Official Report (Hansard)

COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

Health and Social Care (Reform) Bill

25 September 2008

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 
Mr Sam Gardiner 
Mrs Carmel Hanna 
Ms Claire McGill

Witnesses: 
Ms Alice T Casey ) Regulation and Quality Improvement Authority
Mr Malachy Finnegan ) 
Mr Jude O’Neill ) 
Mr Phelim Quinn )

The Chairperson (Mrs I Robinson):

The Committee will now hear evidence from the Regulation and Quality Improvement Authority (RQIA). I welcome Alice Casey, the interim chief executive of the Regulation and Quality Improvement Authority (RQIA); Phelim Quinn, its director of operations; and Jude O’Neill, its head of mental health and learning disability. We have set aside 40 minutes for you to make your presentation and to take questions from Committee members. I will now hand over to you.

Ms Alice T Casey (Regulation and Quality Improvement Authority):

Thank you very much for inviting us, Chairperson. Malachy Finnegan, our communications manager, is with us this afternoon as well. I will take a couple of minutes to make a few opening remarks, and then Phelim and Jude will talk more about how we will operationalise the functions of the Mental Health Commission, subject to the legislation’s passing.

The RQIA welcomes the opportunity to provide oral evidence to the Committee on the Health and Social Care (Reform) Bill, and to clarify, and expand on, the written evidence that we previously submitted. We were established in 2005 to register and inspect health and social care organisations across Northern Ireland. Our powers in the regulated sector include the ability to carry out announced and unannounced inspections of care organisations, nursing homes, residential homes, children’s homes, and a whole range of other services that came under our regulation on 1 April 2008.

Our powers include the ability to make recommendations for improvement; to enforce requirements; and to issue failure-to-comply notices. We can also administer the ultimate sanction of prosecution and compulsory closure of those homes. In the statutory sector — that is, hospitals, and community and primary-care services, including dental services — we have the ability to enter premises, to obtain information and to undertake reviews of those services. Some of the reviews that we have already undertaken include the hygiene reviews, which were publicised quite recently; clinical and social-care governance reviews of all trusts, and many more. The review that we are currently finalising is the clostridium difficile review, which is to go to the Minister shortly.

All our reports are made public and are available on our website; everything that we do is published. The RQIA cherishes and will defend vigorously its right to independence. We are the independent regulator for health and social care in Northern Ireland; we are independent in thought and purpose, and we believe that our work to date has demonstrated that. We have no qualms over reporting on what we see when we inspect or review organisations.

We review constantly our practices, we learn from sharing our experiences with other regulators across Northern Ireland and the rest of the UK, and we collaborate and share expertise. We also use clinical experts from across the UK when we review particular services, and we have experts to look at those services objectively. We used experts when dealing with the clostridium difficile outbreak, the hyponatraemia review and our review on blood safety. We will also use experts for our planned review of maternity services across Northern Ireland and for child protection arrangements, and so on. We have a wholly lay board that is made up of 12 members and a chairman.

The Bill does three things for the RQIA — we shorten the name of the authority to RQIA, because we find it easier to say. First, it tidies up our title and establishes the RQIA in legislation, — in place of the Northern Ireland Health and Personal Social Services Regulation and Improvement Authority — and that is welcome as it clarifies the situation for many people.

Secondly, the Bill impacts on the organisations that we will review. For example, we will have responsibility for reviewing and regulating the proposed new regional organisations: the regional health and social care board; the regional agency for public health and social well-being; and the regional support services organisation.

Thirdly, it transfers the functions of the Mental Health Commission to the RQIA, and that change is welcome. Since the transfer of the Mental Health Commission was first mooted some 12 to 18 months ago, the RQIA has worked collaboratively with the Mental Health Commission on a range of issues. Over the summer, we took a strategic approach on an operational level to discuss and plan how the services will come together, if the legislation comes into effect from 1 April 2009. We have established a project board, which includes the chairman, the chief executive and the commissioners of the Mental Health Commission with officers of the same rank in the RQIA.

The project board’s work to date has included developing an action plan in response to a due diligence report that the RQIA had undertaken; clarifying the legal implications of the change on the Mental Health (Northern Ireland) Order 1986 for the RQIA; clarifying the implications for our board — our 12 lay members and chairman; reaching agreement on the workforce plans and the financial implications with the Mental Health Commission; and developing an appropriate communications plan so that the public know exactly what is happening. The project board’s work has also included developing and reaching agreement on how the RQIA will take over the Mental Health Commission’s operational work. That was an important piece of work, and I am pleased that we achieved full agreement with the Mental Health Commission at our project-board meeting last week. We have now agreed how we will take the work forward, which is a major step.

The pathway is now clear for the transfer to take place. The RQIA is ready, willing and able to progress that important work, and it has wider powers than the Mental Health Commission. It means that the Regulation and Quality Improvement Authority will regulate all services in the health and social care family in Northern Ireland. It will also be subject to the necessary vigour that is required under the regulation.

I shall now had over to Mr Quinn and Mr O’Neill, who will tell the Committee how that will be done.

Mr Phelim Quinn (Regulation and Quality Improvement Authority):

I shall deal with the discharge of the functions of the Mental Health Commission under the RQIA and the comprehensive model that we have developed in conjunction with the Mental Health Commission’s senior management staff.

In developing the comprehensive model, we have worked in partnership with the mental-health commissioners. We have also used the resources of senior psychiatric professionals across Northern Ireland. Establishing the dedicated mental-health and learning-disability team under that model has been an important factor in developing and delivering the functions of the Mental Health Commission, as set out in the Mental Health ( Northern Ireland) Order 1986. I will speak in more detail about the model as I go along.

That model enshrines several factors. First, the specific care, treatment and human rights of individuals are embraced in the Mental Health ( Northern Ireland) Order 1986. It has been stated that the RQIA concentrates on systems and organisations, but the authority also fully acknowledges its requirement to focus on individuals.

Secondly, it is stipulated that there must be engagement and consultation with wider service users, their groups and advocates. The RQIA is concerned about the context in which care is provided. In a previous submission to the Committee, the authority was told of concerns about psychiatric-unit environments in which care is provided in Northern Ireland. I will address that issue later.

Thirdly, there must be an assessment of the level and availability of care using quality standards, at the same time as considering clinical- and social-care guidelines, legislative regulations and legislative standards.

All those elements will be incorporated in the RQIA’s work under the 1986 Order and the Health and Personal Social Services (Quality, Improvement and Regulation) ( Northern Ireland) Order 2003.

Account must also be taken of enforcement action in response to non-compliance. With both organisations working in tandem under the two relevant pieces of legislation, the responsibility for enforcement lies with the RQIA. Therefore, to some extent, the circle will be squared when it comes to discovering what is going wrong. We can then make recommendations and take any required enforcement action.

The RQIA is committed to promoting and protecting the core functions of the Mental Health Commission. In order to do that, key issues in several areas must be addressed. Those issues include independence, multidisciplinary working, investigative action, inspectorial action, advisory and advocacy work, and protection of patients and the public.

Finding a new way forward involves using the powers that are combined after the transfer in a manner that reflects the Bamford Review’s aspirations. Any work that the RQIA does will be future-proofed in line with that review’s aims, objectives and legislative recommendations. The RQIA will retain and develop its commitment to focus on the individual and the rights of service users and of their carers, incorporating enforcement powers.

The authority will promote multi-professional and lay working. The RQIA wants to include the lay concept in its work under the Mental Health Commission, and in the broader remit to the RQIA itself for inspection, review, governance and service reviews.

Extra emphasis must be put on the promotion and sharing of good practice across mental-health and learning-disability services. Once found anywhere else in the rest of the UK, in the Republic of Ireland or, indeed, in the rest of the world, examples of good practice will be shared with services.

There will be a drive to encourage wider promotion of service-user engagement on mental-health advocacy. That means more than simply looking at mental disorder and learning disability per se; it involves the promotion of good mental health in the Northern Ireland population.

The RQIA seeks to enshrine respect for everyone’s human rights and the right to timely, high-quality care. It aims to promote choice and to listen to the needs of individual service users and the views of their carers in order to develop a culture of learning and innovation. The authority will find and challenge deficient practice, and it will show integrity, and be open and transparent, in its work with service users.

The RQIA wants to work in a more accessible, responsible and targeted manner. It will engage more with the public. The RQIA is about to close consultation on its public-participation strategy. Among the key factors to be inserted into that strategy is the authority’s work in the areas of mental health and learning disability. It is also hoped that two external reference groups with service users will be established — a specific one each for mental-health service users and learning-disability service users. That will enable the RQIA to obtain both constituencies’ views, which will further inform all aspects of its service provision.

On the issue of operational alignment, the RQIA regards the transfer as an opportunity to build on existing resources by adding an expert specialist team of full-time and paid sessional multi-professional officers. Mental health commissioners are currently part-time members drawn from a range of professions. The commission has always aspired to have full-time officers. There is now the opportunity to employ those full-time officers and to supplement skills and expertise with sessional workers, such as psychiatrists, approved social workers and other care workers, who may not be represented in the full-time workforce.

In line with the Bamford Review recommendations, the RQIA visiting programme will include annual announced and unannounced reviews and inspections of mental-health and learning-disability hospital facilities in Northern Ireland.

An additional aspect of that programme that we wish to emphasise is that it will not just comprise visits to hospitals and buildings but will review the effectiveness, quality and safety of the new service-delivery models for mental health and learning disability that are developing throughout Northern Ireland. For instance, we wish to evaluate the effectiveness of home treatment and crisis- and rapid-response services, and consider how they address the needs of individuals who use them.

We are conscious of the high suicide rate in Northern Ireland, and, therefore, we wish to specifically focus on that. We have just completed a risk-assessment and risk-management review of adult mental-health services, and we wish to maintain that focus in order to ensure that health and social care organisations in Northern Ireland are working in line with the Northern Ireland suicide prevention strategy.

There should be a specific focus on services for people with learning disabilities — whether those services are in hospitals or in the community — and we are committed to maintaining a specific review programme for visits to, and inspections of, learning-disability services in Northern Ireland.

The Committee may also be aware that, following the transfer of responsibilities for the commissioning and provision of prison health, part of RQIA’s remit means that it now has oversight of those services. Given the incidence of mental-health problems in the prison population, we are required to continue to review the quality, safety and availability of mental-health services in Northern Ireland’s prisons.

Another area, which I touched on earlier, is our recent programme of unannounced hygiene inspections. Although called “hygiene inspections”, they consider the general environment in which care is provided. Resonating from our previous discussions with the Committee, we wish to extend those inspections to mental-health and learning-disability facilities in order to help us make robust recommendations about how such facilities should be improved for service users.

Those measures consider service provision. We wish to protect the rights of individuals in the service and to maintain a focus on people who are subject to guardianship orders, whether such people be in hospitals, in the community or in regulated sector services in the community. Furthermore, we want to maintain and deliver a service that enables us to monitor the key function of detention under the 1986 Order.

We will employ a sessional medical panel to continuously review treatment plans. That panel, under the Order, will appoint part II and part IV doctors. We will also employ a sessional panel of approved social workers to ensure that guardianship is closely monitored in Northern Ireland.

We wish to develop a revised code of practice for governance. Work on that has already started as part of the project plan for the transfer of functions, and it will reflect our responsibilities under the 1986 Order. The code of practice will also take account of the relevant elements of the Health and Personal Social Services (Quality, Improvement and Regulation) ( Northern Ireland) Order 2003.

The functions arising from the 1986 Order will be subject to rigorous, internal performance management in RQIA. We will produce quarterly reports for our board that will reflect activity and outcome measures arising from RQIA’s work on mental-health and learning-disability services. Furthermore, in order to help our board understand the issues for mental-health and learning-disability service users, we propose to develop a mental-health advisory group that will take advice from senior professionals and will reflect the mental-health and learning-disability population in Northern Ireland. Further to our meeting with the project board last week, development of that has already started.

Communication is a significant issue, which was also discussed at our project board meeting last week. Up until now, the Mental Health Commission has always used distinctive blue writing paper. When the mental-health and learning-disability services received blue letters, they were always very mindful that those were letters of significance that could have highlighted any issues or problems that arose in those particular services. As a proven brand, the RQIA proposes to use the same blue paper and envelopes that were previously used by the Mental Health Commission, so that that message continues in the services across Northern Ireland.

We are very happy to take questions.

The Chairperson:

Do you want to say anything at this juncture, Jude?

Mr Jude O’Neill (Regulation and Quality Improvement Authority):

To build on what Alice and Phelim said, the RQIA will endeavour to protect and promote the core functions of the Mental Health Commission, as enshrined in the Mental Health ( Northern Ireland) Order 1986, as they transfer across to the RQIA. That includes a commitment to maintaining the spirit of the view of the 1986 Order — an approach that reflects a body that is independent, multidisciplinary, investigative, inspectorial, advisory and protective.

The Chairperson:

We had a tour of Muckamore Abbey earlier today and discovered that there is 100% occupancy, which means that people are being turned away. Some of the families of inpatients, who may have been here for 40-odd years, think that those inpatients could be put into the community. There is a feeling that that is the way to go, because Paul Goggins said that nobody should be institutionalised by 2014.

However, the Committee holds the view that one size does not fit all. We have heard from families and friends of Muckamore Abbey patients who would be loath to see family members who have been here for perhaps 40 years being put into the community — particularly older parents, who could not manage to care for their son or daughter. They would need a 24/7 service, and the cost of providing that is over £100,000 a person.

What is the RQIA’s role in a situation in which people feel that their family members should stay in a secure environment rather than being put out into the community? Do you have powers to become involved and make recommendations to reflect the fact that not everyone wants to go into the community?

Mr Quinn:

The quality standards for health and social care, as published by the Department, are mindful to reflect the views of service users and their carers. They form the basic framework against which the RQIA assesses services. I am in absolute agreement with the Committee: one size does not fit all. In the regulated sector, we find people who regard their placement in that sector as their own home. To some extent, the long-term residents or patients of Muckamore Abbey and their carers regard it, or some of its wards, as their own home.

Currently, we have the right to assess those services to find out whether adequate views are taken from service users about how their care packages are being planned, and whether it is appropriate for people to be placed in the community. Through any review process, we will ensure that there is robustness and an evidence base, as well as an engagement with residents and their carers in placing people in alternative services. We will assess those services, and we will make recommendations on the back of those assessments.

The Chairperson:

There are over 200 people in Muckamore Abbey at the moment, and it is planned that the number of beds will be reduced to 87. However, people are not being placed in the community. Bed blocking and 100% occupancy already exists.

How can you argue for resettling patients into the community when, currently, you cannot cope with getting them out of the care facilities? There are people in Muckamore Abbey who should have been out in the community a couple of years ago; they still cannot get out because the facility and back-up to do that is not available. I am interested to hear your views on that, and I welcome the fact that you will examine the issue.

Unannounced visits are also an issue. The Committee has asked for its members to be able to examine standards in their own communities and in one another’s communities, collectively or individually, because it is us, the politicians, who get it in the neck. As elected representatives, we are on the front line; our constituents fill mail bags with letters about the state of our hospitals, the lack of hygiene and the non-implementation of the policy of staff not wearing their uniforms outside work. I still see physiotherapists and other healthcare professionals shopping in my local stores while still wearing their uniforms. My understanding is that there is a Health Service-wide policy about not wearing uniforms outside the workplace.

Do you think that elected representatives should be allowed to make unannounced visits? Members of the community come to us first, telling us, for example, that their relatives are in a hospital ward that has blood splattered on the walls and floor, that the ward is never cleaned, and so forth. I know that this issue is a hot potato.

Mr Quinn:

It is, and it is not, a hot potato, in that we believe that patients’ experience is probably the first indicator of their perception of their quality of care. To some extent, the public-observed experience of what is happening in hospitals is the only valid view. Having said that, I think that that must complemented by the professional view on infection-control practices and other forms of estates management relating to infection control.

I am sure that elected representatives do go into hospitals, and I am sure that they make comments. We are happy to take those comments on board. The RQIA can take direction about unannounced visits to specific facilities. I am conscious of the Chairperson’s comments at our last meeting, which have been at the forefront of our minds concerning unannounced hygiene inspections.

I will give you some background. We were asked by the Minister to conduct a series of unannounced hygiene inspections. We did that without any additional resources, and those inspections were, to a certain extent, a test bed. We have started to recruit a specialist team of inspectors, and we intend to run a full programme of annual unannounced inspections from November. Those inspections will go beyond acute hospital facilities; they will extend into mental-health and learning-disability facilities, community facilities and will also provide advice to the regulated sector. There will be no hiding place from our unannounced hygiene programme. We will be there, and we will report. The inspections may take different forms at different times. We hope that we can do them in clusters, so we will do a round of visits in, for example, a maternity service or in a group of acute mental-health hospitals. We will report on that very openly, as we have done previously.

The Chairperson:

As elected representatives, we also have a duty of care to our constituents. When we take a phone call telling us that we should see the state of the bed, the ward or the toilets that someone’s relative or loved one is having to put up with, I think that we should be able to do something about that, thereby complementing one another. There is the possibility of overstepping demarcation lines that have been set by professionals, but elected representatives are not going to cost the Government anything by doing this. We are elected and paid representatives, and, therefore, it will not drain financial resources. Thank you for your points; I will take them on board.

Dr Deeny:

I commend the RQIA. When we met previously, I asked Phelim whether the authority could hold the Department and the trust to account. Since that occasion, you have conducted three unannounced hospital visits.

Mr Quinn:

We have conducted five visits.

Dr Deeny:

I can recall the visits to Downe Hospital, Craigavon Area Hospital and Altnagelvin Area Hospital. Where were the others?

Mr Quinn:

They were at Belfast City Hospital and the Causeway Hospital.

Dr Deeny:

I commend you for arriving unannounced, inspecting the premises and publicising your findings. It demonstrates that the RQIA can hold trusts to account and, furthermore, justifies the motion that the Committee tabled in the Assembly. Although the Minister wanted to focus on one trust, you visited different trusts. Indeed, four of those visits took place outside the Northern Health and Social Trust, and deficiencies were found on every occasion.

Alice mentioned the organisation’s independence. What is your role within the structures? It is difficult for the public, the Committee — and even a healthcare professional such as me — to understand all the acronyms, and so on. Who guides and instructs you? Will you remain independent? That will enable you to hold the Department to account.

I reiterate the Chairperson’s comments. Although I have travelled the road to the airport many times, today is my first visit to Muckamore Abbey. I am impressed with the standard of care received by people with learning disabilities. You mentioned that you will assume the remit and duties of the Mental Health Commission. Will you be involved in commissioning mental health?

Ms Casey:

No, we will not.

Dr Deeny:

Will you have an influence?

Mr Quinn:

We will influence the shape of the quality safety agenda for mental-health and learning-disability services. Our focus will be on individuals because, under the Mental Health ( Northern Ireland) Order 1986, loss of liberty will be a major issue. We must defend people’s liberty and ensure that, when people lose their liberty under the Order — through a detention or guardianship — it is done within the law, and every technical detail is checked and monitored. Until now, that has been the Mental Health Commission’s role. However, we value the fact that it will be our responsibility from 1 April 2009.

Dr Deeny:

I have worked in the community for years, and the services at Muckamore Abbey could not be matched or afforded in the community. The services are wonderful, and I am delighted that I came today. Some of the people here are severely disabled and have left the community because they could not cope with the stigma or had been picked on. Moreover, safety is an important consideration. Those people live in a safe environment and in a happy comfort zone. We have all learnt from today’s visit. Will you explain your independence?

Ms Casey:

The RQIA believes that it is independent. We are a non-departmental public body that is funded by the Department. Therefore, we use public funds. However, beyond that, we determine our own journey. We have a lay board that comprises 13 significant people from Northern Ireland, who, rigorously, hold us to account on our independence. Although some of our work is commissioned by the Department and the Minister, we determine the majority of it ourselves. We establish our own agenda and work, and we are currently planning a three-year programme of reviews of health and social care services and the regulated sector. That review will be unveiled at a board meeting in November 2008.

Nobody influences our reviews, which we send to the Department and to the Minister. For the sake of factual accuracy, reports go back to the trust or organisation that we reviewed, but the findings are our findings. That has always been clear to us, and, judging from my discussions with the Department and with the trust chief executives, that approach is recognised and respected as being necessary for governance purposes.

As the Bill states, the RQIA currently reviews the health and social services boards and other agencies. We believe that we will review the new regional health and social care board, the regional agency for public health and social well-being, the regional support services organisation and any other new organisations. Although we believe that we are, to a large degree, our own masters, we recognise that we cannot all be our own masters in this world. We will, however, have some element of independence.

Mrs Hanna:

The RQIA’s subsuming the Mental Health Commission will mean quite a change from its present role; it is an additional responsibility. The commission is concerned with people whereas the RQIA is, perhaps, more concerned with institutions. Phelim listed the endless issues involved; are extra resources available? Much more expertise will be required for the RQIA to go in a different direction. It is interesting that the Mental Health Commission is to become part of the RQIA, and I can understand why that decision was taken. However, will it be within the RQIA’s remit to consider any proposed legislation for competence for patients? Users and healthcare professionals have concerns.

Ms Casey:

The current budget for the Mental Health Commission will transfer to the RQIA. There will be a slight reduction in that budget because Lombard House, where the commission is currently based, will not have to be maintained. There will be greater economies of scale because there will be no duplication. As Phelim explained, the plan is that a distinct team of people will be employed who are resourced to undertake this important work. The budget is adequate, and we will decide how to use that money.

Mr Quinn:

As Alice says, we are considering a radically different model of delivery for the functions of the Mental Health Commission under the Bill. We are moving to an employee-based model, which may look slightly more expensive but is, in fact, built within the confines of the existing Mental Health Commission budget. There have been early indications that the Department is committed to that budget, with an in-year uplift for any cost-of-living increases. The money is there; however, if we find that our ability to discharge those functions is challenged by budget restrictions, we will make representations to the Department. The transfer of functions must be done properly; we do not want to cut corners and risk individuals’ human rights.

It is a different departure for us, but we are working closely with our colleagues in England and Wales, who are currently undergoing the same type of transfer. From 1 April 2009, in England, the Care Quality Commission is assuming the responsibilities of the Healthcare Commission, the Commission for Social Care Inspection, and the Mental Health Act Commission. Similarly, in Wales, Healthcare Inspectorate Wales is assuming the responsibilities of the Mental Health Act Commission, and something similar will happen in Scotland under the Crerar Review. It is useful to have that peer group working to the same timescale in developing models of delivery for a piece of work that is focused on the individual in organisations that have formerly been focused on institutions.

Mrs Hanna spoke about the capacity legislation to which reference is made in the Bamford legislative framework. I will be honest; we will have to consider the details, but it is our view that the RQIA, in subsuming the functions of the Mental Health Commission, will have a role to play in the protection of individuals. I cannot say how that will play out. That legislation has not yet been made, so we do not know the details.

Mrs Hanna:

When you make those recommendations, you will find — as we and everyone else does — that the resources are not available for their implementation. Will you then act as champions for mental health? I suspect that you will make recommendations, but, as we saw here in Muckamore, the resources are not available, even for good recommendations that everyone supports. That is the situation.

Mr Quinn:

There is the potential for that to happen.

People continually warn that the budget is not available to do x, y or z. However, I will give you a small example. The RQIA happened to be in Craigavon Area Hospital for a clostridium difficile review a fortnight after the unannounced hygiene inspection. We were pleasantly surprised that the chief executive and the chairperson had walked the floor of the hospital after the inspection to ensure that all the estates issues that had been identified as a result of the inspection were being addressed. When we were there a fortnight later, they had been addressed. At times, it had been said that the money was not there to address those estates issues, yet — by virtue of the fact that we were going to publish the findings of that report, which includes photographs of the state of the facilities — action was taken. We were very pleasantly surprised by that.

Ms Casey:

It is important to remember that not all recommendations cost money and that sometimes we can cut through all of the financial issues and simply get people to do their jobs properly.

The Chairperson:

Sometimes that is the answer: doing the job properly.

Mr Gardiner:

Ms Casey, you represent the Regulation and Quality Improvement Authority. For the benefit of the public, I give the full title, as you were directed to do by the Chairperson but failed to do so.

I am disappointed by what you said in relation to your organisation. It has responsibility for the hygiene and cleanliness of hospitals. Blame me as being the culprit of Craigavon. I visited the hospital and made public the state it was in, because I had been made aware of the dangers of clostridium difficile, and I know of a lady who died as a result of that infection. That fact was not even recorded on her death certificate, which represented a risk to the undertakers who handled the body. That is under investigation.

I met the chief executive of Craigavon Area Hospital, and also the chairperson of the trust, who arrogantly maintained that she knew what she was talking about and asked how I dared to criticise her hospital. It is not her hospital: it is there to help and to cure people. Since the hospital is in my constituency, I represent the people who use the hospital and who work in it. I drew attention to what I had observed: children were going in and out — with their parents, admittedly — at all times, and visiting hours were not regulated. Fortunately, that issue has now been brought into perspective, and visiting times are now enforced. Children were climbing over and under the beds, when clostridium difficile was rife in the hospital. That should not have been permitted, and it has now been brought under control. I spoke with the Minister — blame me again — and voiced my concern about what was happening. He acted, and he told me that he had ordered an independent visit to the accident and emergency department, which was still not up to standard.

Had your organisation been on top of things, it would not have been necessary for me, or any member of the Committee, to bring that to the Minister’s attention or to make the public aware of the situation.

The Chairperson:

Ms Casey, do you have any comment?

Mr Gardiner:

Guilty.

Ms Casey:

We are not guilty. The clostridium difficile review required us to examine the state of Northern Ireland’s preparedness for an outbreak. Across Northern Ireland, we found good and bad. Some trusts were better than others. That is what we found, and that is what we reported to the trusts and to the Minister.

We are not complacent. There is no doubt that all the trusts can improve, and some show more room for improvement than others. We did a good job on that first part of the review. We saw what we saw on the day that we visited the hospital. We did not, and could not, visit all areas of the trust. We did not visit for a longer period of time because that would have required far too many resources. On the day that we visited Craigavon Area Hospital, what we saw was quite reasonable. Undoubtedly, however, there was room for improvement.

Mr Gardiner:

Was that on your second visit?

Ms Casey:

Do you mean was it on our second visit or on the visit that we made in order to carry out the hygiene report?

Mr Gardiner:

On which visit was the matter first drawn to your attention?

Ms Casey:

The hygiene report was carried out around two weeks before we visited the hospital to conduct the clostridium difficile review.

Mr Gallagher:

It is important that you clarify a little comment that is made in Alice’s letter to the Committee Clerk, which states:

“The RQIA recognises that it must make provision in its governance structure for an increased emphasis on mental health and learning disabilities.”

That recognition is important and welcome. First, can you clarify whether it will be your responsibility, or that of the Department, to make an appointment? Secondly, how do you envisage that that will work? Will it involve one individual or several? What do you seek to achieve? It would be best if someone were involved on the board who is a powerful advocate for people who suffer from poor mental health or who have learning disabilities.

I am trying to make the point while having every respect for you. We often come across that type of phraseology. Often, the outcome is simply a token gesture. How do you imagine that that will work?

Ms Casey:

I can say clearly that the board will not have a member who represents mental health and learning disabilities. That is not in the plan. The board consists completely of lay people. It does not have representation from any group at all. It examines how the Regulation and Quality Improvement Authority carries out its work and whether it does so appropriately in all circumstances. However, strong governance arrangements will ensure that we do what we should do in respect of that new area of care.

Part of our responsibility is to establish the team that will undertake that work. Although it will be led by Jude, it will be managed by, and accountable to, me. Therefore, a team of people will be dedicated to undertake that work, which will fit into our governance and quality-assurance arrangements, and will be scrutinised by one of our other executive directors. Regular reports will be made. The board currently receives regular monthly reports on work progress with the Mental Health Commission to effect the transfer properly. Those reports will continue after 1 April 2009 so that the board can discuss how progress is being made to absorb the Mental Health Commission’s work.

The main focus of Phelim’s earlier point is that an expert advisory panel will be appointed to guide the board and the senior officers of the Regulation and Quality Improvement Authority on how we conduct our work on mental-health and learning-disability services. Therefore, governance checks will be carried out at all levels of the organisation.

The Chairperson:

Everyone who indicated has been given the opportunity to ask questions. I thank Alice, Phelim and Jude for coming along and giving their presentation.