Review highlights need for nursing home regulatory reform

An independent review assessing the regulatory processes of the Health Information and Quality Authority's (HIQA) inspection of nursing homes has highlighted the need for regulatory reform in a number of key areas.

The review was requested by the Minister for Health and the Minister of State with responsibility for Older People following an RTÉ Investigates programme about two nursing homes owned by Emeis Ireland.

Its aim was to provide an independent assessment of regulation, identify areas of improvement and to consider whether the regulatory framework should be strengthened to reflect changes in the operating environment.

Conducted by Forvis Mazars, the final report stresses the need for parent companies or nursing home groups to be held to account by the regulator's chief inspector.

It has also called for resident involvement in care decisions, providing them with independence, and ensuring care upholds residents' rights.

The report recommends a review of the nursing home regulatory framework to ensure it reflects current policies, strengthens oversight of providers, aligns with the changing environment, with a greater emphasis on resident outcomes and rights.

It points out that the regulation of nursing homes in Ireland has "progressed" in the last 17 years, from a focus on minimum safety requirements towards a more comprehensive rights-based approach prioritising safeguarding, dignity and overall wellbeing.

However, it says the transition in ownership models, from local-rooted community-based providers to large corporate entities, has introduced increasingly complex regulatory challenges.

"In order to effectively respond to the demands of an ageing population, the regulatory framework must continue to evolve, ensuring robust assessment of the fitness of all parties both at local operational levels and within broader corporate governance and financial structures.

"Ultimately, these efforts are essential for ensuring that older people receive care that is not only safe, but appropriate, person-centred and responsive to their individual needs," it said.

The report acknowledged that the Chief Inspector of HIQA's remit applied to the registered provider, which is the legal entity that operates the nursing home, rather than the corporate group or ultimate owner but the legal separation "creates potential gaps in responsibility, accountability and financial transparency".

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Therefore, staffing, budgets and closures are made at group level, but regulatory accountability for the nursing home lies with the registered provider.

It has also pointed out that in cases of insolvency or regulatory non-compliance, the Chief Inspector cannot hold anyone other than the registered entity to account, even where the evidence indicates that strategic and financial decisions are made elsewhere.

"The evolving ownership landscape presents one of the most complex challenges facing the regulatory system - how to ensure that the legal framework can be better aligned to the business reality of ownership so as to properly safeguard residents' rights, care and support needs," it said.

It has suggested that the inspection approach to culture and staff behaviour within nursing homes should be strengthened, particularly in relation to its relevance in terms of the lived experience of residents.

Another recommendation is a strengthened focus in all inspections on those areas that matter most to residents and their families.

Areas for renewed focus include assessing residents’ involvement in decisions about their own care, promoting residents’ independence, and ensuring that the care and support for residents upholds their rights.

The review found that overall HIQA’s Chief Inspector’s regulatory and inspection processes are effective, in line with its powers under the Health Act 2007 (as amended) and regulations.

It confirmed that the Chief Inspector’s registration and inspection activities follow a standardised and consistent approach, and are carried out in a fair and proportionate manner.

It also noted that the Chief Inspector placed a significant emphasis on safeguarding residents through its specific programme of safeguarding inspections and, in line with its legal remit.

HIQA's CEO Angela Fitzgerald has welcomed the recommendations, pointing out that the watchdog's role as regulator is to ensure that providers meet their responsibilities to deliver safe, quality services and to protect residents.

"Where providers fail to do this, we use our powers to ensure that providers take action in the best interests of residents," she said.

However, the regulator has acknowledged that it must always be open to critically evaluating its work.

"In particular, we are committed to reviewing how best we continue to hold providers to account. In this context, we are redoubling our efforts to evaluate how providers support and enable positive staff culture and behaviour in their services to ensure positive outcomes for people using services," according to Ms Fitzgerald.

"We are looking at how we plan and carry out different types of inspection and strengthening how we use information to enhance our understanding of the quality of service being delivered by providers on an ongoing basis. We will engage with providers as part of this process so that we secure their direct input and ownership."

On the matter of regulatory reform it said it was continuing to engage with Minister for Heath Jennifer Carroll MacNeill and the Minister of State with responsibility for Older People Kieran O'Donnell on areas for improvement in the regulatory framework.

54 inspection reports published

HIQA has also published 54 inspection reports of nursing homes owned by Emeis Ireland.

Following the airing of the RTÉ Investigates Programme on two nursing homes within the Emeis Group, which highlighted examples of poor and unacceptable staff behaviours and practices, it says that HIQA’s Chief Inspector of Social Services undertook a significant programme of regulatory action.

The Chief Inspector conducted a programme of targeted inspections in all nursing homes owned by Emeis Ireland and required the directors of the individual nursing homes to take "urgent action" with immediate effect to address the safety and wellbeing of residents.

HIQA's Chief Inspector also engaged with Emeis Ireland and requested that they stop admissions to all centres owned by Emeis Ireland with immediate effect while a review of quality and safety of care for residents was being undertaken by HIQA.

The regulatory programme included an increased number of targeted inspections and monitoring of all nursing homes operated by the nursing home group over time to ensure ongoing safety and sustained improvements for residents.

It found evidence that a number of the centres were operating to a good standard and providing safe and effective care.

The inspection programme also identified that seven centres had significant challenges in delivering safe and effective care.

This required additional regulatory action which included undertaking additional inspections, placing restrictive conditions on those nursing homes, including a requirement to restrict the admission of new residents until further notice and requiring the provider to increase staffing.

HIQA's Chief Inspector also made referrals to An Garda Síochána as appropriate.

The regulator engaged directly with residents and families on their feedback and concerns. As part of this, HIQA’s CEO and Chief Inspector visited the nursing homes that were the subject of the programme to hear directly from all residents and families.

The two centres that were the subject of the RTÉ Investigates television programme were among the Emeis Ireland centres which required increased regulatory action.

The inspection reports for these centres are not being published at this time as HIQA has said that it is awaiting the outcome of legal proceedings seeking access to all video footage relating to the programme.

'Implementation plan'

The Minister of State with responsibility for Older People has said the Department of Health is "undertaking a detailed assessment of the report's findings and recommendations".

This, Minister O'Donnell said, includes "alignment with ongoing reforms aimed at strengthening governance, safeguarding and quality in long-term residential care".

"A detailed implementation plan will now be developed," he said.

"Action has been taken across legislation, regulation and system reform, supported by a programme of inspection and engagement, and increased funding has been secured for the sector to support improvements in the quality of care and lived experience of residents," he added.

The minister said the welfare, dignity and safety of nursing home residents "is the Government's primary concern".

He said work "will continue" with "a clear focus on strengthening governance" and accountability, adding that "mistreatment neglect or any form of abuse of a person living in a long-term residential care centre is completely unacceptable".

Call for 'consistency of approach'

Nursing Homes Ireland called on the Department of Health and HIQA to take a more holistic view of how it plans to enhance the regulatory process to ensure "a consistency of approach across inspections carried out in nursing homes".

It said NHI engaged and met Forvis Mazars during the review process to facilitate the provision of its expert sectoral insights.

In a statement, CEO Tadhg Daly said NHI would "remain engaged" with the Department of Health and HIQA on the recommendations.

Emeis Ireland committed to 'high quality care'

In a statement, Emeis Ireland acknowledged the publication of the inspection reports.

A spokesperson said it had worked closely with HIQA and respective stakeholders throughout the process and had implemented significant improvements across our nursing homes.

"We note that HIQA has recognised evidence of Emeis centres operating to a good standard and providing safe and effective care," it said.

It added that in a number of cases, detailed implementation plans were and are in place with respect of facilities identified with challenges.

"We remain fully committed to providing safe, high quality care for all residents and will continue to work constructively with HIQA to ensure these improvements are sustained.

"The wellbeing of our residents remains our highest priority."