Inspection is a retrospective snapshot of the status of events at a given timepoint, the output of which usually results in various grades of findings or observations. The auditee has to respond to these observations/findings and typically there is an agreement between the auditor and the auditee as to how those findings can be corrected and what actions can be put in place so that they do not occur again in the future. This response in the world of Quality are known as “Corrective and Preventive Actions (CAPA).”

HIQA began inspecting nursing homes in July 2009. At the launch of this activity, it stated, “Our aim is to safeguard and drive improvements in the quality of life of older people by emphasising what life should be like for people living in residential care.” Acknowledging that great strides have been made since 2009, nonetheless it appears through the lens of the greatest medical challenge in recent times to befall us, i.e. the COVID-19 pandemic, that great failures still exist. According to the results published in the COVID-19 Nursing Home Expert Panel Report there are challenges in key areas such as nursing home procedures, staffing levels, skills mix, and infections prevention and control. The question then must be asked, was the promise by HIQA to drive improvements completely realised?

Speaking as a relative, the only quality-driven activity by HIQA that I am aware of is “The Inspection Process.” There are thousands of inspection reports available for review by the public on their website. All of the nursing homes that experienced widespread carnage due to COVID-19 had been inspected by HIQA prior to the pandemic and so we have to question why those key failures, as so forensically reported by the Nursing Home Expert Panel were not previously identified by HIQA? Has the inspection process failed? Was there a systematic failure of the agreed CAPAs between HIQA and the nursing home provider? Is the inspection process no longer fit for purpose? Is there another way of driving quality into the process rather than trying to “inspect it in?” I believe that there is an absence at all levels of a true quality culture. We cannot have quality processes unless a culture of compliance sits firmly behind it. Who then would drive this new culture of quality and compliance? The regulator, the nursing home provider, residents relatives or medical experts? I would propose that all should collectively execute a level of responsibility to ensure that this happens.

It would appear to me that the group currently best resourced to drive this new quality of culture and compliance is the regulator. From reviewing the expansive suite of publications on its website ranging from health information to health technology assessments, it is well equipped to create user friendly tools/guidance in both paper and electronic format to help all-sized nursing homes to become more compliant. However, such tools must be fit for purpose, be user friendly and there must be a move away from bulky worded documents that are too time consuming for the users to digest. For example, a recent guidance published on the HIQA website 17 Sep 2020 entitled, “ COVID 19 – An assurance framework for registered providers” whose objective is to “assist registered providers and staff to identify good practice and areas of improvement in this crucial aspect of care, and take the necessary actions to effect changes in line with the National Standards for infection prevention and control in community services (referred to in this guidance as the national standards)” is unwieldy, top heavy with sections/sub-sections, and not wholly user-friendly.

The non-user-friendly document approach by HIQA is also embedded in the nursing home inspection reports. The language contained therein continues to be subjective, top heavy with irrelevant comments such as the one I noted in a nursing home report, dated July 2020 which stated; “It was a gorgeous summer’s day and there was a live music session in the Blackwater garden with the musician playing songs of their era, however, staff present did not help residents participate in the session. One resident got up to dance but no-one came to him so he sat down again; other residents sat forward in their chairs looking around, possibly for someone to sway to the music with them but sat back in their chairs again as nobody came to them.” Indeed, this reads like a passage that could have been taken straight out of a novel! I have listened to many nursing home providers share their experience of the inspection process. In general, the feeling is that the inspection process is harsh and unhelpful. One need only look at the terminology within the nursing home reports to support this statement. Findings or observations are not referred to as that but rather as “judgements.” This kind of language needs to be eradicated from the regulator terminology as it is doing nothing to drive quality and improvements but rather creating a sense of fear and reluctance and an absence of transparency between all relevant parties. NHQI believes that there is a need for a fresh vision and brand new legislative framework that will bring the service user to the centre of nursing home oversight and guarantee by statute their role as partners in the process.

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