There are a number of inter-related issues at play in relation to the safety of the nursing home environment for staff and residents, namely, the quality of care experienced by these same residents and the comfort and confidence of family members and the wider community. These issues include the suitability of nursing home premises, the adequacy of staffing numbers, their skill levels, the commitment of providers and the competence of managers/persons-in-charge. The various reviews carried out into the nursing homes’ response to COVID-19 paint a picture of an unstable staffing model, overly reliant on the services of temporary and agency staff, often working in multiple facilities and with inadequate sick pay arrangements. They also highlight the existence of multiple-occupancy wards as an obstacle to the containment of the spread of infection. These wards should have been phased out by 2015 but providers were given an extension until the end of 2021.

We would like to know how confident HIQA is that the 2021 deadline will be met – or are we facing demands from the HSE, other providers and local politicians for a further extension to the 2021 deadline? NHQI welcomes the findings of the COVID-19 Expert Panel (August 2020) in relation to preparedness for future outbreaks, including the development of staff training and education programmes on infection prevention and control plus the appropriate use of PPE for all nursing home employees. This should include quality review with regular monitoring of knowledge and practice, and particularly given the implications to nursing homes where employment of agency staffing is adopted and given the additional risks of transmission noted from the evidence. The Panel also proposes that consideration must be given to supporting the health and wellbeing of all staff employed in a nursing home during an outbreak, including financial support during periods of isolation and quarantining.

The Panel also states that the voices of all involved in the care and management in nursing homes, especially those of residents and their families, should be at the heart of practice developments. We interpret this as an exhortation to nursing home providers, management and staff to listen and respond to the concerns of their service users through this unprecedented and challenging time. In turn, service users will look to the management and staff of nursing homes to become beacons of best practice in hygiene and infection control in their communities by, for example, not wearing duty uniforms outside of the nursing home setting. We want to see better staff patient ratios, particularly at night as well as improvements in general standards of hygiene and infection control. Stakeholder evidence to the Expert Panel indicated that an analysis is required of the Person in Charge role ‘across types of residence and long-stay facility and the ongoing workforce challenges related to dependency levels in older persons.’ It suggested that gerontological qualifications should be a pre-requisite for working in the sector and that the skill mix and nurse: client ratio in nursing homes be defined. Among other suggestions was that there be an integrated approach for nursing homes and community supports going forward.

While the depth and detail of the HIQA and Expert Panel reports are to be welcomed and supported, nursing home users may find the final proceedings and findings of the Oireachtas Committee (October 2020) and of its interim report (July 2020) more accessible. The Committee heard in evidence that the primary responsibility for the provision of safe care and service to nursing home residents rests with individual nursing home operators, who have a duty to provide appropriate medical and health care in accordance with professional guidelines and a framework of regulation and standards. This includes the prevention and control of healthcare-associated infections. The Committee heard evidence of a 2018 report from HIQA which indicated an 18% rate of failure or non-compliance with infection control standards and questioned why residents are sent to homes, which are either not fully compliant or are not compliant with regard to infection control. The Department of Health and HIQA appear to have set out to explain away this conundrum – an explanation that is lost on the NHQI team, but which may convey to the layman that somehow ‘improvement’ is important, but ‘compliance’ is not! One wonders whether indeed there are objective (minimum) standards prescribed.

HIQA went on to inform the Committee that one of the big causes of non-compliances are related to premises, explaining that under statute, nursing homes have until the end of 2021 to become compliant and that until they reach that level of compliance, they cannot meet infection control standards. The Committee expressed its concern that patients continue to be placed in non-compliant nursing homes, even while there are questions over their ability to control infection. While the COVID-19 crisis has exposed the weakness of this practice as it currently operates, NHQI has long been concerned about the fact that nursing homes with persistently poor records of non-compliance over lengthy periods, sometimes years, can remain fully operational while due regulatory process runs its course with no communication to service users or their representatives of a possible risk to residents.

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