I will do my best. I thank the Chairman for the invitation to meet the committee. I hope we will be able to address the issues raised.
There are currently 436 private nursing homes in operation throughout the country. The vast majority of these provide a very high level of care for their residents and their highly committed, professional and well trained staff members strive to deliver excellent care. As these homes provide varying levels of care for older people, from low to high dependency, it is essential that the HSE, as the national health authority, should work with them to regulate the work they do and ensure they provide care that is safe and secure. The HSE continues to take steps to ensure the highest quality of services are available in nursing homes for older people and that where there are substandard services, they are identified speedily and appropriate corrective action taken.
It is important to note that nursing home owners are primarily responsible for providing a high quality service for those in their care and have a duty of care to their residents. As in all health care delivery, the professionals employed in nursing homes, principally doctors and nurses are accountable, like all health care professionals, for their own actions and inaction as governed by their professional bodies such as the Medical Council and An Bord Altranais.
The HSE is responsible for inspecting these services to ensure they comply with the relevant regulations. The HSE also provides subventions for residents and contracts beds directly with the nursing home sector. It registers nursing homes and subsequently inspects them. More than 18 inspection teams are currently in place across the country. These are three person teams consisting of doctors, nurses and environmental health officers and each team inspects nursing homes at least twice a year and does this on an unannounced basis. Many nursing homes have follow-up inspections, some as often as weekly or fortnightly. Where necessary, teams are at liberty to make their inspections at night or at weekends. Between January and October of this year, the HSE carried out 666 statutory inspections. This does not include follow-up inspections.
At the outset in 1993, the regulations were interpreted separately by each health board. The HSE is now taking a consistent and standardised approach to the registration and inspection process. The Health (Nursing Homes) Act 1990, the only legislation pertaining to the older persons sector and the Nursing Homes (Care and Welfare) Regulations 1993, which follow from the Act, allow a health authority to issue proceedings against a proprietor or person in charge. Where, in the opinion of the authority, the regulations are not being complied with, prosecutions can only be instigated in the District Court and there is no provision that allows a health authority to make an application to the court for the closure of a nursing home.
The procedure for removing nursing homes from the registration is a lengthy and cumbersome one and can be delayed considerably in the event that a registered proprietor resists an action. Members may recall the former South Western Health Board commenced a process to remove Rostrevor Nursing Home from the register but the health board was so concerned at the time about the welfare of the residents of the nursing home that it sought to obtain a High Court injunction closing the nursing home pending the outcome of the proceedings already in train in the District Court. The case was heard by Ms Justice Finlay Geoghegan who expressed concerns from the outset that the 1990 Act and 1993 regulations did not contain provisions whereby a nursing home could be closed pending deregistration. The judge refused the relief sought by the South Western Health Board.
There is a further provision in section 9 of the Health (Nursing Homes) Act which allows health authorities to apply to the District Court for an order granting them temporary management of a nursing home. Such an application requires the authority to demonstrate a failure by a nursing home to comply with the regulations. The authority must be in a position to identify the person to manage and take charge of the home. An application under the section can be brought on an ex parte basis initially for a period of two weeks or on notice to the proprietor and, if successful, shall last for a period of three months. While the provision appears to constitute a ready-made option of the type favoured by Ms Justice Finlay Geoghegan, it implies significant issues for the HSE. The HSE would have to secure and appoint staff to a private institution and, in taking over an institution, take over the liabilities of a private enterprise.
The Circuit Court has jurisdiction on the hearing of an appeal to grant an order declaring that a registered proprietor should be disqualified during such period as may be specified in the order from continuing to be in charge or concerned with the management of the nursing home to which a conviction relates or, at the discretion of the court, any nursing home. In such an instance, the standard of proof is high and the gathering of proof by designated officers is not always easy. To bring a prosecution, the HSE must rely on the evidence of the designated officers, who are the three inspectors who can be formally designated. Such evidence is usually required to include the provision of a great deal of detail including dates, times, who the designated officers met, why they were there, who else was present, what they recorded, etc. Generally, issues raised relate to care and where prosecutions fail it is due to the inability of the health system to describe what constitutes suitable and sufficient care. There is a lack of regulation to state this.
The current Act and regulations fail to provide for a speedy remedy in cases in which the HSE is concerned about the care and welfare of residents of a private nursing home. The current Act and regulations are cumbersome and it has been recognised for some time that new regulations and legislation are required. The Department of Health and Children is currently revising the Act and regulations to provide for more robust and speedy responses to issues arising in the care and welfare of patients in registered private nursing homes.
Following recent inspections, the HSE has suspended admissions at seven nursing homes in the eastern region. One of these has now complied with all conditions and is being advised in this context, while two in Louth and Meath respectively have been the subject of a long-running legal process in the District Court. Within the current regulatory framework, the HSE is unable to name these nursing homes until due process has been completed. HSE inspection teams have carried out risk assessments in all of these nursing homes and consider that there is no immediate risk to residents. It is important to underline that an objective risk assessment was carried out once it was identified that we needed to suspend admissions. The principal issue was that the home could not cater for any additional dependency load. All the homes in question are being monitored actively and further action will be taken as necessary.
The imposition of the suspensions is in line with recent public assurances by the HSE that where concerns are raised by inspectors about a private nursing home, no beds will be contracted by the HSE with that home until any issues are resolved. Furthermore, any such home will be advised not to take privately referred admissions during the suspension period, display a notice to this effect and inform all current and prospective residents. We are developing and finalising a protocol for advising nursing homes of admissions being suspended.
Members will be aware that the HSE came into being at the beginning of 2005 and was in a period of significant transition for at least the first half of that year, about which time the "Prime Time" programme on Leas Cross was aired. At that time we brought together an internal working group chaired by Paschal Moynihan who is here with me and who is director of services for older people in the HSE western region. The group comprises current inspection team members from the medical and health professions, including doctors, nurses and environmental health officers. The individuals were invited to join because of their current expertise.
The group reported in July and most of its recommendations have now been implemented. These include standardisation of the inspection process with the result that the inspection process and reporting structure are now uniform across the country, as well as the publication of the inspection reports. We have started posting the reports on the HSE website. There has been an issue regarding indemnity for the inspectors if their names are brought into the public domain. We have now dealt with that issue and are satisfied that all reports can now be posted on the website. Our intention is that the reports for all 400 nursing homes will be on the website by the end of the first quarter of 2007. The delay period is needed to make sure that all due process issues have been dealt with before the reported is posted. All inspections are now unannounced, but it is important to point out that inspections were unannounced in many health boards since 1993. However, it was not a standard practice.
Other recommendations include the establishment of dedicated teams. Fully dedicated teams now exist in Dublin north east, which has the largest number of private nursing homes in the country, as well as the former mid west. The HSE is moving to put dedicated teams in place across the country. There are issues in several areas where there is a shortage of medical staff available to do this work. This transition will also raise IR, HR and resource issues, but priority is being given to assigning these resources. This will allow for all teams to operate on a full-time basis, building the expertise and information that can be shared nationally. A new national training programme for inspection team members has been designed, and an independent professional training programme has been tendered for to replace the existing schemes that operated under the former health boards. This comprehensive training programme will begin in January and will be completed by April.
The HSE is a strong advocate of an independent inspectorate. Our roles as inspector, provider and purchaser are inconsistent. We anticipate that legislation allowing for an independent inspectorate will be established. Once this has been enacted, the inspectorate will be established on an independent, quality assured basis. It will come under the auspices of HIQA, the Health Information and Quality Authority.
The inspection team consists of a doctor, nurse and environmental health officer. During inspections they look for patient details, nursing records, rug records, care plans — a recent development — patient registration, admissions and discharges, contracts of care, complaints, PIN or nurse registration details, staff rosters and policies and procedures. They will visit each room and talk with patients, although these are not formally recorded interviews. The medical officer has the facility to examine patients and patient records if appropriate. The team will discuss all matters with the manager. As the inspections may be unannounced, it may be necessary to visit the nursing home again to speak to the proprietor.
Where a decision is made to suspend admissions, an objective risk assessment is carried out to assess the level of risk to current residents. This assessment becomes a part of an ongoing monitoring process. As an assurance, it is necessary that once we make a decision on a nursing home, we do not abandon the people in that home. We must assure ourselves that there is no risk to the clients in that home. If the risk increases the HSE will re-assess the situation at each and every visit. It may then decide to cap the number of residents. The nursing home must advise all current and potential clients that admissions are suspended and, where necessary, inform residents and their families. This is only necessary where patient care is compromised. We are always balancing the issue between protecting clients and making them insecure. We must remember that the nursing home is that person's home for a time. The HSE may then decide to take a legal route and initiate legal proceedings against the home. Under the new standardised regime, inspection teams are obliged to discuss the conclusions of the inspection with the nursing home proprietor at the premises and are obliged to make them aware of any issues that have arisen.
The members will be fully aware of all aspects of the Leas Cross case. The HSE published the independent report on 10 November. The report was commissioned by the HSE and compiled by Professor Des O'Neill. His report was received by the HSE during the summer but, owing to legal constraints, primarily the fact that Professor O'Neill was not prepared to revisit the report on foot of submissions, it was necessary for us ultimately to issue his unedited report with the submissions received from those who were readily identifiable in the report.
The HSE has fully accepted all the recommendations in the report. We have taken steps to implement them and many are already in train. Professor O'Neill has been invited to participate in a group to oversee the implementation of the recommendations.
As part of the information released at the time, we outlined what specific action was being taken in regard to each recommendation. We have forwarded the report on Leas Cross to the Garda Síochána, An Bord Altranais and the Medical Council for their consideration. While it is not clearly identifiable whether criminal matters are involved, there may be professional matters for doctors and nurses that should be dealt with by their professional bodies. The Garda Commissioner has advised me that he is having the file examined by the National Bureau of Criminal Investigation and we will work with him in that regard and provide him with any information that is available to us.
In recent days the HSE met some relatives of former Leas Cross residents and has written to more than 100 known relatives offering them individual family meetings with senior personnel. Patient consumer advocacy groups have met and continue to meet senior management of the HSE. A meeting has been arranged for 11 December with Age Action Ireland, Patient Focus, the Irish Patients Association, the Irish Hospice Foundation and others. The objective is to develop a framework for the inclusion of knowledge advocates. We believe the inclusion of older people in establishing and monitoring standards of care would be an important step forward. We are seeking a way to include them in the inspection process.
With regard to complaints, Ms Mary Culliton has responsibility for the implementation of a comprehensive complaints policy in the HSE. We believe the complaints have a direct relationship with the implementation of quality and standards across the HSE and across the areas for which we have regulatory responsibility. The new integrated complaints system will provide an additional pathway for patients and relatives with concerns about a nursing home.
Death notifications were an issue in the Leas Cross report. Under current legislation, nursing home owners are obliged to notify the local area medical officer of all deaths in a nursing home within 48 hours. If they fail to do so, they are in breach of the regulations but it is a technical breach and it is very difficult to impose sanctions on a nursing home if this section is not adhered to. We anticipate the new legislation will strengthen the sanctions available.
The HSE information line — 1850 24 1850 — is available for anybody with concerns about care of the elderly, elder abuse and nursing home issues. We will ensure matters are followed up.
