December 2020: A new group, Nursing Home Quality Initiative (NHQI) led by concerned, volunteer citizens from around Ireland, has pledged to campaign for systemic change in the care and quality of life of older people. The group is calling for volunteers to join and become actively involved. All NHQI members either currently have or have had loved ones in nursing home care. The group is committed to monitoring compliance and enforcement of nursing home regulations and standards as well as best practices in Ireland and other jurisdictions.

Announcing the establishment of the group, Joe Boyle, NHQI said, “Our brief is to be a voice of residents in nursing homes and their relatives, share our own experiences, and echo concerns in the wider community about the services provided in nursing homes and the impact of the National Standards on those services. According to the Special Oireachtas Committee on Covid-19 Final Report, published the 9th of October 2020, 56 percent of all deaths from COVID-19 in Ireland have related to nursing home residents. Sadly, the voices of residents and relatives have been absent from much of the subsequent debate.“ Annette Condon, NHQI added, “We are also looking beyond COVID-19 to longer-term care and quality of life. There are a multitude of untold, small things every day that collectively add up to unfulfilled lives. This is an issue that will affect us all. By 2041, it is estimated that at least one in four people in Ireland will be over the age of 60 – we need to establish the right models of care now.”

NHQI has laid out its priorities in a six-point plan, which calls for:

  1. An independent complaints resolution process
  2. Proper consultation with residents and relatives
  3. Reform of the regulatory framework and the current inspection model
  4. A new culture of quality of compliance, driven by the regulator in consultation with service users, and transparent sharing of quality management indicators with the general public
  5. Improved staff to patient ratios in nursing homes, especially at night, enhanced staff training coupled with increased hygiene and infection control measures
  6. A model of community clinical care and equal access to services

Longer-term, NHQI wants agreement on new models of older person care, including an end to the divide between public and private nursing homes, where residents in private nursing homes have lower staff-to-resident ratios and are more likely to incur charges for additional services. NHQI is available to speak with the Minister for Older Persons, the Department of Health, the HSE, HIQA, NHI, advocacy groups as well as researchers, academics, media and other stakeholders. The group asks to be consulted in advance of the development of any new standards and the publication of corporate reports that relate to residential care for older persons.

In particular, NHQI would welcome participating in service user panels, focus groups and national patient experience surveys. The group stands ready to make submissions on behalf of residents and relatives to expert groups on key issues, such as medicines management, use of restraints, staffing levels and skills mix. Likewise, NHQI would welcome regular meetings with the Nursing Home Providers to exchange views, discuss new developments and clarify areas of mutual concern.

About 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 NHQI understands that 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.

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Editor’s Notes: NHQI 6-Point Priority Plan: Learn more here:

  1. An Independent Complaints Resolution Process

The absence of an independent and timely procedure for handling complaints is one of the more glaring omissions from HIQA’s current model. This state of affairs has been a cause of much distress and frustration for countless nursing home residents and their families over these past eleven years. Currently, if you raise a complaint with HIQA, it is not necessarily followed up or investigated but is noted and reclassified as a “concern” for inclusion in the next nursing home inspection. It is not clear from published HIQA inspection reports if complaints are subsequently reviewed by the inspecting parties, or what feedback, if any, is given to the complainant.

  1. Proper Consultation with Residents and Relatives

The establishment of the Nursing Home Expert Panel in response to COVID-19 was a necessary and commendable step on the part of Government. While the group was given a short-term focus and an extremely narrow timeline in which to complete its work, and while it did receive numerous submissions from stakeholders, we were disappointed with the Group’s overall lack of engagement with service users.

There has been huge variation reported by relatives around the country, seeking to visit their relatives in nursing home care. While many nursing homes are motivated by safety concerns, for some, it is an easy option to stop relative visits. There appears to be little consultation or dialogue with residents and their families with nursing homes arbitrarily developing their own rules. Stopping all visits should be the last line of defence – not the first. NHQI stands ready to take part in any discussions between HSE, NHI and HIQA in this regard.

  1. Reform of the Regulatory Framework and the Current Inspection Model

Regrettably, the national standards and regulatory process are not robustly enforced. There is no apparent evidence that they assist service providers to develop a real culture of quality care and continuous improvement. We are not aware of any efforts by HIQA to have the quality standards improved or updated. We believe that the existing regulation governing care plans need to be strengthened while the terms of nursing home contracts of registration could be made more effective through inducements to adhere to better practices.

We call for additional oversight by local clinicians and the addition of new expertise to HIQA inspection panels, for example, gerontologists, psychologists, infection control specialists and management assessment skills. The group also wants to see the introduction of annual online compliance training by nursing home managers plus the introduction of mandatory relative questionnaires as part of HIQA inspections.

  1. A New Culture of Quality of Compliance, Driven by the Regulator in Consultation with Service Users

There should be a public consultation process put in train to give the wider population an opportunity to contribute their views on the entire nursing home regulatory system. We want to see far greater transparency in HIQA’s quality management system, key performance indicators and reporting metrics. In particular, HIQA’s recent claims to the Oireachtas Committee that it needed further powers to enhance nursing home regulations need to be urgently clarified.

This and HIQA’s apparent prior knowledge of some nursing homes failing to routinely comply with infection control measures and related standards of governance and suitability of premises, did not seem to be highlighted prior to the COVID-19 crisis. Likewise, we believe that nursing homes need to acknowledge their own shortcomings and failures in relation to COVID-19, including the lack of crisis planning.

  1. Improved Staff Ratios, Enhanced Staff Training and Improved Hygiene and Infection Control

The nursing home sector requires a champion to lead a culture change in hygiene and infection control, for instance, the laxity around the wearing of duty uniforms outside of the nursing home setting (coming on duty and going off duty) needs to be addressed. We want to see better staff patient ratios, particularly at night as well as improvements in general standards of hygiene and infection control.

We are anxious for a review of the current model for training staff. What ongoing professional development opportunities are available for nurses, working in nursing homes? How often are their skills refreshed? What are the minimum qualification requirements demanded of care assistants? Why were the regulations changed in 2013 to dilute the requirement that there be a registered nurse on duty at all times in all residential settings?

  1. A Model of Community Clinical Care and Equality of Access to Community Services

For years, nursing homes have operated in isolation with private nursing home residents denied access to routine health services open to others in the community, such as physiotherapy and occupational therapy. In our view, this idea of ‘other’ contributed in no small part to the COVID-19 crisis, where the HSE did not view nursing homes as being part of the healthcare system. This was further exacerbated by the general lack of medical equipment in nursing homes

There is currently no system in place in Ireland that provides a proper assessment tool for residents and no system that allows for the transfer of information between nursing homes and other care facilities such as hospitals. We welcome the recommendations from the Nursing Home Expert panel, especially those relating to the continuation and formalisation of contingency measures, already introduced for the clinical support of nursing homes by the wider health networks and community services. Additionally, we believe that there is an urgent need to establish a Clinical Leadership/Medical Director that would link up all of the services and provide specialist advice for defined areas.

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