Joint Committee on Disability Matters debate -
Thursday, 31 Mar 2022

Independent and Adequate Standard of Living and Social Protection - Safeguarding: Discussion

Chairman

The purpose of the meeting is to discuss the standard of living and social protection - safeguarding. On behalf of the committee, I extend a warm welcome to Ms Carol Grogan, chief inspector of social services, HIQA; Mr. Finbarr Colfer, deputy chief inspector of social services with responsibility for disability services; Professor Amanda Phelan of Sage Advocacy; Professor Brendan Kelly, professor of psychiatry at Trinity College Dublin; Mr. Vivian Geiran, chair of the Irish Association of Social Workers, Ms Celine O'Connor, and Ms Sinéad McGarry. I am aware that a wide range of issues will be the subject of the meeting. If necessary, further and more detailed information on certain issues raised can be sent to the committee for circulation to members.

I remind members that they can only participate in the meeting if they are physically present within the precincts on Leinster House. In this regard, I ask members joining remotely to confirm they are on the grounds of Leinster House prior to contributing. For members watching online, some of our witnesses are accessing the meeting remotely. Due to unprecedented circumstances, I ask all present to bear with me in case of any technical issues arising.

Witnesses are directed that only evidence connected to the subject matter of the proceedings should be given and to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.

I advise witnesses giving evidence from a location outside the parliamentary precincts to note that the constitutional protection afforded to witnesses before the committee may not extend to them. No clear guidance can be given.

Members are reminded of the long-standing parliamentary practice to the effect they should not comment on, criticise or make charges against a person or entity outside the House in such a way as to make him or her identifiable.

We look forward to our discussion today. I call Ms Grogan to give her opening statement.

Ms Carol Grogan

I thank the committee for this opportunity to contribute to its deliberations on the implementation of the United Nations Convention on the Rights of People with Disabilities, UNCRPD, particularly regarding safeguarding.

The Health Act 2007 established HIQA as an independent authority to drive improvements in Ireland’s health and social care services. We have a broad and growing remit. However, our core focus has always stayed the same: to drive improvements in the quality and safety of care provided to the public. The Act sets out the services, also known as designated centres, that are subject to regulation, which include nursing homes, residential services for people with disabilities and children’s special care units. HIQA’s role as the independent regulator is to ensure people living in designated centres are provided with a safe living environment and have a good quality of life.

Social care is evolving, and based on our 15 years’ experience as a regulator, we believe changes to the legislative framework are required to better support people who may be vulnerable. We have previously highlighted the need to reform the Health Act 2007 and associated regulations. For example, the Act contains a narrow definition of a designated centre that limits the regulatory protection for people with a disability to the confines of the centre’s footprint. We need a broader definition that takes a more holistic view of the supports people with disabilities require, providing greater protection and enhancing their quality of life.

The 2013 regulations made under the Act, which set out the minimum legal requirements for the providers of disability services, must also be reviewed to better reflect new and innovative approaches to meet the needs of people with disabilities. HIQA has made submissions to the Department of Health regarding its work on deprivation of liberty arrangements, which are another key component for the implementation of the UNCRPD, and which should be reflected in the 2013 regulations. Furthermore, we are informed the relevant sections of the Assisted Decision Making (Capacity) Act 2015, under which the decision support service was established, are due to be commenced in June this year.

HIQA has always continued to campaign for the introduction of strong and effective adult safeguarding legislation to ensure the most vulnerable people in our communities are protected. Everyone has the right to be safe and to live a life free from harm. Placing adult safeguarding on a statutory footing acknowledges the State’s commitment to adults at risk and the duty of civil society to adopt a zero tolerance approach to adult abuse. In the absence of safeguarding legislation, HIQA is committed to using the current regulatory framework to minimise risk for people living in designated centres. However, ensuring people with disabilities are free from exploitation, violence and abuse can only be achieved when all parties understand and exercise their responsibilities.

The primary responsibility for protecting people with disabilities in designated centres rests with providers, who must ensure their staff can recognise and report any suspicions of abuse and that residents are empowered to do the same. When suspicions are reported, it is essential that providers have measures in place to prioritise the protections of residents and to investigate these allegations. HIQA’s role is to examine the safeguarding measures in place to ensure they are as robust as possible and, where there are inadequate arrangements, to require the provider to take action to improve them.

Another aspect of safeguarding relates to the accommodation of residents who do not wish to live together or who are living in large groups, sometimes in overcrowded environments. This has led residents in some centres to express their distress and unhappiness behaviourally. It has also, on occasion, led to residents hurting and harming themselves or their fellow residents, sometimes on an ongoing basis, and to residents living in fear of their peers. This is not acceptable and has been a major challenge for the disability sector.

Sadly, we not only witness examples of residents abusing other residents but also of sustained organisational abuse where the provider has failed adequately to protect residents and meet their needs. While this situation can occur in any setting, there is a higher risk of organisational abuse in congregated settings than in community-based houses. Residents who live in congregated or campus-based settings often experience inequalities in the quality and safety of their services, control over their own lives and the ability to exercise their rights and choices independently. While there has been a continued effort within the disability sector to reduce the number of large congregated settings, many residents continue to be accommodated in these living arrangements. Some 2,419 people currently live in congregated settings, and while this is a reduction of 422 people on 2020, further work is required to ensure the reliance on congregated settings is reduced.

Finally, I assure the committee of HIQA’s commitment to promote and protect the rights of people with a disability to live in a safe environment. I will continue to engage with the Department of Health and the Department of Children, Equality, Disability, Integration and Youth to support the development of safeguarding legislation and to update the Health Act 2007 and associated regulations to ensure they continue to provide protection for people with disabilities and reflect changes in the legal landscape, including the implementation of the UNCRPD.

I thank the members for their attention this morning, and we look forward to answering any questions.

Professor Amanda Phelan

I represent Sage Advocacy, but I am also the programme director of Ireland’s only dedicated, multidisciplinary and multisectoral adult safeguarding programme, which is hosted in the school of nursing and midwifery in Trinity College Dublin. Safeguarding may be defined as, “Putting measures in place to reduce the risk of harm, promote and protect people’s human rights and their health and well-being, and empowering people to protect themselves.”

Sage Advocacy is an independent organisation, operating across Ireland to provide information, support and advocacy for older people and adults who may be at risk, be they in the community, residing in long-term care or other settings. We seek to promote social inclusion, equality and social justice in all aspects of our work. We engage with policymakers, civil society partners and media to raise awareness of systemic issues in the public interest as well as conducting research in these areas. The service provides information and support and individual case-based representative advocacy. Annually, we provide advocacy support to almost 1,500 people as well as information and support to 2,000 people.

The right of a person to have his or her voice heard and to participate in making decisions that affect him or her is a fundamental principle in a democratic society. It is a principle that can be simply stated as: nothing about you without you. For people at risk, having independent advocacy is crucial. This is the process of supporting people to make and communicate decisions and to participate in decisions about their lives, such as access to finances, accessing services, planning ahead, support when there is desire to move residence, issues relating to abuse and-or neglect, and barriers to decision-making. Consequently, our work maps to the objectives of the UN Convention on the Rights of Persons with Disability, which Ireland ratified in 2018. The work we undertake provides an important resource for individuals at risk of abuse, yet statutory advocacy support on an independent basis, despite being available in other jurisdictions, is not within Ireland’s safeguarding responses.

It is a fact of life that some adults will find themselves at risk. While thousands of adults receive care at home, with family members acting as a principal carer, more still receive care in a variety of residential care settings.

It must be acknowledged that though many caregivers discharge their responsibilities conscientiously and to the best of their abilities, this does not guarantee that the rights, will and preference of the individual are front and centre.

The pandemic is unprecedented in living memory and Sage Advocacy has observed that it has exacerbated existing safeguarding concerns while enabling new ones. This strengthens the argument to take action and we refer, based on a number of years of experience in this area, to two imperative areas. These are safeguarding legislation and attending to the deprivation of liberty. We strongly support a legislative framework to protect adults at risk from abuse. What we know from other countries that nobody is getting it completely right but the presence of legislation, such as the Care Act 2014 in the UK or Nova Scotia's Protection for Persons in Care Act 2004, as amended in 2017, are useful instruments in prevention, intervention and ongoing case management.

Abuse and neglect of vulnerable adults is significantly under-reported in Ireland due to a lack of public awareness of what constitutes abuse, cultural issues and a lack of comprehensive policy and legal safeguards to prevent the abuse of adults at risk and to protect them from abuse. Current safeguarding policies are limited, resulting in inconsistent approaches across sectors and organisations and gaps in responses from State agencies and other parties to adequately safeguard the person at risk of abuse. In the absence of primary safeguarding legislation, guidance and information is required to ensure personal sensitive information and data can be shared securely for the purposes of safeguarding a person at risk. This contrasts with the suite of legislation available for safeguarding children.

In addition, we have an obligation to address explicitly liberty protection. Everyone has the right to liberty. This means persons cannot have their liberty taken away unless it is in accordance with law. This might seem to be something that is taken for granted but our experience demonstrates blurring of lines and supports the impetus for overt robust safeguarding responses in this regard.

We wish to make a number of key points. A deprivation of liberty is defined as an oppressive restriction by a third party. People are de facto detained if they are in residential care and the building is secured, requiring residents to ask permission to leave the premises. Where a person’s liberty is being restricted, they should have access to an independent advocate to ensure their will and preference is heard. Any process to safeguard a person's liberty should apply to all people equally. Individuals who are residing in a care setting may not have made the choice to do so but are there due to a lack of a statutory right to homecare, a lack of flexible models of care to meet individual's needs, and lack of adequate homecare service provision. In supporting the case for exercise of the right to liberty by a person at risk, care should be taken to ensure that the situation of persons whose rights might be disproportionately harmed by such an exercise are fully considered and discussed with all relevant parties.

Having structures of legislation and policy are important but oversight of the process translates to its efficacy and quality, especially for the adult at risk. Observing the work of safeguarding in the UK, Sir James Munby, former president of the Court of Protection, commented on the importance of actively supporting the will, preference, values and beliefs of individuals. When judging a case a number of years ago he asked, "What good is it making someone safer if it merely makes them miserable?" Working through a human rights lens by authentically using the principles of safeguarding developed by HIQA, the Mental Health Commission and other agencies will underpin supporting each individual's will, preference, value and beliefs, regardless of physical or cognitive ability, biased influence from others or domicile.

Professor Brendan Kelly

I thank the committee for this opportunity. My evidence reflects my views as an academic clinician and not necessarily the views of my employers. I am professor of psychiatry at Trinity College Dublin and consultant psychiatrist in the public mental health service. My chief interest is social justice and safeguarding mental health, freedom, autonomy, and social well-being as reflected in Articles 16 and 19 of the UN Convention on the Rights of Persons with Disabilities. I submit that Ireland is failing to safeguard these rights for people with severe mental illness such as schizophrenia and bipolar disorder. These failings, although not deliberate, are widespread, systematic, predictable and preventable. They constitute a form of structural violence that amplifies disability, stigma and social exclusion. I will outline three challenges and solutions. These are treating mental illness, safeguarding liberty and safeguarding social and medical well-being in the community.

Mental illness is treatable, mostly by primary care and community teams. Ireland devotes 5.1% of the health budget to mental health. Sláintecare recommends 10%. The World Health Organization suggests 12% and in the UK, it is almost 13%. Ireland has the third lowest number of psychiatry inpatient beds per 100,000 population in the EU. Recruitment problems are endemic. Consultant posts commonly attract zero applicants. These deficits severely impact rights, especially full inclusion and participation. That is the first challenge, namely, treating mental illness. What are the solutions? Mental health services require 10% of the health budget. The division between mental health and addiction services needs to be resolved. Addressing service deficits will help recruitment.

With regard to safeguarding liberty, in the 1950s Ireland had more than 20,000 people in psychiatric hospitals, the highest rate in the world. By 2020, we had 1,826 adult psychiatry inpatients and 50 inpatients aged under 18. This is a dramatic reduction. Our involuntary admission rate is half that of England. This is very positive but low admissions come at a price, which is people with mental illness in prison, homeless or at home and too ill to accept treatment but not ill enough for treatment without consent. My colleague Professor Gautam Gulati led reviews of mental illness in Irish prisoners and found elevated rates of mental illness, substance misuse, homelessness and intellectual disability. Prison is toxic for people with mental illness. That is second challenge, namely, disproportionate deprivation of liberty. What are the solutions? Proposals before the Oireachtas to update the Mental Health Act 2001 should be revised and progressed. The Assisted Decision-Making (Capacity) Act 2015 is due to commence in full. The HSE national office for human rights and equality policy is doing superb work to ensure it helps safeguard autonomy. In 2021, the Inspector of Mental Health Services noted we have an excellent but under-resourced and overworked court diversion service. He added that we "still have people who are severely mentally ill locked in isolation units and other areas of prisons awaiting mental health care in appropriate settings". We need prison in-reach and court liaison services in all areas.

With regard to safeguarding social and medical well-being, Article 19 of the UNCRPD articulates the equal right of all persons with disabilities to live in the community. A study at one psychiatry unit found that 38% of all inpatients and 98% of delayed discharge patients had unmet accommodation needs. Data from other countries confirm that men and women with schizophrenia die 15 years and 12 years earlier, respectively, than the general population. The chief causes are cardiovascular disease and cancer, both amenable to risk reduction, screening and early treatment. Antipsychotic medication is associated with reduced risk of early death in schizophrenia. In 2019 the Inspector of Mental Health Services pointed out that "Patients with serious mental illness experience reduced access to health care". US data confirm that people with a recent diagnosis of depression or schizophrenia are seven times more likely to get Covid than people without mental illness, are more likely to require hospital admission and are more likely die of the infection. This is the third challenge, namely, safeguarding social and medical well-being in the community. What are the solutions? They include systematic co-working between mental health services, primary care, and social care. Individual health identifier numbers would help connect services. Psychiatric treatments work well but they are no substitute for a roof over your head and a community that values you. Safeguarding matters, including the work of Safeguarding Ireland. We need legislation that balances protection with autonomy.

I am very happy to address legislators today. Rudolf Virchow, the 19th century German pathologist and politician, said "medicine is a social science, and politics is nothing but medicine on a large scale". Closer to home, in 1977 Charles Haughey concluded that healthcare is about good government and cannot, in the words of the cliché, be taken out of politics. I thank committee members for their attention.

Mr. Vivian Geiran

I thank the joint committee for the invitation to the Irish Association of Social Workers, IASW, to present to it.

My name is Vivian Geiran and I am the chairperson of the association. I am joined by Ms Celine O'Connor, who is a social worker with experience of working in and managing safeguarding services, and we are joined by video link by Ms Sinéad McGarry, a social worker experienced in safeguarding practice. I acknowledge the specific input of Dr. Sarah Donnelly from the UCD school of social policy, social work and social justice, who is the Irish Association of Social Workers' academic safeguarding adviser and who worked with us on today's submission but cannot be with us this morning.

The Irish Association of Social Workers, IASW, was founded in 1971. There are almost 5,000 registered social workers in Ireland and the IASW is the national representative body of the profession. We have members working in various service areas, including children and families, mental health, probation, primary care, disability, hospitals, and with migrants among others. Social work is the named lead profession for child protection and adult safeguarding in Ireland tasked with the primary responsibility for policies that support people at risk of abuse and neglect, including children and adults with disabilities. Social workers work with people with disabilities in their homes and communities, disability services, nursing homes, homeless services, direct provision centres, prisons and other settings across Ireland. We work with many adults with disabilities who have never been formally assessed or supported by a disability service. In this context, adult safeguarding failures in any setting may impact upon people with disabilities.

Focusing on safeguarding in congregated settings and the requirements of Articles 16 and 19 of the United Nations Convention on the Rights of Persons with Disabilities, UNCRPD, social work champions a human rights-based approach to safeguarding recognising that safeguarding is equally about promoting the rights, autonomy and well-being of a person as it is about protecting people from abuse and neglect. It is in scenarios and cultures where rights are overlooked, well-being is ignored and a person lacks choice and autonomy in his or her own life that abuse is most likely to occur. The values of the social work profession, therefore, very much align with the values of the UNCRPD.

Adults with disabilities in congregated settings comprise one of the least protected groups and, compared with children, have far less legal protection in their own home. It is a stark fact that legal protection from abuse, neglect and exploitation decreases for every person, including a person with disability, when he or she turns 18 years of age in Ireland. Our separate written submission document elaborates our position, which is that Ireland is not meeting the requirements set out in Articles 16 and 19 of the UNCRPD. Our move toward de-institutionalisation, where people can live according to their will and preferences, is unacceptably slow and safeguarding within existing services is far too weak.

We have limited data on safeguarding in Ireland. While we know 51,000 concerns about the abuse and neglect of adults have been reported to the safeguarding and protection social work teams since 2015, it is unknown how many of these relate to people with disabilities. The IASW has established that apparently 143 sexual assaults against residents in care settings were reported to HIQA from 2015 to 2022. Eighty-seven of these reported sexual assaults were in nursing homes, where many people with disabilities reside, and 56 were in disability centres. We have also established that An Garda Síochána cannot provide figures about the rates of abuse and neglect of residents in nursing homes or disability centres reported to it.

Concerns about the response to the abuse of adults, including adults with disabilities, regularly enter the public domain. The media reported concerns in Leas Cross in 2006, in Áras Attracta in 2014 and in the Grace and Brandon cases, the events of which spanned decades. Media reports also highlighted delays in reporting alleged sexual abuse of unconscious patients in Naas hospital, failures in the management of safeguarding concerns in HSE community healthcare organisation, CHO, area 7, and reported a pattern of safeguarding failures in HSE CHO area 1. Despite a recurring national outcry in the aftermath of each revelation, little seems to have changed for the better, and events of recent months alone show how little Ireland is adhering to the principles set out in Articles 16 and 19 of the UNCRPD.

In comparison with child protection and despite being lead profession in adult safeguarding, social work faces very real challenges in influencing the governance and management of adult safeguarding and practice through our human rights lens and approach. We encounter the same medicalised model at strategic and practice level as that described by people with disabilities, which does not adequately address their needs. Our separate submission document details our views on the key challenges and solutions. These include the urgent enactment of safeguarding legislation based on appropriate principles, including the UNCRPD; the establishment of an independent statutory adult safeguarding authority; appropriate legal mechanisms to support social workers to do their work; mandatory reporting of abuse and neglect of adults; and adequate data collection and research.

In respect of the gap involving new adult safeguarding legislation, we also call in our more detailed submission for a number of interim measures that should be taken as a matter of urgency. The rights of people with disabilities to live lives where their will and preferences are respected, where their well-being is supported and where they are protected from abuse and neglect must be vindicated and upheld. This is not happening, in the view of the IASW, and it will take a collective effort across all relevant bodies and wider society to change this.

I again thank the committee again for its time and attention. We welcome the opportunity to answer any questions.

Deputy Pauline Tully

I have a number of questions and will start with HIQA. Will the witnesses from HIQA define the authority's power specifically? It can carry out unannounced visits. I presume it has organised visits as well to different services. Does HIQA cover all services, public and private? Does it only act on reports? When it receives reports and investigates them, does it document all reports? Some of these reports are quite serious while others could be addressed within the service itself, something I presume HIQA would speak to the management about. What if the matter is more serious, for example, financial abuse? One case involved staff claiming expenses from the residents' accounts for meals, takeaways and so on. Was that rectified? Were the residents reimbursed? Was it reported to An Garda Síochána? If the report relates to physical or sexual abuse, is it reported to An Garda Síochána or social protection teams?

Professor Phelan from Sage Advocacy mentioned that work on awareness of abuse is needed, meaning what abuse is. I presume people might not know how to report it so what does Professor Phelan propose we do about that? What is the best way to get that message out about what abuse there is?

Professor Kelly spoke about mental health. Obviously, the percentage we spend on mental health needs to increase. He said it is very difficult to recruit consultant posts within inpatient psychiatry. Will he explain why this is the case? He also spoke about health and addiction services. I thought the issue of dual diagnosis was being addressed because, usually, if there is an addiction problem, mental illness will be found and vice versa, where there is mental illness, addiction is often found, so the two need to be addressed together. Professor Kelly also spoke about the lack of joined-up thinking between the different aspects of the health service and individual health identifier numbers. Would personal public service, PPS, numbers not be sufficient to ensure there is joined-up thinking? In this world of IT, that should not be an issue.

If the safeguarding protection teams receive a complaint, for example, from a member of staff in a service, can they act on this? I have been told they cannot. Is this true or is there something they can do? All the speakers mentioned strengthening legislation around safeguarding. What difference would this make to the services they provide and the work they do?

Ms Carol Grogan

The Health Act sets out my powers, which are to register and inspect designated centres. Centres for people with a disability constitute one type of designated centre. I must assess compliance with the standards and regulations. It does extend to public, private and voluntary services so there is no distinction. The Act is very clear that it applies to all sectors. My colleague, Mr. Colfer, can give the committee some detail around the numbers relating to that.

We conduct announced and unannounced inspections. Announced inspections are announced four weeks in advance. This is really to give residents and their families opportunities to make arrangements to meet with us if they so wish so we feel this is also an important aspect. During Covid, we had to slightly adjust our approach to announce more inspections to ensure we could safely inspect services and not put residents at risk as a result of the inspections. However, so far this year, only 8% of our 325 inspections have been announced so we are reverting to the majority of inspections being unannounced.

The regulations require that providers notify us of any suspicion or allegation of abuse. However, we did take a very proactive approach while on inspection. To ensure safeguarding is appropriate, we need to hear from the people living in the centres, find out from them whether their rights are being upheld, whether they are being supported to make those rights real and whether they feel the care and support they get are dignified and respectful to them. That is a key focus. We also follow up on any allegations of safeguarding concerns, which we take really seriously. I will hand over to Mr. Colfer, who might outline some of the actions we take.

Mr. Finbarr Colfer

There are 1,420 designated centres operating in Ireland. In terms of voluntary and State-provided services, the HSE operates 162 of those centres directly and funds the rest. There are 734 centres operating under section 38 of the Health Act 2004 while 524 are operating under section 39 of the Act.

Ms Grogan is correct. We have reverted to primarily conducting inspections on an unannounced basis and 80% of our inspections this year to date have been unannounced. During those inspections, we look at safeguarding in the fullest sense of that term in terms of people's rights and quality of life and any allegations or suspicions of abuse and how they have been responded to. Where we find inadequate arrangements, we use our regulatory powers to require providers to address those issues. Where providers fail to do that, we take further escalated action where we specify what providers need to do and give them a timeframe to do that. If there is a significant level of risk to residents, we give consideration to cancelling registration. We are very careful about taking that action because cancelling registration of a centre causes a lot of distress for people living in the centre and people who are important in their lives like their families. It is an action we take very carefully. In 2021, we cancelled the registration of two designated centres because we were not satisfied that the provider was addressing the safeguarding issues for residents. In most of the situations we encounter, providers do take successful action to address the issues we identify. Since 2013, whenever we commenced registration and inspection, there was an ongoing incremental improvement in safeguarding in centres. It is still something we monitor and observe. Last year, out of 1,420 centres, we carried out 1,220 inspections. In community-based services, we found a 7% rate were non-compliant with regarding to safeguarding arrangements while in congregated settings, the non-compliance rate when it came to protecting residents from abuse was 16%.

Professor Amanda Phelan

The Deputy's question to Sage Advocacy concerned raising awareness. There are a number of domains in that regard. The beliefs in our society contribute to safeguarding concerns, for example, the idea that next-of-kin have a right to make decisions. There is no legal basis for that. There is also a cultural assumption that families are entitled to money. The Deputy mentioned financial abuse. Someone could think that if he or she is getting money in a will, he or she will take it earlier because he or she does not see that as extortion of money. It is about looking at all of those aspects of how we culturally view safeguarding.

This also needs to be looked at in organisational culture. Many organisations talk about person-centred care. I teach on this topic and no student who has come through this course has said we were doing it right. At the end of the programme, students would say they did not understand it and yet their organisations have lovely mission statements. You must transform people's understanding of person-centred care so that they understand it is a way of thinking, not just something that is lovely on a wall. That is important from an organisational point of view.

The individual needs to know he or she has equal rights, that he or she is not beholden to somebody else and that there are helping organisations that are independent. Professionals have a particular organisational orientation and families have an orientation and biases so somebody who is an independent advocate would support that person to navigate through what he or she authentically wants. They can look at issues such as the variables influencing his or her decisions, whether any undue influence is being placed on him or her, if there are ways of thinking that are aligned to gendered ways of thinking and things like the intersectionality of gender, safeguarding and disability and how that impacts that individual.

Some jurisdictions have developed specific safeguarding for adults at risk. The police service in Toronto has specific safeguarding police officers who work in that domain and have developed expertise. Scotland was the first part of the UK to have adult protection legislation. It has developed ways of operating with adult safeguarding and that knowledge is important because it is not the same as other domains. While there are overlaps with child protection and domestic violence, it is different.

In terms of addressing issues as a whole, what we know from case review after case review in Ireland, where it is more related to child protection, and the adult safeguarding boards in England is there is a continued silo approach with nobody taking a macro perspective and looking at the historical origin and development of cases. Individual aspects happen but nobody is knitting them together and taking an overall view. The UK has followed the idea of creating professional curiosity within safeguarding, which is important in Ireland, and ran a campaign called Making Safeguarding Personal some years ago.

Within the legal system, we need to be able to process these cases because very often, safeguarding is breaking the law but it is not always brought to that domain because of a number of issues. Regarding family members committing safeguarding breaches, there is a love-hate relationship. The person loves the individual but hates what he or she is doing to him or her. Regarding legislation, we also need a gateway - a right of entry if there is suspicion of abuse happening within a home or any environment and a right of assessment of that person and working with that person because the welfare of that individual is paramount, not what everybody else says, and that is what we need to keep at the front of our minds.

We are here as the servant of that person, not as their master.

Professor Brendan Kelly

I thank the Deputy for the questions. She asked about consultant recruitment. It is an enormous issue. It is common for there to be no applicant for a consultant job, or sometimes one applicant, leaving very little choice in what occurs. It is part of a broader difficulty with recruitment across the health service in other grades of doctors, nursing and other professions. Doctors are particularly mobile. Consultants are offered jobs elsewhere and we get emails every day about jobs in Australia, New Zealand and other largely English-speaking jurisdictions, where these jobs are embedded in health services that offer more support, more multidisciplinary working and therefore more opportunities for professional flourishing. A great majority of the graduates and people leaving medical school go directly to Australia. It then becomes a task not of retaining them but enticing them back, which is something to which we devote an enormous amount of time. A broader resourcing of the health service, particularly in mental health, would help with that.

The Deputy asked about the distinction between mental health services and addiction services. She correctly pointed out that many people have both problems. For example, the vast majority of the young men I see with psychosis or severe mental illness involving a significant break with reality use cannabis pretty much every day. It is very unusual for me to encounter a case of psychosis or severe mental illness in a young man who is not misusing cannabis. The misuse of cocaine is also very widespread and results in mental health problems. The 2006 policy, A Vision for Change, stated that mental health services were to be focused on people whose mental health problem was primary and that addiction services would be a separate entity. This does not make much sense, certainly in my day-to-day practice. The revised 2020 policy, Sharing the Vision, says:

[A Vision for Change] recommended that specialist mental health services should support only individuals ‘whose primary difficulty is mental health’. This recommendation is now reversed.

In practice, two services cannot simply be united by saying it is so. A great deal needs to happen to connect things up a little more and that has not happened yet, even though it clearly needs to.

The Deputy also asked about the unique health identifier number and whether the PPS number would serve that purpose. Yes, one would imagine it would. However, Ireland has gone down a slightly different path. According to the HSE website:

[Everyone is] given an Individual Health Identifier (IHI) number the first time you use health or social care services in Ireland.

It is used to identify each person that has used, is using or may use a health or social care service.

The [number] lasts for your lifetime.

These numbers appear to exist for almost everybody in the country. However, for reasons I do not understand, they are not used in clinical or day-to-day practice. There appears to be a structure there.

This brings me to the final point, about legislation. I am interested in initiatives that have been started but maybe not completed. These seem like low-hanging fruit for us to make improvements. If these individual health identifier numbers exist, it would seem useful to introduce them, even though they do not appear to be the same as PPS numbers, for some reason. It is the same with legislation. We have the Mental Health Act 2001 and proposals are being scrutinised for revision. These could be revised a little and advanced. The College of Psychiatrists of Ireland has made this point elsewhere about the need for revision. The Assisted Decision-Making (Capacity) Act 2015 is about to be commenced, pretty much in full, and that requires support after commencement. It will introduce possibilities for supported decision-making and advance healthcare directives but these things will not happen overnight. They require education programmes, encouragement and roll-out and hopefully we can reap the benefits of that. There is also a need for dedicated safeguarding legislation but I am pointing to the two initiatives that are very much under way and appear to be near the finish line. They would help enormously.

Mr. Vivian Geiran

I want to respond to a couple of the general questions and then I will ask Ms O'Connor to deal with the specific one on social work. So many of the issues and questions that have been raised overlap in a lot of areas. As Professor Kelly pointed out, the issues around recruitment within the medical profession are echoed across other sectors of the health and social care professional groups, and specifically for social workers in our case. There is a national shortage. Looking at the pool of social workers engaged in the various areas in which we work, collectively there is a shortage in Ireland. There are two issues in relation to that. When initiatives such as new legislation, like we are talking about here, new policies and structures are being considered, we need to bear in mind that there is not a national social work strategy in Ireland. There is not a plan for how Government policies will be implemented and delivered where they depend on social workers and where social workers will have to be in place to do that. There is not a social work strategy or a social work workforce plan at a national level, which needs to be in place.

With regard to strengthening the legislation, there is widespread agreement on the need for adult safeguarding legislation. The Deputy asked how that would help. There are so many ways, which we have included in our written submission. To add to that, in our history to date we have operated a light-touch approach to adult safeguarding in Ireland. As has been said already, the approach in terms of services and structures is also extremely siloed. The legislation we implement in this area should not be siloed because, as Professor Kelly and others have pointed out, it needs to dovetail and connect with the assisted decision-making legislation, and legislation relating to child protection, domestic violence and mental health. Too often we end up with legislation and structures that do not communicate or talk with each other. We have a long and not very positive history of institutionalisation in Ireland. Professor Kelly referred to the history of huge numbers in psychiatric institutions. At that time, we had a couple of hundred people in prisons. As one figure went dramatically down, the other went dramatically up. That gap or nexus between the criminal justice system and mental health services is clear and is further evidence of the need to join up the various elements that currently operate in too much of a silo, unfortunately. I will ask Ms O'Connor to address the question on how social workers can and do respond to complaints.

Ms Celine O'Connor

There are multiple answers to this because it depends where the complaint is coming from and where the person is located. If it is a concern from somebody living in their own home in the community, we can access them with permission. We knock on the door and ask for permission to come in. There is no special legislation or law that grants us access. While we would look for legislation, we do not want social workers to be able to knock at a door at any stage and say they are coming in to have a look. That needs to be a judicial process because people's homes are their protected space. The complaint could also come from a public service. Social workers are often employed in many of our public services so there may be a social worker in those services or in one of the disability voluntary bodies that the person can access.

We have significant issues in the private services and particularly in private nursing homes. In the past there was a HSE elder abuse service which would go in if a concern came in. Oftentimes those were in the private nursing homes. When safeguarding was established, that seemed to change things because the process did not require direct social work involvement in the assessment of concerns about abuse anymore. Instead, social workers on the safeguarding teams had oversight of what the service was doing to protect people. There was a significant difference there. Since the safeguarding policy came in, HSE-funded section 38 and 39 services are meant to safeguard the residents of their services and let the safeguarding team know what they do. There is a paper process and a preliminary screening that is sent in. Within three days of the concern arising, the safeguarding team will review it, make comment on it and ask for more feedback and information to ensure that safeguarding plan is as robust as it can be. Ultimately, the service that reports the concern is responsible for safeguarding. In those services, there may be multidisciplinary teams or there may not be.

There may also be people who have experience of working in safeguarding or protecting. For many services, though, there was a steep learning curve when this was established.

I believe what HIQA is saying is that it is seeing improvements as services are coming to grips with the situation. Training for staff in recognising abuse has been very important. Before Covid, three and a half hours of face-to-face training was provided to everyone in all of the services. It is important all levels of staff be aware because it may be the porter, the cleaner or even the visitors coming in who see something. Unfortunately, training stopped during Covid. There is a 30-minute training video available on HSeLanD. It is useful and accessible to people, but the lack of face-to-face training where people have the ability to ask questions has been a concern.

Another concern for us is that, during Covid, the lack of visiting meant there was no family safeguarding, that is, those externalised who come in and ask what this or that is about. Sometimes, staff in an institution do what they are taught. That is normal. It takes an external eye to ask why we are doing something this way and if there is a better way of doing it. Professor Phelan spoke about person-centred care. When we ask staff about person-centred care, they sometimes tell us they got a coffee machine in the staff room and it was lovely, but when we ask whether the residents can use it, they tell us "No" because it is just for staff.

This comes down to services' understanding and the training they are getting about what person-centred care is and what abuse is. Abuse is when someone is being left for a long time, the bell is not being responded to and his or her needs are not being met. Abuse is when, instead of getting a 20-minute walk in the garden because he or she needs to use the commode, the person will miss out on a walk that day. Abuse is when people's money is being used to pay for things that have nothing to do with themselves. We have had services that have paid for units to be painted rather than for residents to go on activities or get new clothes.

There are many small types of abuse. We know about the big issues – the sexual and physical assaults – but abuse sometimes takes the form of very small issues, for example, units where milk and sugar are still added to pots of tea because that is the way one person likes it and it does not matter that someone else does not, so that is the way he or she is getting it. This culture in services is challenging.

It is great if a service has a social worker. We hope social workers will examine and highlight these issues, although that is difficult to do for a lone social worker working in a service. We have duty social workers on our safeguarding teams, which anyone can ring in to – the Garda, members of the public, the family, services or staff. If concerns like these are raised with the safeguarding teams, the teams will follow them up and contact the services in question. Whether they have direct social work contact is an issue, though. If it is a service, it will be asked what it is going to do about the issues raised with it. Someone in the community or a social worker from a safeguarding team will triage the situation and may knock on the door to ask how he or she can help. If it is a private nursing home, the services will contact it and look to engage with it, but there is no right of access and a private nursing home is not obliged to engage with the HSE services. It can thank us kindly for contacting it and raising the concern while telling us it does not need us.

During Covid, though, there seems to have been a significant change in this regard. Supported by HIQA, there has been far more contact and collaboration on ensuring people are safe regardless of where they live. That last point is key. Whether someone lives in a private or public nursing home, disability service, homeless service or prison, he or she should have the same rights as everyone else.

Chairman

I thank Ms O'Connor for her comments.

Senator Fiona O'Loughlin

I thank the three organisations and Professor Kelly for their thought-provoking and detailed submissions and opening statements. They have painted a grim picture of where we are in terms of supporting and protecting vulnerable people.

This committee is considering what recommendations we can make to empower people to protect themselves from exploitation and abuse. We must also consider how to target the perpetrators of abuse. In their replies, perhaps the witnesses could address the question of how perpetrators are dealt with through the judicial system and the timeframes involved.

I believe it was Professor Phelan who made the point that we also had to promote autonomy, rights and well-being. I could not agree more. We tend to think of safeguarding as protecting people from negative behaviour, but we must include the person in all of this. It is not something that I had thought about as much until I listened to the witnesses. I thank them for that.

Ms Grogan referred to HIQA's new annual overview report and how residents living in congregated settings experienced a poorer quality of life compared with those in community settings. That seems to have been the theme throughout this meeting. I would be interested in hearing a little more about how we as a society can transition more to community settings and about the key changes required. What key measures must be included in the new national safeguarding policy?

Professor Phelan spoke about advocacy and nothing about us without us. Consultation is important. While listening to her, it struck me that people in these settings may sometimes not have been aware they were being abused, even through the small types of abuse Ms O'Connor mentioned. We need to do more to educate people – those in positions of control and those who have vulnerabilities and are being protected – about what abuse is. This is a significant cultural challenge.

The lack of sexual education for women with intellectual disabilities was mentioned. The previous Oireachtas education committee worked on making recommendations on a new relationships and sexuality education, RSE, programme. We made a strong recommendation to the then Minister for Education and Skills on how there was a complete lack of sexual and relationship education for people with disabilities, particularly intellectual disabilities. This has to do with vulnerable people being exploited without necessarily realising what boundaries should be in place.

Professor Phelan might comment on the need for greater regulation of the social welfare payment agency system.

It was mentioned we could examine the role of the public and society in safeguarding. This relates to the cultural issue.

Professor Kelly spoke about the importance of safeguarding in mental health services and the vulnerabilities of people with mental health issues. He was clear on the need for people to live in communities that valued them. I could not agree more.

How we evolve to that situation is crucial to the work we are doing. Could our guests elaborate on what they were talking about with regard to the systemic co-working that is needed in mental health between mental health services, primary care and social care, which is crucial? Can they provide us with their own insight into the model of services needed to ensure that people with intellectual disabilities who also experience poor mental health can be supported in the community in line with the UNCRPD? The figures that have been mentioned speak for themselves.

Ms Geiran and Ms O’Connor spoke about promoting autonomy and the rights and well-being of people, which is of great importance. They said that social workers face very real challenges. On influencing the governance and management of practice, if they had influence, what would be the key areas where they would propose to take action? They have recommended some interim measures. Would they see those measures continuing on an ongoing basis in respect of what needs to be put in place?

Finally, can our guests comment on education and training needs for effective safeguarding around those who are working within congregated settings and for preventative measures right across society as well?

Ms Carol Grogan

I thank the Senator. Everybody spoke about culture. There is a shift from thinking about safeguarding in a negative way. The change in culture involves considering it in a positive way. It is very important that there is an holistic view which takes in the rights and involves a human rights-based approach.

We believe the national safeguarding policy needs to be introduced in tandem with other legislation, including reform of the Health Act. We must look at the changing pace of legislation. It is about meeting the needs of people now and into the future. We know that people who are living in disability services now needed different types of care and support in the past, and we know they will need different types of care and support in the future. It is important that we keep pace with that.

The introduction of legislation and regulatory reform across all of the areas, including the decision-making capacity legislation, brings with it protections for those whom it is intended to protect. In addition, it affords them the same rights as you and me. There should not be a conversation about people having these rights; they should just have them. It should be about supporting them in the best way we can. All of the legislation coming together would support that.

On congregated settings, on the community-based side we find that people enjoy a greater quality of life and can express and exercise their rights more freely. They become active participants in their communities to the extent that they wish. We believe that every person with a disability who is living in a residential care service should be afforded that same opportunity.

I will hand over to my colleague Mr. Colfer, who might tell the committee some of the human stories of people moving out of congregated settings because the most powerful message is to hear from people themselves. Before I do so, I emphasise that we prioritise the registration of new centres to facilitate people moving out of congregated settings. When an application comes in from a provider to help with such a move, we prioritise that and move as quickly as possible on those settings. Mr. Colfer will discuss the congregated settings in more detail.

Mr. Finbarr Colfer

I thank the Senator for her questions. First of all, there is no prohibition in the regulations against the operation of a congregated setting. Our focus has been on the experience of people living there and the outcomes for people living in centres. We all know from international research that people are at much greater risk in terms of their safety, their quality of life and their ability to engage in their local community when they live in congregated settings. Over recent years, we have identified the number of registered places in congregated settings, which is the first time that an independent number has been set out there. We can now see whether there is movement of people out of these settings and we can quantify that movement. The other aspect we have looked at is people’s experience of life. Our inspection reports will detail some of the limitations on people’s quality of life in congregated settings compared to their counterparts living in community-based settings.

As part of our annual engagement with stakeholders, we engage with residents as a fundamental part of our inspection activity. Outside of our inspection activity, we meet with advocacy and residents' groups across the country. Last year, we met with 20 groups, including a significant number of people who had moved out of congregated settings. We have found for the most part that a very positive improvement in people’s safety and quality of life has been reported to us by residents and staff. In one of those groups, we spoke to a person who gave us a very good description of her experience. She said that when she was living in the big house she had a small voice, but now that she is living in a community house she feels she has a big voice. That was a very poignant capturing of people’s experience for me.

We have seen examples of people who had significant behavioural presentations when they were living in congregated settings, but when they moved out into community-based services the intensity and frequency of those behavioural issues significantly reduced. We have seen that pro re nata, PRN, medication has been reduced where people have moved into a different environment. This affects all aspects. We saw another poignant description of a person's experience. We met a resident in a house who had been treated for malnutrition in a congregated setting for many years, was on all sorts of supplements and did not eat very regularly. The staff described how this person came into the kitchen in the new house as meals were being prepared and started to taste food. It was the first time this person had actually seen a raw pepper and started to taste it. The staff found that by allowing the resident to become part of food preparation and purchase - to be part of what we take for granted every day - that person started to eat more and their physical well-being improved. People experience a broad range of improvements when they move from congregated settings. We are seeing those improvements and residents are telling us about them.

Professor Amanda Phelan

There is a golden opportunity here to create the conditions of possibility for prevention, early intervention and ongoing comprehensive management of cases of safeguarding adults. We have the opportunity. We know from various approaches in other countries internationally what works and what needs to be improved. I strongly believe that independent advocacy should be a right of everybody. People do not know what they do not know. If a person who has been in a system of care where other people have been making decisions, and that is the only thing the person is familiar with, is offered a choice to move out, it may not be comprehensively understood. Things might be piloted for a while to see what can be done.

We also have an approach within nursing homes that it is a one-way system. Many older people have said that once they go in, the only way they will be coming out is in a coffin. If someone who goes in for treatment receives three meals a day and is cared for, his or her health may improve. There should always be a possibility of going out back into the community. For some people who are there for palliative and end-of-life care, it just has to be managed. There is an idea and fear for older people that going into a nursing home is not their first choice.

We need to look at the structures in community care which are not affording someone a menu of choice and there are many issues.

I would go back to the Citizens' Assembly in 2017 and listen to the testimony of a lady who was admitted to a nursing home and whose family refused to take her home. She was in Dublin and had to pay for a taxi to drive her back to Cork because none of her family would bring her. What Mr. Colfer has alluded to is that we have to take the happiness of the person into account. It is not always about the system doing the right thing. If the voice of that person is not included and if you are not listening and hearing that voice then that happiness is at risk.

I refer to the evolution of our understanding of safeguarding and protection that has happened over time. If one looks at rape within marriage, for example, it was not seen as an issue prior to the introduction of legislation on same. We need to learn and ensure we have a dynamic and flexible system that can adapt. Just because we have a policy or just because we have new legislation does not mean we should not continually try to improve there. We are not getting there. The statistics we have on safeguarding in any age group would indicate that it follows this idea of an iceberg theory and that we are only looking at the top of that. We need to make sure that people know they have rights; where to go; who to access; that it is safe for them; and that making a report will not impact them. For example, if I report that my caregiver is the person who is abusing me then the answer of the system should not be to put me into a nursing home or a congregated setting because then the system would be abusing me as well. We need to look at all of those cultural issues. An interesting study from New York shows that we are only seeing one in 20 cases in formal systems. This is a study on the elderly and it states that 19 of those cases never come to anyone's attention and those people die having been abused in some way. That is unacceptable for society in the 21st century.

The Senator also alluded to the social welfare payments and I know Safeguarding Ireland is doing a lot of work with the Department of Social Protection on how we frame that. There is the risk of those payments being abused in some way by a third party and that must be addressed. We are hoping to do some research in that area during the summer. We must always keep the happiness of this person in mind and follow his or her will, preference, values and beliefs. Supporting these people is paramount.

Professor Brendan Kelly

The Senator referred to a grim picture in her comments and there is a lot of grimness in the picture. I want to bring a note of positivity and optimism that change is possible. We have seen this large de-institutionalisation occurring in the field of psychiatry and in the dismantling of the large mental hospitals. Some 30% of people admitted to psychiatric hospitals are discharged within a week, 70% are discharged within a month and 95% are discharged within three months. Change is possible, therefore. There are difficulties with the community services that are in place to replace the institutions. The Senator asked about co-working in the mental health services and housing and primary care are key parts of that. Deputy Tully asked about the unique identifier and that would help significantly with that. Primary care is a structure that already exists and there is enormous opportunity there. There is a counselling and primary care service, where anyone with a medical card attending a GP can access low threshold psychological care such as counselling. Unfortunately that is not open to people who do not have medical cards, nor is it open to people under the age of 18 years, and there is a waiting time. That would be one accessible way that mental healthcare could be provided; through expansion and improvement of an existing initiative rather than trying to invent something new. There has been this big de-institutionalisation but the community structures need some work.

On the housing front, the mental health service operates community residences with smaller numbers of people in them and the Office of the Inspector of Mental Health Services reports that in 2018 there were 119 community residences, often housing small numbers of people with enduring mental health problems who would, in another era, have been in a psychiatric hospital for all o their lives. The inspector is good at keeping an eye on them and at ensuring that institutional practices do not emerge within community residences because in the mental health setting we have become aware of how old practices can creep back in. It is another possibility and solution now that the institutions are gone and the main problem is not protection from over-exuberant care but accessing the system in the first place.

The Senator mentioned intellectual disability and mental illness. There is a mental illness in intellectual disability service but those services are mostly resourced to see people with moderate or severe intellectual disability who develop mental health problems, not people with mild intellectual disability who develop mental health problems. It is fair to say there is a general agreement that those services need to be resourced to take on that wider brief so that people with mild intellectual disability and whatever mental health problems they might have get a dedicated service, similar to if they had moderate intellectual disability.

Mr. Vivian Geiran

I want to respond to the Senator’s questions on social work challenges in governance and then there were a number of specific areas that relate to social work that Ms O'Connor might respond to in terms of education, training, the role of the public and society, and whatever else. To go back to governance, there are a number of areas and we have highlighted some of these in our written submission but the Senator referred to some of the interim measures that could happen fairly soon and even ahead of the proposed legislation. We urgently need more and greater transparency and accountability and we have been calling and would continue to call for the publication of inquiry reports and audits, a number of which are not available, and as a result the people who need to learn from the outcomes of those inquiries and reports, including social workers, do not get the opportunity to do that. In governance and strategic responses, we need to learn, as has been referenced already, from the developments of recent decades on child welfare and protection, not just insofar as the legislation is concerned but also in terms of the structures and strategic approaches. In that, I strongly urge that the unique social work voice and expertise need to be recognised and incorporated because it is valuable and it is currently under-recognised in that area.

I will give two examples. First, in the child protection and welfare area we have learned and put in place a good system as far as governance and strategic planning and so on are concerned in the way the Department of Children, Equality, Disability, Integration and Youth operates vis-à-vis Tusla and so on. From a social work point of view there is a head social worker in Tusla and a chief social worker in the Department, which means that at both an operational and strategic level the voice of social workers, among others, is heard. Second is my experience from the criminal justice area. I was the director of the Irish Probation Service for seven years and I am a registered social worker. On the operational and other responsibilities for that national team the buck stopped with me operationally. At a strategic level I also had a significant input, on behalf of the organisation, to the development of policy and strategy and so on, which was set from within the Department. That is lacking in the area we are talking about and it needs to be addressed.

Some of the specific areas we have referenced are that we need mandatory training in adult safeguarding for all HSE personnel. As I mentioned earlier, there is no general strategy for social work at a national level in Ireland or for workforce planning. We need stronger links between adult safeguarding and protection, social work teams and An Garda Síochána. That could and should happen quickly. We also need home care legislation to establish a right to home care package.

The last point I will make is about measures that could and should be taken urgently. Data and research are grossly lacking in the field of adult safeguarding in Ireland. I refer in particular to learning from research that fully takes on board and asks for the voice of the service users and their families. We have a gulf in and a dearth of research in that area. That should be rectified straight away. That would inform how things will develop in the future.

Ms Celine O'Connor

Social workers are often told we focus on what goes wrong as opposed to what goes right, but it is when something significantly horrible happens that we get involved. We look at the strengths of everybody around us, that is, the victim, the team, the staff, family members and communities. We have safeguarding plans that involve local postmen and the neighbour down the road. Everybody can be involved in protecting our most vulnerable members of society. We sometimes find that communities are already involved in safeguarding. We will get a phone call from a neighbour or the postman who has not seen somebody to say he or she is a bit worried and to ask whether we can get involved. There is that knowledge on the ground. During the Covid pandemic we have seen our communities grow again. We have seen those community call services come together and start looking out.

We do not have a memorandum of understanding, MOU, with the Garda in respect of sharing information in the same way Tusla and the Garda share information about perpetrators and victims. The staff of the HSE are obliged to report all sexual offences and physical assaults causing harm under the Criminal Justice (Withholding of Information on Offences against Children and Vulnerable Persons) Act 2012. That is a type of mandatory reporting, but that same reporting does not have to come to the HSE safeguarding teams. Again, it is a matter of information sharing back and forth.

Senator O'Loughlin asked about timelines in respect of working with perpetrators. It is very difficult because when we have to interview people who have a disability, their recollection of what might have happened may be impacted. Their speech and their cognitive abilities can be quite significantly impaired. Their knowledge of sexuality and sex and what has happened to them can be challenged because they may not be aware that what has happened to them is wrong. Senator O'Loughlin talked about education. Looking around the room, I see there are many of us of a certain age who would have got very limited sex education in school. There are women our age in disability services who are now being moved out to decongregated settings and who have had no sex education. Preparing people to move is really important. This is not just a once-off education. It needs to be repeated because, again, people's cognitive abilities to hold information may be very impaired. We have seen a lot of romance scams whereby people chat up people online. Senator O'Loughlin and I, who have a decent level of education, will see through the messages, but they are written in such a way that they seek to pick up people who have vulnerabilities and who do not understand. We deal with people in romances with people who could be anywhere in the world. They send them money. Their quality of life is impacted because they feel they need to send that money or the person will not be in touch with them. We have seen people with disabilities brought into criminal gangs, prostituted and used to deliver drugs. It is getting more and more complex, and we are seeing only the tip of the iceberg.

There is so much hidden abuse in our services and in our communities, so training is really important. I refer to training staff to look out for the various types of abuse, drilling down into what is abuse and what are the signs and symptoms of financial abuse, sexual abuse and physical abuse. Sometimes they are not that obvious. Particularly in residential centres, there will be people with unexplained bruising, but they may be on medication or may have thrashed around a bit. However, staff need to ask questions or use body maps if they keep seeing the same bruises, looking at them, recording them and looking at what the situation leads to. There may be repeated urinary tract infections. There may be a comment that the person has a certain condition, but could the infections be a result of repeated sexual assault? It is a matter of asking those kinds of questions and that curiosity, keeping one's mind open as to whether there could be another explanation for something. We frequently have clients who tell us they told people repeatedly they were being hit, assaulted or sexually assaulted but that nobody believed them because maybe the language was not right. We have the cultural idea that older women, in particular, or women with a disability are not sexually attractive to others. We know, however, that for perpetrators of sexual offences it is not necessarily about attractiveness but about power and control and getting away with it. They groom the person, they groom the system and they groom everybody around them. How many stories have we heard of people who were pillars of society? They were in the local GAA, worked in the services, always did the extra shifts, were there for everybody and covered for staff. Again, it is a matter of asking why they are covering or why they are doing only the night shifts. Why do people flinch when they come in the room? Why do people say they do not want that person with them? Why do we not listen to those messages and have a chat with the person and look at the matter?

We have a fantastic workforce throughout our service. We know that offenders are a tiny part of our population, but they can do awful damage. We want to, and have to, trust our colleagues when we go to work. If there is a question, however, or if somebody makes us feel uncomfortable, we should report that to our line managers and should challenge those people. Often when we have reviews we will hear that everybody knew about someone or everybody had a sense as to what was happening but that they thought somebody else would report the matter. Training needs to tell people not to be bystanders. When we give training we often talk to staff about being brave, standing up, being counted and being the voice for people who do not have a voice. I loved the comment about the big voice and the small house. What we see is that when people get out, they get more control over the small things in their lives. They start being able to raise the bigger issues. They are allowed to choose whether to have a cappucino or a latte or whether to go to the park or to put a bet on a horse - all those small things we would not even consider. They will start to tell us the bigger things. They will start to say they do not like when a certain person is on shift or do not like it when a brother or sister visits. That builds up the trust, that listening ear and that curiosity, and that is what will help protect lives.

The other thing that will help protect adults is all the early intervention services, getting those skills in place and having the diagnoses done early. That is ongoing. It is a lifetime support for the person, not a once-off. With mental health services, there is now the Housing First model. That is what disability needs as well: wrap-around housing supports for people in the community.

Chairman

We are an hour and a half into the meeting. We have heard from two Members.

Deputy Jennifer Murnane O'Connor

We are all going to other meetings.

Chairman

We have heard powerful testimony from our witnesses.

Deputy Jennifer Murnane O'Connor

Absolutely.

Chairman

I am conscious of everybody's time and the pressure everybody is under. I had suggested that, with Members' agreement, we take two members at a time and then go back to the witnesses. Ms McGarry is looking to come in. I will bring her in after the next group of questions if that is okay. We will take two Members and then go back to the witnesses. The subject matter and the testimony are so powerful. I call on Deputy Murnane O'Connor.

Deputy Jennifer Murnane O'Connor

They are powerful. What has been said has been so truthful. All of us would recognise that from our own areas, where we come across these issues, so it is important that they are highlighted and that we do all we can.

I had a few questions about recruitment but a lot of them have been answered. Where there is an issue with recruitment, there is a broken system. I know that everybody is doing their best and that there is funding there, but the issue is that when people are overworked and doing maybe the job of two people because there are not enough staff, straight away there is a failure.

It is no one's fault, but a fault of the system. That must be addressed. How we recruit and keep our people within the system also needs to be sorted. I agree completely on this point.

Safeguarding is extremely important, and this is another issue I wish to address. Regarding safeguarding policies, as someone who works on the ground, like my colleagues, I firmly believe it is necessary to listen to the representatives of disability organisations, service providers and advocacy organisations, because that is where change will come from. In the formulation of any safeguarding policy, we all have a remit to include the people in the know.

I am working with people who come to talk to me about carers and respite. If we examine this issue, we have more than 400 carers aged over 80. We are promoting a system where people will continue to live at home, but I will give examples of two cases absolutely breaking me at this stage. We talk about the lived experience in this context. I have many other cases, but these are just two examples of situations I am dealing with now. The lady in question in one of these cases is in her 90s and she forgets things. Her son is her carer and he is in his 70s. This lady is in hospital now. She has said she would like to go home. The family does not want that because they are so upset. The lady herself is forgetful and does not remember things. Yet the hospital has said she can go home. I reiterate, however, that this lady is well into her 90s and forgets things, while her son is in his 70s and he is very sick. I have told the family members they must go back to the people overseeing the system and say that. The family members are upset about this situation. They are fighting the system because they need to get this lady into a nursing home. They do not want to do that. Do not get me wrong in this regard, because this family is dedicated and committed. There is a concern when situations like this arise, where we have a system that says a lady like this can go home but, technically, she cannot. How do we try to get a system that works?

Another case I have come across involves a lady in her 80s with motor neurone disease. She has been told by the hospital authorities that she can go home but there is no care package for her. When people ask me about care packages, I tell them they will get half an hour, three times a day if they are lucky and get a care package when someone comes home from hospital. If not, the family concerned will be fighting to get that person into a nursing home. These are the realities. I could point to many other people in similar situations.

We need policies and we must examine the system, but if we do not work with the families in the system, then how is this going to work? Families are greatly tormented by what their loved ones are going through. These are good families living this experience every day. They are telling the hospital authorities they want to take their mam or dad home, while wondering how they can do it. They ask about home care packages, only to be told that none are available. That is the case now, even though private providers are being considered. The best efforts are being made in this context because those private providers are being considered. I refer to the HSE. I am not blaming anybody here because I do not know where to start.

My issue is that our society is one where families have parents who are living longer, but we are unable to cater for this reality. We are dealing with situations where families are trying to get their loved ones into nursing homes and it is necessary to engage with the system to do so. This is another battle people face. How do we fix this system? It is failing at certain times and we must examine this. I cannot say this is the situation in all cases, because everybody is doing their best and I am not here to be the bad guy in this context.

We must also explore the culture that exists in this regard. The committee meets weekly. I also work with people on the ground and I am very much involved with the different disability groups in County Carlow. They do a great job, by the way. The reality in this context, however, no matter what is being sought, whether it is a grant for a bathroom adaptation, a stairlift or an extension, is that there is nearly another battle to be faced. I just feel every day in my life is a battle. I come in here then and I am constantly giving out. I feel I am living the reality of what is happening on the ground and listening to the groups and families who have these experiences. In this context, it is important that we have HIQA and the inspections it undertakes to know if things are correct. Regarding those inspections, however, what are the timescales involved if funding is needed? What is the process that follows from there? I ask this because it is important that we have these processes and I welcome them.

I could raise so many other issues, but there are time pressures. I thank the witnesses for attending. What they said today is true and it was important for us to listen to it. In turn, I ask the witnesses to listen to the representatives of all the different groups and to us, as representatives of the people who feel they are breaking point. I feel I am almost at breaking point myself sometimes, because I am fighting with everybody to try to get everything done. I thank the witnesses again. Perhaps they could respond to me later and there might be some solutions to these problems.

Senator Mary Seery Kearney

Returning to safeguarding, I note from one of the briefings provided, and this information comes from one of the reports, a table setting out the profiling of safeguarding concerns, by year and by CHO, between 2016 and 2020. CHO 7, which covers my home area of Dublin South Central, comes out as having the highest number of safeguarding concerns, with 8,743 for that period. Is that because we have a higher population, a higher concentration of disability services or something else? I would appreciate an answer to that query.

The representatives from HIQA might be best placed to answer this next question. Is there a difference in safeguarding reporting between section 38 and 39 organisations and service providers? Is there a difference in the numbers reported and in the likelihood of issues arising? I ask that because I am conscious there are staffing concerns in the context of the two differently funded organisations. A migration is under way from section 39 providers into section 38 organisations. That is because members of one group of staff are considered to be public servants, and having all the attendant supports of that status, whereas the others are employed by private providers and do not have the same pensions and opportunities. Do consequences arise from that disparity in funding? I ask that because it certainly causes difficulties in other areas.

Concerning the interaction of the macro policies with the personalised plans in respect of the needs and wants expressed by individuals, where a safeguarding issue has been established and clearly flagged, is there a policy conflict as that process is gone through? If a person needs to be supported on his or her own or in a different way, do we then end up with a conflict in how that person is catered for and how his or her needs are met? I refer to his or her personal requirements and wants being met. When a safeguarding issue is identified, what is the exact pathway of response?

We are having high-level conversations here and I appreciate the powerful testimonies we have heard. I refer, however, to situations where HIQA notes that a safeguarding issue exists and what happens from that point. I am aware of several incidents in the context of different organisations around the country - and the nature of our role means we hear of such incidents nationwide - where safeguarding issues have been identified, but where nothing has changed several months down the road, if not longer. There have been conversations, applications to the HSE and further discussions, but nothing has changed. My question, then, concerns a situation where a service provider is reliant on funding to deal with a safeguarding issue. I heard much in the contributions concerning service providers having to do X, Y and Z, but service providers do not always have the discretion or funding to do all that. Where is the urgency in the system? How is urgency injected into the system? How do we ensure there is an immediacy of response and ensure that someone is not languishing in an abusive situation for a long time, while discussions about policy and funding are ongoing? None of us would want to experience someone's daily lived experience in that kind of situation.

I have heard of some intolerable cases from throughout the country. It is just appalling and outrageous.

The HIQA report refers to 20% non-compliance. Will our guests unpack that for me? I am familiar with the childcare sector, where someone might get a report from the childcare inspector to say a matter amounts to non-compliance but the matter might be very trivial, while something else that has also been recorded as non-compliance may be considered a very serious matter relating to a failure of staffing or proper staffing ratios. When our guests refer to non-compliance, can we have some idea of the range of the issues that arise?

Ms Carol Grogan

On what we could examine, HIQA produced a report on regulatory reform in early 2021 in which we highlighted the need for a social care policy that will take account of the continuum of care throughout the social care spectrum. In the context of the issues the Senator raised, the research we produced in regard to home care identified the issue's complexity and called for a root-and-branch review of the provision of home care services to ensure the future home care scheme would be fit for purpose and meet the needs. It would also allow for that continuum of care where people may not be able to be cared for at home and may need to move into longer term facilities, with help to be given for that decision-making, which goes back to the rights-based approach.

As for what happens in the context of inspection and the timeframe after that, the function of our inspections is to assess compliance with the regulations and standards, and we take a rights-based approach to that. It is very much about the impact of compliance or non-compliance on the people who live in those centres. There are three categories of compliance, namely, compliant, substantially compliant, which means the provider is almost there but there are some improvements to be made, and non-compliance, which means that the provider has not met the requirements of the regulation, each of which comprises a number of sub-regulations. We ask providers to consider not just the one issue we might have identified on inspection but the entirety of the regulation in order to see how they can come back into compliance and to determine whether there are other areas they need to address.

Not all non-compliance cases are the same. Some might have a greater impact on residents, while others might relate to, for example, a documentation issue. We look at what the impact of the non-compliance is on residents. We take action and, as Mr. Colfer outlined, that action can include the cancellation of a registration as a result of the residents being put at risk, but providers are asked to submit their plans to us. If we believe the risk to the residents has increased, we will outline a timeline by which the provider it must comply. We review the compliance plans. Members will see from our inspection reports where sometimes we have not been assured by a provider's response to us, and we publish that and it is transparent. If we are not assured, we will go back out and not wait, and we will seek updates from the provider.

On the exact response and pathway, Mr. Colfer might outline exactly what happens when we get a notification.

Mr. Finbarr Colfer

Where we receive information or learn there is a concern about an impact on residents, we do not allow that situation to continue. Our inspectors, when they are carrying out an inspection, risk-assess the situation. We have plenty of examples where our inspectors have required providers to put immediate actions in place to deal with the immediate, high-level risk to residents, and providers are then required to respond in the ongoing addressing of that risk, or its elimination where possible.

As for the funding, the Senator is correct. We are detached from the funding side of things. The regulations set out the minimum requirements - they are minimum requirements - that all providers are required to implement to ensure the safety and the quality of life of residents. Our role is to assess whether they are meeting those requirements, and the provider and the funder then have to discuss how to address those matters. Our actions are not informed by that part. If there is an immediate risk and there is a requirement for immediate action, we require the provider to take that action. Providers are in the difficult position of having to engage with their funder to ensure they have funding to do that. Our focus is on the impact of the people living in the centres.

I have worked in the disabilities sector throughout my working life, but I was shocked by some of the cases we found in 2013 when we started carrying out inspections. It was the first time an independent authority had gone into many of these centres and reported publicly on what we found. There has been progress. Our compliance and non-compliance levels, which are set out in our annual overview reports, show that for the vast majority of providers, a good population of service providers works hard to deliver good-quality care. There is also a cohort of centres, however, that does not manage to achieve that, and regulation is very important in that we publicly state that and require providers to take action to address it.

Our pathway is such that when we receive information, it is assessed within three days. We consider the seriousness of the information and base our actions on that. Those actions might involve asking the provider to investigate the circumstances and to report back to us, but it may also be that we have a concern or the issue has been identified at a previous inspection and we now have more information on it. We will then perform an unannounced risk inspection and, if the information is substantiated, require the provider to take action in respect of it. One thing we do not do is wait around for months for the issue to be resolved.

Professor Amanda Phelan

The elephant in the room is that it is difficult to recruit people for various areas and, in rural areas, it is especially difficult in respect of home care. While a person might have been approved for a care package, he or she may have to wait simply because there are no staff working there. Furthermore, there is a higher level of attrition in places such as nursing homes that are heavily reliant on, say, Filipino or Indian nurses and which recruit in that way. If we are looking at care provision, we have to take a step back and ask ourselves how we can make it attractive for people and ensure they will be paid properly for the care they deliver.

One impact of the pandemic, I presume, is that the numbers of CAO places for nursing and midwifery dropped this year. I think that is because people are continually hearing about how difficult it is to work in the healthcare system at the moment and during the pandemic, and people have caught Covid up to four times. They want to continue but it is a very difficult situation. We need to look at the conditions of providing care that are adequate and will provide sufficient care for covering safeguarding. Methods of care are also implicated in safeguarding. If there is neglect in a nursing home, for example, or if there is simply missed care, whereby the pressure on the staff is so great that they cannot complete routine tasks whether in part or in full, that can lead to issues such as pressure ulcers.

When we talk about long-term care, therefore, we are looking at that from the home environment, the whole spectrum, and how can we put in measures that will have the right professional at the right time in the right place for the right individual.

Ms Sinéad McGarry

I thank all of the members for their questions and interest in this important topic. From the perspective of the association, I must make it clear that, at the moment, we have a piecemeal response to adult safeguarding in a way we do not have but used to have in terms of child safeguarding. While the two issues are not directly comparable, the kind of responses we need from the State are. It is heartening to hear all of the things that have been mentioned today, yet, not to negate the optimism Professor Kelly introduced to the room, these messages have been delivered repeatedly. Some of these speakers have repeated these messages for many years. We are not seeing a response from our systems and legislators in terms of adopting these measures and translating them into practices that would change the lived experience of the people who have been mentioned by the Senator Seery Kearney.

To bring it back to the person in a congregated setting, if somebody today experiences abuse or his or her family is concerned about abuse, if it is a residential setting for children, they can ring Tusla. In the case we are talking about, they can ring HIQA that will do all of the fantastic and important measures Ms Grogan and Mr. Colfer have outlined, but at the moment HIQA does not have the authority to investigate individual complaints. Therefore, the system will be looked at overall and there will be that overarching piece, which is vital, important and has transformed our services. The person may then be advised to ring the Ombudsman, who does not investigate clinical complaints. The person might ring his or her safeguarding and protection social worker, who will, if he or she can, look at some aspects of the concern if it is in a public setting, but that social worker does not have a right of access to somebody who lives in a private service provider. It is very important to note that 80% of older people, of whom a significant number may have a physical or an intellectual disability, live within the nursing homes sector and 80% of those homes are owned by the private sector. In terms of accessibility to the supports that they need and safeguarding supports, I do not know if we would accept a situation in this country where 80% of children lived in a home where they could not access safeguarding social worker expertise. I do not think that would be acceptable at any level. A person could also go to the confidential recipient who manages concerns related to HSE services only.

As I list these, I am sure Deputies and Senators, as committee members, may have some familiarity with the services I am talking about. Again, I ask them to go back to the perspective of the residents and their families having experienced some form of abuse or infringement of their rights and the complexity of the system we expect them to navigate. We have options, knowledge and measures, but what we need from the perspective of social workers is political expediency to put these solutions in place. We are talking about governance structures and having a one-stop-shop, as we have in other parts of the State. Tusla has all of the centralised expertise. It is one central authority that will allow the services to respond to all of the issues we have talked about. When things go wrong, one can operate and put in preventative measures and, as needed, safeguarding social work experts, the guards or whoever can come in.

We are missing the holistic piece. As Ms Grogan alluded to, people with disabilities sometimes need additional supports to report their experiences of abuse. It is exceptionally challenging. We reference those 143 sexual assaults that were reported. These were not necessarily substantiated but these were concerns that came to the attention of HIQA. Specific measures are required to support somebody, not just to disclose it but also report it to the relevant authorities such as the Garda. I believe Professor Phelan referenced the specialist policing units that are available elsewhere. We need the same sort of supports here across the investigative units, whether it is social work or the Garda, to ensure people are given every opportunity to tell their story and to have equal access to justice and protection.

We have outlined measures in our submission. As per usual, it is a reasonably lengthy submission but there are very quick easy wins around governance and easy wins around legislative measures that can be taken in the interim. Ultimately, until our systems and laws value this and reflect what we believe, as a society, should be the response regardless of where a person who experiences abuse lives, we are not going to progress as much as we can. The missing ingredient is political expediency and we would love to see that.

Senator Mary Seery Kearney

Why has community healthcare organisation, CHO, 7 the highest level of safeguarding issues? I suspect the reasons are population and the propensity of services.

Ms Sinéad McGarry

It is population-based. It is a long-standing problem. There have been multiple media reports highlighting that it has reduced social work ability to review the plans that have come in from safeguarding services. It may very well be residential services but we do not have a breakdown of that. It is a well-known and well-documented problem. This matter goes back to the point that if we continue just to identify problems and not respond, the problems are not going to go away.

Senator Mary Seery Kearney

I thank Ms McGarry and everyone.

Deputy Emer Higgins

I thank all of the witnesses for their presentations. I have one overall question for them but will first outline what I have gleaned from today's proceedings. From what Sage Advocacy shared with us, it is clear there is international best practice. It is clear that without reinventing the wheel, we could take on some of what is being done in, for example, Toronto and Scotland. It is imperative that we, as a committee, understand what is successful in these regions and see how we can lift and shift those policies, processes or procedures to make a real difference in Ireland.

I thank all of the social workers throughout Ireland for the tremendous work they do. From the perspective of Ms Geiran and Ms O’Connor, I got a sense of deep frustration from them that reports just identify problems. They identify problems and garner a lot of press and media attention and political commentary, but when the dust settles they do not act as a catalyst for change, which is what everybody across the political divide wants. All of us in different parties share the goal of wanting to change things.

I was struck by what Ms O'Connor said about the lone social worker and how that can be a difficult position to be in if he or she is in a situation where he or she is surrounded by, as she put it, smaller signals of abuse. They, too, need to be identified and called out.

From a HIQA perspective, I am pleased to hear about the move back towards unannounced inspections, that they now happen an awful lot of more and are a priority. Ms Grogan explained the benefits of announced inspections from the perspective of collaboration and access to HIQA by families and service users. However, I think unannounced inspections, unfortunately, often throw up dark cases and it is the dark cases that require intervention.

I was struck by what Professor Kelly said about recruitment and how being under-resourced can lead to a situation where signals of abuse are missed. I was particularly struck by his comment that it is not just retention that is an issue and that there is a need to entice people back from Australia or wherever.

I was also struck by the comment on how difficult it is to do that without a reform package and without being able to show we can provide better support and career opportunities. That leads me to the question I would like to ask all our witnesses. How can we change the culture? Nearly all the witnesses have brought up culture at this point. We have talked about changes that need to happen, institutionalisation, the gap between the criminal justice system and mental health services, the gaps in communication with service users and families, and the gap between PPS numbers and our unique hospital identification numbers. These all boil down to a need for cultural change throughout the HSE, Tusla and other agencies set up to deliver the interventions that the vulnerable absolutely need. My question is a broad one but I would really value all the guests' perspectives on it because the committee needs to understand the practical changes that could help to change the culture and create and implement a better service for all service users.

Deputy Holly Cairns

I had to step out to the Chamber, so I hope I do not repeat anything. I thank the delegates so much for attending.

The UN Convention on the Rights of Persons with Disabilities requires the State to put appropriate measures in place to protect persons with disabilities from all forms of exploitation, violence and abuse. That is an important obligation given the vulnerabilities involved for some groups; however, there is also a balance to be reached to avoid being too paternalistic in our attitudes. Generally, the issues raised at meetings of this committee concern not a lack of safeguards but a lack of supports that prevents disabled people from living as independently as possible. However, it makes sense to state those experiencing safeguarding issues may not be in a position to appear before the committee. It is very concerning that of the more than 10,000 safeguarding concerns notified in 2020, 78% related to older people and the disability sector.

My first question is for Professor Phelan. Sage Advocacy casework includes issues related to coercive control exercised by relatives over vulnerable adults, from not allowing people to manage their social welfare payments to isolating people intentionally. The intersections of domestic violence and disability are not discussed enough. Could Professor Phelan elaborate on the issues in this area, as she understands them, and the potential interventions that could help to protect people? She mentioned the financial abuse of vulnerable adults. The assisted decision-making legislation is being amended currently. The Joint Committee on Children, Equality, Disability, Integration and Youth just produced its pre-legislative scrutiny report, and the codes of practice are being drawn up. Could Professor Phelan discuss changes that are necessary or measures that should be included? What could new safeguarding legislation add that cannot be achieved through better implementation and monitoring of existing laws protecting whistleblowers and requiring reporting of criminal offences against children and vulnerable adults?

My next question is for Professor Kelly. The clarity of his opening statement was eye-opening in its understanding of overlapping areas concerning safeguarding in mental health services. I was especially struck by his articulation of how Ireland is failing to safeguard the rights of people with severe mental illness. He helpfully provided several solutions. Could he elaborate on the point on safeguarding social and medical well-being? He mentioned systematic co-working between mental health services, primary care and social care. Could he outline what that would look like in practice? He also mentioned the need for legislation that balances protection and autonomy. This is a key theme, especially regarding the assisted decision-making Bill and efforts to increase community-supported living. Could Professor Kelly discuss this type of balance and, perhaps, the challenges involved?

My next question is for the delegates from the Irish Association of Social Workers. How can new safeguarding legislation ensure that a person's will and preference are at the centre of any safeguarding process and that reporting cannot occur without a person's consent?

My final question is for the representatives of HIQA. In its annual overview report concerning 2022, HIQA notes that residents who live in congregated settings are at increased risk of being exposed to safeguarding issues. Could the representatives elaborate on the types of risks and issues they have encountered and the progress made by providers in addressing these?

The committee has heard that when it comes to discussions on congregated settings, the individuals concerned and their families can feel sidelined. Are there methods to ensure their voices are central in the safeguarding process?

Chairman

We will start with Professor Kelly and then proceed to Mr. Geiran, who is to be followed by Ms Grogan and Professor Phelan. We might take the points that have been raised along with any questions of the previous speakers that have not been answered.

Professor Brendan Kelly

I will start with Deputy Higgins's reference to the recruitment difficulties and changing culture. Culture will change you far quicker than you will change it, which is the big problem. My optimism was referred to earlier. I will return to this because there are many people working in our health and social care systems who are doing fantastic work. There are many organisations doing their best, and committees such as this one are trying to keep the matter on the political agenda. Therefore, there is a great deal that is good.

With regard to recruitment, my experience is mainly in medicine, particularly psychiatry. There are many things going on. For example, the College of Psychiatrists of Ireland, of which I am a member but not a spokesperson, is working hard on recruitment, reforming training processes and streamlining. It is also trying to work on implementing policy and updating the Mental Health Act. All these matter quite profoundly in building a system that will entice people back, although we are competing all the time with pictures of beaches in Australia and landscapes that are very compelling. Nonetheless, we have a very committed generation of medical students who will, indeed, return.

I thank Deputy Cairns for her questions. She talked about the need to protect social and medical well-being. Some of the specific measures I have mentioned would help. I cannot overstate the need for electronic medical and social care records linked by a unique identifier number. This is possible. All of our hospitals have an electronic radiology system, and everyone is identified no matter what hospital they go to. We do not have the same for medicine or social care. For example, if someone is discharged from an inpatient psychiatry unit to a homeless hostel, there is no way for me to know, without a great deal of telephoning, where he or she is two nights later. My prescribing of treatments, while very useful and helpful, is really no substitute for somebody having a bed somewhere and knowing where he or she lives.

The other point on medical well-being, which I mentioned earlier, is that we need an expansion of the counselling and primary care scheme, whereby primary care practices and general practitioners can give people with medical cards, and those without them who are almost eligible, access to the counselling scheme.

The balance between protection and autonomy is a very difficult one to reach. There is a tradition of paternalism. The assisted decision-making (capacity) (amendment) Bill will help in striking a better balance. The programmes of the HSE national office for human rights and equality policy are really focused on this. My main message, however, is that even the passage and commencement of that legislation will not necessarily make what I describe happen in practice. We need an education programme rolled out for staff so people will know the options available to them regarding supported decision-making. Evidence from other jurisdictions on advanced healthcare directives shows that before implementation 90% of people say they are a good idea and that after implementation fewer than 10% actually produce them. That has all got to do with people feeling empowered and supported and staff understanding how to make it happen. My social work colleagues are nodding vigorously at this because they play a key role in this kind of thing.

Mr. Vivian Geiran

I will respond to some of the questions that relate to the Irish Association of Social Workers. Deputy Murnane O'Connor made the point that the system as a whole is failing. That is a very important point. All the words in her statement - that the system as a whole is failing - are important. That is because of the siloed nature of our responses, which we have spoken about. Deputy Murnane O'Connor also referred to the cultural issues, as did Deputy Higgins. The really important question of how we can change the culture was raised.

Professor Kelly referred to the old saying that culture eats strategy for breakfast. I was going to put it slightly differently. It probably eats legislation with its morning coffee. It is a very difficult thing to change but we have to grapple with that.

As regards Senator Seery Kearney's question on how we inject change, urgency in starting and delivering that change is really important. Much, but not all, of the power is in this room, both actually and figuratively, in the sense of the Legislature progressing the much-needed legislation, for example. There is also a responsibility on the Executive side to follow up with urgency.

A couple of members asked what the legislation will change. As I stated, I come from a background in the criminal justice system, in which for many years a significant number of people, including me, recognised the need for much better inter-agency co-operation and working. For many years I operated under the unfortunate illusion that because people recognised that, they would work really hard to change it. Unfortunately, the reality is that many of these problems are not really addressed unless there is legislation and a statutory basis and mandate for that type of co-operation. I refer again to the example that has been cited many times of the situation in respect of child welfare and protection. The changes did not happen because people knew we needed to work better and in a more co-ordinated way or because of all the scandals that occurred; they only happened when appropriate legislation was put in place. I am not saying that legislation can answer or deal with everything - it cannot - but I do think it is a fundamental foundation. As was evidenced in the context of children, we need appropriate structures and responsibility, accountability and transparency to follow on from the legislation.

Professor Phelan or Ms O'Connor may wish to come in on some of the points raised.

Professor Amanda Phelan

The recurring question here relates to how we change culture. Legislation can change culture. We have seen that in respect of teachers slapping children, people wearing seatbelts and smoking, for example. It can change culture and transform the way we see things because culture is a reflection of our values and beliefs. Discursively, we say we value everybody as a citizen of Ireland but, practically, all animals are equal but some are more equal than others. It is about looking at the hard facts in terms of how we treat people who are risk populations within our group and are marginalised because of that.

We need to put a significant focus on prevention. Much legislation in Ireland has been reactive in nature. We have reacted to scandals and crises and so on and things have happened thereafter. We have an opportunity now to be proactive and to focus on prevention and early intervention. What is needed along with that is changing the way people think. Legislation has a significant focus on that. I trained as a public health nurse when the childcare legislation was being fully enacted in 1995. There was a significant refocus of people's responsibilities because there was then a mandate that one had to respond. The same thing should happen in the context of adult safeguarding. There is also the societal obligation that everybody has a duty of care to other citizens. That is enshrined in Article 41 of the Constitution in particular, which refers to the widowed, the aged and orphans. Regardless of naming different sections of the population, we have a responsibility to look after each other. It is incomprehensible that we seem to be trying to learn the same lessons all the time. The Assisted Decision-Making (Capacity) Act is a significant step forward but we are still working under the Lunacy Regulation (Ireland) Act 1871. Members should think about that. The wardship legislation dates from 1871. It is archaic and unsuitable. It is to be hoped that by June, we will have a lot of work done on that. The Government needs to support the decision-making support service to fulfil that obligation to Irish people. We have the advanced healthcare planning. We also need to push out things like powers of attorney such that people can make those decisions when they have decision-making capacity. It is hugely under-used in comparison with the UK.

We have learned from other countries. I led on a report with Mazars that considered safeguarding structures in nine countries around the world and looked at interventions, legislation, policy outcomes and things like that. One can consider what the Office of the Public Advocate does in Australia, for example, or what happens in Canada. I would not pay particular attention to what is happening in Norway because it does not have any structures in responding. Japan has quite an interesting response as the police force there is quite involved in safeguarding. We can learn from those structures. The Child Care Act is founded on the principle of well-being. There are various safeguarding principles that are usually generic in the context of policies on autonomy, self-determination and things like that. There are templates out there. We just need to decide what is suitable for our structure and how we will put it into a process that gets us to the outcome we desire.

Ms Carol Grogan

In response to Deputy Higgins, I make the point that we have all referred to the need for safeguarding legislation. In the absence of such legislation, our key focus is to ensure that people living in designated centres are active participants in their own care and decisions. That can happen now. We advocate for it all the time. We have seen the change because we have widened the conversation. We are talking about safeguarding and everything it encompasses. That, in itself, is changing the narrative in respect of how people can be active participants in their own care. It has to be proactive but it can only be proactive if everybody knows and understands their responsibilities. That can be done now in preparation for any legislation that is coming in. In addition, reporting and transparency are so important. There is a statutory responsibility on providers to report to HIQA. That transparency is crucial. We publish our inspection reports in the hope that services will use them to learn from the experiences of others, such as providers that have good practices and systems in place.

I ask Mr. Colfer to address the issues in respect of congregated settings and the importance of the voices in that regard.

Mr. Finbarr Colfer

There is a process for transitioning people from congregated settings but, in the interim, it is about maximising the safety of people who currently live in such settings. In the context of the cultural question, what struck me when the questions were being asked is that we have engaged with many providers and we have seen changes not just in terms of reducing the incidence of safeguarding issues but also in terms of promoting people's rights and quality of life. I gave some examples of that earlier. One of the interesting things is that when one engages with a situation such as a congregated setting, the main cultural issue is usually institutionalised care practices. People who work in those centres have a certain perspective on what their job is and how they should do it. People who live in the centres get their food from a centralised kitchen and their clothes are washed in a centralised laundry. They have no sense of engagement with or control over their day-to-day living. We challenge that in our inspections. We try to maximise within that environment how people can be promoted in terms of engaging with their own self-care.

In some centres, for example, providers have installed kitchens in their units and involve residents more in the preparation of their day-to-day meals. A difference for residents can be seen arising even from that small action, but what is interesting is that staff, too, begin to see the impact of that action and start to take some pride in what is being delivered, the changes that are happening and the enhancement from what is happening.

Culture is really important, and I agree with the previous speakers in respect of the role of legislation in that culture. I mentioned earlier the kinds of issues we were seeing when we started carrying out inspections, particularly in congregated settings. We have challenged that, including by cancelling a registration in some congregated settings. We have required providers to implement improvements in all those congregated settings and that has driven cultural change. We have seen staff change their approach to practice and to the support of residents. Nevertheless, the difficulty is that over time in congregated settings, there can be a reversion to previous practices and there is a high risk of that. Professor Kelly referred to the issue of people who move from congregated settings to community-based settings, where the practices can follow them. It may, therefore, become an institutionalised practice in a small home in the community. Again, that is something we will and do challenge in our engagement. One organisation whose centres we have registered and which we monitor moved a large number of people to community settings. We have found we are now challenging that organisation in terms of institutionalised care practices within the community settings, but it has made very good progress on improving the rights of the remaining residents within the congregated setting. Culture is the key to all of this.

Senator Erin McGreehan

I welcome our guests and thank them for their contributions. This issue is so important. It is clear we need to raise awareness and let people know what safeguarding is. We also need to ensure people will know that everyone has the right to their own advocacy. This shows the importance of the Assisted Decision Making (Capacity) Act 2015 and the need to change the paternalistic culture that exists in Ireland.

The education of our population is critical. Someone made a point earlier about the existing laws. Accountability is very important to me. When something is a criminal offence, it is a criminal offence whether it happens in a congregated setting or not. Moreover, certain laws protect our vulnerable persons. The briefing note we received referred to 444 people who in 2020 had alleged sexual abuse. How many of those allegations have been investigated? Were all the cases given to the Garda, given that it is the obligation under the current law to do so as quickly as possible? Our guests might correct me if I am wrong in respect of the safeguarding legislation, which I might be misreading. I am sure all those alleged sexual abuse cases were immediately sent to the Garda.

To follow up on Senator Seery Kearney's questions, when HIQA instructs an organisation to put in place a plan to mitigate a safeguarding risk, what threshold is used to measure the adequacy of that measure? We do not want only the bare minimum to be applied to deal with an issue. We want to ensure every issue will be implemented in order that the matter will be resolved.

Many of the other questions I had intended to ask have been covered. In the context of our guests as practitioners and the importance of the safeguarding legislation, perhaps we need to enhance our existing legislation and widen its scope. Often, that is the way in which the Department of Justice likes to work. Should we consider adding a Schedule to the Criminal Justice (Withholding of Information on Offences Against Children and Vulnerable Persons) Act 2012 to include more offences and impose higher obligations on people who care for vulnerable adults? As practitioners, what are our guests' opinions on expanding the offence of coercive control? The offence relates only to people who are in an intimate relationship together, but the idea of coercive control covers much of what we are talking about in respect of safeguarding legislation. Now that, thankfully, there is a law in the form of domestic violence legislation, that could be a place where we could add an amendment to include this issue. Should we mainstream our legislation to take in our entire population instead of pigeonholing our vulnerable population with one item of legislation?

One of our guests quite rightly stated the HSE has no authority to enter a private nursing home and ask questions, but HIQA does, I presume. If the HSE fears something is not right in a private nursing home, is there an automatic transfer of knowledge to HIQA to enable it to investigate an alleged breach of good practice and basic human dignity?

I thank our guests. I have learned a lot from the meeting and I look forward to hearing their answers.

Ms Sinéad McGarry

On withholding information, we know from information we have sought under parliamentary questions that nobody has ever been brought before the courts in respect of the caveat within the criminal justice Act. That has occurred despite the findings of the Brandon report such that abuse of residents that has been acknowledged and accepted by the HSE took place with the full knowledge of staff and HSE management. Clearly, that, in and of itself as a legislative measure, either is not in place as a measure or is not being used effectively.

We need to ask how that can occur over such a long period in one congregated setting and not have any legal consequences for those who are seeing people being harmed in their care. That is not specific to Brandon; it could happen in any service. Clearly, the legislation is not working.

In terms of HIQA and the HSE safeguarding protection teams, it is very important to note that HIQA has a very distinct and separate role to the safeguarding protection teams, as does the Garda in the investigation of abuse. They are distinct, separate and equally vital, and it is important that a person living in a centre receives access to all three services. That would very much be our position. HIQA comes in and does the overall systems regulation, but it cannot look in detail at individual complaints. Mr. Colfer outlined very clearly the significant safeguarding measures that it takes, but HIQA has also called for strengthened powers. We need to start to see that this is not just an either-or scenario. One service should not substitute for another. We do not do that with children and we should not be doing it in respect of adults who are at risk.

Very quickly, to go back to Deputy Cairns point on how safeguarding legislation can align with the will and preferences of people and ensure that reporting does not happen against the consent of somebody, social work is a relationship-based profession. We look to build trusting relationships over time with people. It is really important that safeguarding legislation does not actually worsen the well-being of people by introducing paternalist measures which mean that the State can start to intervene for the sake of stopping abuse, but leaving someone, as Professor Phelan discussed earlier, in a less happy state. The will and preferences of people have to be at the centre of what we do, but we also need to recognise that the lessons from domestic violence carryover. We are working with people impacted by domestic violence all of the time. We are not making reports that are putting their well-being in a worse state. We are supporting people and we are working with them to make the changes that they want to see in their lives at the right time. It is very important that legislation values that intervention so that if somebody declines a legal intervention to prevent the risk from reoccurring, we are recognising they should, if they wish, have access to a service that will support them in managing how they cope with it, increasing their safety so they know that they can come back or engage and get the help that they need at the right time for them. A lot of people are experts in their own lives.

The final caveat is on mandatory reporting. It is that piece that some people do not have the ability to speak up for themselves and seek help for themselves. Our legislative measures have to recognise and respond to that. We should not be leaving people in situations where they would like to be helped but cannot access it due to lack of mandatory reporting. That is it.

Chairman

We are under a time constraint because we have been in the room for so long. We have only eight minutes left, but we will try to get to all six people who are in front of us. We work our way round.

Professor Brendan Kelly

I came here this morning to articulate the need for safeguarding for people with enduring mental illness who are outside of congregated settings, as well as those in them, and including people outside institutions, moving between the criminal justice system and health system and so forth. There are initiatives under way with legislation and so forth that should be finished.

Perhaps the second point I want to make is slipping very comfortably into my role as the optimist here this morning, which is to say that positive change is indeed possible. We have a very dedicated and highly skilled workforce. We have all spoken about the system. As practitioners, regulators and legislators, in a sense, we are the system and well positioned. Sometimes changing the system will mean changing ourselves.

Professor Amanda Phelan

Regarding the need, or not, for specific legislation, I would say it is within members’ gift to do this right and have specific legislation. There is precedence in terms of Colette Kelleher bringing a Bill in 2017 to set up a national adult safeguarding authority. We are seeing gaps and we want the responsibility to be solely within an organisation that will actually map and avoid all of those gaps. It will follow the person and co-ordinate that interdisciplinarity between, say, police, safeguarding teams, the legal system, front-line workers and all of that. That demands that we do it right and do the right thing, which is safeguarding the decision. Members will see the many facets of what could be incorporated in that in the Lower Reform Commission’s 2019 report, where it did a position paper on safeguarding and drew on the many aspects. What came up earlier was something as simple as sharing data, which is not permissible in what we do now. Therefore, we need to make sure that responding to safeguarding concerns is made as accessible as possible for professionals as well as people who are reporting that they are concerned about somebody else or perhaps reporting on a brother or sister who is not letting another sibling visit, because they are the gatekeeper. That is coercive control.

Coercive control has a huge impact because, again, as Ms O’Connor said earlier, much of this is about power control, and that power control can be between people out in the community, but also the power systems and dynamics that happen in the traditional systems of healthcare, where there are powerful people who are nurses, doctors or others who are coming and saying what needs to be done. We need to move away from that. We need bespoke legislation that firmly protects adults. It is not only about adults who are at risk now; we may all be at risk at some point of our lives. In fact, by doing that, everyone is being protected.

Mr. Vivian Geiran

By way of conclusion and to continue the theme of positivity begun by Professor Kelly, we have a certain degree of clarity and agreement in terms of what needs to change broadly in relation to culture change, as we discussed, and the need for urgency in the rate and level of change that is happening, with the ultimate goal that we are trying to get better outcomes for the people involved who may, as Professor Phelan indicated, be ourselves at some stage in the future. It is worth highlighting Ms O’Connor’s point that we have good people in the system and good staff and so on. I would emphasise the need for all of that system, the staff and other people in it, to be supported by legislation, by the role of oversight, governance and monitoring bodies, such as HIQA, or otherwise, is very important.

We have a broadly shared understanding of what is needed. We definitely need legislation that is underpinned by human rights. We need an independent, statutory social work led adult safeguarding agency. We need to clarify, right now and into the future, responsibilities and accountabilities within the system, mandatory reporting from, right away, better data, research and co-ordination, and also in the interim, better information being made available to people at all levels and better and more training. Ultimately, we need a plan with clear responsibilities and accountabilities. Incorporated in that, we definitely need to hear more of the voice of the service users and draw more on the experience and expertise of social work.

Ms Celine O'Connor

It takes 20 years to change a culture. In 2002, we had Protecting Our Future, which was the first research done on elder abuse in Ireland. We have had changes in the past 20 years with Leas Cross, Brandon, Grace and Aras Attracta. I do not want to be here in another 20 years asking what we have done. I have a quote that I often use at training, which I will give the committee now:

May you never be the reason why someone who loved to sing doesn’t sing anymore. Or why someone who dressed so uniquely now wear plain clothes. Or why someone who always spoke excitedly about their dreams is now silent about them. May you never be the reason why someone gave up on part of themselves because you were so demotivating, non-appreciative, hypercritical, or even worse, sarcastic about it.

We need to keep people at the centre. We need to legislation because we have to move culture faster. We cannot allow another 20 years to pass. We currently use the Lunacy Regulation (Ireland) Act 1871 as the only mechanism to protect people. That will be gone in two months’ time. We will have a massive gap in terms of how social workers on the ground go to the courts and look for an order to protect somebody. It is urgent at this state.

Chairman

I like the quote.

Ms Carol Grogan

I might first just address the specific question that was put to us on thresholds used before my closing remarks if that is okay.

If there is an issue around safeguarding or risk to residents, we will look at it in a multifaceted way. The first consideration is the immediacy of the issue and the need to provide protection for that resident and all other residents in the centre. Then it is about addressing the wider issue and asking providers to look at why it happened, what they can learn from it and what they can do to improve in order that it does not happen again. It is sort of a three-tiered system, after which we go back to ensure the change has been embedded. As Mr. Colfer outlined, if the provider fails to do that, we will take action.

I echo what everybody has said today. At the heart of this conversation are the people who receive care. It is imperative for all of us to ensure they receive the safe, quality care they deserve and are entitled to and that they are afforded the same rights as we all are. HIQA and my office are committed to progressing this.

Mr. Finbarr Colfer

One of the points that came through in our discussion is around culture and the ability of legislative intervention to change culture and drive improvements for people. There is an opportunity here. A number of legislative initiatives are happening at the moment that can drive changes in culture and improvements in a number of ways. Sometimes, when we think about safeguarding, we think about abuse. In fact, it is about safeguarding in the broader term, including promoting and protecting people's rights and ensuring they have a good quality of life and a safe place to live.

Chairman

The contributions of both members and witnesses have been very thought-provoking. There was reference to the importance of not taking the sparkle out of people's lives, to use Ms O'Connor's phrase. Certain words have come across strongly this morning, namely, culture, urgency and legislation. The most powerful message, which was from Professor Kelly, is that we are the system, that we, both us as legislators and the various groups, organisations and the people within them, must be very mindful we have a very important role to play, and that no matter how hard the door is locked against us, we must keep banging on it if we believe the cause is right. We need always to remind ourselves we are the system and to keep pushing the boat to ensure the system is people centred and will advance the rights and livelihoods of those receiving care and, indeed, those of the greater population. That is very important.

I thank the witnesses and members for their powerful contributions, for their patience this morning and the time they have given to the committee and to our fantastic background team.

The joint committee adjourned at 12.33 p.m. until 9.45 a.m. on Thursday, 7 April 2022.