Official Report: Minutes of Evidence

The Chairperson (Mr Gildernew): Welcome back, everyone, and thank you for rejoining us. We are now on to our second presentation on our work on the COVID-19 disease response. Today, we are getting an update on care homes from Independent Health and Care Providers (IHCP), and I welcome Ms Pauline Shepherd, its chief executive. Good morning, Pauline. Please go ahead and brief members on the situation in your sector.

Ms Pauline Shepherd (Independent Health and Care Providers): Thank you very much, Chair, and thank you for the invitation to brief the Committee. By way of introduction, IHCP is a membership organisation representing independent providers of care home and home-care services. The membership includes private, not-for-profit, charity and Church-affiliated organisations. The scope is that the independent sector provides 15,000 of the 16,000 care home beds and about 70% of home-care services in Northern Ireland.

I gave a briefing to the Health Committee on the 19 March, which covered a wide range of issues as a result of COVID-19. At that time, the information related to care home and home-care services, but my focus today, Chair, as you mentioned, is primarily on care homes, where the virus is particularly challenging. Home-care services have not been affected to the same degree as care homes, and IHCP is gathering information from home-care providers on how COVID-19 has been managed and monitored in the family-home setting. That area might be of interest at a later stage.

I will initially provide an update on the issues raised on the 19 March, when the problems arising from the pandemic were at a very early stage. Personal protective equipment (PPE) was a particular concern. The provision and delivery of PPE was very slow to start, with initial guidance issued on 17 March stating that the independent sector needed to source its own PPE. In the event that the sector could not source it, it should contact a trust if necessary. PPE eventually started to flow around mid-April after concern about clarity and alignment of guidance. The situation has greatly improved, but there have been recent concerns about quality, with some products having been recalled. We are, however, in a much better position now than we were in March.

I raised concerns about surge planning and staff deployment. I expressed reservations about engagement with the sector and the testing and mobilisation of plans for staff deployment across sectors, which we were challenging, saying that those needed to be tested. We have recently been engaged in formal plans, with actions running over the next number of weeks. From an early stage, there was a willingness from the trusts to provide staff, but this lacked a mechanism to make it happen. Hopefully, monitoring systems will now be in place and clarity on how support will be provided. Care homes are now reporting that staff support is working very well.

On continuity of service throughout and beyond the pandemic, financial support has been provided, and there are further ongoing issues under consideration on additional funding for staff on sick leave due to self-isolating. We welcome the move in the ministerial statement on that issue.

Testing has been given quite a lot of attention, obviously, and on the 19 March I raised a concern about pre-admission testing to care homes. At that point, the testing policy was inconsistent among trusts. We pressed for pre-admission testing for care homes. The roll-out of staff testing was welcome and effective in returning staff to work who had been off self-isolating.

However, there were risks with the testing policy when it was initially applied only to symptomatic residents and staff. We know that people can have the virus and show no symptoms at all. The further increase in testing of all residents and staff continues to be progressed. Obviously, there were ministerial announcements that you will be aware of. There needs to be further clarity about timing and the process for that to happen, particularly the repetition of tests. We are still asking questions about how often tests will be repeated. We now need to work together to provide clear instructions for providers and clarity for the public, because families are asking these questions of care home owners, and we do not have answers to give them.

I will move on to another issue that was raised on the 19 March: restricted visiting and its impact on residents and families, particularly those with dementia and learning disabilities. The impact on those groups needs to be assessed, and, given that restricted visiting may be with us for some time, we need to find a way through this together to balance the risk with the need for family contact. We really need the Public Health Agency (PHA) and the Department to work with us. For instance, is it an option for a family member in a care home to live with another family member? Can we allow a visit under really strict controls and PPE, testing risk assessment? It is a critical piece of work that needs the family to be engaged. Obviously, an increase in the relaxation of community lockdown will increase the risk of transmission into care homes, which is another critical area that needs to be monitored very closely.

On the 19 March, I mentioned regulations and registration. That was about being able to recruit people quickly. All those issues were addressed very promptly with the Northern Ireland Social Care Council (NISCC) and various other bodies. We are now able to recruit quite quickly into the workforce.

Communication was also raised, and it is still a problem. We need a regional approach rather than one based on individual trusts. There are a lot of different interpretations of guidance, and it could be much more streamlined.

That is a quick update on the issues raised on the 19 March. If it is OK, I will move on to the current focus and where we are at this point. The Minister made a number of announcements on the 13 May about testing being ramped up, which is very welcome. We welcome a lot of the comments in the Minister’s 13 May statement. The priority now is the need to reduce the potential for transmission of the virus in the care homes that have it and to try to reduce the risk of it entering the care homes that do not have it. That is the critical area for all of us to work on.

We have a question on antibody testing. So far, COVID-19 testing of staff and residents will not in itself tackle the issue. We need an urgent consideration of antibody testing and how effective and valid it might be. If there were an antibody test, we might be able to have that higher assurance of staff, and, indeed, residents, not being able to transfer the virus.

In the rolling programme, testing will need to be repeated regularly. It will give only a picture or a view at a point in time, so we need to know how often and how regularly that will be done. The Minister has also mentioned human rights issues, and there will be clear challenges in carrying out quite an intrusive test on people who are unable to consent or to understand what the test is about.

I will move on to the Safe at Home project, which I believe the Minister mentioned in his briefing yesterday. The Department is seeking volunteer homes to participate in staff live-in options. It has communicated with care homes to volunteer to pilot that. There is a problem, in that the unions have not agreed the pilot that the Minister referred to, and they will not support the staff live-in option. Any pilot will need to have a full volunteer sign-up, which will be difficult to staff and to manage. We need to keep an eye on that area.

The arrangement for a 48-hour pre-admission test to be done prior to hospital discharge is welcome, and that policy seems to be working well so far. We also look forward to the Northern Ireland Ambulance Service (NIAS) and nurses being available for mobile testing. That process still has to be communicated through, but the approach is very welcome if it can be initiated quickly and we can get those tests out there. They may already be out here — I am not quite sure — but it is a very welcome step in the right direction.

Yesterday, the Minister also mentioned the hospital-to-community outreach teams. We need a bit more detail on that. Again, care homes are very open to whatever support they can get from hospitals into the community and care homes.

In the Minister’s statement of 13 May, he also mentioned the need for reform and investment in social care. We have not been involved in any discussions with the Department on what that might look like, but I heard the Minister mention that social care, care homes and home care have very much been the Cinderella service in the past. It is unfortunate that it has taken this pandemic to highlight the pressures that the sector had been under prior to the pandemic. We look forward to working with the Department in taking those reforms forward and also in relation to training and terms and conditions standardisation, career paths and improved wages. We have had no discussions on what that might look like, but it very much fits with the proposals that we have been putting to the Health and Social Care Board (HSCB) for the past number of years that career pathways and wages need to be improved, so that very much aligns with our views.

To conclude: we agree that there is a total and absolute need for reform of the social-care sector, with action to be taken on the many independent reports over the past number of years, including that the focus needs to be on an independent economic review and possibly a market regulator. We know that there are concerns about care homes and home care making profits, and we want to be able to demonstrate that this is an effective method of delivering quality services in the independent sector. We need to work together to shape what care will be needed in the future and what it will be like. Undoubtedly, services, in particular, will be different coming out the other end of this pandemic.

Attention is needed on home-care services. When families return to work, we anticipate that many of the home-care packages that were cancelled will need to be put back in place. That area will probably need further attention.

That is a very quick run-through and update. I hoped to do it quickly so that you would have time for questions.

The Chairperson (Mr Gildernew): Thank you very much, Pauline, not only for your brevity but your clarity. It is a very good update, on which the Committee will act. We particularly welcome the fact that you outlined a number of improvements that have taken place since the meeting on the 19 March. The Committee is glad that those matters have been addressed and that we can now focus on other serious matters that continue to cause concern. Obviously, the overall situation in care homes concerns all of us. Many residents are most vulnerable not only because of the difficulties of residential settings but because of their age and co-morbidities. It is an area of huge concern for us, and this is a timely session.

You referred to one of the outstanding issues being COVID-19 entering the care home sector. Will you outline for the Committee your suggestions on what measures could be taken to reduce the ability of COVID-19 to enter those vulnerable settings?

Ms Shepherd: Testing all staff and all residents is obviously the key issue. Tests need to be repeated. We already have controls in place for temperature checks and running those checks through residents and staff. We all know, however, that the virus can be particularly difficult to identify. Many people may have it and be asymptomatic.

There is a real challenge in trying to ensure that the virus does not come into a care home or transfer around it. Hence my concern that, as the lockdown lifts and is relaxed in the community, that will increase where care workers are coming in and out. They may be asymptomatic, and there is no way of testing and checking whether they are carrying the virus. We need medical and scientific guidance on testing and repeat testing and how valid and accurate that is in ensuring that someone does not have the virus.

The Chairperson (Mr Gildernew): OK. Could issues be improved upon in step-down or discharge from hospital, or, indeed, step-up prior to admission to a care home?

Ms Shepherd: We have had to accept people from hospital who had not been tested. We were pressing for pre-admission testing. Obviously, it is too late to apply that retrospectively, so COVID-19 is already in care homes, and we cannot go back in time for that. The priority now is that anyone coming into a care home must test negative pre-admission. It goes back to my previous statement that that is not guaranteed, because people may develop the virus within a number of days after that. Again, that goes back to the scientific and medical evidence needed to support how effective the testing is.

The Chairperson (Mr Gildernew): In relation to the Safe at Home project, is it a concern for you that, in the sector, there are concerns about working conditions and union representation? Has that been a barrier to partnership working? Is your sector looking at the issue?

Ms Shepherd: The Safe at Home project was actually suggested by a care home provider in the independent sector. It was piloted in conjunction with the Department, but there were concerns, and I think there was some work to get union agreement on it. That did not happen, so the Department has now decided that it was a worthwhile consideration, but that it needs to have a fully voluntary workforce. That will be very difficult to manage. Obviously, you need additional staff, and staff need to consent and agree to live in. I am aware of it happening in other locations and in areas in England, but it needs full consideration and the full agreement of all staff. It will be a challenge to put in place.

The Chairperson (Mr Gildernew): Finally from me, in terms of communication, I heard you being interviewed earlier in the week about announcements being made publicly at the same time as they were communicated to care home staff. In your presentation, you mentioned the difficulty that that creates, with the public asking care home owners what the situation is, and care home owners not knowing the answer. How do you suggest that those communications could or should be improved?

Ms Shepherd: We are all trying very hard to communicate things out and to get ahead of those issues. I know that the Department is doing a lot of work in trying to address some of the issues, but the problem is that some press releases have come to me at the same time as they go to the press, which does not give me time to consider or for care homes to be engaged in whatever those proposals may be. It was unfortunate that the last press release did not come to me at all, but that may just have been a blip. I think that there is merit in engaging with care home owners earlier in looking at possible solutions, because those people working on the ground know whether or not things actually work. The Minister has spoken about equal partnership, which I fully accept, but we need to get that equal partnership working to develop and look at solutions together, as well as looking at them after decisions have been made within the Department.

The Chairperson (Mr Gildernew): Thank you.

Mr McGrath: Thank you, Pauline, for your presentation. I was not on the Committee when you last presented, but I read the Hansard report and listened to today’s update. Thank you for that.

Do you feel that the care home sector was left behind? There has been a lot of catching up throughout this process. That was typified during our process as MLAs, when it felt as if there was a different priority every week: it went from PPE to testing to care homes. It feels as though the proper emphasis was not placed on the care home sector, yet the knowledge from places such as Spain and Italy was that the care home sector would be impacted. The evidence was there four or five weeks ahead of us. You mentioned that, on 17 March, you were given a directive that PPE was not required at a certain level, but, in the middle of April, it was required. Do you feel that that time — that month — when PPE was not a priority led to people dying?

Ms Shepherd: Your first question was about care homes being left behind. All the independent reports over the last number of years that have been done on behalf of the Department have indicated that the social care sector in general is thought of latterly, and the focus has very much been on hospitals and acute care. All those reports indicated that social care needs to be brought into equal partnership. Yes, I do think that, in this pandemic — quite rightly — the priority at the time was thought to be in acute services, because of the estimates of the number of people who would be impacted. I feel that there was a proactive plan in place for acute care whereas, in social care, it has been reactive. I do not know whether that translates into things not being done on time. I do not know, but I think that a lot of work and effort were put into acute care because that was deemed to be where a lot of the pandemic would present. So, yes, I think that it has been reactive.

You asked about being left behind on PPE. Yes, we did have to struggle and argue about PPE early on. Has that led to any adverse impact on residents? I do not know the answer to that. That will have to be picked up at a later stage. Early on, the virus did not appear to be in care homes. At that time, when we thought that it was going to present, we picked up the issue and talked about the relevant PPE. Early on in the process, we were told that just normal infection control processes were needed and that PPE was really required only when people were symptomatic. It was only later on that guidance came out that asymptomatic people could carry the virus as well. I suppose that people made decisions based on the best evidence that they had.

Mr McGrath: Pauline, I think that we are sitting on a ticking time bomb. It may take a month, six months or a year, but when the full story comes out about our care home sector and the way in which it was left behind, a lot of lessons will need to be learned. We need to ask questions of people such as the permanent secretary, who has been in charge in the Department for the last number of years, maybe more than the Minister, who had been there only a few weeks. We will come to that inquiry at some point.

Do you feel that organisations such as the Regulation and Quality Improvement Authority (RQIA) providing a telephone service has been of much use to your sector? A directive from the Chief Medical Officer stopped RQIA home visits on 20 March, potentially for six to eight weeks. Only one or two visits took place. A lot of people in your sector probably do not want the RQIA anywhere near the door, but do you feel that the support and guidance that it could have offered with visits could have assisted, and that that organisation simply being re-profiled as a telephone service was of little use?

Ms Shepherd: Very early on, the RQIA was keen to provide whatever assistance was of most benefit. There were an awful lot of questions. The sector was coming to me and asking questions, which I was putting to the Department and the RQIA. We were all looking at this and saying, "Look, we need guidance. We need help. We need instructions". The RQIA, I believe, positioned itself to be able to provide that help and telephone contact. It was also a source of information coming from care homes to work with the PHA, and it has joined up with the PHA to share that information.

At that time, we were also looking to reduce the footfall into care homes and the impact of someone coming in, possibly moving from care home to care home doing inspections, and carrying the virus with them. The RQIA positioned itself as best it could to provide assistance. During that time, as the virus developed and progressed, particularly when I was talking about the need for staff resources, could it have been of benefit for inspectors, who are highly qualified and highly skilled on how care homes operate, and nurses who are employed by the RQIA to have been redeployed to provide additional resource on the ground? All those issues had to be balanced with the risks of more people arriving in care homes. We all knew that the virus only moved with people. I think that the RQIA did the best that it could in the circumstances.

Mr McGrath: That is good, robust support for the RQIA. That is novel, so I welcome it.

Given that resources have been cut in the sector, pay is low, conditions can be tough, and you really have to rely on staff and their vocation, would you welcome a full review at the end of this to see how we can better value and support the staff and the whole culture in our home care sector?

Ms Shepherd: Absolutely. I have been making the same case. Every year, I give an update — a presentation — to the Health and Social Care Board. I raise all those things about the challenges of recruitment and retention of staff. We have made proposals about career paths and said that we need to value the people in care homes and in home care, because I am not sure that the complexity of the care that those staff deliver is fully understood by the public and wider society. Unfortunately, it has taken a pandemic to raise that profile, and a lot of work needs to be done to recognise properly the people who work in the sector. You only had to listen to the news earlier this week; there were questions, which I was actually quite surprised by, about whether nursing homes can deal with end of life or with people having COVID-19 at the end of life. As Dr McBride said yesterday, nursing homes are complex environments, with very challenging situations, and there are experienced nurses there to manage those issues.

The Chairperson (Mr Gildernew): Thank you. I will now go to Gerry, Paula and Pam, and then I will go to the members on the phone. I indulged Colin a little as he waived his question in the last session, given the time pressure. I remind members: a maximum of two questions, please, so we can get round everyone.

Mr Carroll: Thanks, Pauline. I pay tribute to the workers in the care sector who are doing incredible work in stressful and challenging circumstances. I urge all of them to join a union, if they are not already members. I know that some care home owners present obstacles in that regard, but it is important that workers protect themselves and patients and people in homes by joining a union.

I have two quick questions. Pauline, do you agree with Eddy Kerr of Hutchinson Care Homes, who publicly said that he was frustrated and found it a struggle at the start of this pandemic, and Anne McCracken from Massereene Manor, who was critical of the information being passed to care homes and indicated that she had to follow what was happening in Italy and Spain to catch up? Has it been the case that care home owners have been buying their own PPE, or has it all been coming from the Department or the NHS? I am very concerned that staff working in care homes are getting only statutory sick pay (SSP) when they are unwell. Do you know how many care homes pay only statutory sick pay?

Ms Shepherd: I agree with Eddy Kerr's statement that there was frustration at the beginning of this crisis. That was probably evident in my last briefing to the Health Committee — the frustration at that point was considerable. There was a lot of communication, a lot of concern, a lot of fear and, probably, a lot of panic. It took a long time to get that stabilised. Yes, I agree that there were concerns and frustrations at the very start.

There were concerns about the guidance. We went from having no guidance to having bucketloads of guidance that we had to try to wade our way through. That was all very difficult. Yes, I agree with that statement too.

On the matter of owners of care homes buying their own PPE, there is a mix. The trusts have really stepped up and are providing and replenishing PPE. At the start, much of the PPE was purchased by providers. As an organisation, IHCP purchased PPE on behalf of providers because we knew that they could not get it. There has been a mixed approach, but, at the minute, I believe that PPE is largely provided by the trusts.

I am very conscious of the issue of statutory sick pay and people having to manage to live on it. We have resolved that issue with the Department in relation to home-care services, and it has now agreed that it will fund the gap. That will be put through the home-care services. I think that it may already have been arranged. The Department is looking at further proposals because we are saying that the problem also needs to be rectified for staff in care homes. That is under active consideration.

Ms Bradshaw: Thank you for all your amazing work over the past few weeks. I have two quick questions. The NISRA statistics that come out each Friday show that 50% of COVID-related deaths are in hospital and 45% are in care homes. What is your understanding of the breakdown of that percentage in hospitals, including the number who had been in care homes but, because of clinical decision-making, were transferred to hospital for treatment and then, unfortunately, lost their life? I wonder about that 50% figure, given that we know that 66% of deaths are among people over the age of 80.

Ms Shepherd: Paula, unfortunately, I do not have that information. We are a membership organisation. I do not collect data from care homes. Not every care home is a member of IHCP, so, in any event, the data would not be complete. So, I am not sure that I can answer your question, Paula. I am sorry.

Ms Bradshaw: No problem. Thank you. My second question is about the Minister's announcement of funding of, I think, £6·5 million extra for care homes. Has that money reached the care homes, and, if so, is there more to come or should there be more to come?

Ms Shepherd: You are cutting out a wee bit, Paula, but I think that your question was whether the funding of £6·5 million has reached the care homes yet.

Ms Bradshaw: Yes.

Ms Shepherd: My understanding is that the money came into accounts last Friday or the Friday before, if my memory serves me right. I believe that it has been allocated. Currently, IHCP has a proposal with the Department in relation to the additional costs of COVID for care homes, and we have put in other proposals. At the minute, the Department advises us that our proposals cannot be seen as independent. This has always been a concern. I have always said that we are very happy to get an independent review of the additional cost. I know that the Department is considering additional funding, but I have not been involved in any of the discussions on what that will look like.

Ms Bradshaw: Thank you. Sorry, I should have declared an interest. I have a family member who works in a care home.

Mrs Cameron: Thank you, Pauline, again, for your attendance at the Committee. It is always very useful to hear what is happening on the ground in the independent sector. I want to ask you about the Safe at Home project, especially going forward into an uncertain future. We know that COVID-19 will not disappear anytime soon, so the threat will be continuous.

You mentioned the impact of the restrictions on residents.

Ms Shepherd: I am sorry. I am having some difficulty hearing all of the question. You mentioned Safe at Home.

Mrs Cameron: I will try again. Can you hear me better now, Pauline?

Ms Shepherd: Yes, I can.

Mrs Cameron: OK. In relation to Safe at Home in particular, you raised the impact of the restrictions on residents. We are aware that many homes have a lot of dementia patients, for example, so there are two parts to my question. It is disappointing that the unions have not been able to support the Safe at Home project. Going forward, that needs to happen in order to maintain safety and remove as much of the movement in and out of care homes as possible. In your view, what are the barriers to the unions supporting that project?

The second part of the question is about your comments on the impact of the restrictions on residents. What more can the independent sector do, in conjunction with the Department, to ensure that the necessary measures — limited or protected visiting, screens, partitions, whatever is required — are introduced into care homes to support not just the physical health but the mental health of their residents?

Ms Shepherd: If I answer only part of your question, I am sorry. The signal is coming and going, so I am picking up only snippets, unfortunately.

We need to find some method of moving forward on the challenges within the Safe at Home project. If this pandemic and virus are to be with us for some time, the community will become frustrated and need a relaxation of lockdown, so there needs to be consideration of how people can visit and get to see their loved ones in care homes. How we do that needs to be a priority. We will never be able to eliminate the risk, so how can we balance and mitigate it? Some care homes have had drive-through visits. End-of-life care homes have kitted out family members in PPE and trained them in its use and how to be safe so that they could spend time with their loved ones. Lots of methods and arrangements could be put in place, such as allocating a staff member to a relative to brief them and make sure that they do not breach any of the virus risks.

We need to be innovative and come up with ideas, but all of this has to be done on the basis of families accepting that there will be a risk. That might mean families having to say that they accept that they are taking a risk but are balancing that against the need to see their loved one. That is how it will be.

I am not sure whether I have answered your full question because I am not sure that I heard all of it, unfortunately.

Mrs Cameron: You have answered part of it, Pauline. I am still concerned about the unions having concerns with the Safe at Home project and that those concerns might stop it progressing.

Ms Shepherd: Right, OK. To be honest, I have not been privy to that. All of that was managed between the Department and the unions. The only input from the independent sector was that a provider had put forward a proposal and suggested that it might be a way forward. The Department worked with that provider and the unions. I cannot answer your question about barriers. I am not sure what they were.

Mrs Cameron: OK, thank you.

Ms Flynn: I want to come back to the point about the stabilising payments for care homes and the additional grants. Do you know, Pauline, what the uptake of those grants has been? Did care homes have any input to designing the criteria for applying?

Ms Shepherd: OK, Órlaithí. They were not grants as such, and there was not really an application process. My understanding is that the Department allocated £6·5 million. The allocation criterion was the size of a care home — the number of beds — and the payments were, I think, £10,000, £15,000 or £20,000. The money was paid automatically to the care homes, and the amount was determined by their size. The payments have come through. The Department has asked the care homes to keep receipts for all their expenditure because it will be monitoring that. That is my understanding of how it worked. It was not a matter of care homes having to apply. They were automatically issued the payments.

The Chairperson (Mr Gildernew): OK, thank you. Are you OK, Órlaithí? Do you have a second question?

Ms Flynn: Yes, just quickly. You mentioned the increased testing in care homes. I know that you are waiting for more information from the Department, but have conversations with residents and their families begun about giving consent to testing?

Ms Shepherd: I am not aware, Órlaithí, of the up-to-date position. The majority of families and the majority of people in care homes will, of course, consent. A human rights issue arises when someone with dementia or someone with learning disabilities does not understand the tests, which can be quite intrusive and unpleasant. I have not heard of any providers saying that people had refused it, but I think that, going forward, that issue will raise its head.

Ms Flynn: Thank you, Pauline.

Mr Chambers: Pauline, you have almost answered my question. The Minister announced a programme of testing throughout the nursing home and care home sector. The Chief Medical Officer has not been able to confirm whether it will be a one-off or whether it will be necessary to make it a routine, regular feature.

In relation to seeking permission for testing from the next of kin of those residents in care and nursing homes who cannot make that decision themselves, you said that the current feedback is that nobody has indicated that they would refuse. I presume that the homes have some authority to allow testing. Is that authority delegated to the management of the home or do residents' next of kin have the right not to refuse but to give permission? Is it a proactive exercise? Do you have to go to the next of kin and ask them directly to give permission, or do you go ahead and do it unless the next of kin come to you and say that they do not want the test carried out?

Ms Shepherd: I do not think that I can answer your question, Alan. I do not have the information. Those are some of the questions that we are asking in relation to the roll-out of the testing. There is a statement that testing will be applied to all care home residents and all staff, but we are asking, in relation to that policy, what that will mean should a resident or family member refuse. Does that mean that the person will have to be isolated completely in a care home until there is some way of controlling the virus or an antidote for it?

I am not sure that I can answer the question. It is probably one for someone from human rights or the medical profession. What do you do if someone refuses and how do you manage that, if it is in their best interests? I am sorry, Alan, but I cannot give you a direct answer.

Mr Chambers: If a child goes to school, you put the child into the care of the school authorities, and they can make decisions about the child's health while the child is in their care. While a patient, say a dementia patient, is in the home, does the provider have to seek permission from the next of kin for every action that they take in relation to that patient? Or do they have some sort of delegated authority that allows them to act in what they consider to be the best interests of the patient at that time?

Ms Shepherd: That would come under the departmental regulations. Homes are highly regulated as to what can and cannot be done. They are monitored by the RQIA. I cannot answer in detail as to what exactly might happen if someone has dementia. I would have thought that the next of kin has the right to communicate on behalf of the person. However, I cannot confirm that.

The Chairperson (Mr Gildernew): Thank you, Pauline. Do we still have phone contact with Alex? Alex, are you there? No, I do not think so. Pat Sheehan, are you on the phone at present?

Mr Sheehan: Yes, I am here, Colm.

The Chairperson (Mr Gildernew): Pat, your question, please.

Mr Sheehan: Thank you for your presentation, Pauline. The Safe at Home model has some merit. There is no doubt about that, but there are also many problems with it. There are too many to go into here and now.

I am aware of some care homes that have cancelled annual leave and have not brought in agency staff. That is not sustainable in the long term. What can be done to prevent infection being brought into the home? For example, agency staff might unwittingly bring the virus from one care home to another.

My second question is short. Why can care homes, particularly nursing homes, not do their own testing, as opposed to having teams coming out and doing that testing for them?

Ms Shepherd: OK, Pat. Your first question is about the Safe at Home model and homes cancelling annual leave and not bringing in agency staff. At the last presentation to the Committee, I said that the sector was not going into this pandemic from a very good place. We have been flagging up staff and nurse shortages. It was a fragile sector, in the first place, and the pandemic adds even more challenges.

In relation to bringing in agency staff and the transferring of the virus, procedures are followed. There is a checklist, which includes checking temperature, to be gone through for staff as they arrive for their shift each day. There are also processes in place in relation to uniform. Those normal processes would be followed, but, as has been mentioned, we are never going to eliminate the virus completely, no matter what checks are put in place.

Mr Sheehan: I am sorry to interrupt you, Pauline. I am thinking about staff who may be moving about a number of care homes. Would it be possible to have a system in place so that, for example, if a person was going to move from one home to another, they would be tested 48 hours beforehand to ensure that they were not carrying the virus? Can we do something along those lines?

Ms Shepherd: That might be possible. The issue is that we are also getting staff transferred from trusts to help out. It is probably a matter of making arrangements that minimise the number of people and keep some consistency in the staff. That goes back to the question of how long the test is valid for. Is it two days or is it three days? How long do you wait for a test to come back? Those, I suppose, are all questions that need to be answered under the roll-out programme.

I took a note of the second question, but I cannot read my writing now. Can you repeat it?

Mr Sheehan: Why can care homes, particularly nursing homes, not do their own testing? Why can test kits not be left at the front door for care homes to take them in and do the testing themselves?

Ms Shepherd: Pat, there has actually been a mixed approach to that. Some trusts have provided nurses to come in and do the testing in care homes. Some have provided online training for nurses who are in care homes, so there has been a mixed approach to it. Some of them rely on nurses coming in from trusts, and, in other care homes, the nurses do the tests in their own care home. So, that is mixed. Obviously, we would like it to be further supported with the Northern Ireland Ambulance Service and those 40 nurses who have been allocated to roll out the testing. Yes, nurses in care homes have been doing it.

Mr Sheehan: Does it not make sense —?

The Chairperson (Mr Gildernew): We are moving on, Pat. Thank you very much, Pauline. We really appreciate your briefing today. I have to say that it is a sector that we have considerable concern around, and we hope to have briefings in the weeks ahead from other perspectives on the care home setting. We are keeping a close eye on the difficulties there. Thank you for that, Pauline, and we look forward to talking to you again.