Official Report (Hansard)
Date: 10 October 2007
COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Regulation and Quality Improvement Authority
11 October 2007
Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mrs Carmel Hanna
Ms Carál Ní Chuilín
Ms Sue Ramsey
Dr Ian Carson ) Regulation and Quality Improvement Authority
Mr Phelim Quinn )
The Deputy Chairperson (Mrs O’Neill):
You are very welcome, Phelim and Ian. Mr Phelim Quinn is acting chief executive and Dr Ian Carson is chairman of the Regulation and Quality Improvement Authority (RQIA). I invite you to make your submission. Members may then ask questions.
Dr Ian Carson (Regulation and Quality Improvement Authority):
Thank you. We are delighted to be here this afternoon, and we are grateful for the opportunity to meet the Committee. I am Dr Ian Carson, and I have been chairman of RQIA since June last year. I am still excited, stimulated and enthusiastic about the work of our organisation and the contribution that we can make to improve the quality of health and social care in our Province. I am as enthusiastic about that now as I was when I took on the responsibility of my position last year.
We fundamentally welcome the opportunity to meet the Committee and to have an opportunity to describe and explain some of the key issues relating to our work programme, which Phelim will do shortly.
However, before I start, I want to emphasise that The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003 that established RQIA was one of the most important pieces of legislation that has been passed in respect of health and social care. There are two reasons for that: first, our organisation was established through that Order but, more importantly, the Order established a duty of quality on health and social care organisations’ chief executives and their boards in taking forward the quality agenda in their organisations, and it established the duty and responsibility that they have to ensure that that is in place. Secondly, we have a regulatory and monitoring role to ensure that that is the case. We will ensure, through our reports and any other opportunities, that the Assembly, the Department and the public are fully aware of the changes in quality improvement in health and social care in the Province.
I am grateful for the opportunity to be able to explain what we do, and I hope that that will be of value to the Committee. Phelim will go through our submission and answer any points that the Committee wishes to raise.
Mr Phelim Quinn (Regulation and Quality Improvement Authority):
I also thank the Committee for this opportunity. I will take members through the briefing paper, elaborate on some points, and take any questions that members may have.
As Dr Carson has said, the Regulation and Quality Improvement Authority was set up in 2005, as a result of 2003 legislation. Its main duty is to encourage improvement in the quality and availability of health and social care, right across the sector in Northern Ireland. That includes not only the statutory health and social care sector, but the independent, or — as we refer to it — the regulated sector. That includes independent nursing homes, residential care homes, children’s homes and a range of other regulated services.
As the briefing document states, ours is a relatively small organisation. We have a staff of 102; and our main functions may be divided into two: clinical and social care governance, which is the review of the quality-improvement arrangements in the statutory sector; and regulation, which is the review of the quality-improvement arrangements in the independent or regulatory sector. We have a small budget, as a DHSSPS organisation: £5∙2 million, a proportion of which is made up from fees generated from regulation activity.
In 2005, we formulated a corporate plan for the good governance of our organisation, which established four key themes. The first of those is raising quality and improving performance right across the health and social care sector.
The second is informing, influencing and enforcing. We inform the Department, the public and the Government of the work that we do and about the state of health and social care in Northern Ireland. We have powers of enforcement under the legislation, especially within the regulated sector. Those powers range from making recommendations, through to the closure, or the placing of conditions on, providers of care. In the statutory sector, our powers extend to recommending that the Minister take special measures.
The third theme is developing people in partnership. Our approach to quality improvement in health and social care is about working in partnership with providers as far as possible. We aim to encourage improvement: we use the carrot as much as the stick. The fourth theme is managing our own resources effectively, efficiently and economically.
Our activities involve monitoring and inspecting the quality of health and social care services in Northern Ireland. We inspect the quality and availability of services through clinical and social care governance reviews. Those can be broad, organisational reviews or thematic reviews, specific to certain services.
We also regulate. That means that we register and inspect facilities, including nursing homes, residential care homes, domiciliary care, day care — the full range of regulated sector services. We also keep the DHSSPS informed of the quality and availability of services. We endeavour to keep the public fully informed of all our activities and all our findings.
The services that we regulate are listed in the briefing paper. Legislation has extended these to domiciliary care agencies, day-care provision, adult-placement agencies, nursing agencies and independent healthcare. A change in legislation led us to regulate the independent hospitals — such as Ulster Independent Clinic and Balmoral Clinic — and also beauty salons that provide services such as laser and intense-pulse light treatment. We also regulate boarding schools across Northern Ireland.
As you can see from the tables in our briefing paper, there is a wide range of residential care services in Northern Ireland. Some 634 establishments provide 15,473 beds. That is significantly more than is provided in the statutory sector. Other regulated activities that are listed in our briefing paper are new services that are being phased in.
We have a requirement under legislation to develop a register, and we hope that that will be made available on our website in the next year to enable the public to see what services are registered so that they can make informed decisions about the placement of relatives, etc.
RQIA deals with complaints that arise from services, but more specifically, we look at how services deal with complaints in the first instance. A key tenet of our work is to ensure that when a user or relative has a problem with the service, they try to seek local resolution with the service provider. However, we have a role in the second stage of complaints, and in the further investigation of unresolved complaints.
Dr Carson already referred to the statutory duty of quality, which was one of the key measures that was brought about through the enactment of The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003.
That legislation stated that:
“Each Health and Social Services Board and each HSS trust shall put and keep in place arrangements for the purpose of monitoring and improving the quality of —
(a) health and personal social services which it provides to individuals; and
(b) the environment in which it provides them.”
That is a key piece of legislation that directs the way in which we work. The Regulation and Quality Improvement Authority has a responsibility to review on an annual basis the clinical, social care and quality-improvement arrangements within health and social services boards, trusts and special agencies.
Earlier this year, we carried out the first review of clinical and social care governance arrangements in 25 organisations in Northern Ireland. Obviously, that preceded the outworkings of the review of public administration, and the changes that took place on 1 April. The results of that review are being presented to our board this afternoon and will be published within the next few weeks. We have also undertaken mental-health and learning-disability reviews, which have just been completed, and are currently being written up.
Those reviews take the form of self-assessment, which is based on the requirement of organisations to assess themselves under the statutory duty of quality, and report to RQIA on how they score themselves in relation to the quality standards. RQIA then validate that self-assessment through visits to the health and social care facilities. In the past year, both in the clinical and social care governance reviews, and in the mental-health and learning-disability reviews, we have used peer and lay reviewers. Peer reviewers are nurses, doctors, social workers and allied health professionals within our teams who review organisations in which they do not work. We also use members of the public as lay reviewers to offer a public perspective on the state of health and social care in those facilities.
There has also been a proposal to merge the functions of the Mental Health Commission with the RQIA, in the draft reform Order that is now under review by the Minister. We are unsure of the status of that matter as it relates to the draft reform Order, but we have been working with the Mental Health Commission on the potential transfer of those functions. One of the key issues is that there would be combined power in the legislation that set up the RQIA as an authority and in the forthcoming Order to enable, and to effect improvement in, mental-health and learning-disability services.
More recently, we have started to look at further work in the review of clinical and social care governance arrangements in primary care, and have appointed a primary-care adviser to scope out what current work is being done on the review of clinical and social care governance in primary care, and more specifically in general medical services, general dental services, pharmaceutical services in the community, and optometry. We hope to report to our board next month on how to proceed.
The Deputy Chairperson:
The Chairperson has arrived, so I shall vacate the Chair.
Mrs I Robinson:
No, finish this session. You began, so you can finish.
Ms S Ramsey:
The Deputy Chairperson:
To what degree are you able to operate independently from the Department? I know that you have said that you have lay reviewers, so I suppose that partly answers my question, but have you any other comments on that matter?
RQIA was set up as a non-departmental public body, and in the legislation it is noted as fully independent of health and social care organisations, and as an arms-length body as it relates to the the Department. We have our own board of 13 members, made up of the chairperson and 12 other members.
In the past, the Regulation and Quality Improvement Authority has conducted two major service reviews: one into the Northern Ireland breast screening service, and the other into the unfortunate death of Mrs Janine Murtagh. In those reviews, RQIA hopes that it has been able to demonstrate its independence from the Department. As part of its review of breast screening, the authority made recommendations to the Department on how it should plan for the workforce in the sub-specialty of radiology that deals with breast screening.
The key tenet of RQIA’s relationship with the Health Service and the Department is that its scrutiny, monitoring, judgements and analyses must be truly independent, in the interests of patients, carers and service users. The board and I consider that to be the fundamental tenet of the authority’s status.
Ms Ní Chuilín:
In order to ensure that the RQIA receives professional advice, its senior structure includes chief advisers for medicine, nursing and social work. Can the witnesses explain why the same equitable arrangements were not put in place for allied health professionals in the senior management structure when RQIA was formed, as had originally been planned? If possible, can the witnesses give specific details about how RQIA currently ensures that it is provided with expert professional advice on quality and provision of allied-health-professional services? The witnesses mentioned their independence from the Department. I have no doubt that that will be expanded on later. Those are my two main concerns.
When RQIA was originally set up, there was to be a small executive team made up of a chief executive, a director of corporate services, and a director of operations. At that time, I was not employed by RQIA. The former chief executive undertook a recruitment programme and advertised for and appointed a director of corporate services. However, she also advertised for a director of operations on three separate occasions, but failed to appoint someone to that post.
There were negotiations with the Department about restructuring the senior team. The team of advisers for medical care, nursing care and social care, to which the member has just referred, was the model that had been proposed. There was also a proposal to consider the employment of other senior professional advisers to the authority on a sessional basis. They would have included senior professional advisers in pharmacy, dentistry and allied health professions. Unfortunately, however, that did not materialise. There was failure to agree on how the model might be taken forward.
As work continued on the quality-assurance of services that were provided by such individuals, the concept of peer review was also developed. The authority believed that in order for it to gain expert advice, it would use peer reviewers from across all professions. At present, there are several allied health professionals among the authority’s cohort of peer reviewers who advise it on its review processes. The authority has also considered the ability of allied health professionals and other professionals to work for it by opening up project-management jobs on clinical and social care governance reviews. RQIA has also opened up its inspection posts, which were formerly nursing and social care inspector posts, to adult care inspector posts, thus enabling allied health professionals to apply.
One of the board members, Professor Patricia McCoy, has a physiotherapy background and has undertaken academic work in the University of Ulster. Therefore, I assure the Committee that the views, the voice and the considerations of allied health professionals are certainly covered at board level.
What were the circumstances surrounding the vacancy for the position of chief executive of RQIA, and how many cases has RQIA examined, and at what cost, since its inception?
The position arose recently because of a personal decision by the then chief executive to retire after 40 years’ service.
How many cases have you dealt with since RQIA’s inception?
That depends on what you mean by “how many cases”. Obviously, there is an ongoing programme of inspections for all regulated health and social care sector facilities in Northern Ireland, which means a minimum of two inspections a year for care homes and more frequent interventions if there are concerns. This year, clinical and social care governance reviews have been carried out in 25 organisations and five health and social care trusts have undergone mental-health and learning-disability reviews. In addition, we recently conducted reviews of respite care in Cherry Lodge children’s home, the Northern Ireland breast screening programme, and into the circumstances surrounding the death of Janine Murtagh. That work was carried out within the cost envelope that is outlined in our annual accounts. We have a budget, which we stick to.
On the vacancy for the position of chief executive, I can assure the Committee that selection and recruitment procedures to seek a replacement have commenced, with the placing of advertisements.
I welcome Phelim and Ian. Having worked in the Health Service for over 25 years, I can state that one of the good things about this job is that one gets to meet people and find out what various bodies in the Health Service actually do. I also meet some people whom I have not seen for years, and it does no harm to say that it is good to see Phelim again. Phelim’s father and my father were the best of friends for many years.
Ms S Ramsey:
Go easy on him.
It was interesting to hear Phelim talking about RQIA’s powers of enforcement. What happens if people do not pay attention?
Secondly, you mentioned RQIA’s independence from the Department. Who can report to RQIA? For example, if I, as a GP, feel that standards are poor in a nursing home or see that patients of different gender must share toilet facilities in a casualty department, am I permitted to report that to you, and do you have the authority to act on that information, or must your instructions come from the Department?
Moreover, who monitors RQIA’s independence from the Department?
Phelim, you spoke about RQIA’s role concerning standards and clinical governance, which is important these days. Does that role apply to standards of clinical practice on the part of, for example, GPs and primary care professionals?
Lastly, I wish to raise a specific practical issue, about which I wrote to the Minister and about which many people were shocked and angry. I have referred many patients to Cuan Mhuire in Newry, as have GPs from across Northern Ireland, because the services that it provides are not available anywhere else. I know that you have a job to do, and I am not blaming you for your decision, but you closed it down. Before reaching the point at which you close a hospital, nursing home or facility such as Cuan Mhuire — and I feel that patients’ health was affected by that closure — could problems not be ironed out, perhaps in consultation with relevant bodies? This may not be the case, but news has filtered back to me that that closure was sudden. Could any measures be taken to prevent such episodes in the future?
I will answer those questions in reverse order, because I will not remember them all and will need a prompt.
I will deal with Cuan Mhuire first. You initially referred to RQIA’s powers of enforcement. Cuan Mhuire was identified as a care facility that was operating outside of the regulations and legislation.
RQIA met with Cuan Mhuire representatives and offered to carry out an inspection, which was accepted. During that inspection, a number of concerns were raised about the estate where services were being provided: fire safety, health and safety, issues of care, pharmacy issues, the protection of vulnerable adults in the facility, and management competency. At that stage, the RQIA started to work with Cuan Mhuire and a series of meetings were held, which documented how we would work constructively with it to maintain its services. Unfortunately, in the middle of those negotiations, the management of Cuan Mhuire had an extraordinary general meeting and wrote to RQIA, stating that they had taken the decision to close because they felt that the cost of the suggested improvements were prohibitive.
RQIA worked with Cuan Mhuire management on that basis, and asked whether they could offer an assurance about maintaining resident safety in the meantime, as there were up to — and often in excess of — 100 residents. We asked for an action plan from Cuan Mhuire, which was provided, but was wholly inadequate. At a further meeting, Cuan Mhuire management informed RQIA that they would cease to take admissions. Since then, a number of meetings have taken place — with the Southern Health and Social Services Board, the Southern Health and Social CareTrust, the Housing Executive, and the Department for Social Development — to discuss ways of maintaining services at Cuan Mhuire. At present, RQIA is working with the Cuan Mhuire management, in an advisory capacity, towards a phased reopening of its services. RQIA is providing advice but, as a regulator, cannot provide absolute support. In the past two weeks, there has been constructive and positive movement to maintain the services at Cuan Mhuire with twenty-first century standards.
RQIA’s powers of enforcement range from making recommendations and requirements — through our inspection processes — to legislative issues, which are called failure-to-comply or improvement notices and are served on residential care homes. If RQIA finds that residential care homes are failing to comply, it has the right to fine them, place conditions of registration on them, or take them to court and seek closure. Our powers in the statutory sector are more limited, although we can make recommendations for special measures to the Minister, who can then give direction about how he wants to see the service managed.
RQIA is looking at what arrangements currently exist to review clinical and social care governance arrangements in primary care. The example that best illustrates that is the concept of the equality and outcomes framework, through the GP contract. The RQIA sees that as a key building block for the clinical and social care governance review in primary care. There are also issues that must be addressed on the commissioning relationship between agencies and their constituent boards.
There are other voluntary schemes related to accreditation of the practices in which GPs involve themselves through the Royal College of General Practitioners. The RQIA’s current primary-care adviser is beginning to look at where the gaps are and how they can be plugged into general medical services (GMS) and general dental services (GDS). Obviously, there are no specific standards for primary care, and the standards set by the Department — which is the standard-setting body — for the statutory sector would not apply well to primary care. Therefore, RQIA is looking at how to help the Department develop specific standards for primary care, which will also cover standards of practice.
Shall I address the issues about RQIA’s independence?
Yes, please, if that is OK with the Deputy Chairperson.
Obviously, as a non-departmental public body, RQIA has an accountability framework with the Department of Health, Social Services and Public Safety. RQIA is accountable to the Minister, and our annual reports are laid before the Assembly. This Committee also has an interest in ensuring the independence of our organisation.
We are also subject to scrutiny by the Northern Ireland Audit Office, which recently published a report on the relationships between sponsoring departmental branches and their arm’s-length bodies, and the same relationships have been subject to scrutiny in GB.
Our board has a scrupulous interest in maintaining our independence as an organisation. Each board member, appointed by the Minister, has a fierce interest in independence. We have to develop a sensible working relationship with our sponsoring Department, the nature of which is laid down in our management statement and financial memorandum. Those are the main tenets for exercising the independence of the authority and its work.
The Deputy Chairperson:
Can you elaborate on how the Department has responded to the reviews that you have carried out to date?
Our current major review of clinical and social care governance arrangements is being considered by our board today, after which it will be sent to the Department. An overview report, followed by a report based on a review of the 25 individual organisations, will also be sent to the Department. The other three major reports that I have noted have all been accepted by the Department, which has disseminated circulars to the Health Service asking it to ensure that the reports’ recommendations are implemented.
The question on who can report to you was not answered. Can I report, or submit statements, to you? For example, not so long ago, casualty departments were full, sick people were left on trolleys and different sexes were sharing the same toilet facilities — that is some “quality”. Indeed, some of my patients have waited for up to 11 hours in A&E — that is poor quality. When we are aware of such situations, can we report them? What is your view on people having to wait in A&E departments for 10 or 11 hours?
Anyone can make a representation to us, and they have done so. Representations have been made by members of the public, members of health and social care services and coroner’s office. In recent times, we have examined a number of cases that were drawn to our attention by a variety of sources.
Having said that, we must go right back to an organisation’s statutory duty of quality. Therefore, when problems arise in A&E departments, or there is a complaint about something such as the use of mixed-gender toilets, those issues should, technically, be raised with that organisation in the first instance. It is only when an organisation fails to address those issues that we would become involved.
Notwithstanding that, recently a number of representations have been made to us about mixed-gender wards. There have been so many representations, and such a high level of concern, that we intend to examine the issue when we carry out our next clinical and social care governance reviews after Christmas. That is an example of when, having tracked trends in complaints and concerns, we have decided that we need to address them through our review processes.
The RQIA has an essential job. It is a huge job and, from listening to you, one that is expanding.
I have a few questions for you today. Is it mandatory for a nursing home to register with you? Do you benchmark when you monitor and inspect? Do you carry out spot checks, or are all your visits arranged?
Mr Quinn, did I hear you on the radio this morning?
You were talking about nursing homes, which is a subject that we often hear about.
The RQIA has such a large and expanding role, and you talked about doing yearly inspections. If there are problems — and we know that there are problem areas; I am aware of some of them — what follow-up action is taken? When you become aware of a serious problem, do you return more regularly?
How do you advertise your role? I suppose that with your budget, and number of staff, it is an essential role. People come into our constituency offices with concerns, particularly about residential and nursing homes. People also have concerns about mental-health issues, which is a huge area to be taking on. How do you manage all that and still take follow-up action on complaints?
To answer your first question on compulsory registration, it is against the law to run any form of care home without being registered. That is basically what was happening to some extent in Cuan Mhuire — the issue that we have just referred to. They were actually providing both nursing care services and residential care services, which fall under the legislation. Therefore, they were operating outside the legislation.
On the issue of benchmarking, we certainly benchmark internally. However, there is a requirement for us to develop further benchmarking. We have close links with our sister organisations across the UK. We are already examining the development of various pieces of research that may enable us to benchmark against similar sorts of services across the UK. We have also made some links with the Health Information and Quality Authority, which is the new body in the Republic of Ireland.
As for spot checks, the regulations actually require us to make unannounced visits. Those visits can take place at any time of the night or day.
How do those unannounced visits work with domiciliary care?
We have started the registration of domiciliary care only recently. We realise that there are difficulties with the logistics of inspecting domiciliary care. Obviously, in the first instance, domiciliary care, by virtue of its nature, is a sort of employment agency that allows people to go into other people’s homes. That raises issues of vulnerability.
We are currently working on a specific methodology on the issue of domiciliary care, which will allow us to check on the safety of the services, but at the same time respect the privacy of people in their own homes. The regulations and the legislation only require us to make one visit annually. It is only in residential services that we have to make two visits.
On the issue of budget and staffing levels, we have been in existence since only 1 April 2005. There has been really slow growth from that time. We assumed responsibility for the old registration and inspection units that were based across the four board areas. Since that time, we have tried to build capacity and capability in the organisation through trying to scope out what the work is and how we can address that work.
This particular year, as we are now registering domiciliary care and day care, it is a major challenge, and those major challenges will be raised with the Department of Health, Social Services and Public Safety in our forthcoming business plan.
Regarding advertising our role, we send out a notice to all relatives of residents in care homes in advance of any inspection. We also have a questionnaire that enables the residents to give us their views on the quality of care being provided in that home.
In recent times, as I have said, we have also advertised in the press for lay reviewers in particular. We have had significant success in recruiting lay reviewers. In our first round, we recruited 44, and in our recent recruitment drive, we recruited 67 lay reviewers. In two recruitment drives, that is significant. There is quite a bit of training to be carried out with the lay reviewers, but our experience to date has been that they have found the role extremely rewarding.
Mrs I Robinson:
I apologise for missing the beginning of your presentation. I welcome the fact that the duties of the Mental Health Commission for Northern Ireland are being transferred to you. I listened to what Carmel said in relation to spot checks, and I wholeheartedly agree, particularly for the aged who do not always have a voice and do not always have family to speak up for them.
One area that I am very concerned about is mental health. The Committee has been to visit outstanding mental-health institutions at Altnagelvin and Craigavon, which are superb models. I had a recent meeting at the psychiatric nursing unit (PNU) at Ards Hospital; anyone who goes there would say that they would not put a member of their family into it — and I am saying that sensitively. The Minister accompanied me. He said that he was there in a private capacity, but he said that he was the Minister and was treated as such, so I do not think that I am letting the cat out of the bag by saying that.
The problem is that the PNU will be transferred to the Ulster Hospital in about 18 months. However, there is no good long-term advantage in doing that. The unit requires a purpose-built facility similar to those in Altnagelvin and Craigavon. Have you been to the PNU in Ards; have you seen the state of the facility? Men and women are in mixed wards, separated only by screens. There are literally only inches between each bed and cabinet and the next. People there have varying degrees of mental health, and I am appalled that, in this day and age, that type of facility still operates. Even the carpet is vile, and the floor is a health and safety hazard for people who suffer from confusion, for example. There are enormous difficulties with that unit.
I ask you to carry out a spot check on that unit and to look at the plans to transfer the unit to the Ulster Hospital. I believe that you would concur with the psychiatrists whom the Minister and I met there that transferring the unit to the Ulster Hospital is only a short-term solution, and that there should be a purpose-built facility.
If we are really going to tackle the inequalities in mental-health provision, the same model must be rolled out and the same type of facilities and professional care provided for people from Londonderry, Craigavon or the lower Ards Peninsula. It is only right that people with mental-health problems are treated equally. Will you look at that matter?
I note your concerns; there are two issues there. Spot checks tend to be focused on the regulated/independent side of our work. That said, we do have a role in the statutory sector — specifically in mental-health and learning-disability services. We have moved to employ an assistant director with specific responsibility for those programmes of care. One of the reasons we did that is because quality and safety issues tend to be dragged towards the acute services, and we felt that there was marginalisation of mental-health and learning-disability services.
We have also recently completed reviews of two areas of mental-health and learning-disability services. Those reviews were commissioned by the Department. One was on risk assessment and management of risk in adult mental-health services. The reviews centred on in-patient and community services. Although I cannot answer your question definitively, there is a chance that those review teams visited the PNU. However, I would need to check that.
The main rationale for the reviews was that the Department had concerns following several serious adverse incidents. One incident, which concerned a homicide, was the subject of the Eastern Health and Social Services Board’s McCleery Report, and two further serious adverse incidents generated independent reviews on suicide. We were asked to review services across all the trusts. We will report on those, probably, by December, because we are seeking a quick reporting turnaround.
The other review concerns the protection of children and vulnerable adults in mental-health and learning-disability units. Again, that arose from a specific independent review that was conducted by the Eastern Health and Social Services Board. That report will also be available in December.
I take on board what the members of the Committee are saying. We want to develop a three-year review programme for mental-health services that takes account of the concerns that are conveyed to us. There are several concerns about mental-health services for children and adolescents and services for people with dementia that we want to roll out over the next three years. Our plan is to carry out two major reviews each year in those programmes of care.
Mrs I Robinson:
The staff in the PNU in Ards do a magnificent job, but they should not have to work in the conditions in which they find themselves. Strangford and east Belfast — the hospital’s main catchment areas — have the highest elderly populations in Northern Ireland. I am concerned that dementia cases are going to continue to surface, unfortunately. A facility within the grounds or adjacent to the major accident-and-emergency unit at the Ulster Hospital would work as a good model, because all the other dispensations are close to hand, just as they are at Altnagelvin and Craigavon. I totally believe that those models will prove to be successful. I was absolutely delighted to see the thought that went into the design, the colour schemes, the materials and the gardens. I would like to see that happening at this end of the spectrum in the Ards area.
From your submission, it seems that you do not inspect hospitals, but I gather from the conversation that you are somehow involved. I would just like some clarification on that. Secondly, there have been a high number of complaints about nursing homes. There are 142 complaints against the 250 nursing homes. There may well be one or two nursing homes. What is the highest number of complaints made against a single nursing home?
We are required to inspect nursing homes. That is our responsibility under the regulations governing nursing homes and registered homes. We assess the delivery of quality in the hospital and community sectors by monitoring clinical and social care governance arrangements. We do that against the standards that have been defined by the Department in the quality standards. The approaches are different between the regulated sector and the statutory sector in relation to hospitals.
That is correct. There is a difference between inspecting and reviewing, but we do go into the hospitals. During the course of the clinical and social care governance reviews that have just been completed, we visited every major acute and mental-health facility. We cannot cover all areas of all healthcare facilities in the course of a three-day review, so we have to sample. As we move increasingly towards a more bespoke methodology, we might do a thematic review where we would visit all A&E departments; if it was cardiology, we would visit all cardiology units.
At the moment I cannot answer your question about which home had the highest number of complaints.
I did not ask which home. I asked what was the highest number of complaints received from a single home.
Do you mean in relation to the nature of the complaint?
No, just the number of complaints.
I do not have those details at the moment. I appreciate what you are saying; it appears that there have been quite a high number of complaints. We are dealing with those complaints at the second stage. There are other complaints that are made directly to the home. There would be many more of those than are documented here. I hope that the ability to make complaints provides the ability to encourage improvement. We encourage complaint-making as a way of encouraging improvement.
Do you also receive second-stage complaints about hospitals?
No. There is a completely different mechanism for dealing with complaints in the statutory sector. In those cases, complaints go to the boards for independent review and, beyond that, to the Northern Ireland Ombudsman.
Ms S Ramsey:
There is a maze out there. By the time people have gone through all of the procedures, they are completely tired. That is probably a bit of my cynicism coming out. However, I thank you for your presentation. I welcome your presence as an organisation that is needed.
I want to raise a number of issues about children and young people who are being placed in adult facilities, whether they have mental-health or other illnesses. You say that your organisation has carried out a number of reviews, which the Department of Health, Social Services and Public Safety has accepted. I take it that recommendations were made as a result of those reviews?
Ms S Ramsey:
Have those recommendations been accepted, and have they been implemented?
Yes, they have. Of the three major reviews that I have spoken about, the recommendations have been accepted and circulars have been sent to the service about the implementation of those recommendations. We have also followed up the recommendations of the review of the death of Janine Murtagh and the Northern Ireland breast screening review as part of our clinical and social care governance review. Therefore, we have monitored progress on the implementation of those recommendations. For example, one of the recommendations that resulted from the Murtagh review was on the issue of what are known as “early-warning systems” in surgical wards. We have found that there has since been a quite high uptake of early-warning systems, not only in surgical wards, but also in medical wards in the acute sector — which is good to see.
The lack of facilities for children and young people has been highlighted to us, both individually and in our work with the Mental Health Commission. We would like to examine the area of mental-health services, which is one of our key areas, and to make recommendations on the placement of children in adult facilities, which is unacceptable.
Ms S Ramsey:
I know. However, it is still happening. These homes are run by the Department, and your organisation is an extension of the Department, although you have a bit of independence. They are still placing kids in inappropriate homes: who is held accountable for that?
You are right that most of the children’s homes in Northern Ireland are provided by the statutory sector. Recently, for the first time ever, a children’s home failed to comply with our requirements. That resulted in legal action being taken against the trust. The trust had to comply with the requirements that our organisation made of it as regards that children’s home.
Ms S Ramsey:
I am trying to tease out the issue. I appreciate your recommendations and previous reviews. However, there is an issue of accountability. Has anyone been sacked or put on notice, or has any legal action been taken, as a result of any of your organisation’s reviews? It is about being proactive. Otherwise, we may return to the same issue time and time again. You can undertake reviews and report back, saying this and that. What we need to say is that enough is enough. Probably, what you said about a specific home or institution five years ago is similar to what you are saying today.
Again, in relation to the statutory sector, we are maybe concentrating on children’s homes in the first instance, and recommendations around children’s homes. Our powers are limited in the statutory sector, except in making recommendations to the Department. Therefore, we cannot make the ultimate decision to sack someone. However, the Minister, technically, can make a directive in that regard. That has not yet happened.
In the independent sector, however, we have recently ensured the closure of a particular home that we felt was not providing safe services. In fact, we have also made recommendations to professional regulatory bodies about the individuals involved.
Ms S Ramsey:
According to your website:
“RQIA also has a role in assuring the quality of services provided by health and social services boards, trusts and agencies, to ensure that every aspect of care reaches the standards laid down by the Department of Health, Social Services and Public Safety and expected by the public.”
Where does that sit when we are hearing day and daily about the postcode lottery? One trust or two trusts might be providing certain things. In fact, we have just come out of a lunchtime meeting in which three trusts were providing stuff and the other trust was a wee bit wobbly. How can we move beyond that problem, and do so quickly? Does the organisation have any plans to proactively tackle the problem of methicillin-resistant Staphylococcus aureus (MRSA)? The approach to dealing with it seems to be good in one area, but not so good in another.
Finally, I want to raise the issue of the death of children in hospitals. There was an article in ‘The Irish News’ last week about the death of a mother and child in Daisy Hill Hospital, and I raised that matter with the Minister. Does the RQIA look at hospitals in general and collate information about such incidents, especially those that involve children? Does it consider how such matters can be addressed and how changes can be made across all the trusts?
We have not carried out any specific work on MRSA and healthcare-acquired infections. An advisory group was set up to look at the work of our organisation, as we felt that that was required to ensure that we were getting it right. The group has advised us that we should take a specific interest in healthcare-acquired infections, and we hope to do that. We will want to use not only information that we will gather ourselves, but also information that has been gathered on behalf of the Department. We will want to at least comment on that. That information will be gathered in both the statutory and the independent sectors.
You mentioned deaths in hospitals in specific circumstances, and a number of referrals have been made to us, both by organisations and by the coroner. We have acted on a number of coroner’s cases over the course of the last two years, and, again, we have made recommendations to trusts, or at least checked with trusts to ensure that they have learnt lessons from those tragic deaths. I am not aware of the specific incident in Newry that you mentioned; I would have to look into that.
Ms S Ramsey:
It was in ‘The Irish News’ last week.
Who is held accountable in the event of an outbreak of MRSA or other related infections? We have all been to hospitals where we are struck by the fact that there are bags of clinical waste lying around, and so on. This is a matter of making people accountable for the jobs that they do. The emphasis must be on the follow-up procedure.
I go back to the legislation and The Health and Personal Social Services (Quality, Improvement and Regulation) ( Northern Ireland) Order 2003, which established RQIA. The second key tenet in it was the duty on the organisations themselves to deliver the quality and the standard of care that we expect, and as is defined through the quality standards that the Department have developed. The responsibility and the accountability to deliver fall to the accountable officer in each health and social care organisation, namely the chief executive. They are the people who are accountable for delivery, and our responsibility is to monitor the effectiveness of that. Are the trust boards that oversee the work of each organisation taking an effective interest in the delivery of standards throughout their organisation? Are they holding their own chief executives to account to ensure that there are good practices and procedures and satisfactory delivery of standards within their organisation? The responsibility lies with the delivery organisation. It is our responsibility to ensure, through regular monitoring and inspection, that that is what is happening.
Following our last review of mental health, we asked each of the chief executives to make a declaration to us based on their self-assessment. Thus, they must sign off their self-assessments. It is a mechanism by which we can, at least, have some form of signed accountability on the returns being made to RQIA.
I want to ask one last question about accountability and quality, which are very important issues in the Health Service. You mentioned standards in trusts. If a trust’s delivery is identified as being substandard, and it then does not raise its standards as promised, can we call on you?
Secondly, moving higher again, our job is to hold the Department to account and to monitor what it is doing. If it is making promises, can we use your authority to take the Department to task?
No. Under the legislation, we cannot hold the Department to account. We pushed it with the governance review of the Northern Ireland breast screening programme by making recommendations to the Department. We are not covered to do that, but the Department acknowledged that there were failings in medical workforce planning, and it addressed them.
Issues can be brought to us, and we are happy to raise them in the necessary forums. However, the requirements of the legislation must be observed.
May I make a final comment? This is a key part of our role and function on behalf of patients, carers and the public in general. We have the freedom to comment on access, availability and the delivery of quality within the services. It is important that we reflect that to the Department and to the Minister. The Committee will have a great interest in some of the products of that monitoring and the effectiveness with which it is carried out. The Committee and the RQIA, which is charged with that responsibility, have many interests in common.
The Deputy Chairperson:
Thank you for coming along and giving us that overview. I am sure that we will be in touch in the future.