Official Report: Minutes of Evidence

The Chairperson (Ms Maeve McLaughlin): You are very welcome. We have Chris Matthews, director of mental health and disability in older people in the Department of Health, Social Services and Public Safety (DHSSPS); Fergal Bradley, head of quality regulation and improvement in the Department; Glenn Houston, chief executive of the Regulation and Quality Improvement Authority (RQIA); and Kevin Keenan, assistant director of older people and adults at the Health and Social Care Board (HSCB). I invite you to make an opening presentation. Then, we will open it up to members' comments.

Mr Chris Matthews (Department of Health, Social Services and Public Safety): Thank you, Chair. I do not want to take up too much time with opening remarks, but I want to provide some background on how we have approached this piece of work and give you some detail on what we have delivered and what work is ongoing. I am pleased to be supported by my colleague Fergal Bradley and by Kevin Keenan from the HSCB. Between us, we will attempt to deal with any questions that you may have. The Committee also asked for the RQIA to attend the session with us. As you know, RQIA is operationally independent from the Department. I am very pleased to have Glenn Houston here, the chief executive of the RQIA, who will make a separate opening statement.

The care of older people is a priority for the Department of Health. It is important that people have confidence that our health and social care system is providing safe, quality care for older citizens. It was on this basis that the Department considered the advice in the 'Changing the Culture of Care Provision in Northern Ireland' report that was presented directly to the then Health Minister, Jim Wells, at a meeting in November 2014. The Minister provided initial response to the commissioner in December 2014, which was followed up by a full response to each of the 13 proposals in the cover of a letter from Minister Wells in February 2015. More recently, an updated version of this response was provided on the cover of a letter from me to the commissioner's office in late June 2015. That covered a number of queries including an update on the Culture of Care report.

Ahead of this session, we provided members with a detailed written report on the current status of the proposals. While I do not propose to give a description of the status of all 13 proposals, the Committee may find it useful if I highlight a number of the key areas raised. As you will appreciate, some of the issues fall independently to the RQIA and I will leave those to Glenn's presentation.

Proposal 1 deals with rights, quality of life and dignity. This proposal goes to the heart of the health and social care sector's approach to care. Person-centred planning is at the core of how the system develops care plans for older people. Kevin may be able to expand on this in operational terms. The aim of the system is that everyone receives a care plan which is personal to them and which reflects their specific assessed needs and characteristics. As part of this, the Department's standards for nursing and residential care homes recognise the importance of concepts such as the need for dignity and respect for human rights. The Department recently published revised care standards for nursing homes. In fact, this work was accelerated as a direct response to the Northern Ireland Human Rights Commission's report 'In Defence of Dignity: The Human Rights of Older People in Nursing Homes', which I am sure that members of the Committee are aware of.

In developing these revised standards, the Department engaged early and regularly with the Human Rights Commission, which evaluated the standards and made very helpful comments before they were issued for consultation. The revised standards put human rights at their centre. Indeed, the Human Rights Commission issued a statement at the time of publication commending the participatory approach of the Department. This included ensuring that older people's views were actively sought as part of that process.

Proposals 3 to 5 relate to the processes and sanctions. Glenn will provide the detail on the processes around this, but I think that it is worth noting that RQIA presently operates under provisions in legislation that is now 12 years old. That is the Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003. We recognise the limitations that working from this legislation creates. New technology and policy developments mean that there is now a strong case for evaluating the 2003 Order. The Minister, in a statement to the Assembly when launching the Donaldson report in January, announced that we would be reviewing this legislation. This work has already begun.

While the RQIA already has a range of sanction and enforcement powers that it can and does use does escalate issues of non-compliance, we appreciate the fact that the review of the 2003 legislation will need to look at those powers and engage with a wide range of stakeholders as to whether there is a need to change those powers.

Proposal 7 suggests that trusts should not place older people into homes where there are compliance issues. Obviously, this is a very important issue. Older people can be vulnerable and the system needs to ensure that they are placed in facilities which can safely meet their needs. For this reason, the trusts' regional contract makes clear that no person can be placed in an establishment where it is subject to formal enforcement. In addition, the relevant departmental guidance on this makes clear that care managers must ensure that a home is operating in compliance with the regulations and standards before placing someone into care.

Proposal 11 addresses the need for a well-trained and registered social care workforce. Again, this is a very important area of work in the social care field. Last month, we began a process of registering the whole social care workforce in Northern Ireland, beginning with domiciliary and day-care workers. Our aim is to complete that work by December next year, with the registration of around 12,000 additional social care workers.

Proposal 12 deals with complaints processes, and the need for those to be brought to the attention of service users and their families. It is an important part of any service delivery system that there are effective mechanisms for raising concerns. For that reason, all regulated establishments — that is, all facilities subject to RQIA inspection — are required to have complaints procedures that meet minimum standards.

That includes not only publishing the existence of a complaints procedure but making sure that complaints are investigated within a time frame. Any complainant must also be made aware of their right to approach the Ombudsman with their complaint.

Proposal 13 deals with the contractual safeguards to avoid the termination of a placement without due process. That is important in terms of the protection of older people from unfair or capricious practice, and the need for potentially vulnerable people and their families to have confidence in the stability of their living arrangement.

For that reason, the regional residential and nursing home specification and contract was revised in September 2014 to strengthen the relationship between a trust and provider, and to ensure that processes are in place to manage disputes fairly. In the past month, that contract was again updated and reissued.

The Department continues to work on a number of areas highlighted in the report, including, following the publication of the adult safeguarding policy, examining the need for new adult safeguarding legislation; reviewing and updating the 2003 Order, as I mentioned; and a review of whistle-blowing arrangements in the HSC. As part of that, we asked the RQIA to examine arrangements in HSC bodies, and we expect a report on that in the first half of next year. Finally, there is completing the roll-out of social care registration.

I hope I made clear that the Department has made significant progress and continues to take action on these important issues. It is a complex and challenging piece of work, and requires a long-term commitment to improvements.

Thanks for your time. I am happy to take questions after Glenn's presentation.

Mr Glenn Houston (Regulation and Quality Improvement Authority): Chair, members of the Committee, I welcome the invitation to come here today to represent the RQIA. I particularly appreciate having an opportunity to make my own opening statement. In the interest of making best use of the time available, I will keep my remarks brief.

Chair, the RQIA has taken steps to respond to the recommendations in the Older People’s Commissioner's publication, "Changing the Culture of Care Provision in Northern Ireland ". Since publication, we have made a number of improvements to our inspection systems and processes to address those recommendations. In addition to the statement provided by Mr Matthews, I want to outline the actions that the RQIA has taken in respect of a number of the Commissioner's recommendations that are primarily for our organisation to address.

Recommendation 3 states:

The RQIA has moved from a platform of a mix of announced and unannounced inspections to primarily unannounced inspections of residential care and nursing homes. That new arrangement will continue.

Inspectors use the regulations and the DHSS standards as the framework for inspections. They are focused on key outcomes for older people and their families, including the leadership of the service, and safe, effective and compassionate care. Inspectors have a right of entry to any registered service at any time of the day or night. Whilst the majority of our inspections take place during weekdays, we continue to reserve the right to inspect at weekends and early morning and late evening where necessary.

Registered providers know that an inspector has a statutory right to enter their care home at any time unannounced. If an inspector finds an issue of concern, they insist that immediate action is taken to address the situation before the inspection is completed. An inspector may also issue at the point of inspection an urgent action letter, which will be reflected in the inspection report and the improvement plan requested from the care provider.

When the threshold for enforcement is reached, action is taken immediately to initiate the process. Naturally, a considerable proportion of our time is focused on dealing with registered providers that are in formal enforcement. We have a well-established process for reviewing information and intelligence about regulated services that are high on our radar at any given time.

Recommendation 4 states:

There is no stated policy position on the use of formal rating systems in the inspection of care homes. Consequently, the RQIA has not used formal ratings to represent the outcomes of inspections.However, we do assess compliance with the relevant standards and regulations as being either met, partially met or not met, and we report our findings accordingly. In addition to the programme of care inspections, we carry out inspections focused on the estate, the buildings, pharmacy practices and finance practices in care homes. These additional focused inspections are unique to our particular inspection regime.

We agree with the commissioner's views on ratings, and we are committed to developing and piloting a performance rating system in residential care and nursing homes. We have stated this publicly, both in our corporate strategy and in our annual business plan. The intention is to use a system to provide older people and their families with a clear and concise summary of inspection findings in a format that it is easy to follow. We want to acknowledge best practice in the care of older people whilst highlighting and eliminating poor practices, and we want to make sure that registered services achieve compliance with or, indeed, operate above the DHSSPS standards and regulations. We wish to encourage care homes in particular to commit to a continuous cycle of quality improvement, and we intend to identify best practice and report on registered providers that do this and are doing it consistently well.
There are different types of rating systems in use by regulating authorities, and some of those systems have been the subject of critical review. In July of this year, we presented a paper to the Department comparing and contrasting the approaches applied in other countries that make use of formal ratings. RQIA, in conjunction with the Department, is giving due consideration of a formal rating system for use here. It is likely that this change will require consultation with relevant interest groups.

That brings me to priority 5, which indicates that there should be clear and rigorously applied sanctions taken against care providers for non-compliance with minimum standards. This particular proposal also links closely with proposal 6. We use the powers available to us under the Health and Personal Social Services Order to hold providers to account for their performance. We do use these powers to the full, and, when formal enforcement is taken, we publish this information openly on our website. For example, on our website today, we have cited 18 registered providers that are currently subject to enforcement. These include dental practices, a domiciliary care agency, care homes for adults and children's homes. Last year, in 2014-15, we took formal enforcement action in respect of 51 registered services, including five care homes. We also notify the board and the trusts as the commissioning authorities of any enforcement action that we take so that they in turn can take appropriate steps under their responsibilities in keeping with the terms of the regional contract and the policies on safeguarding.

Improvement starts with recommendations and requirements, which are detailed in many inspection reports. In some cases, the inspector will insist that action is taken during the inspection to rectify a breach in regulations or standards. The first step of formal enforcement is a notice of failure to comply with regulations, which will detail the regulations breached and stipulate the actions and time frame by which the provider must return to full compliance. This will inevitably require additional inspections to provide the necessary assurances that breaches have been addressed and that the service has returned to compliance. In other circumstances, it may be appropriate to place a condition on registration. These conditions may be time-bounded. For example, a common condition is one of no new admissions until such times as RQIA is satisfied that the provider has addressed fully and completely any issues of concern.

The ultimate sanction is to cancel registration, which may in turn result in the closure of a registered service. Any enforced closure, particularly of a care home, can be very traumatic for older people and their families. I contend that this should only be used as a measure of last resort. In circumstances where cancellation of registration is warranted, it is possible that another provider may come forward for registration to take over the running of an existing service as a going concern and to operate that service in line with the standards and regulations. In these circumstances, we will always seek legal advice, and we will always act in the best interests of the residents and their families.

As Mr Matthews said, the statute that sets out the powers available to us was enacted in 2003. The landscape has changed considerably in the intervening period. RQIA is currently engaged in conversations with the Department to review the powers available under this statute and the associated fees and frequencies of inspections regulations. We believe that RQIA requires greater flexibility in targeting our resources where they are most needed and to be able to apply financial sanctions where that would be a deterrent to poor performance; for example, the power to charge for additional inspections required to assess compliance where a regulated service is deemed to be in breach of regulations or standards or is subject to formal enforcement.

I just wish to sum up by making a few higher-level points. First of all, I wish to assure the Committee that the system of regulation of care homes for older people in Northern Ireland is robust. There are currently over 470 registered care homes and some 300 registered domiciliary care agencies subject to regular inspection. All care homes in Northern Ireland receive a minimum of two inspections each year, and domiciliary care agencies are inspected on an annual basis. Where it is necessary, we will inspect those services more frequently.

Last year we completed 1,350 inspections of care homes. We published all of those reports on our website. Over the past year we have changed our inspection focus, as I said earlier, from an announced to a mainly unannounced platform, and our inspection reports are shorter and easier to follow. In every report we include reference to leadership and to the management of the home. We encourage all registered providers to aspire to excellence and, with that in mind, we will require home owners to identify how their commitment to quality improvement impacts on the lives of the people in their care.

The challenge going forward is to encourage continuous improvement of care, particularly in the area of quality of life of the residents of residential care and nursing homes. Critical to that is the need to have a system that recognises good and, indeed, outstanding performance, while ensuring that timely action is taken to address unsafe and poor practices. I wish to assure you, Chair, and the Committee that RQIA operates within our own continuous improvement cycle. We are fully committed to the process of improving regulation and inspection of services for older people. We will continue to keep our inspection systems and processes under regular review, taking account of feedback from the commissioner and from other sources, and by benchmarking our systems and processes with recognised best practices in other jurisdictions. Thank you very much for the opportunity to speak.

The Chairperson (Ms Maeve McLaughlin): Thank you both for your presentations. What I am hearing in response to the commissioner's formal guidance to the Department, which was ultimately about changing the culture of care provision, is that you are effectively saying that things are mostly OK.

Mr Matthews: I would probably not characterise it quite like that. I do not want to come across as being complacent. I think it is more the case that what the commissioner has identified are clearly the right issues. We take a certain amount of comfort from the fact that she has identified things that we were aware of from other things that were going on in the system and that we have been taking action against the areas that she has identified. I do not want to give the impression that we are in any way complacent about the system. Any system requires continuous focus, monitoring and improvement. I do not think that anyone could sit here, say that everything is fine and just move on.

What we are trying to put across today — obviously Glenn can speak for himself — is that we are alive to the issues and are taking action to address them.

The Chairperson (Ms Maeve McLaughlin): In terms of the Department's role, what are the key areas that potentially need to be actioned urgently?

Mr Matthews: I think we probably have taken action in those areas that are urgent. There are now a number of longer-term things, such as review of legislation, review of whistle-blowing arrangements and that sort of thing, which will take a bit longer. There are issues that emerged around the time that the report was initially made around contracts and so on, which have since been addressed. For example, I think one of the issues raised by the report was the fact that some people felt that they were insecure in their homes and the owner could just turn them out as the result of a dispute. That has been addressed by action taken by the board last year and again this year. There are probably things that you would say were priorities — things that directly affect people and the security and safety of their accommodation. The system is also looking at the longer-term things such as legislative reform, whistle-blowing and so on, which are more complicated and just take a bit more time.

The Chairperson (Ms Maeve McLaughlin): I have a policy question. Is it appropriate that the departmental approach is towards minimum standards?

Mr Fergal Bradley (Department of Health, Social Services and Public Safety): The legislation is from 2003 and reflects the policy position that was developed in the late 1990s. Unfortunately, at that time, yes, we used the terminology "minimum standards". For the purposes of enforcement, standards have to be continued to be referred to as "minimum standards". We have tried to set out that, when it comes to the developing of standards, they are anything but minimum. We develop a set of standards that is primarily based on the rights of the users, where we can. When developing the standards for nursing homes, we engaged extensively with a wide range of stakeholders. We used Age NI to engage with older people and engaged throughout the entire process with the Human Rights Commission. The whole idea was, at the end of the day, to develop standards that are primarily focused on the rights of the people living in the homes. We consulted widely on the final standards. We approached the Older People's Commissioner during various stages of the process, and she also responded to the consultation. It is unfortunate that that term is in the legislation and that people are able to characterise that as the minimum in some way, but I give the Committee an assurance that that is not the bias that is built into the standards. When we consulted, we had people saying that they are too strategic, too detailed, there are too many or there are too few. In terms of the bias, such as there is within the standards, the bias in how we develop the standards was towards the views of what older people said.

The Chairperson (Ms Maeve McLaughlin): You said that it is "unfortunate" that "minimum standards" is in the legislation.

Mr F Bradley: It is unfortunate that that is the terminology.

The Chairperson (Ms Maeve McLaughlin): Can you expand on that? What is the impact of that?

Mr F Bradley: The impact is that, unfortunately, there is a misunderstanding that people believe that the standards that go along with the legislation are minimum. We have tried to develop the standards that are appropriate for the service that is being regulated. It is not done on the basis that this is the absolute minimum that you have to do. We have tried to identify standards that are appropriate to a particular service.

The Chairperson (Ms Maeve McLaughlin): So, regardless of what the Department or anybody else tries to do to raise those standards, the legislation and policy direction as it stands could ultimately be perceived as a risk to care?

Mr F Bradley: I am sorry; I do not understand that.

The Chairperson (Ms Maeve McLaughlin): You have "minimum standards" in the legislation. You have minimum standards as a policy framework.

Mr F Bradley: The legislation says that RQIA will enforce against something that is referred to as "minimum standards". For RQIA to take enforcement activity, it has to have standards that are issued under that legislation. We issue them under that legislation. I am saying that it was never intended at the outset that the standards would be minimum as in the absolute lowest level. That has never been the way in which we have developed the standards. We have increasingly moved towards trying to develop standards on the basis of the rights-based approach, and we would be quite happy to go through the standards and give the Committee the opportunity to look at them.

The Chairperson (Ms Maeve McLaughlin): I am trying to drill down. You used the word "unfortunate" and said that it was never the intention for the standards to be low. Regardless of how people try to benchmark higher, "minimum standards" is still in the legislation. I am trying to tease out how much risk ensues.

Mr F Bradley: It does not involve risk. I am saying that it is unfortunate that it has led to this misunderstanding that the standards are in some way the bare minimum or the lowest level that you need to do. That is not how the system operates in practice. That is not how we have developed the standards.

Mr Houston: I want to comment. The points that you have raised illustrate very neatly the issues around the use of the term "minimum standards". In the public consultation, which Fergal referred to, we submitted our view. The standards are the departmental standards. We believe that they should not been known as "minimum standards"; they should be known simply as "the standards". We have taken that view because we have looked at how the arrangement operates in other jurisdictions, and, in most other jurisdictions, they refer not to "minimum standards" but to "standards". If we were able to clarify the language on all the standards, whether it is for domiciliary care, children's care, residential care or nursing homes, it would make life much easier and simpler for everybody to understand.

The Chairperson (Ms Maeve McLaughlin): Can I ask a direct question? Why did that not happen?

Mr F Bradley: We need to amend the primary legislation. We are in the process of doing that. There are a number of things that we want to look to at in how the 2003 legislation operates. We expect to put forward the suggestion that they will be referred to as "published departmental standards". The word "minimum" will not appear.

It is not applicable in practice, as regards what we have done, how we do things and how the system operates.

The Chairperson (Ms Maeve McLaughlin): When did the process of amending the primary legislation start?

Mr F Bradley: The Minister announced it as part of the response to Donaldson. I would need to go back and check the exact date; it was around December. Since then, we have been going through our legislation and looking at information on how the legislation has developed in other jurisdictions. We are in the process of setting up groups to start engaging with a wide range of stakeholders. The intention is to develop a set of policy proposals that will allow us to go out to future consultation. If there are to be legislative changes, you would expect them to be made in the next mandate of the Assembly.

The Chairperson (Ms Maeve McLaughlin): That concerns me. We have a process and an evidence base, through the formal guidance from the Commissioner for Older People, that goes back six or seven years, and we have information from the Cherry Tree report, over an eight-year period; but you are saying now that only since December have you been considering that the term "minimum standards" needs to be changed in the primary legislation.

Mr F Bradley: The term needs to be changed.

The Chairperson (Ms Maeve McLaughlin): Yes. Can you understand what I am saying? We have an ample evidence base and formal guidance to the Department on standards and recommendations, and I am hearing today that it is only since December that this has been considered.

Mr Matthews: I think it is fair to say that the use of the term "minimum standards" in the primary legislation does not necessarily constrain what goes into any standard that is issued under the 2003 Order. The unfortunate thing, as Fergal says, is that it creates the perception, or understanding, that these things are in some way limited in how far they can go, because of the use of that phrase.

The Chairperson (Ms Maeve McLaughlin): With respect, it is a policy direction, and it is a piece of legislation.

Mr Matthews: There are probably two issues. First, there is addressing the perception, cultural issue or understanding of minimum standards through primary legislation. Secondly, there is the question of whether there is a practical issue or problem with the current standards: if there is, they can be changed more readily. So, there is a material difference between the two things. The standards are reviewed fairly frequently. If they need to be altered, they can be altered more readily than primary legislation.

The Chairperson (Ms Maeve McLaughlin): Do you accept that the formal guidance to the Department clearly indicated that the standards needed to be altered and that it was about changing the culture?

Mr Matthews: Which is a different thing to changing the primary legislation.

The Chairperson (Ms Maeve McLaughlin): You just said that if issues need to be altered, they can be altered more readily.

Mr Matthews: Yes, in terms of the established —

The Chairperson (Ms Maeve McLaughlin): Formal guidance stated clearly that standards being struck at "minimum" are having an impact

Mr F Bradley: Again, it goes back to the fact that it is an unfortunate side-effect of the fact that the original legislation used that word. We can take the Committee through the process on nursing home standards. There was a wide range of engagement. We talked to older people, and we went through it with all of the stakeholders. At the end of that, as I said, we came up with a set of standards. Throughout the process, we engaged with the likes of the Human Rights Commission. This is a rights-based set of standards. If you read them, you will see that they start with emphasising the rights of the people who are living in the homes. That goes right through the entire table of standards. We are happy to meet the commissioner again to take her through it and ask her to identify her concerns for us, but there was wide engagement around those standards.

The Chairperson (Ms Maeve McLaughlin): Can I come back to you on that? I have read the standards. The Commissioner for Older People's work was very, very clear in relation to dignity. You have mentioned putting that at the heart of delivering care a few times. Dignity is mentioned once in the residential homes and domiciliary care standards, and human rights are mentioned once.

Mr F Bradley: I am talking, initially, about nursing home standards. We are currently looking at residential home standards.

The Chairperson (Ms Maeve McLaughlin): With respect, I cannot take from you today that we have read human rights and dignity throughout the standards process when both are mentioned once.

Mr F Bradley: Historically, standards have never been developed on the basis of the term "minimum". We are looking to build the language of rights into the standards. We have already done that with nursing home standards, and we are currently looking at residential home standards.

The Chairperson (Ms Maeve McLaughlin): I am going to ask you a direct question. As it stands in the "unfortunate", as you described it, definition or reference to minimum standards, you will assert that issues like dignity and human rights are throughout the process. I take issue with that, because I have gone through them. Does it mean that there will be, potentially, a negative impact on the level of care that we provide?

Mr F Bradley: It is impossible to answer that in simple terms. You would need to sit down and look through both sets of standards.

The Chairperson (Ms Maeve McLaughlin): I have looked.

Mr F Bradley: In terms of residential home standards — and we have been looking at this — if you were just doing a paper-based exercise and were not going to go through the proper process and engage with the full range of stakeholders, then you could probably take the vast majority of nursing home standards and say that they would read across to residential homes. But, we cannot do that. We have to start at the beginning each time and engage with the range of stakeholders and go through proper process in order to develop standards for each sector.

The Chairperson (Ms Maeve McLaughlin): But you accept that residential and domiciliary care standards refer only once to dignity and only once to human rights.

Mr F Bradley: I do, but we update the standards regularly. We are trying to move in that direction in the language. We started with nursing home standards and are moving towards other standards.

The Chairperson (Ms Maeve McLaughlin): Glenn, just specifically, there were very obvious issues around Cherry Tree. It was clear to anybody involved with that issue, or looking on, that there were many inspections over an eight-year period. Enforcement action was taken on several occasions but it was just too slow and ineffective.

Mr Houston: We took the independent review report seriously when it was published. It was undertaken by three people independently of the RQIA. If you go back over an eight-year period in any nursing home, you will see a high number of inspections. As a regulator, one of the things we do when a home is in enforcement is to step up the number of inspections in that establishment until we are satisfied that the home is coming back into compliance.

One of the big challenges for us — and it is an appropriate challenge and is being re-emphasised by the Commissioner for Older People — is to make sure that, where the trigger for formal enforcement is met, we act swiftly to take whatever action is needed to bring that service back into compliance.

The Chairperson (Ms Maeve McLaughlin): So, if it was too slow and ineffective over an eight-year period — and most of society would accept that — why was it too slow or ineffective?

Mr Houston: In any situation, you are looking at it at the point of inspection. Sometimes, a service might be deemed to be operating outside the minimum standards, and, when we go back, we do a further inspection and see signs of improvement. We are always trying to encourage improvement and raise the bar in every inspection.

The independent review was, rightly, critical of the fact that in Cherry Tree there were a number of occasions — in fact, they mentioned two specifically — when the threshold of enforcement was met. We have absolutely learned the lessons from that process and are applying them in our inspection regime.

The Chairperson (Ms Maeve McLaughlin): Could you today give assurances that there are no more scandals like Cherry Tree waiting to emerge?

Mr Houston: My board asks me that question regularly. I always try to be honest and clear in my answer. We can give you that assurance as far as we can, but that does mean that it is never going to be an absolute guarantee. It would be wrong and misleading of me to tell you that that would be the case, because in every system across Europe where there are inspections of hospitals, residential care homes and nursing homes, things happen that take a service from compliance into a difficult place.

The Chairperson (Ms Maeve McLaughlin): Does the 2003 statute limit what you can do?

Mr Houston: It does. As I said in my opening remarks, the 2003 statute is now 12 years old. The landscape has changed enormously in not only the number of services we regulate but the range. As a regulator, we need faster opportunities and options to call providers to account. We will always use those options and opportunities appropriately and in a balanced and proportionate way, but I have made reference to one, which is the ability to levy a charge for additional inspections that are required to bring a service back into compliance. I have a limited capacity, and if I have to take inspectors away from one place to focus on another place, there is an opportunity cost in that.

The Chairperson (Ms Maeve McLaughlin): Ultimately, would it follow that, if the statute is 12 years old, it limits what the RQIA can do and brings a degree of risk?

Mr Houston: We use the statute as best we can, and, in doing so, we have never shied away from taking enforcement action where we have felt the threshold for doing so has been reached. There is ample evidence of us having done so. I have referred to the number of times last year when we took enforcement action. If you were to go to our website today, you would see 18 services listed that are undergoing enforcement currently. It is more around the breadth and scope of the options available to us that, I would argue, need to be given further and more detailed consideration.

The Chairperson (Ms Maeve McLaughlin): Just on that, can you give us an indication of how many two or more failures to comply you have had to process over the last number of years?

Mr Houston: I will pick out two things there, Chair, because I think that you have hit an important point. One of the challenges that came out of the independent review was the number of times that a recommendation or requirement would be restated in an inspection report. We have looked at that, and we have come to the view that we should not repeat recommendations and requirements time without number. If we state a recommendation once, and, particularly, a requirement, because that relates to the regulations, and we go back and see that it has not been dealt with, then we will then consider our next steps. That might very well trigger formal enforcement, but there are some occasions with particular establishments where we might have to issue two, three or four failure-to-comply notices. In those cases, we will almost always consider placing a condition on registration, which says that there will be no new admissions until the establishment is back into compliance.

The Chairperson (Ms Maeve McLaughlin): Does it mean that the care provision, facility or home and patient care, tenant care or resident care would be at risk? If you are saying that if there are two, three or four failures to comply you will stop admissions —

Mr Houston: What we always look at are the areas where the faults occur. Some of them may directly affect patient care. One of the themes that came out of the independent review was, for example, continence management. We took that on as a high priority for our inspection in the subsequent year, but there may be things that, for example, relate to the building. I mentioned the building, pharmacy inspections, finance inspections and all that. It depends very much on the context. The reality is that no service should operate outside the regulations or standards at any point, and we would treat every breach as a serious breach.

The Chairperson (Ms Maeve McLaughlin): You may not have the information today, but can you provide the Committee with a list or an indication of the number of two-plus failures to comply over the last five years?

Mr Houston: We monitor that. We can do that. Absolutely.

Mr McCarthy: Thanks very much for your presentation. I do not know whether you saw or heard the presentation given by the commissioner a couple of weeks ago. It was scathing on the lack of determination to put things right that were, in her opinion, wrong. I have the highest admiration for the work of Claire Keatinge, as, I am sure, have the Committee and you. However, she used the word "shameful". Is that a term that you would go along with in relation to what we are talking about?

I also received her annual report, and, on this very subject, she talked about, as the Chair mentioned, Cherry Tree House and the repeated failures of regulated care, including the lack of timely enforcement, protection, whistleblowing, etc. That is all down there. Can you give us a guarantee that this will not happen again to any of the homes that we have in Northern Ireland? She said, initially, that there was some excellent provision, and we were happy to hear that. But, we want to make sure that the ones that are not so good are challenged. Maybe you will want to respond to that first. There are a couple of things on the proposals.

Mr Matthews: OK. There are a few issues there. I can assure you today that the Department is determined to deal with the issues that the commissioner described. I hope that the work we have planned and which we have set out to do makes it clear that we take this issue seriously. We are investing resources and people in dealing with the issues. I have no comment to make on how she wants to describe things. I have complete respect for the work of the commissioner's office; we take her reports and we deal with them. I can completely understand why you would be alarmed about the terms in which it was described.

Turning to the issues relating to Cherry Tree House and so on — and the commissioner said that there are examples of good provision as well — it is important to clarify and discriminate between areas where very specific problems have happened and the generality of the system. Where something like Cherry Tree House occurs, we obviously have to deal with the issues raised there, and we have done so. While we need to take any lessons for the wider system from that and action them, we also need to avoid making out that everyone behaves in that way. Some people are better than others; that is inescapable in any system, and that is why we have standards and inspections. It is very important for the confidence of the people who are living in those homes but it is also about respecting the hard work that goes on day and daily in all these care homes.

We need to be very clear about why we are acting and on what basis we are taking action. If we are doing something to the whole system, we need to ensure that we are not simply projecting from one instance and that we have a good understanding of what is happening across all the homes.

I do not know whether anyone else wants to come in on that, but the Department is absolutely committed to making sure that there is good care and that the legislative framework is there.

Mr McCarthy: One of the commissioner's major criticisms was about the length of time it takes the Department to do what has to be done and do it right. In your opening statement you mentioned the length of time that things take. It almost seems as if there is foot-dragging and that people suffer.

Mr Matthews: If we have given the impression that we are dragging our feet, then I apologise for that. The issue with things such as standards and primary legislation is that it takes a long time, maybe two or three years, to change primary legislation. However, the standards themselves, as Fergal has described, can be changed more regularly because they are in subsidiary legislation and can be done without going down the primary legislation route. As we have shown, we have taken action in a number of areas. Some areas are more complicated and difficult than others.

I take the point that there can be frustration at how long it takes. All of us will get frustrated, I am sure, about the time it takes us to do things and change things. That is not because we are dragging our feet; sometimes it is because these things are more complicated than they initially seem to be.

Mr McCarthy: This report started in 2013 and it was published in 2014. Claire Keatinge had a meeting with the Minister this time last year and she maintains that very little has been done. Two years have gone past and the progress that she would like to have seen in her reports has not been made.

Mr Matthews: If that is her assessment, we have to accept that.

Mr McCarthy: I want to move on and talk about two of the proposals. Glenn mentioned proposal 4, which is about the rating system. The commissioner is very much in favour of that in her report, and you mentioned it widely in your presentation. How long will we have to wait for that? According to the information in our papers, there has been enormous progress with rating systems elsewhere. How long are you going to take to decide to get onto that?

Mr Houston: I will pick up on that because it is an important consideration. First, we have a commitment in our strategy and in our business plan. I referenced that, Mr McCarthy, in our opening statement. We have moved beyond that and have developed a paper for consideration and consultation which looks at the use of ratings in other contexts. It looks at, for example, what the Care Quality Commission is doing in England and at what the Care Inspectorate in Scotland is doing. We have looked at Wales and the Republic of Ireland and at a range of approaches to ratings.

We have also looked carefully at a very important report that was published by the Nuffield Trust, 'Rating providers for quality: a policy worth pursuing?'. That report sets out the opportunities, the advantages and the rationale for using formal rating, but it also cautions against how ratings, if they are developed too quickly, if you like, and applied without thought, can be challenging and create difficulties. One of the things worth mentioning that the trust particularly highlighted is that if you live in a small rural community in which there is one facility — one nursing home — and the regulator carries out an inspection of that nursing home and says that it is inadequate, it can undermine public confidence in that establishment. Therefore, we need to look very carefully about how ratings are applied, and I am sure that members of the Committee are aware of some of the criticisms that have been levelled in the past at the use of ratings in other contexts, particularly hospitals.

We are absolutely not resisting the Commissioner for Older People's views; in fact, we have reflected them. We are saying to the Department that we want to get on and look at this and do it properly; we may have to consult various interests groups, and we want to make sure that whatever steps we need to take are taken in the right order.

Mr McCarthy: Of course, it takes time.

Mr Houston: It takes a bit of time.

Mr McCarthy: I want to make sure that no time is wasted to get where we want to be.

Mr Houston: I do not disagree.

Mr McCarthy: Finally, I come to proposal 10, which relates to people who do their work — I do not like using the word "whistle-blower" — and simply do their job and report instances of abuse. How are we going to get on top of that? On different occasions, the Minister said to me and to the Committee that he supports the idea of people coming forward with information on what is happening in any institution. How are you going to get that right —

Mr Houston: I will pick up on that. Two organisations are designated under the Public Interest Disclosure Order to which an individual working in health and social care can make what is known as a protected disclosure; that is a protected whistle-blowing disclosure. One of them is us — the Regulation and Quality Improvement Authority — and the other is the Northern Ireland Social Care Council. That is hugely important. Quite a while ago, we provided explicit guidance on our website for individuals who believe that they have a legitimate concern and who may want to bring that concern to our attention. Any guidance, whether it is produced by organisations locally or by Public Concern at Work, which is a national charity, will say, "Take that issue up with your employer or the provider". However, if you are not getting the response that you need and you have a genuine concern, you can bring it to the attention of those bodies. People contact us regularly, we pick up on those issues, and we follow them through very diligently to make sure that they are being dealt with in the proper quarters. Sometimes, an approach to RQIA might trigger an immediate inspection of an establishment if we felt that there was a concern.

Mr McCarthy: Is the message getting out to the staff involved that if they do the right thing they will not be put in jeopardy and their job will not be a stake?

Mr Houston: If an individual has acted reasonably and in the context of the public interest disclosure legislation, it affords them a degree of protection. It is very difficult to stand up and say that something is terribly wrong in your place of employment and to persuade the powers that be that you are right about it. We do not underestimate the challenge for individuals, but we feel that it is important that if someone steps forward they are given the necessary guidance as to how to deal with that and support if they are struggling.

Mr McCarthy: Finally, you mentioned penalties. Have there been any cases of homes being forced to close because of their bad behaviour, and have there been any prosecutions? When the commissioner was making her report, I said that you can close a home but that if somebody is found guilty of the abuse of an older person, there should be more than that; there should be prosecutions.

Mr Houston: I saw you making that point, and I think that you made a very valid point. That brings into play things such as, for example, the regional strategy for the protection of vulnerable adults. It brings in questions, and my colleague Mr Keenan from the board may wish to comment on that. It is always appropriate where there is any evidence of individual acts of abuse that the police be told about them because the police have the primary responsibility for investigating them and bringing prosecutions. We all know of very high-profile cases across the whole of the UK where the police have been involved. I am thinking, for example, of Winterbourne View, where there were bad practices and where the police intervened and prosecutions were taken and people were brought before the courts to give an account of themselves. In every situation, we will work collaboratively with the Police Service where we need to. We will work within the framework of the regional policies and procedures for safeguarding vulnerable adults, and if that requires us to have conversations with the health board or, indeed, with other organisations, we will do that.

The Chairperson (Ms Maeve McLaughlin): If I may, Glenn, I will pick up on the issue of whistle-blowers. There was evidence that, in the case of Cherry Tree, a whistle-blower had contacted the trust in the region of 74 times.

Mr Houston: I would need to go back on that. Absolutely; there was a whistle-blower who had, as part of the process, raised concerns at local level initially and felt that those concerns had not been properly dealt with. Chair, you are quite right to say that that was documented in the report. What I have said about our response is that we have recognised that we need to give as much advice and guidance as we can to individuals who are in that situation so that they are heard and that their concerns are taken seriously. I could quote you examples of where individuals have come to RQIA with a particular concern about an establishment and how we have responded to those concerns.

The Chairperson (Ms Maeve McLaughlin): I do not doubt that, but there is an example of how it absolutely did not work.

Mr Houston: We are on record as accepting the report of the independent review that made it very clear that the whistle-blower had difficulties in getting her story across.

The Chairperson (Ms Maeve McLaughlin): There are difficulties, and there are 74 attempts.

Mr Houston: They were not all made to one organisation. I think that the key in all of this always is the need to coordinate where coordination is required between the regulator, a trust as the primary responsible authority for investigating under the safeguarding policies and procedures, and, where the PSNI needs to be involved, with the PSNI.

The Chairperson (Ms Maeve McLaughlin): For any society to have somebody come forward 74 times to do the right thing is a damning indictment.

Mr Houston: I do not deny that, Chair. This is one of the real difficulties in having an effective response to whistle-blowing. It involves hearing it, considering what the person is telling you and deciding what is the best and most appropriate means of responding and making sure that it is followed up quickly.

The Chairperson (Ms Maeve McLaughlin): I am going to labour this point. The Donaldson report, which came after all the issues with Cherry Tree and the formal guidance to the Minister on changing the culture of care, said:

There was a specific recommendation that the Regulation and Quality Improvement Authority — you — should review the policy on whistle-blowing and provide advice to the Minister. Has that review happened?

Mr Houston: It is starting as we speak, Chair.

The Chairperson (Ms Maeve McLaughlin): I do not understand why we are hearing today that it is starting. The review was published in December, and this issue is only starting today. We have eight years of evidence.

Mr Houston: I should draw your attention to the fact that, in November 2014, guidance was published by the four national Audit Offices entitled 'Whistleblowing in the Public Sector'. It was a good-practice guide for workers and employers. When we received it, we immediately revised the information available on our website for individuals who might need to come forward as a whistle-blower, so I do not want you to feel that no action has been taken.

The Chairperson (Ms Maeve McLaughlin): Yes, Glenn; I get that about guidance. That is fine. Every organisation should reflect and do that, but there was a very clear recommendation in this that talked about reviewing the current policy and giving advice. You are saying that this is starting only now.

Mr Houston: As Mr Matthews said, the request was for us to undertake the review as an extra piece of work in that programme this year and to provide a report by March next year. That is exactly what we intend to do, Chair.

The Chairperson (Ms Maeve McLaughlin): Well, it says that you should review the current policy on whistle-blowing and provide advice to the Minister.

Mr Houston: There are two issues there, Chair —

The Chairperson (Ms Maeve McLaughlin): That is a recommendation.

Mr Houston: Well, that is a recommendation from the Donaldson report to the Department. What the Department has asked RQIA to do — and I believe that it will help to inform the advice to the Minister — is for us now to undertake the review of the whistle-blowing arrangements in place across the system.

The Chairperson (Ms Maeve McLaughlin): OK; so it has not started yet.

Mr Houston: We will be rigorous in doing that.

Mr McKinney: I will just revisit some of the remarks made by my colleague Kieran about the Commissioner for Older People's presentation to us last week. It is good to have a bit of difference, but do you accept that there is a yawning gap between her understanding of your movement on any of these issues and what she is looking for? What is your assessment of how you are doing?

Mr Matthews: It is not really for me to comment or critique her analysis, but maybe just to —

Mr McKinney: I am not asking you for that. She said one thing, and you are accepting to me that there is a yawning gap, so why is there a yawning gap?

Mr Matthews: A gap between what she has described and how we would describe where we are?

Mr McKinney: Yes, and what you are not doing.

Mr Matthews: We have presented the evidence of what we have been doing and what we plan to do. We can discuss that. I do not think that it is really for me to critique or otherwise the commissioner's position. It is her perfect right to express a view; that is her role. I accept that that is her view. I do not think that it is really for me to —

Mr McKinney: No; do you accept that she has a point? Is she wrong?

Mr Matthews: As I said, I do not really think that it is for me to critique her analysis —

Mr McKinney: She is not wrong?

Mr Matthews: What I am saying is that all I can do is present to you what we have been doing and where we are and be judged on that.

Mr McKinney: Yes, I understand that, but she is saying that you are not moving far enough, fast enough. Do you agree with that?

Mr Matthews: Would I prefer to be further on in some of these things? Absolutely.

Mr McKinney: Why are you not?

Mr Matthews: Essentially, because there is limited resource in the Department and other places and there is only so much work you can do in any given period. This is not the only thing that we are all working on. We give this priority and we try to press it on, but there is a whole range of other things happening at any one time and there are limits to how much we can achieve in any period.

Mr McKinney: So she is right.

Mr Matthews: Again, it is not for me to comment one way or the other on her opinion.

Mr McKinney: But you would also accept that the TYC plan had older people at the heart of it, strategically.

Mr Matthews: Yes.

Mr McKinney: Would you expect therefore that some movement might be prioritised in that regard?

Mr Matthews: I would not necessarily draw a parallel between the Culture of Care report and TYC; I think that they are probably in different territory.

Mr McKinney: Proposals 9 and 10 of Transforming Your Care were to move people out of residential and nursing care and into the community.

Mr Matthews: Which, I think, is different from the culture of those homes themselves. We can talk about TYC, absolutely. However, I am not sure that the commissioner's report is necessarily about where TYC suggests we should head with care for older people.

Mr McKinney: In general terms, she is talking about standards. We are talking about closing homes and moving people out to places. Trusts are cutting budgets, so only those in severe need get domiciliary care packages. If you do not see all that marrying, I am a bit worried.

Mr Matthews: There is a range of issues there with regard to the resourcing envelope that we have, where TYC says what the best place to care for older people is and what the commissioner is saying about the current system. Obviously, there is a through line in the sense that they deal with the same subject matter, but I am not sure that what the commissioner's report tells us about the current system necessarily impacts on the overall vision of TYC.

Mr McKinney: I see it all as one work stream, if you like.

Mr Matthews: Sure.

Mr McKinney: The Department should have been doing work on this area. We have heard at other Committees that the board is doing only scoping-out exercises on older people. I see this all as forming a continuing narrative. If work is not being done, the frustrations expressed by the Commissioner for Older People, in whatever way she has articulated them, have validity, I would argue. What I am hearing was what she said last week and you saying, "Not much to see here."

Mr Matthews: As I said, I do not want to give the impression that we are in any way complacent. I hope that we have made it clear that we are taking action in all the areas that the commissioner has identified. Now, there is a difference of opinion, obviously, in how far we have gone. However, I contend that we have made strenuous efforts to move this along, although I accept that the commissioner would like us to have gone further. I think that all of us at the table would have liked to go further than we have as well, but I do not think that we have, in any way, dragged our heels. I do not think that we have allowed any dangerous situations to develop because of inaction, and I do not think that we have been, in any way, complacent. However, this is a very challenging issue; it is amongst a whole load of challenging issues around caring for older people. It is very difficult and complex, and it takes long-term commitment.

Mr McKinney: On the issue of minimum standards, would you accept that the low pay received, particularly in the independent sector, is a minimum standard?

Mr Matthews: We are looking at that key issue. Obviously, there is a lot of discussion about the minimum wage, the increases next year, the issue of living wages, and so on. That is part of the work that we have to do generally in workforce planning because, as you know, we have recruitment issues in certain areas. Pay might be one aspect; there could be others.

Mr McKinney: What work have you done on that?

Mr Matthews: At the minute, the board has just completed a review of the domiciliary care workforce, which is one of the areas where we have a particular issue. That will feed into a review that we are doing on the reform of the whole of adult social care, as I have talked about here before, and will look at things like workforce, housing, legislation and how we pay for social care. We also have a separate workforce-planning strand that looks at recruitment and retention in these areas.

Mr McKinney: In England and the wider UK, it is £15·27 an hour for a home-care service. Would you accept that the £11·35 that is paid here and the £10·66 that is paid in the Western Trust is a minimum standard?

Mr Matthews: I do not know if you want to —

Mr McKinney: No; I am asking you.

Mr Matthews: Well, the issue about commissioned services is —

Mr McKinney: I am asking you about the minimum standard. It is not a maximum standard if we are not getting —

Mr Matthews: Again, I am not sure that I would draw a parallel between minimum standards for the regulation of nursing homes and payments that are agreed between the trust and an independent provider.

Mr McKinney: It might feed in if people are getting low pay and feeling stressed in those circumstances.

Mr Matthews: That is something that we have to be attentive to, but if there are specific issues arising out of that —

Mr McKinney: Do you see them as being specific issues to be addressed?

Mr Matthews: Absolutely. The sustainability of certain markets —

Mr McKinney: What are you doing to address them?

Mr Matthews: As I said, we commissioned the board to do a review. Payments, and so on, are reviewed regularly. Those issues are decided independently of the Department through the board and the trusts through the commissioning process. Absolutely: there are issues, as we know, of market fragility. We are alive to those issues.

Mr McKinney: Are you aware that, nationally, NICE has now recommended under its social care guidelines 30-minute-minumum care packages? We are down to 15 minutes and eight minutes. Do you accept that those are minimum standards?

Mr Matthews: There is an interesting discussion about that. At an event held by the commissioner, there was a discussion about that. At the minute, there is a clinical decision on how needs are met, but I think that there is an issue about whether you go for a flat assessment of how much time is spent with someone or whether it is based on an assessment of specific need. There may be people who need longer intervention and those who need shorter intervention.

Mr McKinney: I am asking about the comparison between what NICE is now recommending in England as a 30-minute package and what is routinely, or at least regularly, delivered here. Would you accept that that is a minimum standard?

Mr Matthews: Those are clinical assessments.

Mr McKinney: It is not clinical.

Mr Matthews: The NICE guidelines —

Mr McKinney: Do you want to reject it as a minimum standard or accept it as —

Mr Matthews: Again, it is not for me to accept or reject NICE —

Mr McKinney: You guys have come here to tell us that while it is in the legislation as a minimum standard, we do not operate to minimum standards; we operate to something else. I am only testing —

Mr Matthews: There is a difference between domiciliary care visits and minimum standards for residential homes.

Mr McKinney: This is how the customer and the public perceive what you are delivering. You are saying that you deliver over and above. You are saying, "It's in the legislation, but no, not at all, we deliver over and above". I can point to low pay, underfunding and minimum care package times. Do you accept that, collectively, they represent minimum standards?

Mr Matthews: I think that they represent a group of issues that will have an impact on the sustainability of that market. I am not sure that the term "minimum standards" is relevant to all those issues.

Mr McKinney: Even in your language of standards, does it represent a maximum standard or a "have-reached" standard?

Mr F Bradley: It is worth noting that the NICE guidance is not mandatory in England. It is basically something that the commissioners of service in England and the CQC will use as part of the evidence to establish the rating of services. There is no legal or mandatory impetus behind them.

Mr McKinney: I am, obviously, aware of that, but we are now looking to 30-minute care packages in England, but less here. I am sure that the Committee will take a view on this, but, Glenn, you talked about things happening. In answer to a question by the Chair on Cherry Tree, you said that your board had asked you the same question and that "things happen". Do the low pay, minimum care package and underfunding issues represent things happening that could lead to a situation further down the track? When are we going to hear from the RQIA that these standards are not good enough?

Mr Houston: At the commissioner's invitation, we took part in a recent event specifically about domiciliary care. I think that it was a timely event, because it was an opportunity to highlight some of the things that you touched on around how domiciliary care is commissioned in Northern Ireland and how domiciliary care workers are remunerated, and the fact that many domiciliary care workers do not have contracts of employment and may be on zero-hours contracts and that commissioners, in trying to stretch their budgets, are paring back intervals of care. I was speaking publicly at that event. I said that I thought that a number of things needed to happen and to change. I said that it was my view — I was speaking largely personally, Mr McKinney, but I am sure that you will understand — that we should be thinking about all those issues. I said that we should be moving to a situation where we should be shoring up provision of domiciliary care.

One thing that I am concerned about is that we have a regional system for setting the tariff for residential and nursing home care in Northern Ireland, but we have five separate trust-led systems for setting domiciliary care contracts. I do not know what the answers to all those issues are, but I know that we are hearing that there are pressures in the system. One of the good things about the impact of Transforming Your Care is that we are seeing a growth in the number of domiciliary care providers, but we absolutely must make sure that they operate safe and effective services and that they do not miss calls. Those are things that I, as the regulator, am extremely concerned about.

Mr McKinney: Is that what we are experiencing at the moment? Last week, or the week before, the Committee received a letter from independent care providers warning of the dangers. That is a whistle-blowing exercise if ever I saw one.

Mr Houston: We have been speaking to the umbrella organisation that represents the interests of domiciliary care workers. They have put enormous effort into looking at what happens across each of the countries where they represent. There is some helpful and compelling information in that that is worthy of due consideration.

The Chairperson (Ms Maeve McLaughlin): Sorry, Fearghal, Kevin wanted in on this.

Mr Kevin Keenan (Health and Social Care Board): Thank you, Chair. I will make two points of detail and then maybe a broader observation. The hourly rate of £15·27 that you cited is advanced by the industry as the recommended rate, and it does not apply across the whole of the UK.

That said, we pay among the lowest hourly rates across the country; we are in the lower quartile. We recognise that the rates that are paid are challenging to the providers of the service. We need to have a serious look at that.

Mr McKinney: I am happy to clear up the point that it was the United Kingdom Homecare Association, just in case there is any difference. I am happy to reflect that.

Mr Keenan: The NICE guidance does not establish 30 minutes as the absolute minimum in provision. NICE has consistently argued that 15-minute calls are inappropriate for people with high clinical needs. However, there is a recognition that this is horses for courses. If some people need only minimal input, 15 minutes can, on occasion, be appropriate. The biggest thing that we are concerned about would be if that became anything like the norm, or there was a large increase in such small allocations of time. I just wanted to clarify that.

On the broader picture, we encompassed some of the issues that Glenn talked about — and that you picked up yourself — in the work that we are taking to our board on 12 November. We are tabling a wide-ranging report on domiciliary care that covers a lot of the issues that you touched on, and more. We are going to have a serious discussion with our board about to what extent we can shape and influence the factors, problems and challenges within domiciliary care in Northern Ireland. That is a huge priority for us.

Mr McKinney: Yes, I —

Mr Keenan: I am sorry, Fearghal; I have just one last point.

Mr McKinney: Go ahead.

Mr Keenan: I do not know whether, in the report of the proceedings with Claire Keatinge, it was you who talked about the representations made by the industry on the pressures and problems that it was experiencing. We acknowledge those. Where we maybe have a slight difference of opinion is on the seriousness of the instability. It is an industry that is facing serious challenges, but I am not hyping up the instability of it. We need to work with them to try to resolve these matters.

Mr McKinney: I have reflected that it has come from the independent sector. Clearly, they have their own issues. The point I am making about the social care issue is that, whatever about the timings, we are not a signatory to the social care aspect of NICE. We are a signatory to the health care side of NICE, although I see that we do not sign up to the cancer drugs initiative.

Thank you, Kevin, for your contribution. The RQIA needs to have a stronger voice, not just post-event or in the middle of the journey or at some later point in the journey, but at the start of the journey. It should be around whistle-blowing — yourself, around funding and around others. Do you agree?

Mr Houston: We welcome every opportunity to shape the debate and influence thinking. Our board is strong on making sure that we are involved in key discussions, particularly where they impact — if I may say, Mr McKinney — on the shape of regulation and inspection.

Ms McCorley: Thanks very much for the presentations. Going back to minimum standards, is there a minimum standard and then other levels? What way does it work? If you just have minimum standards and someone or some establishment continually flits around them, that means that people are being failed. I have a difficulty with that, because they could be seen to be complying a lot of the time but if they do something wrong, once you fall below that you are into unacceptable standards, whatever that might mean for a person. As we know, these are vulnerable people. There is a need for something higher that should be an accepted standard. There has to be an area where you are preventing people from falling to dangerous levels. When you fall below minimum standards, you are into dangerous levels. I would like a wee bit more of an idea of the way it actually works.

Mr Houston: That is an important issue in the framework within which we carry out inspections. We have just introduced a new series of inspections of the experience of patients in hospitals. Within that, we have a handbook and a framework that indicate the areas that we examine. In the residential care, home sector and nursing home sector, in addition to the standards, there are the regulations. If we are taking enforcement action, whilst we might be concerned about the level of compliance with the minimum standards, our enforcement action will always be taken around breaches of regulations. The challenge is not only for the system to have the correct standards — whether you call them minimum standards, national standards or simply the standards — but also to keep the regulations under regular review, because that is the framework where we are able to hold individual providers to account.

I think that you make a very valid point. Regulations are sometimes brought into effect, but time moves on very quickly. There should be regular review points to make sure that the regulations are as robust as they need to be.

Ms McCorley: OK, but do you accept that point? I think that you acknowledged that you want to have some way of capturing when something is starting to deteriorate, so that you can bring scrutiny to it before it gets to "dangerous". You do not want some vulnerable person to —

Mr Houston: Absolutely. We would far rather intervene at a point when it is possible for the provider to identify what needs to be done and put it right than intervene much further down the line, when we are taking action that may result in the cancellation of registration or the closure of a facility. You are absolutely right on that point.

Ms McCorley: In her report and at the evidence session last week, the Commissioner for Older People talked about the need for timely and decisive action. She said that responses that she had seen to issues like Rowntree House were neither timely nor decisive. Do you agree that she is right to say that action needs to be timely and decisive? Is that where you are aiming to be? How and when will you get there?

Mr Houston: Absolutely. I will answer that in two ways. First, we absolutely accept what the commissioner said about timely intervention, particularly if we are in the situation where a service finds itself in breach. Secondly, since the independent review, we have looked at all our systems and processes to make sure that we respond and will respond as quickly as possible where we see a service failing individuals. The evidence of that is clearly available through the information that we put on our website, which is in the public domain. Where we are taking enforcement action, we believe absolutely and fundamentally that it is in the public interest for that information to be in the public domain, and we will continue to do that.

Ms McCorley: When someone asked you about ratings earlier, you mentioned how you might have one care home in a rural setting — a less populated area. Tell me again what you were saying there.

Mr Houston: This came out of the Nuffield Trust report that I mentioned, 'Rating providers for quality: a policy worth pursuing?'. It says that if, for example, in the particular situation that you have a nursing home or a care home that is the only one within 20 or 25 miles, and an elderly person or their relatives want to place a family member in that establishment because it is convenient, and if, at appointment time, the regulator — whoever that may be — says that that service is inadequate, that could make it impossible for individuals to place a person in that establishment until such times as that situation changes.

Fundamentally, we may all agree that that is the right and proper thing to do. However the important thing is that, in giving individuals choice, we must recognise that some people will want to stay in their own communities. The important thing from the regulator's point of view is to get in quickly and fix the issues that are causing that home to be in that situation. One of the criticisms of rating systems in the past was that the regulator might have come along and put in an assessment of "inadequate" and not come back to review that service for quite some considerable time, so that service is carrying that label of "inadequate" for longer than necessary. It is about making proper decisions about, first, the best way to reflect the outcome of inspections and then to follow through quickly on any breaches of standards or regulations and make sure that the interests — this is the fundamental and absolute point — of the people who live in that home are protected.

Ms McCorley: I hear what you are saying. I take the view that you might want to look at it differently. You might want to take the view that in a rural setting, where you have one establishment and there are fewer options for people who live there, you might want to put an extra spotlight on places such as that so that there is more rigorous inspection. That might be a better way to look at it.

Mr Houston: I do not disagree with you. That is why I said very deliberately in my opening statement that we need as much flexibility as possible to direct our inspectors where they need to be. In the context of having a limited number of people and a limited capacity to do inspections, we are always making those kinds of judgements. I fully recognise and accept the point. That would be a very big consideration if we were looking at information, say, at a particular home that was struggling.

Ms McCorley: I want to ask about hard copies of the minimum standards not being able to be provided — I think it was at point 2 — because of cost savings. I just wonder what sort of expense is involved in providing hard copies of minimum standards printouts. I believe that it is important that people have that information so that they can judge whether they are being allowed to be compliant with those minimum standards.

Mr F Bradley: It is not a huge cost, but finances are very constrained. We have developed a user-friendly version, which is much easier to use. We are looking at whether we can print that or get hard copies of it and make them more widely available, targeting service users rather than printing 200 pages of standards for a nursing home, for example. The user-friendly version runs to about 20 or 25 pages when you include graphics and things like that. We are looking to see whether we can do that.

Mr Keenan: One of the actions from the original review was for the board to work with the trusts on the information that was available to people in nursing homes. The trusts have reviewed that material and updated it. We have asked for hard copies. They need to provide an information pack to people on admission. Here is a copy of the nursing home standards. If we gave everybody all the available material at a time when they are very vulnerable, or maybe at a point of crisis, and a family just wants a safe haven for their mother or father or whatever, that would be overkill. It is about giving people the right amount of information at the appropriate time. If, after that, when the person is settled, for example, and a son or daughter wants to see more about what the person's rights are and what they are able to get, that information is available. However, we do not want to produce tons and tons of paper for people. We want to get their care sorted out first and point them in the right direction for information, and then people need to make their own decisions about what they want access to and how they want to use it.

Ms McCorley: It is very easy to find ways to make that available so that you do not burden everybody with it; maybe a notice in every room, just informing people. It is also important for staff, too, to know that this is available and to know where to find it if they want to look at it. That is how to do it.

Mr Keenan: That is a requirement in the regional contract. The home has to make that available and visible and accessible.

Mr F Bradley: Glenn mentioned earlier that RQIA has done a lot of work to make its inspection reports easier for service users and their families to read. I know that RQIA is doing some work on its website. All the reports and inspections are published on the website. I think that I am right in saying that RQIA is doing some work to make it easier to navigate the website so that users can get straight to the reports for particular facilities.

Mr Houston: Absolutely. By next March, we will have a new website, which will be easier for the public to navigate. We would also be very happy to work with the Department or the Health and Social Care Board about making a user-friendly set of standards available. I would welcome that, because it would be very useful.

Ms McCorley: There is just one last thing, and it is to do with the issue of training. When Ms Keatinge was here, she said that there are just not enough people with the training on site and on hand to help people to do the things that they need to do. Is that something that you are aware of?

Mr Houston: From our point of view as the regulator, staff training is a very important aspect of safe care, and, as I said to you at the beginning, our focus on inspections is safe, effective and compassionate care. If we were concerned about failures to train staff appropriately, we would pick that up absolutely immediately as a concern, particularly if it was around training to do with any aspect of patient safety — around moving and handling, for example, fire safety or any issues. Where there is a requirement for mandatory training, we always make sure that that is followed through.

Ms McCorley: So what you are saying is that all staff in all care homes and nursing homes can only be employed there if they are trained to that standard.

Mr Houston: Obviously, one of the things that happen from time to time is that there is turnover. Staff come and work in the facility, and they maybe have access to training. When they leave and go and work in another facility, somebody new comes in and they have not had the same exposure to training, so this is a cyclical thing. You need to keep looking at training, and you need to make sure that staff are properly trained.

The other area that we have concern about where, in any care home, there is a high level of agency staff. Agency staff are there on short-term arrangements, and they are not necessarily linked in to the same degree to any training programme being provided by the care provider. Those are all very important considerations in that particular area and that standard.

Ms McCorley: Do the trusts provide the training? If it is a private establishment, who is responsible for providing the training? I presume that there is standard training.

Mr Houston: The person who is ultimately accountable is the registered person. Let me explain that, if I may, just briefly. The registered person can be an individual or a company, but if the registered person is a company such as Four Seasons, there is a responsible individual within that company. Our relationship as the regulator is always with the responsible individual. There will be some responsibilities, as well, with a registered manager in a care home or nursing home to make sure that staff are effectively and appropriately trained. So the responsibility sits at the top. That is why I was explaining earlier, if I may just remind you, that leadership and management is an important consideration in the inspection process. That is why we have built that in to our approach to inspections.

Ms McCorley: OK. Thank you.

The Chairperson (Ms Maeve McLaughlin): Can I clarify that? Was there a review of minimum standards last year?

Mr F Bradley: The nursing home standards were updated last year. They were published in April 2015.

The Chairperson (Ms Maeve McLaughlin): Were they reissued for consultation?

Mr F Bradley: They were issued for consultation.

The Chairperson (Ms Maeve McLaughlin): So there was a review of nursing home minimum standards.

Mr F Bradley: Very deliberately, they are just called care standards. We were conscious of the perception of how the word "minimum" played into it. As I said before, they are not designed or developed in that way. So the care standards for nursing homes were updated over 2014-15. They were published, finally, in April 2015 following consultation, and we are currently looking at the residential home standards.

The Chairperson (Ms Maeve McLaughlin): So care standards for nursing homes have been implemented.

Mr F Bradley: Yes, and those are the ones where we have tried to bring the emphasis on rights, dignity, etc right through those.

The Chairperson (Ms Maeve McLaughlin): But you have not done that, as I said earlier, for residential homes. Do we have examples of breaches of minimum standards that go into the hundreds?

Mr Houston: It is unlikely. Do you mean — let me just clarify that —

The Chairperson (Ms Maeve McLaughlin): In care facilities.

Mr Houston: In a particular establishment?

The Chairperson (Ms Maeve McLaughlin): Yes.

Mr Houston: I do not think that we could tolerate a situation in an individual establishment where breaches of standards go into their hundreds. I am trying to think of the standards that there are currently. You are talking about perhaps 48 standards in a nursing home.

The Chairperson (Ms Maeve McLaughlin): That is 48 breaches.

Mr Houston: That could be a number of breaches, because within every standard there are criteria or indicators.

The Chairperson (Ms Maeve McLaughlin): My question is this: how far does it go in relation to breaches of minimum standard? What is the worst-case scenario that you have been faced with or are looking at?

Mr Houston: It might be a situation where we have a home with a number of failure-to-comply notices in operation. There may be circumstances where the situation is such that we decide that we need to immediately impose a condition on the registration of the individual. It might also be a situation of imposing that condition or considering cancellation. All of those factors —

The Chairperson (Ms Maeve McLaughlin): Can you provide the Committee with that detail around failure to comply?

Mr Houston: We can.

The Chairperson (Ms Maeve McLaughlin): OK; thank you.

Mr McCarthy: Just briefly, before you go, when do you expect that the 13 proposals by the commissioner will be fully implemented?

Mr Matthews: It is difficult to say, because some of them rely on legislation that will be taken forward by other Departments, but we expect the bulk of it to be complete probably in the early part of next year.

Mr McCarthy: You can see no inordinate delay.

Mr Matthews: No; we are working on those things now. The key outstanding thing is the review of the 2003 Order. Once we get somewhere with that, the legislation might take time, so there will be some outliers because the processes following them take time, but I think we are looking to say that it is mainly done by the early part of next year.

The Chairperson (Ms Maeve McLaughlin): Can we get some sort of report that indicates each proposal and a timeline?

Mr Matthews: A timescale, sure.

Mr Keenan: One of the proposals is about a well-trained and registered social care workforce. The issue of training is ongoing. We are not going to give you a date when everything will be sorted.

Mr McKinney: One of those recommendations on the response around the well-trained categorically said "properly remunerated", but there is no reference from the Department about remuneration in your response.

Mr Keenan: In terms of remuneration, we have an uplift in the minimum wage this month, and then we are heading towards the challenge of meeting the living wage in the early part of next year.

Mr McKinney: I accept what you say. Those are outside things, but the Department did not respond on the remuneration point.

The Chairperson (Ms Maeve McLaughlin): OK; I thank you for your time. I have to say that it has not instilled great confidence in me that the whole issue of changing the culture of care has actually been taken forward with any urgency. I say that particularly having heard today that the recommendation from Donaldson is only now being looked at and, indeed, that the review of changes to primary legislation only started in December. We have a plethora of evidence and formal guidance to the Department — evidence that goes back some seven or eight years. I am increasingly concerned that that has not been driven enough, to the detriment of the care that we provide as a society, particularly to older people. I thank you for your time today.