03/11/2020

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The Report deals with several key issues relating to the particular impact of Covid-19 in nursing homes, including: deaths in nursing homes; systemic weaknesses in the care of the elderly; the need to improve the regulatory framework; the role of nursing home workers; and the provision of self-isolation facilities in State-supported premises.

Deaths in Nursing Homes

One of the principal issues addressed by the Special Committee, and the one which consumed more meeting time than any other, was the issue of deaths in nursing homes. The Report states that nursing home deaths as a result of Covid-19 amounted to 985 people. This was 56% of the total deaths caused by the virus across the country, borne by 0.65% of the population.

The Special Committee examined reports from HIQA[2] and the Expert Panel on Nursing Homes[3] which highlight some of the systemic weakness.

Key Findings

The Report summarises the key issues that emerge from the evidence as follows:

  1. The public health authorities of the State became overly focussed on preparing acute hospitals for the oncoming pandemic in February and March 2020 and failed to recognise the level of risk posed to residents of nursing homes.
  2. The State delayed in reacting to the deteriorating situation in nursing homes, especially in the provision of supports like PPE and supplemental replacement staff.
  3. While major efforts were made by staff in nursing homes, there are outstanding questions as to why some nursing homes were free of Covid-19 whereas others were heavily impacted through the sickness levels of staff and the death of residents.
  4. There has been a failure to provide answers to the relatives of the deceased, exacerbating their pain and suffering.

Recommendations

Firstly, the Report recommends that a public inquiry be set up to investigate all circumstances surrounding each individual death due to Covid-19 in nursing homes.

Secondly, the Report recommends that a review be undertaken into the impact of the privatisation of Ireland’s nursing homes.

Systemic Weaknesses and the Care of the Elderly

The Special Committee found that Covid-19 revealed systemic weaknesses in the provision of services by the State which resulted in negative outcomes for, among others, residents of nursing homes.

The Special Committee heard that there is an absence of statutory staffing ratios. HIQA reported that there is no minimum staffing level or national staffing ratio as it is on a discretionary basis with each provider. The Department of Health stated that it would work with HIQA going forward to apply the HSE guidance framework on staffing levels to nursing homes.

The Special Committee concluded that support of elderly people at home must have a publicly funded and publicly provided model of care underpinned by community intervention teams from the HSE.

Key Findings

The Report outlines the key issues which led to negative outcomes for residents as follows:

  1. Failure by the State to upgrade homes leading to a situation where ill residents could not be isolated and were sharing bedrooms and bathrooms. This contributed to the spread of the virus.
  2. Ongoing decisions by the HSE during the pandemic to place residents in nursing homes that have compliance issues with infection control.
  3. Lack of a proper framework relating to the number and skills capacity of health care workers in nursing homes. This was left to the discretion of the owners of nursing homes.
  4. Delay by the State in reviewing the adequacy of the regulatory framework for nursing home care, an issue that was highlighted by HIQA over a number of years.[4] HIQA has advocated for stronger powers of inspection, giving evidence to the Special Committee that the pandemic has exposed the weakness in the regulatory framework of nursing homes.
  5. Absence of a clinical oversight and care pathways between nursing homes and the public health authorities of the State.
  6. Failure by the State to invest in acute and step-down hospital bed capacity which led to the HSE transferring over 10,000 patients into long-term residential care settings, including nursing homes, in order to prepare hospitals for the potential arrival of members of the public requiring acute care having contracted the virus. Not all of those who were transferred out needed to go into institutional care and not all were being tested.[5]
  7. Lack of a coherent policy from the State on the care of the elderly which, through the provision of tax incentives, has seen the continuation of long-term institutional care where ownership has transferred from public to private sector.
  8. A policy of privatisation of nursing homes that was disconnected from the public health system without due consideration.
  9. The failure to prioritise empowering the elderly to remain at home and develop smaller domestic-style units integrated into towns and city community areas.

Recommendations

Firstly, the Report recommends that an implementation plan be put in place for the recommendations contained in the Report of the Covid-19 Nursing Home Expert Panel with a requirement for six-month progress reports to the Oireachtas.

Secondly, the Report recommends that standards regarding staffing and staff ratios in nursing homes be developed by HIQA.

Improving the Regulatory Framework

The Special Committee heard evidence from HIQA and the HSA which demonstrated the need for stronger regulation in the relevant sectors to reduce non-compliance. HIQA completed 170 inspections in the first quarter of 2020 but ceased on-site inspections after 13 March. Consequently, there were no nursing home inspections carried out during the height of the pandemic.

The Report notes the Expert Panel’s concern regarding two HIQA regulations: (i) the requirement for the ‘person in charge’ of a nursing home to have a formal gerontology qualification and (ii) the requirement for the presence of a registered nurse on duty at all times.

Moreover, the Special Committee found that the workload of HIQA and the HSA was such that they did not have sufficient staffing levels to fully investigate compliance matters.

Recommendations

The Special Committee recommends that an “urgent review” of the regulatory framework in both HIQA and the HSA be carried out. The review should examine the powers and resources available to both bodies.

The review should also address specifically the decision to remove the two regulations (i) requiring the ‘person in charge’ of a nursing home to have a formal gerontology qualification and (ii) requiring the presence of a registered nurse on duty at all times and the argument for their reinstatement. The Special Committee recommends that a report on the findings of the review be put to the Oireachtas.

Nursing Home Workers

The Special Committee found that the transmission of Covid-19 in “congregated settings”, such as nursing homes, was exacerbated by the fact that workers felt compelled to attend work due to the absence of income support if they decided to report sick. Consequently, nursing home workers posed a significant risk of unknowingly transmitting the virus to residents. The Special Committee describe this as a “catch-22 situation” for such workers.

Recommendations

Firstly, the Special Committee recommends that the Government make provision for a statutory sick pay scheme to cater for low paid workers such as those in nursing homes.

Secondly, the Special Committee recommends that the Government make Covid-19 a notifiable disease under health and safety regulations.

Provision of Self-Isolation Facilities

The Special Committee found that there is still many residents of nursing homes who are residing in “nightingale-type wards” where they spend the majority of their time in the same room with communal facilities.

Recommendations

The Special Committee recommends that the Government phase out support for facilities where residents cannot self-isolate and accelerate the capital works in all State-owned facilities to ensure that residents can adequately self-isolate.

Issues for Ongoing Consideration

In addition to the above over-arching recommendations and findings, the Special Committee identified several issues relating to nursing homes which it assessed ought to be considered further and thereby referred to the Joint Committee on Health. These issues include:

  1. The implementation of Recommendation 15.3[6] of the Final Report of the Covid-19 Expert Panel on Nursing Homes on the establishment of a statutory agency to investigate abuse or neglect in care settings be implemented immediately, instead of within the 18-month timeframe highlighted in the report.
  2. The need to ensure that data sets regarding outbreaks in nursing homes and outbreaks in other settings be linked in order to provide a more systematic report on the risk factors for outbreaks.
  3. The need to explore in detail issues concerning the future model of care for older people in Ireland.
  4. The need to continue to monitor the State’s response to Covid-19 in nursing homes and actions taken to protect the elderly from Covid-19.

With regard to nursing home premises, it is important to note that the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013 came into operation on 1 July 2014. The 2013 Regulations cover a range of areas including staffing, nutrition, governance, risk management and safety and set out requirements in relation to physical premises.

The 2013 Regulations were subsequently amended by the 2016 Regulations, which came into effect in June 2016. The 2016 Regulations inserted further requirements for the State with regard to physical premises. The State’s deadline for compliance was also extended until 2021 to allow designated centres to carry out extensive capital works and come into compliance with directives pertaining to the physical environment and bedroom sizes.

There will be a chronic shortage of beds in the elderly care sector shortly.  We have the 2021 deadline for compliance with the National Standards for Residential Care Settings for Older People 2016 on the horizon and inevitable changes which will be required to respond to infection control issues highlighted by the COVID-19 pandemic.  Combined these point to an urgent, substantial and sustained requirement for capital investment in the sector.

The authors would like to thank Eamonn Butler for his assistance.

[1] Final Report – Special Committee on Covid-19 Response

[2] HIQA Report on the Impact of Covid-19 on Nursing Homes

[3] Report of the Expert Panel on Nursing Homes

[4] Overview of 2016 HIQA regulation of social care and healthcare services, at p. 7.

[5] HSE Guidance on the Transfer of Patients (19 March 2020)

[6] Recommendation 15.3 of the Report of the Expert Panel on Nursing Homes states: The Department of Health should explore a suitable structure and process for external oversight of individual care concerns arising in nursing homes, once internal processes have been exhausted without satisfaction.