Nursing Home Reform

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The fact that so many Covid related deaths have occurred in nursing homes has drawn attention to the fact that there must be something intrinsically wrong with the way some nursing homes are managed, writes Martin Cowley. 

Even though my background is the acute hospital sector, I have recently become a member of an advocacy group for residents in nursing homes referred to as the Nursing Homes Quality Initiative (NHQI). 

Originally established in 2010, the group came together as volunteers in response to an invitation from HIQA to nursing home residents and their relatives to join a service user forum. At that time, the establishment of the Forum was cited by HIQA as a first step towards the creation of a wider network of service user contributors in relation to both nursing homes and other social service sectors within their remit. However, this has not happened, and HIQA is now following a different engagement strategy. The core group that remained active now operates independently of HIQA, has recruited new members, and continues to be committed to improving the quality of life of nursing home residents.

The purpose of this article is to make you aware of how elderly people are cared for in some private nursing homes and, also in some publicly funded institutions. This can in some circumstances be characterised as a denial of human rights. It is not acceptable that vulnerable persons are not always treated with the respect and dignity that they deserve at the end of their lives. Many of the shortfalls in these homes came to light at the time of the outbreak of Covid 19. Indeed, there have been calls for a commission of investigation into the devastating impact of Covid 19 on the residents of nursing homes.

The issues identified in this article have been discussed with HIQA. HIQA is limited as to what it can achieve, mainly for legal reasons. However, in general it does a good job

The shortfalls so identified relate mostly to private nursing homes, which are motivated by profit. We would like to emphasise that many ofthese weaknesses can also be applicable to institutions run by or financed by the HSE.

At the outset I would like to state that many if not most nursing homes provide a fine service which is most appreciated by the residents and their families.

Therefore, this article is referring to those homes which are not performing as they should be.

A more rigorous oversight of nursing home performance, within existing regulations, is feasible and would make a significant contribution to higher standards without the necessity for amendment to statute. However, in some cases it may be necessary to enact new legislation to achieve the required results.

The following is a summary of what needs to be actioned:

  • More stringent regulation of nursing homes. The regulator should apply stricter conditions when he/she deems this to be necessary.
  • An annual inspection which means that nursing homes will have to renew their licence annually.
  • Stringent penalties for failure to comply with the regulations.
  • Reform of complaints processes to the extent possible under existing regulations (in consultation with the Ombudsman).
  • Nursing home residents and their families be provided with relevant information relating to HIQA standards and the regulations.
  • Establish Boards of Management in all private nursing homes with an independent chairperson and an expert in quality and risk.
  • The creation of an Ombudsman for older persons
  • The provision of single rooms for residents, subject to the availability of funding and resources.
  • HIQA should be independent of the Department of Health and should be accountable only to the relevant committee of the Oireachtas
  • HIQA should have the sole power to draw up the regulations and standards. These, in my view, are in urgent need of reform.
  • There must be a meaningful recognition of the service users in the inspection process. In the Scottish equivalent inspectorate, volunteers are utilized. These volunteers would be better able to reflect the concerns of the residents and their families, providing important complementary evidence to that of the HIQA inspector.
  • The one major factor affecting nursing homes at the present time is the high turnover of staff. Nurses can already avail of higher qualifications in gerontology, but they must be adequately remunerated. It is good to see that placements in care homes by student nurses is now mandatory
  • Alternatives to nursing home care must be uppermost in the strategic planning of the older persons’ care. Ireland has the highest percentage of nursing home residents in Europe.
  • A review of the adequacy of medical equipment in care homes is necessary in the opinion of NHQI.
  • I recognize that the early discharge of patients in acute hospitals is crucial, given the capacity issues in our public hospitals. However, in planning the discharge of patients to other settings, consideration must be given as to how appropriate it might be to transfer certain patients to nursing homes and whether such transfers would be in the best interest of the patient. 

Members of our team undertook reviews of inspections which were posted on the HIQA website. 

In relation to the Dublin Area, the following is a summary of what we found: 

There were 87 inspection reports for 2021 up to November 30. Additional reports were issued on December 8. These are not included in this analysis.

There was a total of 86 non compliances.

The most serious of these were, in our opinion.

  • Premises: 9 non compliances
  • Governance & Management: 15 non compliances
  • Residents’ rights: 4 non compliances
  • Staffing: 3 non compliances
  • Infection/hygiene:7 non compliances
  • Fire Precautions: 11 non compliances

It also emerged in this analysis that the residents themselves were happy in their nursing homes. However, who will criticize the “hand that feeds me”?

We also undertook inspections of institutions in other geographical areas. Again, we came across serious problems.

The following are the constant themes running through these reports:

  1. Some of the residences have premises not fit for purpose. Two public institutions have plans for rebuilds, but to date the required funding has not been put in place
  2. Lack of adequate infection control measures. This is very serious given the Covid 19 pandemic.
  3. Lack of privacy, particularly in relation to personal belongings.
  4. Poor fire precautions. Most of these relate to evacuation procedures, fire drills and staff not being adequately trained in fire procedures
  5. Lack of sufficient staff was a problem. In fairness, it is difficult in the present environment to procure staff especially in rural areas. The turnover of staff is high, which inevitably diminishes the quality of the service delivered.
  6. Lack of consultation with residents.

The above reflects an unsatisfactory situation. 

HIQA itself recognises that there are weaknesses in the regulatory framework and has written a paper on this issue which is available on its website.

 In summary there are 5 main areas which require immediate attention:

  1. A major revision of the 2007 Health Act. This should allow greater flexibility to HIQA to manage the review process and to amend the regulations and standards as it sees fit. 
  2. A meaningful review of the existing standards and regulations must take place as a matter of urgency.
  3. More robust systems for ensuring compliance with the regulations.
  4. There must be greater involvement of the residents themselves and their relatives in the overall review process.
  5. A fit for purpose complaints procedure.

Finally, I would like to thank Joe Boyle, a member of the NHQI team who contributed towards the formulation of this article.

Martin Cowley FCA

Former Chief Executive Mater Misericordiae Hospital

Former President Health Management Institute of Ireland