Introduction

Chairperson, Members,

On behalf of the Health Information and Quality Authority, I would like to thank the Oireachtas Joint Committee on Health and Children for giving me the opportunity to discuss our annual overview report of our 2013 regulatory programme of designated centres for older people.  I am joined by Marty Whelan, our Head of Communications and Stakeholder Engagement. We welcome this opportunity to appear again before the Joint Committee and engage with Members.

The Authority, as part of the remit given to it by An Act passed by these Houses, is responsible for setting quality and safety standards in health and social care services in Ireland, with the exception of mental health services. Since 2009, HIQA has been responsible for the registration and inspection of designated residential care services for older and dependent people. All designated centres for older people are required to be registered by us.

The purpose of this regulation is to safeguard vulnerable people who are receiving residential care services. Regulation provides assurance to the public that people living in a designated centre are receiving a service that meets national quality standards and regulations. This process also seeks to ensure that the health, wellbeing and quality of life of people in residential care are promoted and protected.

Regulation also has an important role in driving continuous improvement so that residents have better, safer lives. We endeavour to always publicly share information about the nature and outcomes of our work.

Today, we are here to discuss our annual overview report of our 2013 regulatory programme in designated centres for older people. This is the first overview report that we have produced, and we are eager to listen to your views about how these services are provided across the country and the communities that you represent.

The report describes a national set of residential services that are vastly better, and safer, than the services that were available when HIQA was first established in 2007, following public concern about Leas Cross nursing home in north Co Dublin.  Providers of residential services are to be commended for the significant improvements that have been achieved since then.

Summary of the annual overview report

The report provides an overview of the regulation by HIQA of long-term residential care for older people in Ireland in 2013. As of 31 December 2013, there were 566 designated residential centres for older people in the country. The majority of these (75%) were privately-operated nursing homes.

The remainder were centres operated by the Health Service Executive (HSE) (20%) and centres operated by bodies in receipt of HSE funding (5%).

The report, in essence, captures the findings of the 814 inspections of 565 centres that HIQA carried out last year. Seventy-eight percent of those inspections were unannounced; 22% were announced. There is a value in unannounced inspections: inspectors conducting these inspections see the service ‘as it is’.

There is also a place for announced inspections.  They are an opportunity for providers to show us their service as they would like it to be seen, and they also enable access to information and documentation that may not be readily available if an inspection were unannounced.

Good practice in the care of older people was observed in the majority of the centres that we inspected and our inspectors noted improvements in most centres following inspection. This is to be expected.

The report also makes clear that there are issues where further improvement is required. HIQA inspection reports are standardised and contain action plans, which are the main tool we use to drive improvement at local level. We inspect and report under a maximum of 18 outcomes, each of which is a statement of what is expected in a service when the relevant standards and regulations are met.

Outcomes are grouped under five themes:

• Theme 1: Governance, leadership and management
• Theme 2: Safe care and support
• Theme 3: Effective care and support
• Theme 4: Person-centred care and support
• Theme 5: Workforce.

Of the 8,697 actions that were required by HIQA for compliance across the country’s suite of residential care centres,

• 13% (1,119) of actions were aimed at achieving improvement under the theme of governance, leadership and management. The issues that were included in these areas for improvement related  to  statement of purpose, the contract for the provision of services,  the suitability of the person in charge and the records and documentation to be kept at a designated centre.
• 31% (2,726) of actions were related to required improvements under the theme of safe care and support. Issues being dealt with under this theme included safeguarding vulnerable people, health and safety  issues, risk management practices, medication management and the statutory notification of incidents as required under regulations.
• 34% (2,943) of actions were required in effecting improvements in the area of effective care and support. The actions prescribed under this theme dealt with issues of quality and safety of care; how the health and social care needs of residents were being assessed and provided; and the safety and suitability of premises.
• A central issue in the provision of long term care to older persons is the concept of person centredness, in other words ensuring that the care being provided meets the individual needs of every resident. In this regard 11% (959) of actions related to person centred care and support.  These actions dealt with the requirement for improvements in dealing with and enabling older people to make informed decisions and acknowledging their ability to participate in the day to day life of the centre. Issues dealt with under this theme include the ability to make complaints and suggestions for improvements to the service.
• Of all of the actions cited in our reports, 11% (950) related to workforce issues. Issues identified under the workforce theme included the way in which the provider was dealing with staff recruitment practices and was ensuring that staff in the centre had the required qualities, skills and experiences.

Pilot programme - thematic

Shortly after taking up my post as Chief Inspector I was keen to ensure that, as well as ensuring compliance, our programme of regulation would place emphasis on the improvement of services. This overview report also describes the full findings of a pilot programme of thematic inspections which we introduced late in 2013 and which was aimed at improving particular aspects of service provision on a year to year basis.

The first themes that we introduced were aimed at improving some of the most fundamental elements of residential care.  They included a mechanism for improving end-of-life care and food and nutrition in nursing homes. The pilot programme consisted of conducting the thematic inspections in a selected representative group of 52 nursing homes. The part of the report describes both areas of good practice that the pilot inspections identified, and it describes areas where services needed to improve.

Food and nutrition

When we looked at the area of food and nutrition, which is a basic and fundamental standard for vulnerable people, over half of the centres (30 of the 52) were fully compliant with standards relating to food and nutrition care.

Examples of good practice were evident in all of the centres that we visited. Residents in all 52 centres had access to fresh drinking water. In 48 of the 52 centres, inspectors found that residents were being supported to eat and drink, with person centred approaches used in their care.  Our inspectors found that meals were served at times that suited the expressed needs of residents in 42 of the 52 centres that were inspected as part of the pilot programme.

End-of-life care

Given the nature of the age and illness profile of residents, all centres should ensure that they have the ability to deliver appropriate and dignified care to people at the end of their lives. Typically, staff of residential centres have understanding of the life limiting conditions that many residents may have.

Overall, we found that residents received appropriate and safe end-of-life care. We found that 23 of the 52 centres inspected during the pilot programme were compliant with the relevant standards and regulations.

In 51 of the 52 centres, residents, or family if appropriate, were given timely information in order to make informed choices about future health events.

In 33 of the centres, residents were given opportunities to discuss their end-of-life wishes, which is a comfort to them and their families.

Feedback from service providers and the inspection findings both demonstrated the positive impact of the new thematic approach. 

As a result of this pilot we are applying the same methods to all remaining designated centres in 2014, with a view to identifying further inspection themes for 2015 based on our knowledge of the services and any risks that we identify through our inspection activity.

Enabling through regulating

The report outlines our evolving approaches to the regulation of services. We see regulation as a mechanism for improvement and we are always conscious of the burden that regulation can place on providers. We also take very seriously our responsibility as a State agency to provide value for taxpayers’ money through our programmes of registration and inspection.

As a regulator, we therefore aim to reduce the overall burden that is placed on service providers wherever possible while maintaining an emphasis on our objectives for safety and quality improvement.

Regulation in the social care sector is intended to help service providers to improve the quality of care for residents, to protect their basic rights, and to stop poor or dangerous practice.We make sure that we are targeting our resources at areas of greatest need and highest risk.  A major part of our programme is the registration of services with a requirement to renew the registration every three years. 

Renewing providers’ registration is a public confirmation that they have maintained their fitness to carry on the business of running a nursing home. During 2013, we processed 82 registration-related applications. Fifty two of these applications were registration renewals, as each registration expires at the end of the three-year registration cycle, which started in 2009.

We alsorecognisethe need to ensure that our registration process enables the introduction of new beds into the system. To this end, we have a priority system for the registration of new buildings. Providers who plan to apply to register a new designated centre are referred to our Registration Office, which makes them aware of obligations and requirements in respect of the service they intend to provide. Timelines are shortened to facilitate the swift introduction of quality beds into the system. This report details how we granted 21 new registrations in 2013.

In certain situations a provider may apply to change or remove a condition of registration. Applications to reduce the maximum number of residents accommodated in a centre were granted to two centres and applications to increase the maximum number of residents accommodated were granted to seven centres. These decisions resulted in an increase of 65 beds in total in 2013.

The Authority’s approach to regulation ensures that those providers who are persistently non-compliant with the standards and regulations, and who place people at risk of harm, are identified quickly and face proportionate and meaningful enforcement action.

Formal enforcement procedures were used in respect of one centre last year, when a decision to cancel registration of the centre was issued in January 2013. In this case the provider consented to the decision of the Authority. 

It should be noted that this is one of 565 designated centres which we inspected in the year – less than 0.2% of the total national complement.

We remain unequivocal in the appropriate application of our enforcement powers were we believe that vulnerable people are at risk.

This report also describes the findings of a questionnaire that we conducted across inspected centres in 2013. Provider feedback is generally positive about the way we conduct our work, with 91% of providers noting that the inspection process led to service improvement and was helpful in identifying gaps in services.

I would also like to note the quality of self-assessments that were returned to HIQA in 2013 by providers.  Self assessment is a valuable part of regulation methodology and helps to develop self awareness of the need for improvement.

Our experience in 2013 was that there was a substantial correlation between the findings on inspection and providers’ own self-assessed judgments, with the vast majority of providers making realistic assessments of their service.

Legislation passed by the Houses of the Oireachtas requires nursing home providers to notify us, without delay, of specified incidents involving residents which occur in nursing homes. The purpose of these notifications is to alert us to potential risks to the health, safety or wellbeing of residents. The range includes possible incidents and risks, as well as events that occur.

In 2013 we received 5,362 of these notifications from nursing home providers. In addition, we also received 355 items of unsolicited information – most of which comes from concerned residents, relatives of residents and in some instances staff working within centres. These reported concerns related to 213 nursing homes in 2013.

All of this information was risk assessed by our inspectors who consider any risks arising from the information and in turn engage the most appropriate next steps based on the concerns that we might have about the centre and the information received. It should be noted that this figure relates to both confirmed and unconfirmed or suspected abuse.

As mentioned, 31% (2,726) of actions required to comply with the regulations were related to required improvements under the theme of safe care and support.

The safety and interests of vulnerable older people are at the heart of our regulatory and inspection process and appropriate action needs to be taken to investigate and deal with suspected or confirmed abuse.

I believe their well-being and interests would also be well-served by enhanced legislation that enshrines in law the safeguarding of vulnerable adults in receipt of care services. It is important for our work that a culture exists where staff and providers have the confidence to report such matters to the regulator.  

HIQA would welcome an opportunity to work with Members of the Joint Oireachtas Committee on Health and Children towards the development of more effective national policy and up-to-date legislation that would address this issue.

Conclusion

The overall assessment of the Authority is that, in the four and a half years since the introduction of regulation of nursing homes in Ireland, there has been significant improvement in the quality of care that is provided to residents. The Authority is using the findings of this overview report and the outcomes of our inspection work to inform our assessment of risk within the sector and plan for our ongoing and future regulatory activity, such as the selection of areas of care for our ongoing programme of thematic inspections.

Findings on inspections, such as those presented in this report, also inform the guidance that we produce which assist providers to improve the quality of their services.

All of this activity, along with a commitment to continued improvements in our regulatory approaches, demonstrates HIQA’s commitment to ensure that the rights and experiences of older persons in residential care are protected and improved.

We look forward to continuing this important work, and to continuing to work with Members of the Joint Oireachtas Committee on Health and Children, in the interests of improving the quality and safety of care that is provided to older people who live in residential care in this country.

I thank the Members of the Joint Oireachtas Committee on Health and Children for inviting us here today to discuss this report. I look forward to hearing your questions and to learning where you think we can further improve the process of promoting the quality of life of our older generations living in nursing homes. 

Thank you.

Ends