A review of the regulation of health and social care published today by HIQA has found that while the regulation of specific aspects of care is beginning to sustainably improve services in social care services and hospitals, some nursing homes, residential centres for people with disabilities and foster care services must take stronger measures to protect vulnerable people in their care against abuse, harm and exploitation.
The Overview of 2016 HIQA regulation of social care and healthcare services is the first combined analysis of its kind by HIQA, covering regulation of nursing homes, residential services for people with disabilities and children, and themed inspections of key areas of hospital practice. The report found much good work in Ireland’s health and social care services.
The HIQA review found:
- a culture of regulation is now embedded in nursing homes and is influencing improvements in hospitals, disability and children’s services
- there are clear links between good governance of services and better outcomes for people using services
- some services must take safeguarding more seriously, particularly having Gardavetting in place for all staff and volunteers
- national health and social care policy needs to be developed and followed to support improvement in services which may be locally-driven
- those who fund services need to take a greater role in holding those services to account.
Mary Dunnion, Chief Inspector of Social Services and Director of Regulation with HIQA commented: “In general, many of the people using services that we spoke with in 2016 were happy with their service and felt that they were receiving good care. Nonetheless, a considerable number of people told us that they were not satisfied; that the services were not person-centred; and that services were failing to meet their needs.”
The importance of good governance
A consistent theme throughout all of our regulatory activities in 2016 was the critical importance of good governance and management.
Mary Dunnion continued: “Invariably, where HIQA finds services that are well managed, it also finds residents and service users who enjoy a good quality service that protects and promotes their rights. Good governance also means having a positive attitude to regulation and using inspection findings to improve care. On the other hand, poor governance leads to poorer quality outcomes for residents and people using services.”
Safeguarding measures enable children and at-risk adults to live free from abuse, neglect, harm and exploitation. In 2016, HIQA encountered services where safeguarding was not sufficiently strong and comprehensive.
Mary Dunnion continued: “In 2016, some services were still not taking the issue of Garda Síochána vetting sufficiently seriously and were thereby failing in their legal responsibility to safeguard adults and children. In addition, in a range of disability services, we found that leadership and practice in recognising, preventing and protecting people from harm was deficient. HIQA believes safeguarding needs to be further strengthened by introducing new legislation to better protect those who may be at risk.”
HIQA believes providers should be accountable to service users and also to those who fund services.
Mary Dunnion commented: “This is why the concept of commissioning is worthy of further consideration in the Irish context. A well-established practice in other countries, commissioning is a strategic process of identifying a population, community or individual service need; and designing, sourcing and delivering those necessary services.
“The State distributes large sums of funding to various organisations to provide a service on its behalf. However, there is often insufficient oversight of how this money is used or on the outcomes it achieves for service users. HIQA acknowledges the preliminary work done by the Health Service Executive on developing such a framework.”
The need for policy and implementation
The absence of a clear plan for the future of the health service continues to impact on the delivery of services and reform is clearly needed in this area.
Mary Dunnion stated: “The 2016 overview report shows there is a requirement for clear national policy direction, policy implementation and timely decision-making in terms of health and social care services. This was a key finding in both of the reviews conducted by the healthcare team in 2016 in relation to the country’s ambulance services and the services at Midlands Regional Hospital, Portlaoise.”
Escalation and enforcement
In nursing homes and residential centres for people with disabilities, HIQA has powers to enforce compliance with regulations. During 2016, the Chief Inspector issued 11 notices of proposal to refuse the application to register and cancel the current registration status of designated centres for people with disabilities. Throughout 2016, disability service providers were required to attend 153 meetings with the Office of the Chief Inspector to account for their failure to meet their regulatory responsibilities. In older people’s services, a total of 38 nursing homes had restrictive conditions applied to their registration.
The HIQA report contains examples of both good and poor practices seen during 2016 inspections.
Mary Dunnion concluded: “HIQA recognises that there are many challenges facing service providers. Notwithstanding these challenges, we believe services can improve by learning from and applying good practices seen elsewhere, applying evidence-based standards and guidelines, and constructively engaging with the outcomes of assessments such as those carried out by HIQA. We hope this report will help to foster a culture of shared learning across service providers with the ultimate goal of improving outcomes and experience for people using services.”
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Notes to the Editor
Overview of inspection and monitoring findings
People with disabilities
In 2016, 735 inspection reports on residential centres for people with disabilities were published. The experience in residential services for people with disabilities is somewhat mixed. While many are receiving a quality service and enjoying a good standard of living, a significant number of people are experiencing a quality of life that is well below that which would be expected in modern Ireland. These people have been living over a long period of time in institutionalised services that do not promote person-centred care and where abuses of their rights have happened. In some instances HIQA has assessed the care being provided as unsafe.
In total, HIQA completed 608 inspections of 494 centres. Most centres are demonstrating a good understanding of the regulations and standards and are responsive to findings of regulatory non-compliance. HIQA anticipates that providers are now focused on achieving a level of quality above and beyond minimum compliance with the regulations. Notwithstanding this, we continue to encounter difficulties with outdated nursing home buildings impacting on residents’ privacy and dignity, and their right to be safe. HIQA is working with all nursing home providers to address these shortcomings.
In 2016, HIQA’s healthcare team found that while a significant amount of improvement in services may be driven locally, in some instances only substantive decision-making at a national policy level will truly address key areas of outstanding risk for patients. Meanwhile, there is both variation in the effectiveness of local management practice, and an inequitable distribution of resources between and among hospitals and hospital groups. This highlights the need for a clear vision on how Ireland provides hospital services into the future.
In 2016, inspectors met with 236 children living in foster care (131), residential centres (98) and special care units (seven). The children’s team found that once children had access to a child protection or alternative care service, most received a good service. There is some good work being done on supporting children to access educational opportunities and in maintaining contact with their birth families. However, more work is needed to ensure all children receive a service that is appropriate to their assessed needs. Issues of significant risk included children being inappropriately placed and children’s needs not being met in the absence of regular child-in-care reviews taking place.
Looking to the future – research
During 2016 HIQA developed two research papers to inform future regulation processes. The first was a review of the regulatory systems in 16 jurisdictions internationally as a result of the Department of Health proposals to establish a licensing system for public and private hospitals. In 2016, the Department drew up a draft general scheme for licensing and invited stakeholders to participate in a related working group.
The draft general scheme envisages that HIQA will be the licensing authority and will be responsible for monitoring compliance with forthcoming regulations. In order to inform its own deliberations on the challenges posed by licensing hospitals, HIQA researched how such regulation is being carried on in a number of other countries.
In the second, HIQA researched the concept and definition of a designated centre in the context of new and emerging models of social care in Ireland. The research considers all of the different models of care in Ireland today, both for people with disabilities and for older people. It gives a brief overview of how such models are regulated in other countries.