTÉ Investigates” programme was truly shocking and should never have happened. I apologise again to those directly affected and to anyone who feels let down by us, as the regulator. I assure the committee that we are taking regulatory action with the nursing homes operated by this provider group. We are working closely with the Minister and the Department on those areas where the regulatory and policy framework can and should be strengthened. We are also engaging directly with families and residents.
It is also important that we look at ourselves. We are committed to strengthening our regulator role and its impact. We are also committed to looking critically at how the approach we have allows providers, in the first instance, to assess their own leadership, culture and behaviour and lets us look more closely at that, allows us to leverage the use of data through regulatory reform to support ongoing surveillance between inspections and allows us to amplify communication with the public about what we do, how we do it and areas in respect of which we can learn.
I thank members for inviting us to speak to them on our accounts but also on wider issues. I know I speak on behalf of our board and all our staff in reiterating our shared commitment to developing the very best outcomes for all who use our health and social services. We want to be the trusted regulator. We know there are challenges based on recent events but we will seek to work with all of our stakeholders to drive continuous improvement in the overall experience of people using our services. We are happy to take whatever questions members may have for us.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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We will suspend for a break at 12 noon and resume shortly afterwards. I will now open to floor to members. The lead speaker is Deputy Cathy Bennet. The Deputy has 15 minutes.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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I will just get straight into my line of questioning. The fact that 198 complaints of neglect were made over a three-year period in respect of Beneavin Manor beggars belief. What would have happened when complaints were made? What happens directly after a complaint is received?
Ms Angela Fitzgerald:
I will ask our deputy chief inspector to talk specifically about Beneavin. We rely on our inspection process. We also rely on what we call statutory notifications, which is where providers are obliged to notify of us anything of concern. We will give some context on that. Second, we rely on direct feedback from staff and service users. We have a number of feeds that we assess and risk rate. I will ask Ms Cliffe to come in directly on this.
Ms Susan Cliffe:
Our process is to review every piece of information we receive, assess the level of risk posed to each resident and look at what action has already been taken on foot of such information. If we are not satisfied with the action that has been taken, we can revert to the provider and request additional information. We can ask providers to carry out further work if we feel that is what is necessary on the basis of the information we already have. We can schedule an inspection on foot of that or we can align it with the rest of the information we have about a centre and use it in a line of inquiry for an inspection that may be already be planned for a centre. The final thing we will do is look at the information. If it makes reference to areas outside our area of expertise or our regulatory powers, we may look to refer that to other authorities, such as environment health officers, the fire authorities, the Garda or the Health and Safety Authority, if that is what is relevant.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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How many times has HIQA referred instances of complaint to the Garda or other agencies?
Ms Susan Cliffe:
We look at transfer of information to external agencies in two ways, one of which is under information that is specific to the protected disclosure process. In 2024, we had 34 referrals from that process.
In 2024, 28 referrals were made to An Garda Síochána, two to the Department of Social Protection, two to the fire authorities, one to the Food Safety Authority of Ireland and one to HSE adult safeguarding.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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What happened after the referrals? Were the nursing homes involved closed?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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They were not closed.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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What is the role of HIQA? Does it not have authority to close nursing homes?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Why would they not be closed if they are not applying rules and regulations in the correct manner?
Ms Susan Cliffe:
We would not close a nursing home unless there was absolutely no other option and we had no hope that the registered provider involved would be able to deliver quality care to the residents. We have a pyramid of escalating regulatory engagement that we use. Where incidents arise, we have a cautionary meeting with a provider. Our first step is probably to give feedback and say, "You need to get this sorted." If that does not work-----
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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That obviously has not worked. This issue is ongoing. HIQA has been in place since 2007. How many nursing homes have been closed in that period? Ms Fitzgerald stated that HIQA sets standards. What standards are being set if nursing homes are the subject of reports such as the one broadcast by RTÉ? Does HIQA have enforcement powers? What is happening? Nobody is running scared of the fact that HIQA is going to carry out inspections. That is because nothing happens and there is no enforcement after HIQA staff visit a nursing home and find that it is not compliant.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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How many has HIQA closed?
Ms Susan Cliffe:
In 2020, we closed two. In 2021, three nursing homes were closed on foot of action by the chief inspector. One was closed in 2022. Three were closed in 2023. A total of ten notices were issued in 2024. Of those, seven homes have closed and one case is still under appeal. In 2025, one nursing home has closed on foot of proceedings that were instigated in 2024. What that shows is that where we cannot be satisfied that registered providers will take action to keep residents safe, we will use the law and the legal framework available to us. However, we are very conscious a nursing home is home to residents - to a large number in some cases - so decisions like that are only made as the last option. We will work with providers in the initial phase, requiring them to deliver the quality of care they are being funded to deliver.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Has Beneavin Manor been closed?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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It is still open-----
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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-----even after the disclosures in the RTÉ programme?
Ms Angela Fitzgerald:
It is important to note that we have stated publicly, both on record and in the report we have made available to the committee, that while our regulatory inspections identified areas in relation to staffing, supervision and the poor training and qualifications of staff - and these were part of why we were in escalation - at no stage through our inspection process did we witness anything that was witnessed in the programme. If that was ever witnessed by our staff-----
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Then maybe HIQA's inspections are not thorough enough.
Ms Angela Fitzgerald:
That is a fair comment. Are we doing enough? Do we see enough?
What was evident from some of the footage is that some staff knew that this was the wrong thing and chose to do it. There are limits in terms of what an inspection process will do. We have been trying to look at two or three things. The second is that we are in an escalatory process with both centres, but with the group as well. There is a programme of inspections under way. We have applied some restrictions to admissions. The latter is one the safety mechanisms implemented in order to allow the staff who are available to deal more appropriately with the number of residents in a facility. We will take action. We are obviously in the process of doing that, but we cannot comment on what those actions will be.
It is fair to ask if the inspection process reveals enough. That is a question we are confronted with. We are looking at it in a number of ways. First, in the context of the regulatory powers. Second, there is the question of surveillance data. For example, I refer to the routine information that was relevant in respect of Beneavin was the level of turnover of staff between inspections and regarding the change in the profile of residents. That information is not currently statutorily made available to us.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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My time is running out. I have just a few more minutes and I have a number of other questions to ask.
HIQA was formed in 2007. Therefore, it has taken almost two decades for it to realise that the existing inspection process is not working. Obviously, it is not working if RTÉ staff can walk into a nursing home and get camera footage. Are inspections always notified or can inspectors just walk in? Are the operators of facilities always not notified?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Should they not all be unannounced? Should inspectors not just walk in and see the real picture?
Mr. Finbarr Colfer:
Often, that is the question asked of us. A percentage of inspections are announced, for various reasons. One reason is that in the context of renewal of registration, we may need to access particular personnel, management or staff. More importantly, announced inspections allow residents and their families to know that we are coming and to engage with us. A small percentage of our inspections are announced, but the majority of them are unannounced. All of our risk inspections are unannounced.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Is HIQA confident that next year there will not be another RTÉ documentary? I am sure that when was HIQA set up, it was to ensure that something like this would not happen. It has happened, and that is why-----
Ms Angela Fitzgerald:
It is important that we acknowledge the challenges that were presented by this and that we look at how we can continuously improve. It is also important to say - and this is not just us because it is evidenced by the lived experience - that if you look at the overview reports that were published, which looked back at disability and older persons, there has been a demonstrable and sustained change in the lived experience of those in residential care. I have been in that situation with my parents and my in-laws, and I know how big a decision it is for families to make. We know the position, both directly from a very significant number of families and from a number of different input. When things go wrong, it is important that we take stock and look at regulatory changes and at changes in how we do our work.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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I find it hard to believe, after 20 years of HIQA being in operation, that something like this could still happen. That is difficult to understand.
It was reported in the media that a particular IT project is running behind schedule. How much has that project cost?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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What is the cost?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Is it in operation?
Ms Angela Fitzgerald:
We are moving towards implementation. We have the foundation built and tested. It works. We are working entirely within the budget. It is a fixed-price contract. We have very strong internal controls. We have had a delay, so we had to invoke some of the levers within our legal framework to drive performance. However, we now have a solution.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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When will the system be up and running?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Is Ms Fitzgerald confident that the project will be operational?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Who is the provider?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Has HIQA discussed the use of Kodak with the Department of Public Expenditure, Infrastructure, Public Service Reform and Digitalisation or the Office of Government Procurement? Did they recommend Kodak to HIQA?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Who told HIQA what it needed exactly? Did it request help from the Department of public expenditure and reform or anybody else to make sure it was getting the right IT system?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Does HIQA have full confidence that this system will be fully operational starting this year?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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I am happy with that. Hopefully if representatives from HIQA are back in again next year, the IT system will be fully operational and the €8.6 million spent on it will have been put to good use.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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It was reported in the media that it was running well behind schedule. Is Ms Fitzgerald saying that is not the case?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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When was it supposed to be operational?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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When will it be operational?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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My last question is on HIQA's income and expenditure. In 2009, it had expenditure of just €24 million but in 2023 that had increased to about €39 million. Why is there such a difference in expenditure in those years? Why has so much more money been spent?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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HIQA had more staff in those years.
Ms Angela Fitzgerald:
We had an 11% increase between 2022 and 2023 in our funding allocation. As we set out in the opening statement, there are three sources of funding. We get the block grant from the Department of Health. We also get fee income and then we have funding for specific other projects, including funding for IPAS. The 11% increase in funding is directly related to both Departments' requests to us to take on a significantly expanded remit and that has continued into 2024.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Just on-----
Paul McAuliffe (Dublin North-West, Fianna Fail)
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The Deputy is over her time.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Regarding the income, does HIQA still receive the nursing home expert panel grant and the international protection accommodation grant?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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The nursing home expert panel grant was specifically for Covid-19. Why does it still receive that?
Ms Angela Fitzgerald:
The decisions on the continuation of that are made without us. What I can tell the Deputy is how it is being deployed. As a result of Covid, we engaged with the Department on specific requirements that would enhance our regulatory role coming out of Covid. One of those was in relation to infection. As was set out in the more detailed opening statement, we were mandated to do two inspections over a three-year period. The Covid expert panel funding allowed us to increase that to one inspection a year. In practice, about 40% of our nursing homes are inspected at least twice and many of them far more frequently. It gave a much more stable funding base to allow us to extend our regulatory lens in those areas.
The other piece that was funded is that there was a request to look at extending the care experience programme, which is a collaboration between three organisations. We looked at the end-of-life survey which was very relevant in the context of Covid. That survey is funded from that funding to us.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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Perhaps that is something other members might take up.
James Geoghegan (Dublin Bay South, Fine Gael)
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I thank all the witnesses for attending. Ms Fitzgerald mentioned her own experience of care with her parents and her in-laws. She did the same when appearing before the health committee, presumably to demonstrate she is a real person with empathy and a level of understanding. Would she be happy to have any of her loved ones in an Emeis Ireland-run nursing home right now?
Ms Angela Fitzgerald:
I think the first thing for me when I made the choice to look at anywhere is you look at what are we saying about it. That is an important piece. You also look at your own requirements in terms of your loved ones. What I can say is that the two nursing homes in question have a lot of work to do. They have restrictions on their admissions. They have a very strong compliance requirement coming out of the compliance plan. They have significant work to assure us that they have the necessary management, leadership and capability and we are not satisfied yet.
James Geoghegan (Dublin Bay South, Fine Gael)
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Therefore, Ms Fitzgerald would not put her loved ones in those two nursing homes. Emeis Ireland currently operates 23 other nursing homes. Am I right in saying that HIQA has taken a decision not to allow any further entrants into the 25 nursing homes that Emeis Ireland runs?
Ms Angela Fitzgerald:
That decision was taken by Emeis itself in discussion with us. As the Deputy knows, we have no regulatory role vis-à-vis Emeis as an entity. We do have with each of the individual providers. Through discussions with the chief inspector and the deputy chief inspector, it took that decision. We are in a programme of inspection by agreement with the Minister and we will make a separate and independent decision about whether that restriction should remain in some or all of them.
It is important to say that I went to the two nursing homes in question and met with a very significant number of residents and their families. We spoke at length with residents who were able to talk to us about their own experience. Notwithstanding what we saw, and I am not in any way trying to minimise what we saw, a number of residents who had the capability were able to tell us their direct experience and many of them had very good experiences, as had their families. We need to tackle what we saw but we also have to acknowledge that some aspects of care were, and continue to be, good.
James Geoghegan (Dublin Bay South, Fine Gael)
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As matters stand, in terms of the group I hear what Ms Fitzgerald is saying in a regulatory sense, but obviously this group has suffered enormous damage to its brand, credibility and trust. Would Ms Fitzgerald be confident having any of her loved ones right now in a nursing home in the Emeis Ireland group? I think she sort of said she would not be happy having her loved ones in the two nursing homes that were subject of the "RTÉ Investigates" report. Am I right that she said that?
Ms Angela Fitzgerald:
No, I think what I said was that the two nursing homes in question have significant work to do to assure HIQA that they can meet the standards consistently. It would be inappropriate for me to comment on every single one of the other nursing homes because we are in programme of inspecting them.
James Geoghegan (Dublin Bay South, Fine Gael)
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Ms Fitzgerald is at the public accounts committee, a public committee. The public out there just want to know. HIQA is the regulator. If people working for HIQA are not satisfied to put their loved ones in an Emeis Ireland-run nursing home, how can the public be satisfied that they can safely put their loved ones in an Emeis Ireland-run nursing home? It is a fairly simple question. Given everything that Ms Fitzgerald knows - the representatives of HIQA have better information than anyone else here does - would she be satisfied to put her loved one in an Emeis Ireland-run nursing home?
Ms Angela Fitzgerald:
What I can say about Emeis is that in my direct engagement with it and in our direct engagement as a regulatory team, it has demonstrated a strong commitment to address the issues. It has demonstrated that by taking necessary actions, which were not imposed on it. We can say that we see very significant challenges in terms of maintaining the management and other capabilities in two of the nursing homes. We are in the process of looking at a number of other ones. We will be happy to provide a comprehensive report to the Minister on our overall assessment when that work is done. We have an obligation to the nursing homes concerned to be fair to them and not to pre-empt that.
James Geoghegan (Dublin Bay South, Fine Gael)
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Ms Fitzgerald said at the health committee that the first time she saw footage of what took place in the "RTÉ Investigates" programme was in fact when the programme was aired. Is that right?
James Geoghegan (Dublin Bay South, Fine Gael)
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I am not trying to be personal about this, but where did she watch that programme as a matter of interest?
James Geoghegan (Dublin Bay South, Fine Gael)
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I am not trying to put personal accountability on Ms Fitzgerald, but she is at the top of this organisation. When she was sitting on the couch watching it at home, how did she personally feel watching that, leaving aside all the legalese and regulatory structures? She mentioned her in-laws and her parents. How did she personally feel watching that?
Ms Angela Fitzgerald:
I can tell the Deputy very honestly because Mr. Colfer and I had extensive engagement during the programme and after it. I was shocked and appalled and felt let down by the provider in terms of what I witnessed. I also felt deeply saddened that staff did not have the skills, experience and insight to see what they should do.
For me, as the regulator, I do feel a sense of accountability. That is why I am here today. The Deputy spoke earlier about the levers. It is important that we have regulatory levers and it is also important there are standards in relation to minimum staffing. It is also important that we look at what we can do between inspections. To go back to Deputy Bennett's comments about looking between inspections at what we can do, there are a number of things to be done. However, at a human level, I was shocked and appalled.
James Geoghegan (Dublin Bay South, Fine Gael)
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Had Ms Fitzgerald ever seen anything worse?
James Geoghegan (Dublin Bay South, Fine Gael)
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In her entire time as-----
Ms Angela Fitzgerald:
In the sense that I had never seen the type of behaviours, and I think my colleagues, as inspectors, would never have witnessed the behaviours there. We said earlier that the type of behaviours that were witnessed on the programme are linked to a specific lack of understanding and a lack of insight in terms of culture.
James Geoghegan (Dublin Bay South, Fine Gael)
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If someone making a difficult decision and looking at nursing homes in the area in which they live were to learn that one of them was an Emeis Ireland-run nursing home, Ms Fitzgerald will understand the fear that person would have of putting their loved one, whether a child or partner, in an Emeis Ireland-run nursing home, having watched the programme.
James Geoghegan (Dublin Bay South, Fine Gael)
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No, this is very specific to Emeis Ireland. The RTÉ programme was the worst thing Ms Fitzgerald, as the head of HIQA, has ever seen. How would someone in that position feel? She will understand the fear they would have.
Ms Angela Fitzgerald:
I think we can all understand that fear. That is well established. We have to be fair. There are 23 individual providers which are part of the Emeis group. They are being subject to a programme of inspection. Each of those will be evaluated and then we will be in a position to say what is required. That does not mean that people cannot have a view right now based on their own experience of what they witnessed. However, as a regulator, we have often been challenged for taking decisions in relation to the closure of nursing homes in specific areas. We have to be proportionate here. It is very appropriate that I give a human response, because I am a human, but it is also important, as the regulator, to give a proportionate response, which is to say we have a job to do, a programme of work is under way and we have agreed to give that report to the Minister. We are giving him the reports as we continue. That will inform appropriate regulatory action.
James Geoghegan (Dublin Bay South, Fine Gael)
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Is the problem not that the inspections regime in relation to the two nursing homes that were the subject of the “RTÉ Investigates” programme fundamentally and catastrophically failed, to such an extent that the actions Ms Fitzgerald witnessed in the TV programme were, as she just said, some of the worst things she had ever seen? Notwithstanding the regulatory regime we have in place, it catastrophically failed those residents who were subjected to abuse and this has called into question the entire inspection regime that HIQA operates and whether it is fit-for-purpose. Does Ms Fitzgerald accept that is the natural consequence of the “RTÉ Investigates” programme?
Ms Angela Fitzgerald:
I accept that when something occurs, as we have witnessed, it demands a response. I have outlined what that response is. We have agreed with the Government and the Minister what we are doing, which is three things. We are looking at what needs to change in the policy and regulatory framework; what action needs to be taken in relation to each of the nursing homes under that group, and that is under way; and what changes would enhance our ability, in terms of inspection and outwith inspections, to do our job.
James Geoghegan (Dublin Bay South, Fine Gael)
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Does Ms Fitzgerald think HIQA’s inspectors are good enough? Are they sufficiently qualified to do what they are supposed to? What are their qualifications? Do they all have nursing qualifications or gerontology qualifications? Has HIQA looked at that in terms of the people who carry out HIQA inspections?
James Geoghegan (Dublin Bay South, Fine Gael)
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That is not being changed.
Aidan Farrelly (Kildare North, Social Democrats)
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I thank the witnesses for being here. Their opening statement and contributions have been very informative, I appreciate that. I will start with Mr. Colfer. Is it correct that he, in his role, has powers of prosecution?
Aidan Farrelly (Kildare North, Social Democrats)
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Mr. Colfer does in his role.
Aidan Farrelly (Kildare North, Social Democrats)
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Given the experiences and reflections we have shared on the two Emeis properties, why are they still open?
Aidan Farrelly (Kildare North, Social Democrats)
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There is still potential that those properties could close.
Aidan Farrelly (Kildare North, Social Democrats)
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How many Emeis sites has HIQA visited since the RTÉ documentary was aired?
Aidan Farrelly (Kildare North, Social Democrats)
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How many Emeis sites?
Mr. Finbarr Colfer:
There are 25 in total. Since the programme, we have inspected 16 of them. We are in the process of issuing our findings to the provider. Under the Act, the provider has 21 days to come back and correct any factual inaccuracies or challenges on our findings. We have a programme of work to visit the rest of them which is very active.
Aidan Farrelly (Kildare North, Social Democrats)
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To carry on from Deputy Geoghegan’s point about the calibre of the inspectors, I have a query about the nature of those inspections. How many night-time inspections does HIQA complete? What would be the percentage, roughly?
Mr. Finbarr Colfer:
In general, our framework allows for day-time inspections. However, where we have information of concern, we do undertake out-of-hours inspections. In 2024, I think 24% of our inspections were out of hours. It is one of the questions we are examining ourselves in relation to perhaps having a more scheduled approach to a 24-7-type of inspection. We are very conscious health services are operating on a 24-7 basis.
Aidan Farrelly (Kildare North, Social Democrats)
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Would the 24% of inspections that were out of ours have all been unplanned? The providers would not have been given notification that the inspectors would visit at, say, 9 p.m. or 10 p.m.? They would all have been unplanned? They were done on foot of a concern.
Aidan Farrelly (Kildare North, Social Democrats)
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That information might come from a resident or a resident’s family or would it have to be from the provider itself?
Aidan Farrelly (Kildare North, Social Democrats)
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Looking at the 2023 accounts, will Mr. Colfer elaborate on what seems to me to be a real reliance on agency staff? An average of €1 million has been spent each year over the last ten years on agency staff. Are they specifically investigators?
Aidan Farrelly (Kildare North, Social Democrats)
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Who are the agency staff?
Ms Angela Fitzgerald:
We have 450 staff. On average, at any one time, we would have about 15 staff on agency. For the chief inspector, and inspectors, we are precluded by law from using anyone other than a permanent employee, so no inspectors are employed on an agency basis. However, like all organisations, where we have short-term absences in critical functions, typically in operational areas such as payroll or in areas where there is continuity, we use agency staff for short-term absences. We had an unplanned absence in the area of risk, for example, where somebody had to take a few months out for personal reasons. It would be very difficult to recruit somebody for that piece. We provide for that in how we work with our Department. We absolutely operate within our approved envelope but our reliance on agency is about 3% of the workforce and we seek to drive that down. We would like not to have it but there will always be short-term absences that arise where they give rise to agency. Our staff are senior. The Deputy asked that question earlier. We have senior staff so the agency cost will be commensurate with the fact that we are looking for senior staff on a short-term basis.
Aidan Farrelly (Kildare North, Social Democrats)
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If it is averaging out at that every year for ten years, there must be trends. Would HIQA be better served making a request for a permanent position in that role rather than spending €900,000 in one year and €1.2 million the next year? It is a trend as opposed to a one-off.
Ms Angela Fitzgerald:
Every body, public sector and private, will have short-term absences for parental leave, unpaid leave or maternity leave.
I have given one example recently. We provide for that but we seek to keep it to a minimum. Our desire is to maintain expertise and maintain continuity. For example, if we are in the middle of a project where continuity is essential, it may be that we would support that project. In the CHI review where we used our own staff, there would have been an administrative piece that may have been additional, and rather than displacing someone, we would have used agency staff for a period. They are very much short term, but one would have that every year. On a base of 4,509 staff, it is somewhere between 3% and 4%.
Aidan Farrelly (Kildare North, Social Democrats)
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As to that expertise, to what extent does HIQA have staff on the payroll with ICT expertise?
Ms Angela Fitzgerald:
We have three types of arrangement for ICT. We have permanent staff. We have a small team of staff numbering about 20. Like most public sector organisations, we also have a helpdesk support function. Typically, that is outsourced because we would not have that expertise or be able to recruit that expertise. That runs on a 24-7 basis. For specific projects, which we are doing under our digital strategy, we would buy in expertise because we simply would not have that. Having that expertise available to us is essential in terms of being able to manage external contractors and hold them to account. We use it wisely. We work very closely with the Department around the use of it and we seek to keep it to a minimum. We have seen some changes in the market arrangements. We have seized that opportunity. For example, we had 97 applicants in a recent competition that, if held 18 months ago, we would not have got a candidate. Where we can, we seek to recruit people. We want to build that capability. We are in discussions with the Government about taking on a role as the competent authority for cybersecurity. Having that capability available to us is really important. However, we also recognise the public sector rates will not always allow us to buy it at the level we need.
Aidan Farrelly (Kildare North, Social Democrats)
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I accept that. With that assertion, does Ms Fitzgerald think the market has changed? For 2023, there were 55 incidents of purchase orders for ICT or consultancy services in that 12-month period.
Ms Angela Fitzgerald:
Some of those consultancy services would be for contractors delivering programmes of work. We talked about the digital strategy earlier on. In its five years, we have delivered over 100 projects that support infrastructure in terms of keeping the lights on in technical terms, ensuring that systems talk to one another and leveraging those systems from a cybersecurity point of view. We have 24-hour surveillance for cybersecurity. A lot of those purchase orders relate to that space. I agree with the Deputy that it is important that we have the internal capability. With the support of the Department, we are looking to repatriate some of that cost into our core budget.
Aidan Farrelly (Kildare North, Social Democrats)
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We acknowledge that HIQA is being proactive in that regard, but it just does not seem to be sustainable. There is such a diversity, with many different companies and bodies doing what appears to be, in simplistic terms, similar work. Is there any potential conflict of interest in the organisations and companies HIQA is hiring? Everything is going through appropriate procurement processes. If there are former board members or board representatives that are now members of these companies, is there anything to be concerned about in that regard?
Ms Angela Fitzgerald:
We have a conflict of interest policy. Through our procurement process, we are obliged to look at that as well. Any companies we take on are also bound by conflict of interest policies. For example, where we procure a legal service, the provider has to declare for each project or every initiative we are doing whether there is a conflict for it. There are obligations on providers and us.
Aidan Farrelly (Kildare North, Social Democrats)
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When there is a former board chair that is part of a company that is part of these consultancy services, that provider is going through a transparent process.
Albert Dolan (Galway East, Fianna Fail)
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I thank the witnesses for attending. HIQA has an incredibly important role in our society. It protects all of our loved ones, or at least it is supposed to. I hope HIQA leaves today with a renewed vigour to ensure safety and the highest standards across our nursing home sector and all health service providers. As an entity, HIQA has huge potential but we have to have a serious conversation today about what has happened, what has come to light and where we are going from there.
I want to pick up on Deputy Farrelly's point. According to the purchase orders, over €500,000 was paid on ICT contracts in 2024 to a company whose managing director had been the chair of HIQA between 2013 and 2018. Are the witnesses aware of the relationship between the company and how its managing director was the former chair of HIQA?
Albert Dolan (Galway East, Fianna Fail)
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Do they believe that is an acceptable level of risk or is that relationship too close?
Albert Dolan (Galway East, Fianna Fail)
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Was there a conflict of interest declared, given that that person may have had close relationships with people still at HIQA from the time when he was chair?
Ms Angela Fitzgerald:
We work very closely with the Office of Government Procurement in carrying out any appointments for procurement. I am not aware of any relationship. It is a very specialist area. It is cybersurveillance. It was done through a competitive process. I am not aware of any relationships current or prior to that. I have absolutely no relationship-----
Albert Dolan (Galway East, Fianna Fail)
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I know, but Ms Fitzgerald can imagine how, when the public hears that the former chair of HIQA is the managing director of a company that now makes hundreds of thousands of euros a year providing ICT services to HIQA, people need reassurance that there is no close relationship and every accountability is in place.
Ms Angela Fitzgerald:
None of us on the executive has any relationship. I do not actually know the gentleman at all. I know that the service provided by BDO - I believe it is BDO that the Deputy is speaking about - has been essential for us. BDO has a 24-hour surveillance service that has picked up a number of potential threats to us. The procurement was done through an entirely open process.
Albert Dolan (Galway East, Fianna Fail)
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Are the witnesses proud of HIQA's procurement track record?
Mr. Sean Angland:
Yes, we are. Look at our accounts. Like all State bodies, we have an obligation to publish any non-compliance with procurement regulations. There was none identified in 2023. There were no issues picked up by the Comptroller and Auditor General that year. We also had internal audits of procurement.
Albert Dolan (Galway East, Fianna Fail)
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There is a reason I asked that. Witnesses can correct me if I am wrong. I am looking at the description of the purchase orders and the number of purchase orders from top to bottom across the entity. There were eight purchases orders, with the description "mobile phone charges", of over €512,000. I want to check that is correct and over what time period that would have been.
Albert Dolan (Galway East, Fianna Fail)
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That is for that set of financial accounts.
Albert Dolan (Galway East, Fianna Fail)
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Okay.
Albert Dolan (Galway East, Fianna Fail)
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In the constituency I represent, there are many smaller nursing homes. They might be family-owned businesses and they take great pride in the work they do. There is a big concern that if a smaller provider were to put one foot out of step, HIQA would be down on top of it making sure everything is compliant. There would be recommendations for that provider and an inspection and a report. However, more than 200 complaints were made about Beneavin Manor and a statutory investigation was not initiated before the RTÉ exposé. I can only imagine that if there was one complaint about a small nursing home down the country, HIQA would be down on top of it. Now, we see 200 complaints in this case and no action. How do we explain this?
Ms Susan Cliffe:
We have one assessment judgment framework, one set of care and welfare regulations and one set of registration regulations. These are applied regardless of whether a registered provider is public, private or voluntary, or whether there are 185 beds, 120 beds or 20 beds. The same regulatory framework is applied across the board. When our inspectors arrive to inspect a nursing home, it is immaterial what the provenance of that provider is and whether it is public, private or voluntary.
Albert Dolan (Galway East, Fianna Fail)
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Do inspectors choose what inspections they take?
Albert Dolan (Galway East, Fianna Fail)
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If I am an inspector, therefore, is it easier for me to go and inspect the small nursing home where there are one or two complaints than to go to the nursing home where there are 200 complaints? Do the caseloads where there are 200 complaints get left until last because it is known it is going to be the hardest work?
Ms Susan Cliffe:
No. Each nursing home is inspected according to the requirement to inspect, at a minimum, once a year, do an unannounced inspection once every three years and inspections in response to risk. For example, one nursing home last year was inspected nine times in response to the level of risk reported, notified or we were aware of. It does not matter. There is not a different framework for nursing homes that operate under the umbrella of a group, as a stand-alone provider or under an organisation as big as the HSE. It is the one regulatory framework.
Albert Dolan (Galway East, Fianna Fail)
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Is it HIQA or the chief inspectorate that decides when there will be a prosecution or that legal action will be pursued?
Albert Dolan (Galway East, Fianna Fail)
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In the office of the chief inspector, if it is decided that an entity will be pursued, is the Chief State Solicitor used or are external legal firms used?
Albert Dolan (Galway East, Fianna Fail)
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In the last few years, who would have been the office's go-to legal adviser that would have done the most work for it?
Albert Dolan (Galway East, Fianna Fail)
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What is the chief legal firm HIQA goes to?
Albert Dolan (Galway East, Fianna Fail)
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I would just like to get the name of the firms.
Albert Dolan (Galway East, Fianna Fail)
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What is the largest provider at the moment?
Albert Dolan (Galway East, Fianna Fail)
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Would I be correct in saying - Ms Fitzgerald can tell me if I am wrong - that Mason, Hayes and Curran is also advising Emeis?
Albert Dolan (Galway East, Fianna Fail)
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There were media reports in the past 12 months that would have confirmed there was a relationship between Mason, Hayes and Curran and Emeis. Now, it is also the biggest legal advisers for HIQA-----
Albert Dolan (Galway East, Fianna Fail)
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-----and we have not seen any prosecutions over Emeis yet.
Albert Dolan (Galway East, Fianna Fail)
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I do not want to think that HIQA has the same legal advisers as Emeis. If we have separate legal advisers, at least there is no cross communication. I just want to make sure of this.
Albert Dolan (Galway East, Fianna Fail)
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When did HIQA get the second firm?
Albert Dolan (Galway East, Fianna Fail)
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Can Ms Fitzgerald confirm HIQA's independence legally from Emeis?
Albert Dolan (Galway East, Fianna Fail)
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How can that be confirmed?
Paul McAuliffe (Dublin North-West, Fianna Fail)
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Deputy Dolan is over the time.
Albert Dolan (Galway East, Fianna Fail)
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I know. I thank the Leas-Chathaoirleach. This is my last question.
Albert Dolan (Galway East, Fianna Fail)
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I assume HIQA would only take action off the back of the firm's advice?
Paul McAuliffe (Dublin North-West, Fianna Fail)
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Go raibh maith agat. I thank Deputy Dolan. I call Deputy Ardagh.
Catherine Ardagh (Dublin South Central, Fianna Fail)
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We know HIQA was established in 2007 to ensure service users across residential settings live in dignity, in a clean and safe environment, with purpose and in high-quality accommodation. The most important people in the picture are the service users across the country, whom HIQA and we serve. Following on from Deputy Dolan in relation to the failure to prosecute, why have no prosecutions been brought? I know HIQA can only prosecute summarily in the District Court and it cannot issue fines. How many prosecutions have been brought in the last 12 months against individuals or nursing homes using the limited powers available to HIQA?
Ms Susan Cliffe:
In the last 12 months, we have not prosecuted any registered provider. Where we have situations of serious concern about the care and welfare of residents, we will go straight to the cancellation of the registration of the nursing home. If we were to issue prosecution proceedings against a provider, we would potentially be allowing the situation in the nursing home to continue while that prosecution was going through the courts. If we are so concerned about the care and welfare of the residents, then the appropriate action is to cancel the registration or to take one of the lesser regulatory actions, such as perhaps attaching a condition to stop admissions to the centre or attaching a condition to require it to have something in place in the designated centre. The most important people in the picture are the residents in the nursing homes. Our focus must always be on what is going to effect the quickest change and ensure they are safe and get the care they deserve to receive.
Catherine Ardagh (Dublin South Central, Fianna Fail)
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There is nothing stopping HIQA prosecuting and stopping a registration. Is this correct?
Catherine Ardagh (Dublin South Central, Fianna Fail)
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Does the law allow HIQA to do both at the same time?
Catherine Ardagh (Dublin South Central, Fianna Fail)
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I thank Ms Cliffe.
Catherine Ardagh (Dublin South Central, Fianna Fail)
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The UK's Care Quality Commission, which is sort of like HIQA's brother organisation there, is allowed to impose fines and to prosecute at a higher level, either in the equivalent of the Circuit Court or High Court. Is it felt there are legislative gaps in HIQA's suite of available prosecutions? From what has been said, it seems HIQA is quite reticent in even using the summary suite of prosecutions it is allowed.
Catherine Ardagh (Dublin South Central, Fianna Fail)
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There have been no prosecutions in the last 12 months. What prosecutions is Mr. Colfer referring to?
Catherine Ardagh (Dublin South Central, Fianna Fail)
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Was this in the last 12 months or previous to that?
Mr. Finbarr Colfer:
It was in the last 12 months. We do, therefore, look at the possibility of prosecution.
We weigh up how to effect change as quickly as possible. Our experience with prosecution is that it is heavily resource dependent and the outcomes from the prosecutions we have taken have been quite low.
Will the Deputy repeat her last question?
Catherine Ardagh (Dublin South Central, Fianna Fail)
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I asked how many prosecutions HIQA has made and whether it would like to be able to access-----
Catherine Ardagh (Dublin South Central, Fianna Fail)
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And fines. Would HIQA like to be able to impose fines?
Mr. Finbarr Colfer:
We are open to looking at any levers we can bring in to help us to effect change more effectively. We are having discussions at the moment about various options, including the possibility of fines. It is in discussion phase at the moment, but certainly we are willing to explore it.
Catherine Ardagh (Dublin South Central, Fianna Fail)
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How soon does HIQA think it might be in a position to do it? How far away is that legislation?
Catherine Ardagh (Dublin South Central, Fianna Fail)
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Is it something HIQA has formally asked of the Minister?
Ms Angela Fitzgerald:
In discussions with both Ministers, we looked at the recent regulatory changes and the impact they will have. They will certainly have some impact on some of the issues raised today. We have looked at additional measures and they fall into two main categories. One is the powers-----
Catherine Ardagh (Dublin South Central, Fianna Fail)
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Does Ms Fitzgerald mind if I continue with my questions as I only have five minutes?
Catherine Ardagh (Dublin South Central, Fianna Fail)
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I thank Ms Fitzgerald.
On the use of CCTV, the Care Quality Commission in the UK has expressed its view that more widespread use of CCTV would protect residential care users and service providers. As my friends have said, many of the drops in the level of care happen at night. That is why we need more unannounced inspections during out-of-hours times. That is where CCTV comes into play. What is HIQA's role in ensuring all residential settings, not only large ones but also small ones, are mandated to have CCTV that is accessible? It is thought in the UK that this type of legislation will be coming down the road.
Catherine Ardagh (Dublin South Central, Fianna Fail)
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In the UK, people are looking at having CCTV in those situations, especially when it comes to vulnerable children and adults, because that is where people are being cared for intimately. That is where families probably have the most concerns, especially those with a vulnerable child or adult.
Mr. Finbarr Colfer:
We have seen a small number of situations where CCTV has been used in different services. We would look for a very high level of evidence that it is necessary and that other options have been looked at. At this point, we are not supporting the widespread blanket use of CCTV. There are issues about people's right to privacy and those issues need to be teased out before we would ever sanction a widespread use. However, within the Deputy's question, there is a more important point about the culture of a service.
Catherine Ardagh (Dublin South Central, Fianna Fail)
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I will stop Mr. Colfer. I do not mean to be rude, but I only have limited time.
How many children's residential centres have had their registration cancelled or conditions to it attached in the past five years?
Catherine Ardagh (Dublin South Central, Fianna Fail)
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Has HIQA attached conditions to any?
Catherine Ardagh (Dublin South Central, Fianna Fail)
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Has HIQA made any complaints?
Mr. Finbarr Colfer:
To clarify, while there are more than 200 children's residential centres, we do not regulate them. We inspect and monitor against standards, but we do not have regulations for those centres. There are three secure children's units and we do regulate those and they are registered.
Catherine Ardagh (Dublin South Central, Fianna Fail)
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What is HIQA's policy then for follow-up inspections when there is non-compliance in any of its care facilities? For instance, if it were to refer a matter to the HSE, Tusla or An Garda Síochána, does it have a loop back from them and are there timelines for that?
Catherine Ardagh (Dublin South Central, Fianna Fail)
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Yes.
Mr. Finbarr Colfer:
After inspection we make our referrals. Generally speaking, the other authorities or bodies do not come back to us but we follow up on the issues through follow-up actions and follow-up inspections. For example, if there is an issue around adult safeguarding and we have made a referral to the safeguarding team or to An Garda Síochána, An Garda Síochána will not report back to us, but we will follow up on the actions the provider has taken to keep people safe from that action.
Catherine Ardagh (Dublin South Central, Fianna Fail)
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If HIQA has made a referral to An Garda Síochána and it has not attached any conditions to a registration or cancelled any, how does it ensure those service users are not left in an unsafe setting?
Mr. Finbarr Colfer:
We use a number of measures. If inspectors identify an issue on inspection, we will require the provider to take immediate action and, generally speaking, our inspectors will not leave until that action has been taken. A further measure we can use is to require a provider to set out the ongoing actions to ensure a person is safe and to submit them to us. If there is risk, we will go back and do a follow-up inspection to confirm the provider has taken those actions. We have gone back to some centres multiple times. Ms Cliffe mentioned one,-----
Catherine Ardagh (Dublin South Central, Fianna Fail)
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How many times has HIQA inspected the Emeis Ireland homes since the programme was aired?
Joanna Byrne (Louth, Sinn Fein)
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I thank the witnesses for joining us. It is fair to say that HIQA has appeared before Oireachtas committees several times in recent years and it is unfortunate that the same issues keep arising. With that in mind, I will tease out some of its frameworks for measuring performance, if that is okay.
Do the witnesses have a figure for how many compliance notices HIQA has issued in recent years and what is the rate of measured compliance after they are issued? How does HIQA measure that?
Ms Angela Fitzgerald:
I will ask Mr. Colfer and Ms Cliffe to come in on the specifics, but the compliance notices were used administratively. We required people to put compliance plans in place, but the legal basis for that was only commenced at the end of February. Prior to that, in the absence of a legal lever, we issued at the end of every inspection a compliance plan and improvement requirements.
Mr. Finbarr Colfer:
I might make a distinction between a compliance plan and a compliance notice. A compliance plan is where we have always required providers to respond to areas of non-compliance and we publish compliance levels in our annual reports. However, issuing a compliance notice is a new power that was just given to us and we are in the process of implementing it. We had an administrative process, as I mentioned in response to Deputy Ardagh, where we require a provider to take immediate or urgent action, but the compliance-----
Joanna Byrne (Louth, Sinn Fein)
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I am trying to get at how HIQA measures the action the provider has taken. How does it set the bar and measure that the provider is meeting the bar?
Mr. Finbarr Colfer:
When immediate or urgent action is required, we require the provider to demonstrate immediate action and either we do not leave the centre until it does, or we will require evidence within a few days that it has been taken. Providers set out how they will address compliance plans after the inspection. We then review those at the next inspection to confirm whether they have been implemented.
Joanna Byrne (Louth, Sinn Fein)
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My colleague, Deputy Bennett, asked a question about closures earlier and HIQA outlined some figures. There were two closures in 2020, three in 2021, one in 2022 and three in 2023. Ten notices were issued in 2024 but there were seven closures and there has been one closure in 2025 to date.
That is 17 closures in five years. Is that right? Are any of those homes run by the same operator?
Ms Susan Cliffe:
There is a common trend in the closures that happened from late 2023 to early 2025, not in the named provider because the majority were operated by individual companies, but a significant number of them were set under the umbrella group known as the Aperee group. Another two centres were owned and operated by the same provider. They had their registration cancelled. The remaining two were owned and operated by different registered providers comprised of the same directors.
Joanna Byrne (Louth, Sinn Fein)
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Within that common thread, is there additional monitoring by HIQA to look specifically at those that fall under that common-thread umbrella—--
Joanna Byrne (Louth, Sinn Fein)
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-----and any other centres they may operate that have not gone as far as closure.
Ms Susan Cliffe:
We have a system to share the learning from individual inspections. We do not go out expecting to see that because one thing is happening in one nursing home it is happening in another, but we are awake to the possibility that it may be, and we have a process through our regional management structure to share learning from inspections of different nursing homes. It may not solely be private providers. It could be the statutory provider or a trend in the sector, and we have processes for sharing that information internally.
Joanna Byrne (Louth, Sinn Fein)
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It is very positive that HIQA has identified and is aware of that. I am really pleased to hear it is working on that.
In relation to the Emeis managed properties, there was conflicting information. It was said on two occasions that 25 of these are in operation. One person stated that 16 have been inspected since the RTÉ programme and Ms Cliffe mentioned 22.
Joanna Byrne (Louth, Sinn Fein)
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Only one property has had to be inspected a second time.
Joanna Byrne (Louth, Sinn Fein)
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How many times does something have to be inspected before it is red-flagged or elevated to the next level of concern?
Ms Susan Cliffe:
It depends on the issue identified. That is grounded in our assessment of the risk to individual residents in the centre. We afford providers an opportunity to address issues that are identified and expect that they will do it. The vast majority of the sector will do so. However, if we are really not satisfied and it is a repeat finding over multiple inspections that has not been addressed, we obviously will have an increasing concern and the timeframe to make the changes will be shorter. We will then move into escalating regulatory action. We will have enforcement action in the form of conditions and that will bring a shorter window. Like I said, one centre was inspected nine times last year. That is very unusual and it is really important that we recognise the vast majority of the sector takes action on foot of the findings of inspection and starts the work as the inspectors are going out the doors.
Joanna Byrne (Louth, Sinn Fein)
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As regards the inspectors inspecting the properties, it was mentioned earlier that each inspector has a caseload. Is the caseload rotated?
Joanna Byrne (Louth, Sinn Fein)
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The same inspectors do not inspect the same properties.
Ms Susan Cliffe:
We have a process of changing over approximately 25% of centres per inspector per year. We try to avoid that situation, both for the inspector and the registered provider, because if a person is going in the same door he or she stops seeing certain things. However, equally the growth in the size of the team over the past three years on foot of the expert panel review meant we went from four to five to six regions and that necessitated caseload changes as well. All of that contributed to the changes.
Joanna Byrne (Louth, Sinn Fein)
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I draw attention to HIQA’s vision, strategic mission and values. It states HIQA will work to promote human rights, as well as identifying, challenging and reporting on breaches of rights in health and social care services. Given the recent revelations in the RTÉ programme, does HIQA stand over that vision? That is a very hard question to put to our witnesses but it is something people are asking.
Ms Angela Fitzgerald:
It is a fair question. It underlines the importance of reinforcing that is our mission. Certainly for my predecessor, and from the inception of HIQA, one of the things we have driven is that focus on human rights. It is important to say that regulation provides a minimum compliance. What we have tried to do is move people towards a system where they are doing it because it is the right thing to do, rather than because we inspect them. It is an important point to make that if the system of delivery of care becomes dependent on an inspector coming in and shining a light, we will always have people doing things because somebody else is telling them to do it. What we are trying to do is get the system to do it because it is the right thing to do.
In the time I have been in the role, I have attended many provider events and events which mark particular landmarks, and what I have been struck by is the commitment of the vast majority of providers to deliver good care. It is a fair challenge to put to us. We have been challenged by the events, and we do have to make sure that continues to be amplified by the work and training we do, as well as by the learning events we promote with our own staff. We do a reflective practice event every year with all of the regulatory team where we go off site and challenge ourselves to look at where we could do better. We also do that with the provider system. I was at an event recently for all of the providers there, and many of those would have had challenges with us. There has always been a tension regarding whether a regulator can be collaborative. We believe we can. It is a fair question the Deputy put to us and it amplifies the importance for us to do the learning we are looking at for ourselves.
Joanna Byrne (Louth, Sinn Fein)
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I appreciate that. Does Ms Fitzgerald feel that HIQA has lost the trust of the public, particularly since the airing of the documentary?
Ms Angela Fitzgerald:
People feel there is a dent in the armour given we were the trusted voice. We would like to believe our track record in terms of shifting the dial, amplifying the issue of restrictive practices, particularly in disability, and moving people out of congregated settings, which was the work of the HSE but championed by us, will stand to us. With the work we have done with older persons where we really amplified the voice of the resident and tried to put the emphasis on what it is like to live in a setting as opposed to a task-based approach, we have been strong, but we are challenged to do better and that is the commitment we have made. That is not just about us. A lot of the discussion here is about whether we have the levers we need. That is part of it. We may never use those levers but they do act as a deterrent and as a barometer for performance.
Joanna Byrne (Louth, Sinn Fein)
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I am out of time. I thank the witnesses.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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With the agreement of committee I will take my slot now to prevent us having to reschedule the speakers list. Ms Fitzgerald stated there is a dent in the armour. The stronger phrase is that the trust in HIQA and the regulatory regime has been damaged. I have seen a particular impact because Beneavin nursing home is in my own constituency.
I wish to acknowledge the immediate briefing which the three local TDs for our constituency received from HIQA. It was useful in terms of answering the questions of people who were in contact with us. The witnesses are right; they fell into different categories. There were people who were the subject of the RTÉ programme who had questions and there were people who were not the subject of the RTÉ programme but were resident in the nursing home at the time, some of whom had very positive experiences, while others had negative experiences and had made reports to HIQA. The most difficult group for me was people who had family members in Beneavin nursing home who had passed away. They were really struggling with what might have happened.
We should not underestimate the damage that was done. There is a wider impact on other nursing home providers not named in the programme, where a general doubt was rightly raised in terms of how older people are cared for. I put those questions to our witnesses in order to get on the public record some of the answers that were given to us at the original briefing. Ms Cliffe was helpful in providing information with regard to the immediate inspection response for Beneavin nursing home. When I say Beneavin nursing home, there are actually three nursing home providers on that site, all of which are under Emeis and within the Beneavin campus. Can Ms Cliffe tell me what immediate response was taking place in terms of visits to the site?
Ms Susan Cliffe:
We inspected the entire campus on the evening of 5 June. We did that because we wanted to be sure that what we were seeing in Beneavin Manor was not being supplemented by resources from the other two nursing homes on site. What we found was, in response to the programme, the three registered providers had put increased staff in place in all of those centres. They had a focus on the numbers of staff that were available.
They also had a focus on supervision. If the Leas-Chathaoirleach will recall, very often during the programme we heard "This is not the way to do it", "Close the door" and "We should not be doing this" That was not a failure of knowledge or training. It was a failure of supervision.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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All three nursing homes were inspected on one day.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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How many times has HIQA attended the three nursing homes?
Paul McAuliffe (Dublin North-West, Fianna Fail)
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People will be somewhat reassured by the frequency of inspections since then. In those subsequent inspections, has anything been discovered that posed an immediate threat to the health, safety or welfare of the people within the nursing home that would warrant its closure?
Ms Susan Cliffe:
No, we have not seen anything so far that would lead us to take that ultimate step of cancelling the centre's registration. Having said that, there may be other regulatory enforcement action but, because that is under way or being considered, I cannot discuss it further at the moment. That will form part of our regular updates to the Minister. However, we did not see any immediate risk to residents on the day. We met members of the public and relatives and spoke to the staff. What we were really trying to understand was how things had changed so much since we were there last November.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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Many people will have made the decision to place a relative there on the basis of the previous HIQA reports, which effectively gave the centres a clean bill of health. The question arises, how can a clean bill of health be issued for a nursing home in which an undercover investigation - "undercover" might be the operative word - discovered a very different reality? What can Ms Cliffe say to people who made that decision based on the reports issued by HIQA?
Ms Susan Cliffe:
Our reports on Beneavin Manor showed a varied regulatory history over the years. The last report of regulatory compliance, from November, was a good report. We stand over the findings of the report at that time. What we now know is that since that inspection in November, there was a fundamental change to the management structure in the centre. The person in charge and the managers who supported that person had all changed. Some 95 staff members started working in that one nursing home while 35 staff left. The resident profile in the nursing home also changed considerably between November and April.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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When Ms Cliffe mentions the resident profile, she means there was a higher level of dependency.
Ms Susan Cliffe:
I was referring to the dependency level of the residents. In November, there were six residents who required one-to-one care. By April, that figure had increased to 18. The provider knew there was a fundamental change to the staffing and management profile but did not allow for that and continued to admit residents with very high dependency. We believe that-----
Paul McAuliffe (Dublin North-West, Fianna Fail)
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I am glad Ms Cliffe mentioned both management and ratios because the issue of ratios arose frequently in the programme. I believe HIQA does not have a required ratio like the ratios in childcare. Is that the case?
Ms Susan Cliffe:
That is the case. It is the regulations. It is not that HIQA does not have ratios but that the law does not set out required staffing ratios. However, work is well advanced in the Department of Health on what is known as the safe staffing and skill mix framework. That is being progressed. It was recommended on foot of the findings during the Covid pandemic. It is well advanced at this stage. I might defer to my colleagues in the Department on that.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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Does the Department have any comment on that?
Paul McAuliffe (Dublin North-West, Fianna Fail)
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It is accepted that standard ratios are an important factor and should be in place.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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When did the Department come to that conclusion?
Paul McAuliffe (Dublin North-West, Fianna Fail)
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I know the previous Minister of State with responsibility for older people provided additional funding and powers to HIQA, which is reflected to some degree, but the issue of the ratios is key.
Ms Angela Fitzgerald:
We also support that. It gives us a more objective lens in calling out staffing inadequacies. More importantly, it puts an obligation on providers and gives them a framework against which to judge themselves. There is unanimity between ourselves and the Department on the requirement for ratios.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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On the issue of ratios, people often say there are too many managers and not enough front-line staff. In my own private view, when looking at the programme, I saw issues of culture. They say culture is the easiest form of management. If people felt free to compile reports on actions that were not actually carried out or to depart from standard practice even where they know it was wrong to do so, as evidenced by staff saying "Close the door" or "This is not the way we should do this", it is very obvious that there was not sufficient supervision in place. I ask that whatever ratios are put in place include a ratio in respect of supervision and management.
Ms Angela Fitzgerald:
It is a fair point. The other piece is the qualifications of staff. There is currently no minimum requirement as regards qualifications. If you are not appropriately skilled, you do not have enough staff and you do not have appropriate supervision, a very task-based approach is taken and people do not necessarily understand the concept of care. It is very appropriate. The chief nursing officer is leading out on that work in the Department. It is being implemented in healthcare settings. We are confident that it is at an advanced stage. It will definitely support our efforts.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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I have said on the record of the Dáil that you can have all the regulations in the world but if people are willing to fill out forms saying actions have been completed when they know that is not the case or to do things that any decent human would know do not constitute good care, that poses a regulatory challenge. RTÉ was able to discover these things because of the undercover nature of its investigation. Is HIQA allowed carry out undercover investigations? Should it be allowed to do so?
Paul McAuliffe (Dublin North-West, Fianna Fail)
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What is preventing HIQA for using undercover techniques?
Paul McAuliffe (Dublin North-West, Fianna Fail)
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That is useful. I am very anxious to ask about company structures. Ms Cliffe mentioned separate entities. Are there directors in common across all of the Emeis entities?
Paul McAuliffe (Dublin North-West, Fianna Fail)
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The corporate governance element as regards common directorships, term limits for directors and so on is not a matter for HIQA but has it examined that area with respect to these groups of nursing homes? Many people are very uncomfortable with the idea that a corporate entity is not accountable to HIQA while individually-created corporate entities are. It seems like a big gap in the regulatory framework.
Ms Angela Fitzgerald:
It is one of the areas the Minister of State, Deputy O'Donnell, has asked for our input on and that he is prioritising. It is a principle of regulation that you have to able to hold accountable people to account. That is a fundamental principle. I understand that, following the crisis, the Central Bank looked at the whole area of probity with particular regard to director accountability. This is one of the areas on which the Minister of State has engaged with us and at which he is looking. At the simplest level, we want to ensure the regulatory framework we have is effective. If control and accountability are outwith the provider, we need to have a means-----
Paul McAuliffe (Dublin North-West, Fianna Fail)
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I do not want to abuse my position as Chair so I have to limit myself. We will now take a very short break. We will resume in ten minutes with Deputy Séamus McGrath.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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We will start with Deputy Séamus McGrath.
Séamus McGrath (Cork South-Central, Fianna Fail)
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I thank all the witnesses for being here. I do not want to repeat everything that has been said but there will be some repetition, for which I apologise.
I recognise the difficult job HIQA has. It is not easy to be in a policing role. There may be many successes but it is the failures that are highlighted and I do understand this. HIQA's role is not only policing, as it also has a lot of policy formulation input. I recognise this. Obviously, however, with regard to what the country witnessed on "RTÉ Investigates" recently, it is fair to say it absolutely disgusted people. It was an utter failure of regulation, there is no question about it, to see this humiliating, degrading and disrespectful treatment of elderly citizens. People would be rightly outraged if they saw this type of behaviour towards animals. Unfortunately, in this case it was towards elderly citizens. It really resonated with people because we all have elderly relatives and, God willing, we will be elderly ourselves some day. We want to ensure there is adequate trust in the system of regulation of our nursing homes.
I will get into some specific questions, if I may. Again, I apologise if there is repetition. I tried to listen as much as I could but I may have missed some of it. What is HIQA's overall staff count and how many of these staff are directly involved in inspections?
Mr. Finbarr Colfer:
We have 37 inspectors working in older person's services, in disability services we have 40 inspectors, and in children's services we have 14 inspectors.
Séamus McGrath (Cork South-Central, Fianna Fail)
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Does that amount to approximately 100 out of a staff of 450?
Mr. Ultan Hynes:
We have 120 inspectors of all types covering children, older persons, disability, healthcare and international protection.
Séamus McGrath (Cork South-Central, Fianna Fail)
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Out of a staff of 450, approximately 120 are actively involved in inspections. This is a small number of the overall staff count, given the role HIQA has and the importance of inspections in fulfilling this role. Do the witnesses agree?
Ms Angela Fitzgerald:
Maybe the way to put it is that we have equivalent roles. We have significant roles in the areas of health technology assessment and health information standards. While these are the numbers directly involved in inspections, they are also supported by a number of other staff. The total number of staff in the chief inspector's office is more than 200.
Séamus McGrath (Cork South-Central, Fianna Fail)
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Some of these are in administration support, as opposed to inspections.
Séamus McGrath (Cork South-Central, Fianna Fail)
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What percentage of HIQA's overall budget is involved in the inspection role?
Séamus McGrath (Cork South-Central, Fianna Fail)
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I thank Mr. Hynes. I believe it was said earlier that more than 80% of HIQA's visits are unannounced. Is this correct? Will the witnesses briefly walk us through what happens when HIQA makes an unannounced visit to a nursing home? The inspectors walk into a reception and state they are from HIQA. What happens then?
Ms Susan Cliffe:
When the inspectors arrive at a nursing home, they identify themselves and show their identification and their authorisation as inspectors of social services. It then depends on whether the visit was planned or unannounced. If the inspection is unannounced, people in the centre will get themselves organised and together, and our inspectors will very often go right or left from the main entrance and start walking the centre.
Séamus McGrath (Cork South-Central, Fianna Fail)
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This is what I am getting at. Do the inspectors wait at reception for five minutes while somebody comes to meet them or do they get straight into it? Word will spread faster than the speed of light, I would say, that there are inspectors from HIQA. How the process is carried out is very important.
Séamus McGrath (Cork South-Central, Fianna Fail)
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This brings me to my next point. "RTÉ Investigates" uncovered what it did through undercover tactics. Is this something HIQA has ever deployed?
Séamus McGrath (Cork South-Central, Fianna Fail)
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Is Ms Cliffe saying that HIQA is legally not allowed to carry out undercover work?
Séamus McGrath (Cork South-Central, Fianna Fail)
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This is the crux of the issue. RTÉ uncovered what it did because the reporters were undercover. Nobody knew who they were and they witnessed first-hand the behaviour towards residents in these nursing homes. For HIQA to really fulfil its role, it has to carry out the same type of tactics as RTÉ. What needs to happen for HIQA to be able to go in undercover and witness first-hand what is happening? What needs to change for this to happen?
Séamus McGrath (Cork South-Central, Fianna Fail)
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Sorry for interrupting but it was not only about documents. It was the absolutely inhumane treatment from human to human. HIQA will never see this unless people do not know it is there. This is the reality. HIQA can make unannounced visits and, as Ms Cliffe said, the phones are pinging as the inspectors are walking down the corridor. Nobody will treat a resident in that manner in front of HIQA. It has to have eyes and ears there without people knowing. What needs to change legally for this to happen? I believe that is the only way we can have effective regulation and inspection.
Séamus McGrath (Cork South-Central, Fianna Fail)
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I respectfully suggest it is something that needs to happen. It is the only way that people will have full trust in the inspection system for nursing homes. It was mentioned earlier that HIQA has a duty or requirement to visit nursing homes once a year. Is HIQA fulfilling this duty? Has every nursing home been visited in the past 12 months?
Séamus McGrath (Cork South-Central, Fianna Fail)
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I ask Ms Cliffe to repeat this.
Séamus McGrath (Cork South-Central, Fianna Fail)
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By the end of the year HIQA hopes to have visited them all.
Séamus McGrath (Cork South-Central, Fianna Fail)
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All will be visited once and a majority will have more than one visit.
Séamus McGrath (Cork South-Central, Fianna Fail)
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I thank Ms Cliffe. Do further inspections follow from issues that HIQA may have seen in a previous inspection? Do they follow complaints? What are the criteria for HIQA to decide?
Ms Susan Cliffe:
All of the above. There is a baseline inspection. The first inspection of a nursing home may be informed by notifications received, as in the trending of those notifications. It may be informed by unsolicited information or protected disclosures that we receive. It may be to follow up on the findings of a previous inspection and a requirement for a provider to implement a compliance plan.
Séamus McGrath (Cork South-Central, Fianna Fail)
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I couch this with my earlier comment that HIQA can have many successes but its failings is what it is judged on. What accountability has there been in HIQA for what we saw in "RTÉ Investigates" in terms of the utter failure of regulation and inspection? Has there been any accountability in the organisation?
Ms Angela Fitzgerald:
Our accountability is to here and to the Oireachtas. The chief inspector has direct accountability to the Oireachtas. There are three strands to what we are looking at. The first is to look at the regulatory powers. The second is in terms of behaviour and culture. Having adequate staffing, skilled staffing and supervision will go much further than us doing a second or third inspection. It embeds every day what happens, regardless of who is there. The third element is that every year we receive 1,100 pieces of unsolicited information, what we call UROIs. These are concerns often raised by staff which they might not raise when we are there on inspection. We do not just rely on inspections.
Another element is very much how we do our own work. Earlier Mr. Colfer referenced looking at proxies for culture. This is about some of the information we are going to be mandated to regulate-----
Séamus McGrath (Cork South-Central, Fianna Fail)
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As the head of the organisation does Ms Fitzgerald feel the public has confidence in HIQA?
Ms Angela Fitzgerald:
As I said earlier, there has been damage to the confidence because of the nature of what we all viewed. It was so harrowing and difficult. Many people have acknowledged, as has the Deputy, that we continue to do a lot of good work.
However, we have to own the challenges that have been identified there.
Séamus McGrath (Cork South-Central, Fianna Fail)
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Does HIQA measure public confidence? Does it engage or do surveys?
Ms Angela Fitzgerald:
We conduct a number of surveys. HIQA conducts five surveys with patients and residents of nursing homes. Across the domain, approximately 80,000 people have participated. They are independent of us, but they amplify what is good about services and what needs to change. As part of our corporate plan, we engaged extensively with a wide range of stakeholders-----
Séamus McGrath (Cork South-Central, Fianna Fail)
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In terms of the "RTÉ Investigates" programme and the shock to the nation it caused, can HIQA assure people that there will be or that there has been a step change in approach from HIQA in trying to address issues like that?
Ms Angela Fitzgerald:
Absolutely. We have given a public commitment. More importantly, we have to act. The immediate escalatory actions relate to Emeis nursing homes. We have engaged with the Minister regarding regulatory and policy reform and in terms of our own approach. There is also the communications piece to the public. We have talked about a communications strategy that seeks to amplify the good work we do, as well as the areas we are now focusing on.
Grace Boland (Dublin Fingal West, Fine Gael)
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I thank the witnesses for coming in today. In terms of ensuring HIQA is properly accountable and that we have confidence in it, we need to make sure we have a robust regime. What are HIQA's top three requests of the Minister and the Department?
Ms Angela Fitzgerald:
The first is to look at regulatory reform. Deputy Geoghegan talked about being able to hold corporate entities to account properly. That is a key one. In terms of what we witnessed and what we had already identified through our own inspection processes, it is important to have adequate staffing and supervision and staff with the necessary skills. We called that out in both centres through our regulatory function, but it is important that we have a stronger mandate to call that out through the safe staffing framework. Third, HIQA has had some regulatory change which means we can now seek information more routinely. That is where what I call "monitoring surveillance" between inspections takes place. That is about us as well. Having the regulatory right to seek that information means HIQA can provide better assurance between inspections. They would be the three requests.
Grace Boland (Dublin Fingal West, Fine Gael)
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Does HIQA have that right?
Ms Angela Fitzgerald:
We do. There has been a change in the patient safety Act, which now allows HIQA to seek information. The definition of it is quite defined, but we are currently engaging with the Department to see whether we can leverage that further in order that we can have surveillance data. That would go some way towards addressing some of the concerns about undercover because the information that informs behaviour and culture would be available.
Grace Boland (Dublin Fingal West, Fine Gael)
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Has the Department given HIQA a timeline?
Grace Boland (Dublin Fingal West, Fine Gael)
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What trends and areas for improvement has HIQA seen through its various surveys and stakeholder engagement? What are people calling out? In particular, what are patients and people working in these services calling out?
Ms Angela Fitzgerald:
It is a very good question. It is important to note from the inpatient survey that people are overwhelmingly satisfied. We are one of the few jurisdictions that has national, centralised and organised surveys. Somebody mentioned CQC earlier on. There has been quite a critique of the multiple surveys in the UK and the fact that they do not co-ordinate. The surveys identified three things. The first relates to communication. A lot of people need clear communication when they or their family members are anxious and in hospital. That is a clear theme. There is a kind of imbalance of power in a situation where a patient is dealing with a doctor. Having time to explain what is going on is the second thing. For people in residential care, it is about them having much more of a say in what they can do. The early response to delivery of care in nursing home settings was about protecting patients, but some of that might have been taking away the freedom to make decisions, even if those decisions are not always the best ones because we can do that when we live at home. They are the three things that come through.
Interestingly, we did surveys on bereavement, end of life and maternity over a number of years. Those findings are consistent. We are working with the HSE in particular, as well as private providers. We are finding that private hospitals are very-----
Grace Boland (Dublin Fingal West, Fine Gael)
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It is reassuring to hear that about a patient-centred approach. HIQA's responsibilities have grown. Its number of employees has grown to 450. What level of resignations or attrition has HIQA had recently?
Ms Angela Fitzgerald:
We have a very strong track record of attracting and retaining our staff. Most competitions we fill on the first filling. We are a bit different in that respect. Over 40% of our promotions are filled by people from within the organisation. We have a strong track record of retention.
Grace Boland (Dublin Fingal West, Fine Gael)
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What is HIQA's attrition rate?
Grace Boland (Dublin Fingal West, Fine Gael)
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There have been employee difficulties and litigation throughout the public service. What is HIQA's level of employee disputes?
Ms Angela Fitzgerald:
It is very low. In fact, we have very few requirements to use WRC or external bodies. We do two things. We conduct a staff engagement survey through Ipsos every two years. Overwhelmingly, staff have a very strong loyalty to the brand of HIQA, which is very important. They also have a strong commitment to the values of what we do.
Grace Boland (Dublin Fingal West, Fine Gael)
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HIQA has not had any contentious disputes.
Grace Boland (Dublin Fingal West, Fine Gael)
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Does Ms Fitzgerald know how many employees have left in contentious situations, such as where NDAs would have been required, etc.?
Ms Angela Fitzgerald:
In my time, we have had none. I am in the role three years. We can provide that information to the Deputy separately. We have very good HR practices. The Deputy asked about the staff experience of working in HIQA. The Ipsos survey gives us good insights into some of the challenges and tensions for staff in doing a demanding job and always striving for excellence. Another piece that has come through in some of our surveys is the opportunity to make a difference. That is a positive piece. We can certainly provide any information regarding the Deputy's question-----
Grace Boland (Dublin Fingal West, Fine Gael)
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Please do.
Grace Boland (Dublin Fingal West, Fine Gael)
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Two law firms work for HIQA. What type of advice do they provide? HIQA has an in-house service.
Ms Angela Fitzgerald:
We use our legal services in two ways. We support the Department significantly in the development of new legislation. For example, when we went out to tender last time, we were looking for experiences in the area of cybersecurity because it is very likely that we will become the competent authority. We work very closely with the Department in framing the legislation through looking at our own experience. For example, in the home support-----
Grace Boland (Dublin Fingal West, Fine Gael)
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I am sorry but I am conscious of time. I am not trying to put Ms Fitzgerald off.
Ms Angela Fitzgerald:
The other area relates to judicial reviews, legal challenges or when we have to go to court as part of our regulatory function. We use our own teams, by and large, but when we have to defend a case, we may need to use external sources and sometimes we use senior counsel. For example, in CHI, we used external support because we wanted to protect the integrity of that report.
Grace Boland (Dublin Fingal West, Fine Gael)
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HIQA went through a procurement process for the legal advisers and has a negotiated discounted rate with them.
Grace Boland (Dublin Fingal West, Fine Gael)
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Does HIQA negotiate a rate with barristers and the counsel it instructs?
Grace Boland (Dublin Fingal West, Fine Gael)
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HIQA can negotiate with them, just so Ms Fitzgerald knows.
Grace Boland (Dublin Fingal West, Fine Gael)
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The costs were low in 2023. There was an increase in 2024, but it is still relatively low.
Grace Boland (Dublin Fingal West, Fine Gael)
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Will HIQA remind me of the number of inspectors it has?
Grace Boland (Dublin Fingal West, Fine Gael)
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How does HIQA ensure there is no conflict with those inspectors? For example, to ensure there is no familial relationship to any of the entities they are inspecting, or perhaps the inspectors may have worked there before. How does HIQA ensure that does not arise? Will Ms Fitzgerald confirm that both of those facts would be a conflict of interest?
Grace Boland (Dublin Fingal West, Fine Gael)
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How does HIQA ensure that those conflicts do not arise?
Ms Susan Cliffe:
We have a conflict of interest policy, as Ms Fitzgerald has set out there, and that begins from the time somebody takes up employment. It is one of the first conversations that they will have with their line manager where they will identify any centres. In my case, it would be for the team of inspectors of nursing homes, any nursing homes, where they may have worked, where they may have relatives who work or where they may have had some engagement through a former role, because we draw our people from the nursing home sector predominantly, the acute or the community health services. Ireland is a small country.
That conflict of interest policy is a dynamic process because things can change during the lifetime of your employment in the organisation. What we require is that somebody does not inspect a nursing home that they have worked in for a minimum of three years after they have started working with HIQA.
Grace Boland (Dublin Fingal West, Fine Gael)
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Does Ms Cliffe think that is sufficient? Knowing everything she knows now, does that need to be reviewed? I assume HIQA will continually, maybe annually, review these policies to make sure they are updated.
Ms Susan Cliffe:
It is dynamic. If somebody moves to work in a nursing home or transfers between nursing homes, it might cause one of our inspectors to reassess their conflict of interest policy. It is not just done on an annual basis but is run on an everyday basis, if you like.
The three-year mark has served us well, but the question will always be to the inspector, "Do you feel you can independently inspect this centre and come to the judgments that would need to be made at the time?" If the inspector is comfortable that sufficient time has passed, they do not believe there could be any conflict of interest and we do not have a reason to believe there could be a perception of a conflict of interest, then that three-year patter has served us well but I am mindful that it is dynamic and it can change on a day-to-day basis. I personally had to declare a conflict of interest in the last couple of weeks because of a member of my family taking up employment in a nursing home. I will not have any oversight of that nursing home.
Grace Boland (Dublin Fingal West, Fine Gael)
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I thank Ms Cliffe. Thanks, Chair.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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I thank Deputy Boland and call Deputy Connolly.
Catherine Connolly (Galway West, Independent)
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I thank the witnesses for being here. I want to pay tribute to the range of work that comes under HIQA's remit. It is really astounding, and it has been expanded.
Does HIQA have enough staff and resources to cover the whole range of entities it supervises and monitors?
Catherine Connolly (Galway West, Independent)
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HIQA has huge responsibility. Does it have enough to carry out those responsibilities?
Catherine Connolly (Galway West, Independent)
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Is HIQA getting those staff?
Catherine Connolly (Galway West, Independent)
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So there is no question of governance, monitoring or the standard being reduced because of a lack of staff.
Ms Angela Fitzgerald:
No. We did have a challenge in one area for a period of time in disability because of the rate of growth in the number of individual disability centres, but we successfully engaged with the Department and secured it.
Catherine Connolly (Galway West, Independent)
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Is Ms Fitzgerald happy at present with the level of staff?
Catherine Connolly (Galway West, Independent)
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Ms Fitzgerald has pointed out that agency staff at any given time amounts to 3%.
Catherine Connolly (Galway West, Independent)
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Is that right?
Catherine Connolly (Galway West, Independent)
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That is the average. What was the highest percentage? Was it ever 10%?
Catherine Connolly (Galway West, Independent)
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Percentage wise, would it be in or around 3%?
Catherine Connolly (Galway West, Independent)
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Is the price of that commensurate with what HIQA is getting? HIQA is employing a recruitment firm, I gather.
Catherine Connolly (Galway West, Independent)
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Is it the same recruitment firm on a regular basis?
Catherine Connolly (Galway West, Independent)
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How long is that contract for?
Catherine Connolly (Galway West, Independent)
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Is that being constantly renewed then?
Catherine Connolly (Galway West, Independent)
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Will it ever go back out?
Catherine Connolly (Galway West, Independent)
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That is all tied in. The costs seem high in relation to that.
Catherine Connolly (Galway West, Independent)
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Would it be fair to say HIQA is not facing the same obstacles or hurdles that other entities face in recruitment and retention? I think that is what the witnesses have said.
Catherine Connolly (Galway West, Independent)
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I might come back to that in a minute. At this stage, many of the questions have been asked and answered. I will zone in on a few different things quickly.
Catherine Connolly (Galway West, Independent)
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HIQA has included IPAS, or IPAS has been included. How many centres are there? How many have been inspected? Where are we with that?
Catherine Connolly (Galway West, Independent)
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I am only going to ask, at this stage, the number in the country and the number inspected.
Catherine Connolly (Galway West, Independent)
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So it is 51, in total.
Catherine Connolly (Galway West, Independent)
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Will Mr. Egan explain what HIQA has a legal permit for?
Catherine Connolly (Galway West, Independent)
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So there are many more centres than that-----
Catherine Connolly (Galway West, Independent)
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-----but HIQA has no remit over them.
Catherine Connolly (Galway West, Independent)
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Eleven per cent?
Catherine Connolly (Galway West, Independent)
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There is no remit for the emergency centres and remit for 11% of all the others.
Catherine Connolly (Galway West, Independent)
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Have all those of that 11% been inspected now?
Catherine Connolly (Galway West, Independent)
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Are they unannounced inspections?
Mr. Sean Egan:
The majority of them are unannounced inspections. There are certain inspections that are conducted on an announced basis. That is generally to meet certain individuals that we might need to engage with at a senior management level - typically, inspections where we need to go in and look at a specific issue that we have already identified.
Catherine Connolly (Galway West, Independent)
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Could Mr. Egan tell me briefly what issues have arisen?
Catherine Connolly (Galway West, Independent)
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What issues have arisen?
Catherine Connolly (Galway West, Independent)
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There is overcrowding. What other issues?
Catherine Connolly (Galway West, Independent)
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I just want the issues.
Catherine Connolly (Galway West, Independent)
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There are overcrowding and risk issues.
Catherine Connolly (Galway West, Independent)
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Have they got in the reception officers?
Catherine Connolly (Galway West, Independent)
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Okay. It might be helpful if Mr. Egan gave us those issues. That would be very helpful.
Catherine Connolly (Galway West, Independent)
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I thank Mr. Egan. I am sorry but I am watching the clock and the Chair.
In relation to private hospitals, it has taken some time to bring that under HIQA's remit. How many private hospitals have been inspected?
Catherine Connolly (Galway West, Independent)
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HIQA is beginning that process, therefore.
Catherine Connolly (Galway West, Independent)
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Again, does Mr. Egan have any comment on what issues are arising?
Catherine Connolly (Galway West, Independent)
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Will they be the first reports?
Catherine Connolly (Galway West, Independent)
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That is good. Is Mr. Colfer the chief inspector now or a designate, to clarify his position?
Catherine Connolly (Galway West, Independent)
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That explains the word "designate" here. There is a deputy as well.
Catherine Connolly (Galway West, Independent)
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Under the legislation, Mr. Colfer has a particular role, has he not? It is set out under legislation.
Catherine Connolly (Galway West, Independent)
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Does Mr. Colfer have all the powers? I think he said something earlier on and I missed it - I was watching too many things. The role is to register, to inspect and also to bring prosecutions if necessary. Does Mr. Colfer have all of those powers? Have they been delegated to him now?
Catherine Connolly (Galway West, Independent)
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All of them?
Catherine Connolly (Galway West, Independent)
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Were they all delegated at the same time by the board?
Catherine Connolly (Galway West, Independent)
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Was that in November?
Catherine Connolly (Galway West, Independent)
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So all of the necessary powers have been delegated.
Catherine Connolly (Galway West, Independent)
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I thank Mr. Colfer.
To return to IT and legal services, an issue in respect of a possible conflict of interest was mentioned earlier and what would arise if the same firm were to be advising HIQA, the health executive or third parties. I was not reassured by the answer that was given in that regard. Has a particular company of solicitors advised HIQA at the same time it has advised a nursing home or the health executive?
Catherine Connolly (Galway West, Independent)
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I understand.
Catherine Connolly (Galway West, Independent)
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How many times has that happened?
Ms Angela Fitzgerald:
In my time, it happened in a specific instance relating to the ICT project. In respect of regulation, I am not aware that there was ever any conflict for Beauchamps. On the issue raised earlier, should Mason Hayes & Curran have a relationship with Emeis, we would put in place the necessary safeguards that would not allow it to take action. We have the safeguards to allow for that.
Catherine Connolly (Galway West, Independent)
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Ms Fitzgerald is satisfied-----
Catherine Connolly (Galway West, Independent)
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-----that the safeguards are in place to prevent a conflict of interest.
Catherine Connolly (Galway West, Independent)
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I am going to stop Ms Fitzgerald. I take her reassurance on that point for the moment. She mentioned the ICT project and gave a specific figure for it in the region of €8 million.
Catherine Connolly (Galway West, Independent)
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Does that cover everything?
Catherine Connolly (Galway West, Independent)
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Is there an additional maintenance cost ever year?
Catherine Connolly (Galway West, Independent)
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What will be the operating cost?
Catherine Connolly (Galway West, Independent)
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That cost is €1 million per year.
Catherine Connolly (Galway West, Independent)
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I am running out of time. My last question also relates to conflict of interest in the context of procurement and getting experts on board. Perhaps people who worked for different entities are now in those companies. How is that dealt with? Have the witnesses been reassured in that regard? Have any conflicts arisen?
Mr. Ultan Hynes:
No. I know, for example, that during the procurement process, a member of staff stepped down from the procurement panel because they had a relative who was involved with one of the companies that was bidding. That person excluded themselves. We have a conflict of interest policy internally whereby we would expect that of people.
John Brady (Wicklow, Sinn Fein)
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We have completed the first round of questioning. I am going to give Deputy Geoghegan a supplementary three minutes. That time is open to any other members who wish to take it. We will conclude at that point. I call Deputy Geoghegan.
James Geoghegan (Dublin Bay South, Fine Gael)
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I thank the witnesses for the replies they have given so far. Did I hear Ms Cliffe correctly? Did she say that six residents of Beneavin Manor required one-to-one care in November and that by the following April, 18 residents required one-to-one care but there was no commensurate increase in staffing?
Ms Susan Cliffe:
No. Apologies if I did make the situation clear. The staff to provide the one-to-one care were available. The point I was making was that the centre was struggling with changing governance and management, and onboarding and inducting new staff, but continued to increase the rate of admissions and the number of admissions with very high dependency levels. We are satisfied that anywhere one-to-one care was funded, it was in place. I spoke in the context of the overall picture of the stresses on that centre during that time.
James Geoghegan (Dublin Bay South, Fine Gael)
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The nursing home had a sufficient number of staff to deal with the increased number of residents who required one-to-one care. Is that Ms Cliffe's conclusion?
James Geoghegan (Dublin Bay South, Fine Gael)
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I am asking about now, after the fact and after the "RTÉ Investigates" programme. I am asking about the situation now, whatever about when the inspection took place. Is it Ms Cliffe's conclusion that the nursing home had at all times enough staff to deal with-----
James Geoghegan (Dublin Bay South, Fine Gael)
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What happened here? Was it reckless behaviour by one or two members of staff, as is being hinted at here? Was it bad management of this particular centre? What went so catastrophically wrong?
James Geoghegan (Dublin Bay South, Fine Gael)
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Has anyone-----
Ms Susan Cliffe:
There was a failure to allow for the stress that was on the centre. There was a failure to recognise that stress. There are three floors in that centre with three very different cultures on those floors. The residents with the greatest level of need and higher dependency were all accommodated on one floor. Even relatives who spoke to us said their relative was fine now that they were on the ground floor but that they were not happy when the relative was on the first floor. That was the issue. Those in management lost sight of that. They did not recognise the issue and did not listen to what the staff were telling them. We can see in records of meetings going back to earlier this year that the staff were raising this as an issue but it was not being addressed. That speaks to the immaturity of the management structure that was in place. If you change the person in charge and at the same time change the support structures behind that person, including the assistant director of nursing and clinical nurse manager, you lose organisational knowledge and centre-specific knowledge. You also lose that innate knowledge of the residents. When you do not have that at a management level, it does not transform down through the structures to the nursing staff and carers. That is what happened.
James Geoghegan (Dublin Bay South, Fine Gael)
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Are all those people still in place? Has anybody left? Have there been any resignations? Has any single person been held to account for what we witnessed in that programme?
James Geoghegan (Dublin Bay South, Fine Gael)
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What about the managers who are responsible for all of this? Ms Cliffe explained it was more an issue with the managers. I do not want to paraphrase what she said, but she made a clear determination in respect of management, culture and governance. Have any of the managers been held to account?
James Geoghegan (Dublin Bay South, Fine Gael)
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Is that not problematic? In 2019, "RTÉ Investigates" did another programme with public service value. It was another horrific programme about crèches and what was going on in a particular crèche. Within a number of months, the owner of one of those crèches had resigned. She fell on her sword. We have not seen any of that. We are left to harangue the witnesses to ensure they are inspecting nursing homes correctly when there has been no accountability for the appalling wrongdoing that took place. If those were children at a school, I wonder about the response. It frightens me that for whatever reason, we can accept that level of appalling care for elderly people in the most aged periods of their lives. Their dignity was taken from them completely. We have sort of accepted that no one is to be held to account.
Ms Susan Cliffe:
We are working through the processes available to us. We have concluded our inspections. On foot of those inspections, we will now be engaging with the registered provider in respect of the next actions. I am sure the Deputy understands that where there is escalating regulatory action, there is a limit to what I can say at this stage. We are required to update the Minister as we progress through these actions, and we will do that.
Catherine Connolly (Galway West, Independent)
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I will put my hands up and say I think the model is totally wrong. When we went down the road of private, for-profit nursing homes, it was a problem. We have set up structures to try to monitor that but it is the wrong model. I live in Galway. Ms Cliffe mentioned Aperee Living Galway. Aperee is also in Waterford and other places. When those places close down because they are no longer fit for purpose and no longer make a profit, the health executive must move in. Is that not right? That comes at a cost to the public, which is never factored into the cost at all.
People are left. I remember going back in Galway and Oughterard and there is a whole list of places that have closed or have been in trouble in the city and county. Suddenly, public health nurses and doctors have to go in and sort out the mess on public money that has never been factored in. I am just saying that for what it is worth. It is very difficult to watch it all of the time. Has the one in Galway run by Aperee closed?
Catherine Connolly (Galway West, Independent)
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Just one?
Catherine Connolly (Galway West, Independent)
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Are they all being run by the health executive?
Ms Susan Cliffe:
The HSE is operating those centres on the section 64 register, as if the registered-----
Catherine Connolly (Galway West, Independent)
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With the staff that was there with the private provider?
Catherine Connolly (Galway West, Independent)
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Is it operating with public staff there as well?
Catherine Connolly (Galway West, Independent)
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Are public staff members working there on occasion as well?
Catherine Connolly (Galway West, Independent)
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Did the homes in Galway that Ms Cliffe referred to have the same provider?
Ms Susan Cliffe:
They are all different registered provider companies but between one in Galway and the one in Roscommon, there were common directors. Between the one in Galway and the one in Kerry, there were common directors. On a positive note, we have also seen ones where the registration was cancelled and that has been registered with a new intended provider.
Catherine Connolly (Galway West, Independent)
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Again, my difficulty is I see public health nurses in Carraroe where there are 13 beds empty and not enough staff and then we have to put staff into the private system to keep it going. It is a madness really. I do not expect the witnesses to comment on it but it is an utter madness to me and certainly is not value for money, which is our role here and it is never put into the picture. My last question relates to the ICT project. Is that the same company that did the ICT for the Arts Council?
Catherine Connolly (Galway West, Independent)
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I understand all of that and I know the authority is reluctant-----
Catherine Connolly (Galway West, Independent)
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This is the dilemma HIQA has been placed in. It should not be in that dilemma in the first place because now we are making decisions on whether the health executive has enough staff or resources while they are depleting resources elsewhere.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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I thank Deputy Connolly. That concludes our engagement with the Health Information and Quality Authority. I thank Ms Fitzgerald and her officials for their attendance. I also thank the officials and representatives from the Department of Health and the HSE. Before we depart, is it agreed that the clerk will seek any follow-up information and will carry out the agreed actions arising from today's meeting? Agreed. The committee now stands adjourned until 9.30 a.m on Thursday, 18 September, when it will meet the Houses of the Oireachtas Commission.