Congregated Settings: Nursing Homes (Resumed)

I welcome Mr. Phelim Quinn, CEO of HIQA and Ms Mary Dunnion, chief inspector of social services and director of regulation at HIQA. I thank them for joining us in the Dáil Chamber. We are joined from committee room 1 by three representatives from the HSE: Mr. David Walsh, national director of community operations; Ms Sandra Tuohy, assistant national director of older persons services and Dr. Siobhan Kennelly, national clinical advisory group lead older persons.

I advise the witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. If they are directed by the committee to cease giving evidence in relation to a particular matter and continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable.

Members are reminded of the provisions in Standing Order 186 that the committee should also refrain from inquiring into the merits of a policy or policies of the Government or a Minister of the Government or the merits of the objectives of such plans. While we expect witnesses to answer questions asked by the committee clearly and with candour, witnesses can and should expect to be treated fairly and with respect and consideration at all times. If they believe that they are not being so treated I ask them to bring it to the attention of the committee.

We are not taking an opening statement from the HSE as last week we received a statement from Mr. Paul Reid, CEO of the HSE. I invite Mr. Quinn to make his opening statement and ask that he limit it to five minutes. As we received the opening statement in advance, it has been circulated to members.

Mr. Phelim Quinn

I welcome the opportunity to address the Special Committee on Covid-19 Response. I am joined by my colleague, Mary Dunnion, chief inspector of social services and director of regulation.

Before I start, on behalf of HIQA, we wish to convey our sympathies to the families of those who have died in nursing homes and across the country during this pandemic.

HIQA, through the office of the chief inspector, registers and inspects 584 nursing homes accommodating approximately 30,000 residents. From the onset of this public health emergency, HIQA has endeavoured to make an effective contribution to the national response through our interactions with the Department of Health, the HSE, providers, residents and relatives. While routine inspections were not initially possible, HIQA has a process in place whereby all centres are formally contacted by an inspector on a regular basis to assess how they are managing in the provision of safe services to vulnerable service users. In addition, the chief inspector issued eight regulatory notices with the aim of reducing the regulatory burden on providers.

Inspections required to register new centres or facilitate increasing capacity have been expedited within days. HIQA has provided information to the Department of Health and the HSE on those centres with a history of poor compliance with key regulations, as those services were at increased risk of Covid-19 outbreaks.

Formal processes are in place whereby HIQA escalates actual or potential risk to the HSE’s crisis management teams. On a weekly basis, the chief inspector and her leadership team meet the HSE to formally discuss ongoing issues and to escalate risk within the sector.

To support the public health response, HIQA provided the HSE with key information such as the locations of nursing homes, the number of residential beds and staffing levels. Furthermore, the HSE and the Department of Health availed of HIQA’s online notification system to ensure the timely distribution of information to all nursing homes.

Currently, 80% of nursing homes are operated by private providers. Although funded through the nursing homes support scheme, the HSE did not know this sector. As a consequence, the infrastructure required by the HSE to support the private sector was under-resourced and became increasingly challenged. In addition, the current model of private residential care for older persons has no formal clinical governance links with the HSE. Importantly, this means there is no national clinical oversight of the care being delivered to some of our most vulnerable citizens.

Many nursing homes and disability centres were adequately prepared and managed to contain Covid-19 outbreaks. However, the private nursing home sector faced unique challenges. For example: timely testing and results; access to sustainable levels of PPE, oxygen and subcutaneous fluids; and baseline staff numbers, including senior nursing expertise in infection prevention and control.

In recognition of the difficulties faced by the providers of residential services, HIQA initiated a number of interventions from 5 March. These included the escalation to the HSE and the Department of Health of risks and trends requiring a more co-ordinated national response. On 18 March, HIQA made a formal offer to assist the HSE in liaising with designated centres. This was in recognition of the fact that there was no established relationship between the HSE and the private sector.

Every day HIQA collates data on the number of designated centres with suspected and confirmed cases of Covid-19, as well as the numbers of unexpected deaths in designated centres. Since the end of March, this information has been supplied on a daily basis to the Department of Health initially, and then to the HSE and the HPSC.

From 1 April, HIQA requested a formal escalation pathway for a more strategic co-ordinated approach to the supply of PPE, resident and staff testing and results, a longer-term approach to staffing and infection control advice.

To provide support and assistance to providers and staff, HIQA established an infection prevention and control hub on 6 April. HIQA continues to review information received from members of the public, care staff and family members.

It must be acknowledged that the creation of crisis management teams in each CHO area and the resources provided by the HSE at the community level played a significant part in supporting the private sector, and importantly, in protecting residents. COVID-19 has presented significant challenges to the current models of care in place for our older citizens. Since our establishment, HIQA has endeavoured to influence policy in the area of older persons’ services based on our experience of the sector.

HIQA believes that the quality and safety of our health and social care services would be greatly improved by a review of the current regulatory framework and the introduction of an accountability framework, to include a commissioning model. As part of an accountability framework, HIQA believes that a system of care management could be introduced across the HSE’s community service areas. Such a model would closely align with the principles and goals articulated within Sláintecare, as the key aim of the system is to support people in, or as close to their own homes as possible. These care plans are based on a multidisciplinary assessment and would enable a sustained shift away from institutional models towards a more person-centred system whereby care is provided in the home. I thank the members for their attention this afternoon. We look forward to answering any questions they may have.

I thank Mr. Quinn for limiting his opening statement to five minutes. I call Deputy O'Dowd.

I extend my deepest sympathies to the families of all the people who have passed away in our nursing homes and in our society as a result of Covid-19. I recognise absolutely the hurt and pain people have, particularly when loved ones pass away in a nursing home. They do not get to see them or say goodbye. It is an appalling vista which is brought about by the nature of the virus itself. I also acknowledge the tremendous work of all our health service people, workers in nursing homes, care assistants, cleaners and people who help out in every way. These people do fantastic work, often for very poor wages and without proper recognition.

I have met Mr. Quinn and communicated with him. I have appealed some of his decisions to the Information Commissioner in the past, in an effort to get transparency around the care of people in nursing homes. I wrote to him on Tuesday, 24 March seeking an entitlement which I believe the people had at the time and still have, namely, a categoric assurance from HIQA that all nursing homes and care homes are fully compliant in infection control. The reason I wrote the letter was the HIQA report to which I referred earlier, which indicated that, at the time, only 123 of the 581 nursing homes subject to HIQA inspection met in full all of the regulations. I did not get that commitment from Mr. Quinn. While I note what he is saying here today, as I understand it, he has to be accountable. The office of the HIQA chief inspector has statutory responsibility for the registration and inspection of nursing homes and other residential services for children and adults with disabilities. As part of its remit, HIQA can inspect nursing homes and make binding decisions relative to the safety and quality of care provided to residents following inspection. That is the statutory power HIQA has. I note Mr. Quinn's call for additional powers, with which I do not disagree. Why was Mr. Quinn not able to give that categoric assurance to me and, more importantly, to all of the residents that all of the homes they were living in were fully compliant in infection control? Clearly, we both know they were not. That is my first question.

Mr. Phelim Quinn

If it is okay with the Deputy, I will pass to my colleague, Ms Mary Dunnion, chief inspector. To be clear, in my response to the Deputy I suppose what I was trying to articulate was the fact that as part of the general response to Covid-19, a multi-agency response was required in terms of getting that sort of assurance for this pandemic.

Mr. Phelim Quinn

In respect of the some of the figures the Deputy has mentioned, which were contained within our 2018 overview report, I will pass to my colleague, Ms Dunnion, to give the Deputy some update.

With respect, I have no problem with that but right now, the question is to the chief executive, not to the chief inspector. If Mr. Quinn wants to pass it, that is fine, but I think he should answer it.

Mr. Phelim Quinn

The chief inspector of social services is a statutory post-holder directly responsible to the Houses of the Oireachtas. It is for that reason that I wanted her to provide the members with some direct information on the statutory role that she provides.

As a regulator of health and social care services we cannot give absolute assurance. It is our responsibility to provide assessments of compliance with regulations and standards and report on these, and to take subsequent action to ensure compliance is achieved through the enforcement contained in the legislation. I really would like to take the opportunity, if possible, to pass to my colleague to give the Deputy some further details.

I will respond to that reply afterwards.

Ms Mary Dunnion

I thank Deputy O'Dowd. In 2019, which are probably the more up-to-date figures, 238 inspections included regulation 27, which is the one particular to infection control. Of these 238 inspections, 20 cases were not compliant and a significant number were only substantially compliant. There are several reasons for this. The national standards for community centres called for a national integrated approach to infection control and antimicrobial stewardship. To date, this is not in place. On the rare occurrences when outbreaks of winter vomiting and influenza occur these procedures are effective but the national standards are not able to deal with the case of a pandemic.

One of the big issues that makes centres not compliant is the premises. In this context, there is a statutory instrument that gives nursing homes until January 2021 to become compliant. Until they reach this level of compliance they cannot be compliant with the standards of infection control.

For clarity, what was the percentage that was not compliant?

Ms Mary Dunnion

Of the 238 inspected, 20 were fully not compliant with infection control standards.

In fact, this is a higher percentage than the previous year because it was 18% and now it is more than 20%.

Ms Mary Dunnion

No, 20 of the 238 cases.

I apologise. I have not seen the figures. I am glad Ms Dunnion has given them to me.

There is a particular problem when nursing homes are inspected and major or minor non-compliance is found and I will use a particular nursing home as an example but I will not name it. This particular nursing home was inspected in March 2019 and the report was published in July 2019 but the follow up inspection was not until December 2019 and that report was published in March 2020. There was a year between the first inspection with negative outcomes and the report of the follow up inspection which, in this case, appeared to show compliance. Without going into the details, this nursing home was non-compliant with regard to health and social care, safeguarding and safety, residents' rights and dignity and suitable staffing. Its complaints procedure is compliant. Notwithstanding all of the powers HIQA has, the process of inspection and follow-up does not seem to be working as quickly as it ought to be. I appreciate that follow-up is part of the process but it is not fast enough or good enough.

There is no change in the figures we have. The majority of nursing homes are not compliant. In this crisis HIQA is statutorily accountable. I do not suggest it is passing the buck to anybody else, and I agree it includes other agencies, but ultimately the buck stop with it. As an inspectorate, does HIQA require more staff? The witnesses can correct me if I am wrong but the figure in its most recent report was that 76% of nursing homes were inspected last year as opposed to 100%. If HIQA does not have enough staff to investigate, look at, help and support private and public nursing homes it cannot do its job. Does HIQA need more powers? It seems that non-compliance can drag on and on. I do not agree there is a difference between major and minor infractions. By definition, a nursing home should be 100% compliant. Does HIQA need more powers to ensure this happens? A huge part of this is not just finding what are the issues but training and making available to public and private nursing homes the professional capacity to upskill all of their staff. It is good enough finding fault in one sense but if people do not upskill an inspector cannot be there 24-7.

We have had a serious problem with a private nursing home in Dundalk where there has been an awful lot of sadness and upset at the terrible outcome for so many people in a very short space of time.

It seems there was a situation whereby out of a total of 24 professional staff, particularly nurses, only six were available to maintain that nursing home because of illness and absence for other reasons. Given that we are in this sort of crisis, not just nationally but internationally, does HIQA, in the context of its investigations, have the power to seek information from the nursing home, from the HSE and from others in order to get to the bottom of what happened and give closure to the families in Dundalk that are so distressed?

Mr. Phelim Quinn

I will reply, in the first instance, to the Deputy’s question on powers. In recent years, we have sought a review of the regulations. The regulations that currently obtain were developed, in the main, in 2009 and, subsequently, in 2013 and are worthy of review to keep pace with current models of care.

Before passing over to Ms Dunnion, I must stand that, in the context of the training of staff, at the beginning of our corporate planning period last year, we changed the emphasis of some of the work we have been doing regarding standards development. We have been looking at the development of training and guideline materials to assist the implementation of standards within health and care settings. For example, we have developed a training module in regard to infection prevention and control in the community standards and we are also in the process of developing a training and guideline module for human rights-based approaches to care across the nursing home sector.

I ask our guests to be brief because we are over time.

Ms Mary Dunnion

We have enforcement powers but they are sometimes difficult to enforce. By way of example, three nursing homes which were taken to court over the past two years pursued two judicial reviews. We currently have legal cases pending on regulatory decisions I have made in the context of registration. We have the powers to seek the information the Deputy mentioned. We have begun the process for the nursing home he mentioned and, in fact, I am there tomorrow for an on-site inspection.

Were those judicial reviews successful or unsuccessful?

Ms Mary Dunnion

They were unsuccessful for those that made them and successful for us.

I would also like to express my sympathies to the families who have lost loved ones, particularly in nursing homes, and to the staff who cared for them. It is incredibly distressing.

I would like to continue the questioning in regard to Dealgan House Nursing Home. It would be fair to say that Mr. Tadhg Daly of Nursing Homes Ireland spoke about what he saw as a major failing in regard to the testing of residents, the shortfall of PPE and the aggressive recruitment of nursing staff. I would also say that maybe plans were not in place for a situation such as an outbreak of Covid-19 in Dealgan House-----

I am not sure it is appropriate to refer to a particular nursing home.

I have a number of questions which are quite general but if I could have specific answers regarding Dealgan House, it would be helpful. Mr. Daly also spoke about the discharges from acute hospitals and he put it down squarely to difficulties across nursing homes in general. With regard to Dealgan House Nursing Home, there were obviously a huge number of issues and it is an absolute tragedy. I would like to know at what point HIQA became aware and how it escalated the issue. I would also like to know how the HSE first became aware and how it escalated the issue, given that it obviously reached a point where the RCSI hospitals group was appointed in or around 17 April. I would like to have those answers first.

Mr. Phelim Quinn

If the Deputy does not mind, my colleague is dealing directly with the situation in respect of that nursing home and the ongoing investigation.

Ms Mary Dunnion

The way we organise our work is that a number of nursing homes will always have a designated inspector and, as a result, we were very aware of the issues in the particular nursing home. They were escalated in a formal way through the CHO area and through the HSE.

Can Ms Dunnion give me a timeline for that?

Ms Mary Dunnion

I have not got the exact timeline but I can certainly provide it to the Deputy. It was immediate, however, because we have a daily escalation pathway.

We are familiar with the situation and our review of it has begun. We have completed meeting the relatives of families there, and as I mentioned to Deputy O'Dowd, as of tomorrow we will be inspecting in the area we are discussing.

All of that is welcome. I spoke to a number of families and they are glad to have that interaction.

It went from HIQA to the HSE. Can anybody give me an answer to who made the decision, and why, for the RCSI hospitals group to take over operational control?

Mr. Phelim Quinn

Our colleagues within the HSE might be able to help.

Mr. David Walsh

To the best of my knowledge, the first two suspect cases in Dealgan House Nursing Home became known on 31 March and the confirmation of diagnosis was on 4 April. From that time, Midlands Louth Meath community healthcare organisation, CHO, was involved with the nursing home and subsequently on or around 17 March the RCSI hospitals group made a decision to become more centrally involved. In the interim period, however, a number of supports had been given, including staff supports from both the acute hospital and community setting as well as personal protection equipment, PPE, infection control advice.

So the HSE became aware from on or around 4 April?

Mr. David Walsh

We became aware of the first suspect cases on 31 March.

When Mr. Walsh talks about involvement from on or around 4 April or early April, what did that consist of?

Mr. David Walsh

It consisted of staffing, assistance with PPE - I think the first delivery was overnight between 4 April and 5 April - and assistance with items such as oxygen and other advice. Midands Louth Meath CHO, or CHO 8, was involved from-----

That is okay. When was the decision made to take over operational control? Will Mr. Walsh give me the reason, while accepting there were huge problems in the place?

Mr. David Walsh

My knowledge is that, on or around 17 April - I can be corrected on that - the senior staff in the RCSI hospitals group became so concerned that they decided, by agreement with the nursing home, that it was appropriate to put in a bigger team and management team to assist them through the process.

So it was the staff Mr. Walsh put in on the ground who made the decision?

Mr. David Walsh

It was based on that knowledge, yes.

From the start of March to the start of April, how many patients from acute hospital facilities were transferred to Dealgan House Nursing Home? This is one of the problems that Nursing Homes Ireland has put out as being a possibility. It has also put out that the HSE guidelines on visitors could have been a problem.

Mr. David Walsh

I do not have that specific information but I am happy to follow up on it for the Deputy.

That is absolutely fine. At this time, I am glad to see that HIQA is carrying out an inspection and is talking to families. I hope that will arrest any difficulties and highlight any issues that will be built into wider operational protocols across the board so we do not have another Dealgan House scenario. I would like some clarity on whether, when that report is finished, it will be furnished to families beforehand. Beyond that, when will a decision be made on operational control?

Would the RCSI consider handing back control before this report is published? Whatever conditions and mistakes are found in the report, they must be rectified and we must ensure we have plans into the future.

Ms Mary Dunnion

In the context of this particular nursing home, the registered provider is the responsible entity. That is the position as it stands. We publish all reports. We will always link in with those that we have dealt with in the relevant context. The registered provider, as the legal entity for the particular nursing home, will have the right of reply on all reports. The report will have to go through a due process procedure. Once that is finished, it will be published aligned to all the reports that we publish.

Is it correct that there are additional nursing staff in Dealgan House nursing home and that infection control specialists and nursing managers have also been involved? Will that remain the case? I understand that the position is to be reviewed at the end of May, although I know that certain staff working in Dealgan House were slightly afraid that this may happen at an earlier stage. I would like some clarity on what conditions have to be met. We must also ensure that we have best practice and plans to maintain best practice.

Ms Mary Dunnion

I do not know the position because we will not be on site until tomorrow. We will be measuring against the nationally mandated regulations with which the registered provider must ensure compliance. If it is not compliant, it must have a plan to achieve compliance.

Mr. David Walsh

If I could add to that, my understanding is that, as of today, there are no staff from either the RCSI hospitals group or the midlands, Louth, Meath CHO actively participating in a shift in Dealgan House. However, Dealgan House is still availing of advice and guidance from the RCSI hospitals group.

In that case, is it correct that an element of oversight will be maintained? If so, for how long will it be maintained?

Mr. David Walsh

Through the area crisis management team process, there is a system of contact between the HSE and every nursing home, public, private or voluntary. That system remains in place for the duration of the pandemic.

The big thing is to ensure that we arrest all the problems and ensure they do not arise. I would also like to ensure that a contact infrastructure is in place so that when people believe a situation like this is about to arise, that information gets to the HSE and HIQA as quickly as possible. Is such infrastructure in place? How should staff, family members or others act in such circumstances?

Mr. David Walsh

There is ongoing engagement and a system. In the midlands, Louth, Meath CHO specific contact points are available for every nursing home. Should people have concerns, they can contact their local CHO as well as the regulator obviously.

Ms Mary Dunnion

In addition, there is a concerns line in place for all residents, families and staff to contact HIQA. As the Deputy mentioned, some have availed of this.

What is the HSE's response to the various concerns raised by the two witnesses this morning? How many inspectors does HIQA have? Why is there a designated inspector for individual nursing homes? Would it not be better to have random inspections? Did HIQA receive any complaints from nursing home staff, families of residents or individuals with knowledge of nursing homes and the care of the elderly at this particular stage in Covid-19? If so, what was its reaction to them?

In his opening statement this morning, Mr. Taylor stated there was little knowledge of the nursing home sector in the HSE. However, it is the HSE and the nursing homes support scheme that gather all the information on each individual client in these homes. There is, therefore, a lot of information circulating within the system and that seems to have been ignored. Those are my first questions.

Ms Mary Dunnion

I thank the Deputy.

Ms Mary Dunnion

I thank the Deputy. There are 24 inspectors for the 580 nursing homes. We have a concerns line and since 1 March we had 28 concerns in March, 176 in April and 88 thus far in May.

Can Ms Dunnion repeat that?

Ms Mary Dunnion

From 1 March we had 28 concerns in March, 176 in April and 88 thus far in May.

Where are these coming from?

Ms Mary Dunnion

The concerns come from staff, families and residents themselves. Predominantly, the issues staff have brought to our attention are the availability of PPE, testing and results, and infection control advice and procedures. Families have raised significant issues around safeguarding; quality of care; communications; the impact of visiting restrictions; social isolation for their families; obviously and very sadly; and the death of residents. Some families expressed concerns about the fact that we were inspecting. Residents have contacted us and predominantly the areas residents have brought to our attention concerns the issue of isolation and not seeing their families and the loneliness associated with that. They also had some concerns around their food within the particular nursing homes.

We follow up on all of the information we receive. Since 1 March we have conducted nearly 200 inspections across the nursing home sector and, as I said, some risk inspections are ongoing. All these concerns are followed through. Everybody gets to speak-----

What was the finding? Were all these concerns upheld?

Ms Mary Dunnion

No, not all of them.

How many of these concerns were upheld?

Ms Mary Dunnion

I would not be able to give the Deputy the number of concerns that were upheld because the majority of them centred around the fact that families were unable to see their family members within a nursing home. That was significant and such was our concern that two weeks ago we wrote to the Health Protection Surveillance Centre to see if we could get public health guidance on how nursing home owners may be able to open their doors in a controlled manner with public health precautions so families could see their loved ones in nursing homes. That decision has yet to be made.

There is less than a minute left but will the HSE comment on this morning's statements from witnesses?

Mr. David Walsh

I might ask Dr. Kennelly to talk about the discharge issue.

Dr. Siobhán Kennelly

A number of statements were made by Mr. Daly, particularly on the issue of acute discharges and how they were managed over the period of the pandemic. It is important to understand that national guidance was being issued from the earliest possible point. Much of that national guidance reflected the fact that we were learning about the pandemic as it evolved. There is no handbook to much of this, as many of the Deputies will understand.

If I can just interrupt-----

Dr. Siobhán Kennelly

Essentially, the initial guidance issued on 10 March-----

Does Dr. Kennelly broadly dispute-----

Dr. Siobhán Kennelly

-----referred to protocols around how those would be safely managed. In all cases where testing was needed, it was directed. That was based on our knowledge of the clinical course of the presentation of Covid-19 in older people at that time. There were also strong recommendations made in respect of facilities where residents might have had contact with patients in acute hospitals, that those facilities were able to isolate those patients and provide the appropriate level of IPC support. That was all out there from the earliest possible stage.

Can my question be answered when we get the sound sorted?

In fairness to Deputy McGuinness, he had a question which Dr. Kennelly did not hear because there are sound problems. Could the Deputy repeat it?

Does Dr. Kennelly dispute the statements made by both witnesses this morning or does she accept some of the criticism and charges made in those statements?

Dr. Siobhán Kennelly

I refute it. As a matter of public record, I can show the Deputy evidence of the correspondence that myself and officials in the HSE issued through the system, in line with the public health advice and with colleagues from Infection Prevention and Control. It is very important to understand that we are in a very fast-moving situation when we are trying to address these issues. We were aware of the fact that we had approximately 670 delayed discharges in acute hospitals at that time.

One of the biggest concerns for me, both as a clinician and as a geriatrician who is very involved in the care of these patients, was that in the event of an anticipated surge in these acute hospitals, many of those who had finished their acute episodes of care would be at very high risk in terms of contracting Covid. Everything we did and all the guidance we issued - including the very comprehensive guidance that was issued again on 17 March regarding how patients would be cared for in nursing homes, regardless of whether they were in public or private facilities - was on the basis of the information we had and our understanding of the pandemic. In addition, there was a balancing of the risk for individual residents and how that risk would be managed by clinicians in acute hospitals and in long-term care settings.

I ask Dr. Kennelly to send that guidance to the committee.

I think the members should move to the committee room.

It might cause a public health risk if we were all to crowd into a committee room. We are limited in terms of what we can do and how we do it.

Deputy McGuinness queried the appropriateness of inspectors being allocated to certain care institutions and asked whether it should be done on a random basis. What is Ms Dunnion's view in that regard?

Ms Mary Dunnion

I understand why people might wonder about that. The issue is that some inspectors may have responsibility for 30 nursing homes, although that rotates over a period and is not a fixed allocation. As nursing homes and disability centres are scattered throughout the country, sometimes the location determines which inspector can be assigned.

I wish to offer my condolences to those who have lost loved ones and to people living in nursing homes who have lost their friends, especially in light of our normal cultural ways of mourning loss being so difficult to achieve.

It is a great privilege for me to be here to ask questions of our guests. As a social worker, I am usually the one on the receiving end of interrogation by HIQA. It is nice that, for once, the tables are turned. Mr. Quinn stated that there is no clinical governance linked to the HSE for private nursing homes. I ask him to deal with the clinical governance for private nursing homes. Are there minimum staffing levels, staff-resident ratios and so on? How are such matters decided? What clinical governance exists, apart from HIQA enforcing standards?

Mr. Phelim Quinn

In local clinical governance, a number of nursing homes have a system whereby they link in with GPs, have assigned GPs or, in some instances, have medical officers who take responsibility for clinical governance arrangements. Obviously, individual residents who may have been referred into gerontology or other forms of services have specific links in that way. The key issue I outlined in my opening statement is the fact that there is no specific national structure or control in the context of the clinical oversight of the care of people who have been admitted to nursing homes as a result of multidisciplinary or other assessments. That absence is problematic as matters stand.

On minimum staffing levels, I will defer to Ms Dunnion in her role as chief inspector of social services. Issues in that regard were raised in the session this morning.

Ms Mary Dunnion

The regulations are weak when it comes to staffing. HIQA would very much welcome those regulations being looked at and would be happy to work on and contribute to that discussion. The regulations are very weak. It was stated during the session this morning that HIQA does not allow ratio staffing. That is totally untrue. The staffing levels are determined by the legal entity, namely, the provider of the nursing home, be it private or statutory. In a clinical context, staffing levels are not weighted as highly in a nursing home.

By way of example, the legislation describes "a person in charge of a nursing home", whereas a director of nursing with gerontology would be a much stronger description. There are significant opportunities to look in that context at staffing and we can see the challenges staffing brought during this pandemic.

Is there a difference in the requirements between statutory, HSE-run nursing homes and private nursing homes regarding staffing or are the weak regulations affecting both?

Ms Mary Dunnion

The staffing levels depend on the registered provider. We identify a significant shortage of staff if we see it, but it is totally dependent on the provider. Statutory nursing homes and private nursing homes will decide their own staffing levels, and I believe the regulations are poor in that context.

I thank Ms Dunnion. A question that is perhaps more relevant for the witnesses from the HSE concerns how infection control is going to change how nursing homes operate. We are all trying to cope with social distancing, including down to the other side of Leinster House here. Fewer people are going to be in nursing homes as a result of social distancing. How will the system cope, on the statutory side in particular, with those changes and that impact? Is there concern about a reduction in admissions to nursing homes and the knock-on effects? If that happens, there will be a major loss of income from falling numbers. How does the HSE see the nursing home sector in general managing to cope with that? If the private sector is under more pressure, will that in turn put more pressure on statutory and community services?

Mr. David Walsh

I am conscious of the time. Deputy Costello is correct that capacity, in any setting, whether acute or long-term care, will be different in future, depending on the premises. There is an issue, and we need to rethink our model of care to address those issues because there is no short-term way of increasing bed stock or otherwise increasing capacity. We need to examine the model and see how we make it function in future. I am sorry, but I think we are out of time on that issue.

I call Deputy Duncan Smith of the Labour Party.

I would like to pick up on HSE clinical oversight. There is obvious concern about the lack of HSE clinical oversight of nursing homes. HIQA has been the regulator for more than a decade now. After many visits to and engagements with nursing homes, did it at any point write to the Department of Health or the HSE prior to spring 2020 regarding that oversight model? If so, when was that and what were the details of that correspondence?

Mr. Phelim Quinn

In the course of recent years, we have written to the Department of Health on many occasions regarding the regulatory framework and the way that framework impacts on the sector. One of the key issues, for example, even concerning the advent of Sláintecare and planning for a statutory home care scheme, is that we have submitted several regulatory models to the Department of Health. They try to account for the older persons care pathway to ensure the regulatory framework spans that pathway and is not specific to individual care settings. I believe issues such as clinical governance could be addressed in that.

Has any response been received? Was there any kind of encouragement from the Department regarding taking this up or has HIQA been stonewalled?

Mr. Phelim Quinn

I would not call it stonewalling. There has been engagement with the Department on things such as the statutory home case scheme. That scheme, however, appears to continue to be in development as a separate scheme. Our recommendation, however, based on our own experience within the sector, is that there should be more of a regulatory framework that spans the entirety of older persons services.

That is fine. I want to be clear on whether HIQA has physically visited any of those nursing homes in which there have been outbreaks. We know the inspectors need to use PPE etc., but have they gone in person to where there have been outbreaks?

Mr. Phelim Quinn

Again, I will ask my colleague to answer that. Most of what we have done up to this point has been based on information that we have also been exchanging with our colleagues across the four UK jurisdictions and across Europe. The pattern of inspection that we have engaged in has been very much informed by the engagement that we have had. My colleague will provide detail for the committee on the types of inspections that we have done to date and on the fact that we have reserved the right to do what we term risk-based inspection throughout the pandemic.

Ms Mary Dunnion

To date, we have not gone where there has been a Covid outbreak. However, that situation is changing because we are moving now into risk-based inspections under the guidelines of the national public health guidance. As I said, we have conducted a number of inspections since March but these have been, generally speaking, in the context of either opening new centres, changing so that there can be increased capacity if that is feasible and correct in line with the regulations and around contingency planning, particularly in the nursing homes that did not have an outbreak because we identified the risks. We learned, as did everybody else. That has been a good exercise with the nursing home providers. The feedback has been very positive in the context of that. We begin risk-based inspections now.

That will happen in places where there are outbreaks.

Ms Mary Dunnion

Yes.

That is good to know. In terms of the gerontological expertise within the leadership of HIQA, I understand none of the 15 Covid-19 health technology assessment guidance focuses on older people in nursing homes. What is the expertise for the nursing home area within the leadership of HIQA in terms of this crisis?

Mr. Phelim Quinn

There would be no specific medical gerontology expertise within HIQA. However, all HIQA staff are recruited with specific expertise across a range of specific services, which includes gerontology. This could be staff from a nursing and social care background or allied health professionals background.

Is that being addressed now? Has HIQA acknowledged that this lack of expertise should have been addressed previously and is it now rectifying the situation?

Mr. Phelim Quinn

It is not something specific because the other key issue as well is people with an aptitude for the role of a regulator. The Deputy mentioned as an example the evidence summaries that have been developed by our health technology assessment directorate. It must be noted that our health technology assessment directorate works on the basis of engagement with experts and expert advisory panels, which include gerontologists. All that work is informed by medical and other relevant scientists and expertise.

I thank Mr. Quinn and Ms Dunnion for their responses.

I thank the witness for the presentation. I made a point earlier that I think is worth repeating, namely, we are viewing all of this in the context of an extremely weak and irresponsible policy context. If anything, we should learn from this experience that this virus has exposed huge weaknesses in how we provide social care in this country.

I was struck by the comment in Mr. Quinn's opening statement that 80% of nursing homes are operated by private providers and that although they are funded largely through fair deal, the HSE did not know this sector. It is a damning statement of our national health service that in regard to up to 30,000 very vulnerable patients resident in nursing homes, the HSE did not know this sector and it needed to get information from HIQA. Mr. Quinn went on to speak about the current model of private residential care having no formal clinical governance links with the HSE, which is really extraordinary. There is no national clinical oversight of care for what is probably the most vulnerable group of patients in this country. That is damning.

I have some questions in regard to HIQA's action in this regard. It is clear HIQA had serious concerns about the lack of clinical oversight for this large number of patients. What did it do with those concerns? With whom were they raised? Apart from commenting on them in reports, with whom did HIQA raise them and on how many occasions did it raise them with the HSE, the Department or Ministers? What was the reaction when it did so?

Mr. Phelim Quinn

I agree with the Deputy that the circumstances of Covid-19 have exposed a significant number of weaknesses in the system. This is one of them. It is quite interesting that, as part of the solution and in the context of the work being done jointly by ourselves and the HSE in the endeavour to support the work of private nursing homes subsequent to the pandemic, we have seen greater co-ordination of care and a greater understanding of where care takes place within the sector. As already stated, on a number of occasions we have raised issues that we have had regarding the current regulatory framework. We have written papers and submitted them to the Department, which in the main is the policymaker in this instance.

On how many occasions would that have been done?

Mr. Phelim Quinn

There have been a number of occasions and, as an example, we have certainly repeated or resubmitted the paper on the regulatory framework relating to the older persons' continuum on a number of occasions. In the advent of the development of the Sláintecare project office, we had discussions with the director.

Did the authority receive responses to those?

Mr. Phelim Quinn

No, we have not received specific responses. Part of the engagement is ongoing. For example, the discussions relating to this have formed part of the basis of our discussions with respect to the statutory home care scheme.

What about before that or the advent of Sláintecare?

Mr. Phelim Quinn

From memory, unless my colleague would reply differently, I do not remember a specific reply.

There has been no response from the Department of Health to concerns about the lack of clinical oversight in the nursing home sector.

Mr. Phelim Quinn

No.

That is quite extraordinary. I thank Mr. Quinn for his answer. My second question relates to infection control. The authority does many annual inspections in respect of infection control and there are many concerns about that. At what point did the authority raise concerns about particular nursing homes that had fared poorly in inspections relating to infection control in the context of the virus?

Ms Mary Dunnion

We publish all of our reports; they are in the public domain. At the onset of this particular pandemic, we identified premises that would be challenged in the context of managing Covid-19 outbreaks. Our findings would have been communicated to the Department of Health and the HSE. We are talking about February and March.

A list of nursing homes that would have been in the high-risk category would have been submitted.

Ms Mary Dunnion

Yes. We went further than that. We took a look at particular types of nursing homes that would have been at risk in the event of a Covid-19 outbreak. We would have determined these to be single, stand-alone providers and limited companies, as well as those with regulatory non-compliance not only with infection control but with governance and management, risk management and staff training.

To clarify, was a list submitted-----

Ms Mary Dunnion

Yes.

-----or were these types? Was it a list of nursing homes about which there were concerns? Was there a response to that list?

Ms Mary Dunnion

It was just an acknowledgement.

Was it from the Department or the HSE?

Ms Mary Dunnion

It was from the Department.

We are seeing a serious attempt to pass the parcel today on the part of all the witnesses. It is not a failure of any one body - Nursing Homes Ireland, HIQA, the HSE or the Department - but at its heart it is a gigantic political failure to act in the interests of our elderly people. Since the late 1980s we have been privatising the care of the elderly. It was described by the Ombudsman in a 2010 report as a creeping move towards privatisation that has now become a gallop. We have a reversal of what we had in the 1980s today, with 80% of nursing homes in the private sector and 20% in the public sector. There should be no attempt by anybody to say "It is not me, it is them or it is not them, it is me". All are to blame here.

I point out to the HSE and HIQA that this is very similar to the Ruth Morrissey case in the context of CervicalCheck. The court was very clear in that instances when it stated that one cannot argue that because a service or care is subcontracted, responsibility can be passed on. Both HIQA and the HSE accept that patients are referred to private nursing homes. Responsibility for what has happened here cannot be avoided.

I have a couple of questions for the HSE. I understand Mr. Walsh is a member of NPHET. Is that correct? We went through the minutes of NPHET, a committee which has been meeting since early January, and the first mention of care of the elderly was in early March. Can Mr. Walsh tell me when he decided that this was an issue for NPHET?

Mr. David Walsh

I can confirm that I joined NPHET for the first time on 10 March. My knowledge of proceedings starts at that point in time.

Was Mr. Walsh brought on to NPHET specifically for this issue?

Mr. David Walsh

I was brought on as senior operational manager within the HSE. My understanding is that at the time there was a decision to broaden the membership of NPHET to incorporate a broader perspective. I am not sure who else came on board at that time, but I and-----

That is fine. I will run out of time.

Mr. David Walsh

Okay.

It is clear that prior to Mr. Walsh coming on to the committee there is no mention of care of the elderly in the NPHET minutes. Despite this being a global phenomenon, it seems to have gone under the radar.

In the first three months of this year, 2,500 people were transferred from acute hospital settings into nursing homes under the fair deal scheme. Can Mr. Walsh tell me how many of those people were tested for Covid-19 before they were transferred?

Mr. David Walsh

I cannot. I do not have that detail.

Could he get that detail for us? I find it surprising that he does not know how many patients were moved from acute hospitals to nursing homes, having been or not been tested.

Mr. David Walsh

There are a couple of questions within that, including when testing first became available. I am happy to follow up on that for the Deputy.

I thank Mr. Walsh. My next questions are to HIQA. In its statement, HIQA said it told the HSE about specific homes. What specific homes did it warn the HSE about? Did it warn the HSE about specific homes and what action did the HSE take on foot of that? The statement also said that HIQA told the HSE where the homes were. Does that mean HIQA told it where all of the homes all over the country were located? If it did, did it highlight what particular homes it felt might struggle more than others based on its previous inspections, especially the 18% or so of homes that failed inspections?

I ask that particular institutions not be named, if possible.

Mr. Phelim Quinn

That is fine. The first part of the Deputy's question referred to particular homes. We dealt with those homes that had made contact with us and were struggling to cope with the virus within those homes. At that point, we referred specific issues to the HSE for support.

The location of homes gets to the heart of what I said earlier. The HSE is not necessarily familiar with the entirety of the sector. We supplied it with information on locations, the numbers of residents and staff etc. in those homes.

I want to reference the point made by my colleague earlier. She had provided to the Department a list of high risk homes.

I understand Ms Sandra Tuohy, assistant national director for older persons services, wants to answer Deputy Smith's question. Is that correct? I was told by the secretariat that Ms Tuohy wished to speak. If I am incorrect in that, we can move on.

Can I ask one final question?

You are out of time.

I lost seconds because of the Chairman's intervention.

The reason I intervened was that you asked the witnesses to name particular people. You are in the Chamber longer than I am.

I am not asking for names. I want one short message from the HSE. Is it now testing staff before they take up roles in nursing homes?

Mr. David Walsh

I did not hear the start of the question. I am sorry.

Until 12 March, the HSE was not testing staff in nursing homes. Then, the testing started after we raised the issue here in the Dáil. Is the HSE now, this day, currently, testing staff who enter nursing homes to take up a job?

Mr. David Walsh

I will ask Dr. Kennelly to answer that.

Dr. Siobhán Kennelly

One of the opportunities here is to highlight the limited role that kind of testing approach actually has. Unfortunately, the way it actually is with Covid-19 testing is that a person can test negative for it today and be positive for it tomorrow. We have learned hugely through the risk of-----

Please be brief in your answer, Dr. Kennelly. We may get an answer in more detail by way of correspondence.

Dr. Siobhán Kennelly

We have learned hugely about the disease in the course of the pandemic. We know that asymptomatic transmission-----

I do not know whether it is a sound problem or a more general communication problem. Please be very brief and maybe provide a more detailed answer by way of correspondence.

It is a "Yes" or "No" answer.

Dr. Siobhán Kennelly

That is fine. I would simply say it cannot be a blanket "Yes" or "No" answer because actually testing does not work that way.

Thank you, Dr. Kennelly. If you wish to provide more information by way of correspondence, that is fine.

Dr. Siobhán Kennelly

I would be happy to do so.

I apologise for bringing witnesses in and not giving them more time to answer. We simply do not have more than two hours.

The Regional Group is next and Deputy Shanahan has five minutes.

I am unsure who these areas might relate to. They are possibly for HIQA or the HSE. Maybe a written answer for one or two of them might suffice.

My first question relates to nursing homes and personal protective equipment availability. I understand gowns are still a particular issue for several nursing homes. There also appears to be confusion regarding the use of PPE in certain sections and nursing homes, especially over where and when it should be used. This is informally coming back from some nursing homes managers. Have the authorities issued any guidance aside from what came out earlier on in the engagement?

I have a question on staffing, especially in respect of healthcare staff who are deemed vulnerable or at risk. Again, there appears to be confusion in terms of those who are vulnerable. They are basically told to isolate at home. Others who have been exposed to Covid-19 patients are at risk. Maybe this needs to be clarified nationally to nursing home managers.

I brought up another issue in the Dáil some weeks ago. It still has not been addressed by the HSE. Why are senior nurse managers in nursing homes not allowed to take swab tests and present them to the local care setting? I know in Waterford at present we have been successfully using the University Hospital Waterford south east regional pathology laboratory. We are turning around swab tests in less than 24 hours. It seems we have to send out National Ambulance Service personnel to take swabs. Why are we doing that when we have qualified people in-house to do it? Maybe someone could answer that.

The HSE has supplied accommodation relief for healthcare workers who are living together. This was not extended to nursing home personnel. They have to meet these challenges themselves. Does either the HSE or HIQA have thoughts on that?

I want to ask HIQA about nursing home inspections. My understanding is that the authority has been engaged in desktop reviews for quite a period and that authority staff have visited the facilities. I believe any further reviews should be done by way of desktop review. We should not have inspectors coming in or transiting in and out of nursing homes unless the authority has a specific concern backed up by a complaint.

In one of the opening statements, a HIQA inspector stated that significant facilities are the point of failure, in other words, the infrastructure on-site. Has HIQA any plans to support policy to allow some mandating of capital by Government to allow these systems to be rectified? I presume we are talking about private homes that are not in a fit state and that were never meant for the number of patients they are now carrying.

Is there an opportunity to look at the early de-isolation of patients? I am referring to those who have proven antibodies. Surely, we can find a way to recognise these patients and allow them to have access and go back to their family members.

Has HIQA any specific opinion on the failure of the Minister for Health to appoint someone from the nursing home sector to the expert review panel?

I would ask that any questions not answered in a minute and a half be answered by way of correspondence.

Mr. Phelim Quinn

My colleague will take some of those questions.

Ms Mary Dunnion

The Deputy asked about HIQA inspections, and he is quite correct.

We have had a combination of site and desktop inspections. Going forward, they will be risk-based inspections where there is a risk to quality or safety. That is under public health advice.

We will be very pleased to work with the expert review panel and submit any information that we have and that it requires. I think the other questions are particular to the HSE.

Mr. David Walsh

According to the last figure I heard, 29% of the accommodation uptake was from staff in private nursing homes, so that facility is still very much available right across the sector. No differentiation is made. I ask Dr. Kennelly to talk about the testing processes.

Dr. Siobhán Kennelly

I agree with Deputy Shanahan on this. A number of CHOs have put in place training in order that the nursing homes can run that testing. Part of that is about then being able to get the tests to the relevant laboratories. A national testing pathway is being put in place through NPHET and the HSE. That will be available to us in due course in terms of how testing will be upscaled.

The other question the Deputy asked was about the possibility and the role of antibody testing in a nursing home population. Unfortunately, we have very little evidence that antibody testing will play a huge role, particularly in that population, in residents' ability to mount immune responses, so we cannot say with any assurance that that would be the appropriate way to go. We are, however, with HIQA and others, very conscious of the role of visits, which a number of Deputies have highlighted, so that guidance is being reviewed and will go through NPHET - I hope on Thursday, as mentioned - in order that we will be able to start opening up visiting in our nursing homes again.

I welcome our guests. I have a number of questions, starting with HIQA. I understand that for new builds of nursing homes and community hospitals, 80% of resident accommodation must consist of single rooms and there must be no more than four residents per multi-occupancy bedroom. Is this correct?

Ms Mary Dunnion

Yes, there are national standards. There is, however, a statutory instrument which allows both private and public nursing homes an opportunity until January 2021 to become compliant with these standards, and that is ongoing.

The question concerns older nursing homes and community hospitals. I know that a number of them are meeting the 80% single occupancy requirement. Quite a lot of them in my constituency of Cork South-West have been brought up to top standard. For others that are working towards the standards, when is the cut-off date for meeting the standards?

Ms Mary Dunnion

It is expected, on the basis of the statutory instrument, that these physical infrastructure issues are to be addressed on or before 1 January 2021.

Am I correct in stating that the original date to meet the HIQA 80% single occupancy standard was in 2016?

Ms Mary Dunnion

That is correct.

That was changed or extended to a later date. Is that the case?

Ms Mary Dunnion

Yes. There was a statutory instrument which allowed the timeframe for that to be achieved.

In view of Covid-19, does Ms Dunnion think this was a wise decision?

Ms Mary Dunnion

It is an ongoing challenge for providers. We feel very strongly about it and have taken many regulatory decisions based on the amount of space available for each resident. This has been challenged by providers, and the statutory instrument allows them that opportunity until January 2021. We believe, however, that it is very important, not only for infection control but for residents' rights to personal possessions and freedom of space, to be able to have visitors and that privacy. We see that as an essential component of a person's life in a nursing home.

One of the reports is from a hospital in west Cork where former nursing home residents are residing. I will just quote from some of the report and I will not mention the hospital. The report states:

- The use of multi-occupancy rooms for up to seven residents did not support the receipt of personal care and communication in a manner that protected privacy and dignity.

[...]

One resident had complained that sharing a five bedded room with one en-suite bathroom was difficult. Residents in a six bedded room had taken over the bed spaces of vacant beds to store some of their personal items as they did not have enough space by their own beds.

Why were these community hospitals not brought up to standard? I have spoken to the staff in this hospital. The stress they have been working under has been phenomenal.

They have been let down by the Government, the HSE and someone here because the standards should have been complied with in 2016, as with other community hospitals. They were not complied with, though, which has sadly led to Covid deaths. I am not saying that this is the specific reason, but it very much looks from HIQA's report like there was an issue and standards were not met. They still have not been met and it has cost lives. Why were the standards not applied across these hospitals by the first deadline of 2016?

Ms Mary Dunnion

Regulation is an instrument of policy. In this context, I concur with the Deputy. It is of great regret to us that residents are not having a lived experience in nursing homes that allows them the privacy, dignity and rights to which they are entitled.

I have a question for the HSE in the short time available to me. Does it plan to test and monitor the variables within these settings, including the testing of staff on at least a weekly basis with an efficient turnaround of results?

Mr. David Walsh

I might add that the HSE is in the middle of a major capital plan to address some of the issues the Deputy discussed. We will have to assess what the impact is of the current stalling of that because of the pandemic.

Regarding the premises as they currently operate, there are questions as to what their capacity will be in future. Each CHO, linking with its public health colleagues, will follow public health advice in terms of how testing should be conducted within those units.

Will the HSE allow doctors and nurses to carry out Covid-19 tests and local labs, some of which provide same-day results, to analyse them instead of flying them out to Germany?

Mr. David Walsh

A national strategy on testing in the medium term is to be reviewed and completed in the next few days. The testing that takes place will be guided by it. I understand that this matter will be considered by NPHET over the next number of days.

Next is Sinn Féin. For how long is Deputy Doherty speaking?

Ten minutes. I will begin by expressing my sympathy and condolences to everyone who has lost someone during this pandemic as well as to all of those working on the front line in our nursing homes and the organisations that our guests represent who are trying to suppress the pandemic in our communities.

As of yesterday, there were 1,606 confirmed deaths as a result of Covid-19. Thankfully, none was reported yesterday. Long may that continue. My first question is for HIQA. How many of those----

I am sorry, Deputy, but this is entirely my fault. Before the Deputy asks his question, I should say that I have realised that I have taken Deputies in the wrong order. The next speaker is actually from Fine Gael. My apologies.

Deputy Doherty has already started.

Okay. Deputy Doherty can proceed.

Of the 1,606 individuals who lost their lives, how many were residents of nursing homes?

Ms Mary Dunnion

Under legislation, every provider has to issue a notification of an unexpected death. We receive those notifications every day. In 2019, 150 unexpected deaths were reported. In 2020, 1,029 unexpected deaths have been reported as of this morning. This does not mean that all of those deaths are related to Covid-19, but they are classed as unexpected. The validation of those figures will be done by the Health Protection Surveillance Centre, HPSC.

There are reports. For example, we knew on 6 May that 740 of the deaths, or 54%, were in nursing home settings. Is Ms Dunnion saying that HIQA does not know how many of the 1,606 were residents of nursing homes?

Ms Mary Dunnion

No. These are all residents of nursing homes.

I am sorry, but I meant Covid-related.

Ms Mary Dunnion

We do not know the verification of whether that was the cause of death. What a provider must report to us is what is classified as an unexpected death. The relationship between the 2019 and 2020 figures and centres with Covid are the data that we share with the Department of Health, the HSE and the HPSC.

The validation of the actual end figure rests with the Health Protection Surveillance Centre.

The only accurate data I can find that has been published goes back to 6 May, which was that 740 of the Covid-19-related deaths at that time were from nursing home settings.

Ms Mary Dunnion

I am unclear as to the source of those figures but the validated figures are from the Health Protection Surveillance Centre.

Can the HSE shine any light on this?

Mr. David Walsh

I am quite happy to follow up and get an updated figure for the Deputy. I do not have one in front of me.

Are there any figures on the proportion of deaths of residents of nursing homes in the private sector and in the public sector? I put this to HIQA because in its opening statement it mentioned, in particular, the challenges of the private sector. Was there a more acute issue in the private sector than in the public sector or was it balanced?

Ms Mary Dunnion

I do not have the figures but we will be able to supply those to the Deputy. To reiterate, these are classified as "unexpected deaths". Validation that they are related to Covid-19 is not part of the information that we hold in HIQA but I can give the Deputy the breakdown of unexpected deaths from private to statutory centres. We will forward that information to him.

Mr. Phelim Quinn

If I may interject here, a more up to date figure could probably be produced by HPSC given that we have been made aware that 52.4% of deaths so far have been within the long-term residential care sector. There probably would be a bit of work to be done but the HPSC could provide that.

HIQA has in the past given the Department of Health and the HSE a list of centres that would have been in breach of regulations, training, etc., in different HIQA inspections. Has HIQA monitored whether there has been an increased number of deaths in those centres that it listed or has it left it to the Department?

Mr. Phelim Quinn

No, but I think what we probably could do is provide some form of correlation on this. That would be quite an exercise. In the first instance, our rationale for providing the list for what we believed were centres that were more at risk was to enable a swifter response from the support services.

Is HIQA aware of any member of staff who was not allowed to isolate having been in contact with somebody who was Covid-19 positive at the early stages or of staff members who were being asked to return to work, despite the fact they may have been symptomatic?

Ms Mary Dunnion

No, we have no information of that sort.

Can I ask the HSE that same question?

Mr. David Walsh

The public health advice on people with symptoms has always been clear. I was aware of a query in regard to one nursing home but that was clarified and the person was not allowed back to work. I am not aware of any other instances but I will be happy to follow up on any information the Deputy may have that that is occurring.

We will pass on that information afterwards.

On the appeals made by Nursing Homes Ireland on PPE, testing and guidance, what did the HSE do about all of those emails being sent to the HSE, which it was copied into time and again? Did the HSE take any action on the nursing home sector? Specifically, given the number of deaths and the great trauma and heartbreak that has occurred within those settings, does it believe now, with the benefit of hindsight, that any of those deaths could have been prevented? If so, what type of actions could have been taken, which were possible and should have been taken in the early months of February and March?

Mr. David Walsh

The HSE has engaged on Covid-19 with Nursing Homes Ireland since January of this year. I will ask Ms Sandra Tuohy to go into the detail of that.

Specifically, on PPE, the HSE was very clear from the outset that it would not differentiate between public, private and voluntary settings.

I am aware that units, whether public or private, wanted more PPE. We are all clear that the overall increase in demand for PPE required us to prioritise the distribution of same to those premises that were affected by either suspected or confirmed outbreaks. To date, the HSE has supplied in or around €27 million worth of PPE to private nursing homes since the beginning of March.

Nursing Homes Ireland was repeatedly calling for guidance on patient transfer. On 10 March the HSE issued guidance to Nursing Homes Ireland and it responded to the HSE to basically say that it was not good enough, it wanted testing of patients before they were transferred and it wanted PPE. Does the HSE now believe it was a mistake to transfer patients into nursing home settings without being tested first?

Mr. David Walsh

I will ask Dr. Kennelly to address that question because guidance was given and that guidance is still in place.

The guidance did not include testing. Are the witnesses saying it still does not include testing?

Dr. Siobhán Kennelly

No.

If a patient is transferred to a nursing home, is any testing carried out before the patient is transferred?

Dr. Siobhán Kennelly

That is incorrect. The protocols that are in place and that have been developed in conjunction with colleagues in public health and infection prevention control speak to the role of testing in the specific patient scenarios. The Deputy has to remember that in early March we were still in a situation where many of our hospitals did not have Covid-19 and many of the people who were being transferred out would not have had any exposure to Covid-19. In those instances, it was appropriate not to test patients but all transfers were given a caveat that where there were any suspected symptoms, patients were not to be transferred and they were to be tested first. In addition, all facilities were to have appropriate isolation facilities to be able to manage and monitor patients with appropriate precautions from an infection control point of view for a 14-day period when that transfer was made.

Nursing Homes Ireland made the point on asymptomatic individuals who had Covid-19 in the 40% range and in the emails it sent it detailed that it wanted all patients tested before transfer. Does Dr. Kennelly believe that was a mistake?

Dr. Siobhán Kennelly

We did not have information on what asymptomatic transmission looked like in Covid-19 until well into later March. One of the things that is important to highlight in terms of some of the response is that we were also beginning to learn that presentations of Covid-19 in older people were quite atypical. They did not fit the case definition that would have been put out in terms of cough, fever and shortness of breath-----

With respect, we are short on time. The guests from Nursing Homes Ireland told us in the earlier session that it was looking at international experience. Was it the case that Nursing Homes Ireland was way ahead of where the HSE was? It wanted the testing because it was looking at asymptomatic patients. The HSE refused that point blank time and again. It was looking for PPE that was not coming. Most importantly, it instigated visitor restrictions that NPHET - including members from the HSE - overturned. Was it not the case that Nursing Homes Ireland was ahead, that the HSE and the Department of Health were unfortunately behind the curve with the restrictions and supports that were needed and that as a result of this virus, we have unfortunately seen a huge loss of life within these settings?

Mr. David Walsh

The facts show that there has been an unprecedented level of support to private nursing homes since the commencement of this process, including the standing up of nine area crisis management teams and 23 Covid-19 response teams to provide direct support and input into the private sector-----

The facts show that Nursing Homes Ireland was ahead of the curve.

I thank Mr. Walsh and Deputy Doherty. The Deputy has made his point. I call Deputy Colm Burke.

I thank the witnesses for coming here today and for being available to answer the questions we are putting to them. On the 584 centres that HIQA inspect, my understanding is that 80% of those are private and the other 20% are public.

Of the 20% that is public, are they community hospitals and mental health facilities? Perhaps we could get a breakdown of how that is made up and the numbers relating to both private and public.

On the list of facilities given to the Department, may we have a breakdown of what numbers were public and what were private? Perhaps the witnesses might even outline that to us now at this stage.

Mr. David Walsh

I will ask my colleague.

Ms Mary Dunnion

There are 580 nursing homes of which 114 are statutory ones. There are 31,000 residents in total, and 5,708 are in HSE-funded centres. When we talk about this sector, it is all nursing homes, as determined in the Health Act. They are called designated centres for older persons.

In the context of the escalations, yes, there was a percentage which were statutory, a lot of those based on the premises. On the risks that were there should there have been a Covid outbreak, I would not be in a position to give that information at this moment but we can certainly furnish the ratio between private and public.

A list of public and private nursing homes was given to the Department. Can we have the breakdown of public and private?

Ms Mary Dunnion

Yes, we can furnish that information.

I want to ask about the HSE and congregated settings. We had a number of incidents and deaths in a number of facilities like Portlaoise, Phoenix Park and the community hospital in west Cork. I have spoken to people who worked in those facilities. For instance, I know that there were no changing facilities for staff in some of those facilities and there were six patients per ward. Surely these facilities were identified as high risk at a very early stage. What action was taken to deal with the situation when they were identified as high risk?

Mr. David Walsh

The Deputy is correct in that. There have been 76 outbreaks in mental health facilities as well as a very significant number in older persons and disability settings. Without prejudice to the numbers that HIQA may provide afterwards, there were 90 premises on the HSE older persons side that required either full replacement or remedial works to meet the standard around the maximum of four to a room. The infection control guidance and advice that applies to every setting applied to each of those premises as well. As part of the area crisis management team process, each CHO was required to implement those measures right across those settings.

Remedial works, in some cases, were not taken until after people had died in the facilities. Does Mr. Walsh agree with that?

Mr. David Walsh

I am not sure what the Deputy means by remedial works. In fact, as part of the capital programme, there is a very significant amount of pretty serious capital work yet to be done before the overall standard is met. Certainly, services worked within the limitations of their physical infrastructure to meet the standards and implement the infection control guidance with assistance from local departments of public health and from their consultant colleagues from hospitals.

With the ones identified as very high risk, I know that no action was taken with at least two of them, even though they would have been high risk because there were at least six patients per ward. No action was taken until it was identified that patients were positive.

Mr. David Walsh

I am not sure what the Deputy means by "no action."

I am talking about in one case, for instance, a simple one of changing facilities for staff.

Mr. David Walsh

I am not aware of that.

I am aware of it.

Mr. David Walsh

I am happy to follow up on it.

I understand that in more than one place, no remedial action was taken until after people were identified as positive and in some cases until after people had died in the particular facility.

Mr. David Walsh

As I said, the Deputy has information that I do not have. I am happy to follow up on it for him.

I thank Mr. Walsh.

I thank our witnesses for attending today. It seems clear given the scale of clusters, outbreaks and fatalities in nursing homes that opportunities were missed to support the nursing homes and prevent contagion into them. Various vectors into the nursing homes have been discussed today, including staff being discharged from hospitals, for example. I believe one of the reasons is that nursing homes and older people have had no voice in the room where the decisions are being taken, which is the National Public Health Emergency Team. I have put this to the Minister for Health repeatedly in the Dáil and he has repeatedly told me that nursing homes do have a voice and HIQA is their voice. The Minister's formal position is that HIQA is the voice of nursing homes on NPHET. We have a limited number of minutes from NPHET meetings but on 30 January, the second meeting, HIQA was present and nursing homes were not discussed. On 4 February, the third meeting, HIQA was present and nursing homes were not discussed. At the fourth meeting on 11 February, HIQA was present and nursing homes were not discussed. At the fifth meeting on 18 February, HIQA was present and nursing homes were not discussed. On the eighth meeting on 25 February, HIQA was present and nursing homes were not discussed. At the ninth meeting on 3 March, HIQA was present and nursing homes were not discussed. At the 12th meeting, on 10 March, HIQA was present and nursing homes were discussed. The action that was agreed was that the unilateral restriction of visiting to nursing homes was not required at that time. At the same meeting, NPHET agreed that we needed to look seriously at closing all of the schools in the country because the outbreak had become so severe. Within 36 hours, it made that recommendation and the Taoiseach implemented it two and a half days later. If HIQA has been the voice of nursing homes on NPHET, and given that it has clearly been at all of the meetings, why did it never raise the crisis that was emerging in nursing homes? When the crisis was finally raised, why did HIQA stand over a decision that visitor restrictions were unnecessary which the nursing homes had put in place themselves because they were aware that there was a crisis?

Mr. Phelim Quinn

The Deputy is quite correct in that HIQA was invited onto NPHET quite early on. There was no specific reference at that point to HIQA being the voice of nursing homes. HIQA is an organisation with a very wide remit. It has a remit for the regulation of health and social care services in Ireland, which includes our healthcare services, adult social care services, children's services, health technology assessment and standards development. It was from that perspective that it was my understanding that HIQA was being invited onto NPHET. I would appreciate that there has not been reference within the minutes in respect of nursing homes. However, I am also aware that on 4 March there was a specific sub-group of NPHET set up to look at vulnerable people, which would have included the nursing home sector. Colleagues from HIQA were at that point nominated onto that group. I believe it is from that point as well that HIQA played a very significant role in providing information, data and a number of other sources that dealt with the way in which we were looking at nursing homes, perceiving the problems within the nursing home sector and also how we at that point started to support that sector.

Given that HIQA has said the HSE has stated it does not understand the private nursing home sector, it is fair to think the Department of Health does not either as it is a further step removed. The only people on the National Public Health Emergency Team are civil servants from the Department of Health, HSE officials, a few virologists and HIQA. HIQA representatives were the only people in the room at all of those meetings who had any understanding of what was going on in nursing homes. Why did it take so long to raise the issues? When it was raised on 10 March why did HIQA stand over a decision not only not to protect the nursing homes but to open them up again?

Mr. Phelim Quinn

It is my belief the specific decision taken on 10 March was taken on the basis of the disease profile in Ireland at that particular time and the associated public health advice. We in HIQA are not public health experts and we followed and accepted the public health advice at that particular time. I appreciate the public health advice changed two days later when the disease profile also started to escalate in the country. At that point, NPHET decided to restrict visiting.

Does Mr. Quinn accept it was HIQA's role to raise the crisis with the public health officials on NPHET so they could react? This was part of why it was there.

Mr. Phelim Quinn

I believe that role was there but at that particular time the issue of visiting was based on public health advice.

My first question is for the HSE. Mistakes are made in a time of crisis. The most important role of the committee and all of the stakeholders is that we learn to be better prepared in case we have a second wave, which is highly probable. In his opening statement this morning, Mr. Daly of Nursing Homes Ireland referred to aggressive recruitment of nursing home staff initially by the HSE. Is it true that the HSE actively head hunted staff from nursing homes? Was this not unfair and counter-productive?

Mr. David Walsh

I discussed with Mr. Tadhg Daly, I cannot remember the exact dates but early in the process, the issue of recruitment. I assured him of a couple of things. The first was that the national director of human resources wrote to each CHO and hospital group asking them not to recruit actively from the private nursing home sector. The second was regarding the Be On Call For Ireland panel. The national director of human resources made it clear within the HSE that nobody working in a healthcare setting in the country, including in private nursing homes, should be recruited through that process but that it should be used to bring in new people.

Unfortunately it still happened and I believe Nursing Homes Ireland requested a moratorium regarding staff. I know the HSE cannot prevent a staff member moving to another job but at this time of an unprecedented pandemic it had a huge effect on the ability of nursing homes to be properly staffed during the peak of the crisis.

Mr. David Walsh

I know that in a number of cases arrangements were made, even though contracts had been signed, to leave people with their current employers for a period of time. I know there have been a couple of cases where people did move, and that is regrettable, but in the main private nursing homes are not a target for recruitment by the HSE. Obviously there are people on panels, and Mr. Daly said so this morning, and there is movement between the sectors at all times, but certainly the message I have given out, as has the national director for human resources, is that we do not want to undermine in any way the provision of healthcare in any other part of the system.

Does Mr. Walsh accept that patients being transferred in March and April from acute hospital settings to nursing homes should have been tested for Covid-19?

Does he accept this non-testing would have contributed to higher mortality?

Mr. David Walsh

I will ask Dr. Kennelly to address that.

Dr. Siobhán Kennelly

I thank Deputy Butler. With regard to the staffing issue, it is not in anybody's interest for one sector to deprive another sector of staffing. Clearly, there are going to be major issues to be addressed as a result of this in terms of governance and resilience in general within the private nursing home sector, in particular a need for them to reflect on their own staffing issues and possibly the issues that arise in terms of short-term contracts and the security they themselves can give to those staff.

To move on to the Deputy's question with regard to the transfers, again, the big learning has been around the fact that asymptomatic transmission was not a feature of WHO or ECDC guidance until 18 March and the guidance we had been issuing around the end of February and in early March did not reflect that. In fact, if we look at the WHO guidance, it indicated “possible” asymptomatic transmission, so everybody was still rigorously applying a case definition that was based on people having symptoms. When these patients were moved, they were not tested on the basis they did not have symptoms.

The other key piece was that if staff coming in from the community to work in these care settings did not have symptoms, they were not being tested either. We have learned a lot from the mass testing exercise in that regard. Clearly, the guidance we will be issuing to revisit that will look substantially different on the basis of the learning we have had in terms of that testing piece.

I would like to reiterate it is not the case that testing gives a definitive result where Covid is concerned. People can be Covid-negative today and Covid-positive tomorrow. That is the nature of the condition itself, particularly in the pre-symptomatic phase. It is also the case that we know that about 20% of patients who test as negative or not detected for Covid may actually develop symptoms in the following 14-day period. For that reason, all of these transfers were advised to be isolated and monitored for a 14-day period because these are our best safeguards.

I want to reiterate the second part of the question. Does Dr. Kennelly accept that this non-testing, even after 18 March, would have contributed to higher mortality in nursing homes?

Dr. Siobhán Kennelly

It is very hard to say that, with all due respect. We have looked at the international evidence. The first published report that really reflected the high prevalence of asymptomatic transmission, particularly in congregated settings, was on 27 March in the New England Journal of Medicine. That is how quickly things have been evolving in this pandemic. We know we had testing of asymptomatic residents in our mass testing exercise, which took place on 14 April. It is very difficult to say because we do not know what the mortality looks like in terms of patients who have tested positive but who were asymptomatic. Clearly, we are going to have to look at the staff testing protocols, how that is to be done on a regular basis and how that situation gets managed from here. That is what the national testing strategy is going to inform in the coming weeks.

At the outset, I want to convey my sympathies to the families of all those who have passed away in the nursing home setting at this time, and to acknowledge the trauma for families and, equally, for nursing home staff.

The focus today is very much on Covid-19 and how that has hit the nursing homes but, in the interests of balance, it is important to acknowledge that many nursing homes remained free of Covid. Equally, with regard to the nursing homes that were hit by Covid-19, it was not just peculiar or particular to nursing homes and it is what we are living with currently. There needs to be balance in the whole discussion.

Deputy Butler put it superbly when she acknowledged that in any crisis situation, the measure will be what we learn from it. In that respect, I would like to point to the fact there was quite an amount of confusion and lack of clarity at the outset as to how things were operating within the nursing homes. Nursing homes were told that patients were to remain in nursing homes and not be transferred to hospitals yet, at the same time, patients were being discharged from hospitals and brought to nursing home settings without testing. All of that confusion did not help the situation.

Equally, it is my understanding that on 14 April the HSE informed HIQA that due to difficulties in sourcing PPE it would not be possible to provide the three day baseline for PPE, as promised, and PPE would be directed to those areas termed greatest risk. On that particular date, 14 April, the number of clusters in nursing homes had risen to 158. There was a litany of confusion and lack of clarity but going forward, and I have discussed this with a number of nursing homes in my own constituency, is there an ongoing commitment from the HSE to provide PPE or is there a cut-off date?

Mr. David Walsh

The HSE is committed to providing PPE and as the CEO said, probably at this committee last week, we are looking at a probable total commitment over a 12 month period of in excess of €1 billion across all sectors. To date across private nursing homes, the HSE has provided in or around €27 million worth of PPE and millions of items. At this time there is no suggestion whatsoever that is going to cease. If anything, as more need is identified, it is met. That being said, in discussions with Nursing Homes Ireland we have encouraged it to continue to explore its own sources because more is better. Until such time as we can not only meet demand but begin to accumulate stock to provide a buffer, I do not think any of us will be satisfied on the overall position regarding PPE.

I welcome that. A point raised with me by a number of nursing homes is the current position where if a patient has to be transferred to a hospital for a minor procedure - it may well be an X-ray, a cardiac issue or a pacemaker or a defibrillator check - on return to the nursing home, even though he or she might have only been on the hospital campus for an hour or two, he or she is expected to go into 14 day isolation. That adds considerable trauma for the individual, families, and the nursing home. Nursing homes are now making the decision on what is most urgent so that people might or might not attend hospital. Is there a better way of doing things going forward? Is it possible services may be made available at nursing home sites rather than people having to go to hospital? Is there an opportunity for learning there?

Dr. Siobhán Kennelly

As we speak, guidance around all of that is being revisited to give clarity. As somebody who has been working in the sector for a number of years, I am well aware of how people are trying to balance those risks. We are trying to issue guidance on what care can be delivered, when, and by whom in as responsive a way as possible. It is important to reiterate that.

On those short-term visits the Deputy is talking about, the feeling is that anything that can be done in a short period does not require isolation afterwards. Again, it is important that people understand the role that asymptomatic transmission and the potential for asymptomatic transmission play in this. Clearly, people who need overnight or more prolonged stays will require isolation on transfer back. That will all be addressed. It is important to note everything that is happening is being monitored on a close basis by our colleagues. Massive issues have been highlighted by the Deputy's colleagues with regard to the discussion around governance and resilience, and how they are going to be managed out in terms of the ongoing risk of transmission and ongoing risk to nursing homes. As a clinician, I am alive to it, as are most people here, and unless there is a systemic address of some of the issues that have been highlighted throughout the discussion they will continue to pose a challenge.

The turnaround for testing of staff in nursing homes has proven quite problematic as well. I want to raise that with the witnesses.

Mr. David Walsh

I can answer that. When we started large-scale testing in nursing homes turnaround times were not where they needed to be. That has improved week on week, and there is still some improvement to be got. The GP referrals are now working very well. We need the same turnaround for nursing home testing and any employment-related testing.

I have a couple of questions before we finish. The witnesses from HIQA spoke about national clinical oversight. The Care Quality Commission, CQC, HIQA's equivalent in the United Kingdom, required that a clinical lead be identified by each care facility by 15 May because the situation in the UK at the time was the same as the situation still is here, wherein a number of different GPs were going in and out of care facilities treating different patients without clinical oversight in the care institution. Is that something HIQA would like to see happen here and, if so, would it require legislative change? I ask that question given the committee's remit.

Mr. Phelim Quinn

I am not specifically aware of that particular recommendation by the CQC-----

It was not a recommendation; it was a legal requirement.

Mr. Phelim Quinn

That would certainly be worthy of exploration in the current context. Given that Covid-19 will be with us for quite some time, that would be a useful step.

Is "worthy of exploration" as far as Mr. Quinn will go?

Mr. Phelim Quinn

Yes. I would not want to bounce into something that is unexplored at the minute and how it would actually work in the context of nursing homes. Clinical oversight would certainly be extremely useful, however.

Does Ms Dunning have any view on the matter?

Ms Mary Dunnion

Yes. An expert group has been brought together by the Minister and we are waiting to see what its interim arrangements will be. There is a longer-term issue around policy on the care of older people and the alternative pathways that might be there for them. That issue is really worthy of exploration. It would be timely for the legislation and regulations to be reviewed and considered by the Oireachtas.

The issue of rooms with more than one person was raised. I appreciate that this is not ideal and it is certainly not suitable in these times. Beyond that, however, there are patients who do not want to be in single rooms. I appreciate that it may not be possible to facilitate that now but hopefully it will be possible at some point after we return to normality. I expect there will be patients, including one person who was very close to me until earlier this year, who are adamant that they do not want to share a room and be isolated. I wondered if HIQA, in laying out standards, considers this. People should not be forced to share a room but perhaps they should be able to do so. Does HIQA have a view on that?

Ms Mary Dunnion

Yes, we are very conscious of this issue. We view a nursing home as somebody's home. The residents have made a decision to live there and, as a consequence, it is important that it is designed to meet their requirements. To address the Chairman's point, the important question is what will be the future of the sector. There are many different types of steps which would be really important. One step would be to recognise that some residents do not require the same level of care as others and that, therefore, there would be different types of facilities. We are more than delighted to share a paper we have done that looks at the regulation of services as opposed to the premises, which is all about rooms, facilities and so on.

Dr. Kennelly pointed out the frailties of the testing system insofar as one could test negative one day and positive the next. We need to be wary of that. Those who test positive are isolated for 14 days if they are in hospital or in a care facility. Are they tested again at the end of the 14-day period?

Dr. Siobhán Kennelly

Until recently people were regularly tested at the end of the 14-day period, and that is still going on. One of the issues that we have come to understand in the course of this is that some patients who have been hospitalised have been persistently testing positive beyond the 14 days. What we understand better now than might have been the case even some weeks ago is that the positive status one gets at 14 days probably has very little of what we would call active virus in it, so the potential for infectivity is low.

The guidance has been amended to say that if one tests positive at the end of the 14-day period, one is recommended for a further isolation period of seven days. There is no further testing after that period. That came through the national expert advisory group on Covid-19 that meets on a frequent basis to assess this evidence as it comes through. On people who want to transfer and who may have been positive at the end of the 14-day period, they are still safe to transfer as long as they can be accommodated in single room accommodation for that seven-day period. We believe the risk of transmission to be very low at that point.

If there is random testing in the population, how does one know whether it is somebody testing positive at the beginning of the 14-day period, at the middle of this period or at the end of it?

Dr. Siobhán Kennelly

It will depend very much on whether somebody had symptoms. I am not a virologist or an infectious disease expert and some of these questions might be better directed to such an expert but essentially patients knowing when they may or may not have had symptoms will influence when we might know when the 14-day period started. In general, it is taken from the date of the first test result that is positive. In the absence of symptoms, the 14-day period is completed from then on.

I thank Dr. Kennelly for answering my questions and all of the witnesses for answering all of the questions of committee members.

Sitting suspended at 4 p.m. and resumed at 4.30 p.m.
Deputy Mary Butler took the Chair.