Following a Ministerial request, HIQA prepared an internal report on three nursing homes that were subject to concerns in an RTÉ Investigates programme. The document again underlines the need for regulatory reform, reports Catherine Reilly
Minister of State for Mental Health and Older People Mary Butler requested HIQA to prepare a report on its regulation of three nursing homes following an RTÉ Investigates programme in July 2021 (‘Care in Covid’), which broadcast allegations of abuse and poor standards of care.
The HIQA report, dated 23 July 2021, provided details on regulatory oversight of Caracalla Community Hospital and Hospice, Co Clare; Carechoice Ballynoe, Co Cork; and Tara Winthrop Private Clinic, Swords, Co Dublin. The Authority released the report to the Medical Independent (MI), with significant redactions, under Freedom of Information law. The details of the report point to deficiencies in the current system of regulation, a matter on which HIQA itself has voiced considerable concern.
Cahercalla Community Hospital and Hospice had 33 findings of non-compliance with regulations since 2015, including 15 non-compliances identified in two inspections in the first quarter of 2021. A judgment of not compliant means the provider or person in charge has failed to comply with a regulation and that considerable action is required to reach compliance.
There were also 19 findings of ‘moderate’ non-compliances since 2013. The facility had been inspected 10 times since 2013, culminating in the most recent unannounced inspection on 16 March 2021. Many of the findings of non-compliance against key regulations, which underpin the care and welfare of residents, were repeated across the inspections since 2019 (eg, Primary Regulation 9: Residents’ Rights found to be breached in the May 2019, September 2020 and January 2021 inspections).
The centre had complied with mandatory notification requirements, the number of which was redacted (these are incidents which must be reported to the Chief Inspector). HIQA had also received 11 pieces of unsolicited information about Cahercalla in the previous two years, five in 2020 and six in 2021. The nature of this information was redacted, but prompted HIQA to seek “provider assurance reports”.
The systems in place to govern and manage Cahercalla had been “a cause for concern for a significant period of time and as a consequence the provider was required to take action to strengthen their governance and oversight of the centre”. However, the “repeated failure” of the provider to take the necessary action to strengthen governance “contributed to their inability to respond appropriately to the outbreak of Covid-19”.
“The care of residents was negatively affected by an institutional approach to staffing which favoured staff preferences over residents’ needs,” it stated. In February 2021, HIQA’s Chief Inspector issued a notice of a proposed decision to cancel the centre’s registration. On foot of escalating regulatory action, the centre entered an agreement with Mowlam Healthcare Ltd to oversee operations. An inspection in March 2021 found that the revised governance and management arrangements were associated with improved care of residents.
Carechoice Ballynoe had been inspected seven times since 2013, culminating in the most recent unannounced inspection on 27 April 2021. The findings from the two most recent inspections, in 2021, had not been concluded. In prior years, two non-compliances and three ‘moderate’ non-compliances were identified. The issues of concern identified following a September 2019 inspection – relating to premises and training and staff development – were followed up in subsequent inspections, noted the report.
The centre had complied with mandatory notification requirements, details of which were redacted. All notifications had been “reviewed and risk rated and where appropriate inspectors have engaged directly with the provider”.HIQA had received 24 pieces of unsolicited information since 2020; with 22 received in 2021 to the date of the report. The concerns raised were redacted from the report. However, it referred to unsolicited information of concern from distressed and bereaved relatives following the “large” number of Covid-19-related deaths.
In January 2021, some 45 residents at the home contracted Covid-19. The number of people who died was redacted. A section of the report covering the impact of Covid-19 was almost entirely blacked-out.
Tara Winthrop Private Clinic
Tara Winthrop Private Clinic had been inspected six times since 2014, culminating in the most recent unannounced inspection on 19 August 2020. It had two findings of non-compliance and five ‘moderate’ non-compliances. In the past two years, HIQA had received 17 pieces of unsolicited information, 12 in 2020 and five to date in 2021. Details of these concerns was redacted.
In regard to mandatory notifications, the number of which was redacted, the provider had a “good reporting culture”.HIQA outlined that it had engaged with the centre on foot of unsolicited information and mandatory notifications.Tara Winthrop Private Clinic was one of the first nursing homes in Ireland to experience a large outbreak of Covid-19.During the outbreak the provider required “significant levels” of assistance from the HSE to access appropriate quantities of personal protective equipment, Covid-19 testing, and assistance to manage and staff the centre.
Details on fatalities arising from the outbreak were redacted. “At times during the outbreak the provider did not have a system, arrangements or the resources in place to maintain the required level of contact with the relatives of residents living in the centre – understandably this led to anxiety among families and relatives.” During the most recent inspection in August 2020, it was found that the centre “was beginning to return to normal albeit still very much affected by the devastating impact of the outbreak”.
In correspondence to HIQA after receipt of the report, Minister Butler noted its level of regulatory concern in relation to two of the nursing homes. She wrote that she “would appreciate if you could ensure that an appropriate regulatory focus on these centres is maintained”.
A HIQA spokesperson told MI it “continues to engage with and monitor those centres in line with its regulatory powers”.
Asked how many older persons’ centres were at high risk of non-compliance with regulations, HIQA’s spokesperson said the regulatory status of any given centre “is subject to constant review where any associated regulatory risk may increase or decrease in accordance with current available information”. HIQA was continuing to engage with the Department of Health on “the need for regulatory reform”, confirmed the spokesperson.
In February 2021, HIQA published a document which set out the urgent requirement for reform of the regulatory framework for social care services.
The Authority has highlighted several issues of concern, including that the process to cancel the registration of a provider, or attach additional conditions of registration, was often slow and the legal threshold to cancel registration was very high. According to HIQA’s February 2021 report, all the regulations and notifiable events pertaining to social care services should be reviewed as a matter of urgency.
“There is clear evidence that regulations need to be regularly reviewed to determine their effectiveness,” outlined The Need for Regulatory Reform.
“Although Covid-19 has exposed further weaknesses in the regulations given the significant impact it has had on nursing homes in Ireland, we cannot lose sight of the fact that these weaknesses have been present for a significant period of time. The pandemic has only served to highlight the critical importance of the need for regulatory reform.
“In this regard, HIQA has been consistent in advocating for a review of the regulations and this is also something which was deemed good practice. Additionally, this should also include a review of the provisions of the Heath Act 2007, that give enforcement powers to the Chief Inspector…. There is a need to ensure that while the decisions of the Chief Inspector are open to challenge, this does not place residents at unnecessary risk. At the present time, lengthy legal challenges can dilute the enforcement powers of the Chief Inspector.”
Department of Health
MI asked the Department of Health if it received regular updates on designated centres with high rates of non-compliances against HIQA regulatory standards, and if so, how it used this information. The Department’s spokesperson commented: “Shortly in advance of publication, HIQA provides notice to the Department of reports that are due to be published. These reports are provided for the Department’s information.
“The Department reviews these reports to identify any trends in non-compliance and provides a summary of the reports to Minister Butler for information. Where relevant, trends identified may be highlighted as part of the Department or Ministers’ engagements with HIQA and other relevant bodies, such as the HSE or Nursing Homes Ireland.”
In regard to HIQA’s call for regulatory reform, the spokesperson said Minster for Health Stephen Donnelly and Minister Butler had approved “a two-phased approach” to examining the legislation, with a view to proposing “enhancements” to the primary and secondary legislation governing nursing homes.
“Phase one will bring forward interim enhancements to the primary legislative framework to enhance governance and oversight of nursing homes. The proposals will, amongst other things: Provide new and enhanced enforcement powers for the Chief Inspector; reduce timelines and processes for regulatory actions; and introduce a new reporting system for the reporting and publication of key operational data to support national planning in an integrated way and improve the information available.
“The Government is committed to the reform of the regulatory framework governing nursing homes and approved the inclusion of a Health (Amendment) Bill on its legislative agenda. It is expected that, subject to Government approval, a draft General Scheme will be published in early 2022, with a Bill being developed and published thereafter.”
In addition, secondary legislation will be drafted to “enhance” the current regulations. A bilateral project group comprising representatives from the Department and HIQA is supporting the legislative process, said the spokesperson.
A wider review of the regulatory framework (phase two) will commence in the second half of 2022, taking into account a programme of longer-term strategic reform considerations arising from “pandemic learning”, among other aspects.