Official Report: Minutes of Evidence

Committee for Health, Social Services and Public Safety, meeting on Wednesday, 7 October 2015

Members present for all or part of the proceedings:

Ms M McLaughlin (Chairperson)
Mr Alex Easton (Deputy Chairperson)
Mr Tom Buchanan
Mrs Pam Cameron
Mrs J Dobson
Mr K McCarthy
Ms R McCorley
Mr M McGimpsey
Mr Fearghal McKinney


Ms Claire Keatinge, Commissioner for Older People for Northern Ireland
Ms Emer Boyle, Office of the Commissioner for Older People for Northern Ireland

'Changing the Culture of Care Provision in Northern Ireland': Ms Claire Keatinge, Commissioner for Older People for Northern Ireland

The Chairperson (Ms Maeve McLaughlin): I welcome our guests here today.

Ms Claire Keatinge (Commissioner for Older People for Northern Ireland): Thank you very much, Chair.

Ms Emer Boyle (Office of the Commissioner for Older People for Northern Ireland): Yes.

The Chairperson (Ms Maeve McLaughlin): You are both very welcome. I am pleased that you can attend today. I remind members that officials will attend the Committee meeting on 21 October to provide the Department's response to the commissioner's report, which was subject to some discussion in the earlier part of the meeting today. I will hand over to you, Claire, to set the context, and then we will open it up to members for questions or comments.

Ms Keatinge: Thank you very much, Chair. Thank you for the invitation to address the meeting today. The concerns that I intend to raise relate to advice that I initially put to Minister Wells in November 2014 and are contained in the report 'Changing the Culture of Care Provision in Northern Ireland'. I was due to meet Minister Hamilton this month to restate the advice and to seek confirmation from him that the advice had been formally taken and would be comprehensively acted on, but, due to the current circumstances, it was not possible, and the meeting with Minister Hamilton was cancelled.

Before I start on anything in the report or the outstanding issues, it is important to state that there are excellent examples of care across Northern Ireland. I regularly hear from people who live in residential and nursing homes and from their families about exemplary care and care workers going above and beyond the call of duty, making the care home facility a place where people can live full, dignified lives as independently as possible. That is very important to note. However, that is not always the case, and there is a considerable need for improvements.

I have worked extensively with older people for many years, and it has always been clear to me just how many of the issues that relate to older people are directly in the context of health and social care. As you may well know, this will be my last opportunity as commissioner to raise these issues directly with you. My term of office finishes at the start of November 2015, so I appreciate being afforded this opportunity.

When I met Minister Wells in November 2014 on the changing the culture of care report, he indicated that he would need time to consider the advice, and that is reasonable: the Minister must consider the advice. However, it is now October 2015, and I have still not had a full response to my advice or a commitment in full on the issues that I raised.

For the record and for those of you whom I have not met previously, as the Commissioner for Older People, I am an independent champion for older people with a statutory duty to safeguard and promote their interests. I am empowered through primary legislation in the form of the Commissioner for Older People Act (Northern Ireland) 2011, and I have a variety of statutory duties and functions, including a requirement that I advise Government on matters affecting older people. I can carry out informal or formal investigations on any matter affecting older people. I can issue guidance on best practice in relation to any matter concerning the interests of older people and make recommendations to any organisation, public authority or person concerning the interests of older people.

I also have the power to support and establish mediation and alternative dispute resolution services in relation to disputes with older people and public authorities, which might otherwise lead to proceedings involving either law or practice. Fairly obviously, from the publication of this report, I can commission and publish research. That is my statutory function.

The context of my meeting in November 2014 with Minister Wells was to discuss my advice, which was reported in 'Changing the Culture of Care Provision in Northern Ireland' report, and to emphasise the need for action. That is based on recommendations that were made by an independent review into Cherry Tree House in Carrickfergus. That review was commissioned when the Chief Medical Officer of the Department asked the Regulation and Quality Improvement Authority (RQIA) to seek external assurance that all appropriate actions had been taken. That followed a rise in complaints and incidents in the home since 2005. That review covered the period 2005 to March 2013 — a substantial period.

By way of a clear description, the independent review of the actions taken in relation to concerns raised about the care delivered at Cherry Tree House:

"reported at length on the regulated care system failing to be able to ensure good quality care, and of standards of care which were consistently falling below an acceptable minimum standard."

The report detailed significant failings:

"including the lack of timely enforcement action, a lack of protection and support to whistleblowers, inspection processes lacking a person-centred focus, a lack of protection for individuals, and a poor culture of care."

The report on Cherry Tree House is damning: for eight years, a home, in spite of being regularly inspected, was able to fail consistently to meet even the minimum standards of care. Many people who live in nursing homes do not live for eight years in nursing care, so there would have been a number of people who lived their entire latter years in nursing care in a home that consistently failed to meet even the minimum standards, and that is shameful.
When I left that advice with Minister Wells last year, I agreed with him that I would leave it until the new year to seek a response, giving him time to consider it. The Minister explained to me that he had tasked a working group of officials from across the DHSSPS, the Health and Social Care Board and the RQIA to implement the 22 recommendations in his independent report, and that they had till the year end to do so and to provide him with an update. I agreed with Minister Wells to wait for the outcome of that implementation, which means that I was expecting a final report on the status of those 22 recommendations by January 2015. My advice, which I now provide to the Committee, remains relevant and current and is provided on the basis that I have yet to receive a final report on the implementation of the 22 recommendations in the Cherry Tree House independent report. It is now 15 months since the review report and 11 months since I met the Minister. I have received interim updates from departmental officials outlining ongoing activities, but I have not received any overall complete response to the recommendations, nor a report to confirm a commitment, with timescales, to full implementation of the independent review team's recommendations.

My office and I are approached daily by older people, their relatives, carers and care workers and, indeed, by the nursing home sector, raising concerns about a wide range of issues associated with care and people's experiences of care. Those issues span general care provision, the quality of care, safeguarding and abuse, standards and regulation, whistle-blowing, management and staffing. The list goes on and on, and the same issues come up again and again. In light of the caseload of my office and the independent review report, I felt compelled to meet you to convey my advice that you need to lead a whole-system change to the culture of care that we have in Northern Ireland; because older people must be protected from the failings that were so evident in the independent review report on Cherry Tree House.

When the report on Cherry Tree House was released in July 2014, I made very strong comment in the media, voicing my concerns. I was overwhelmed by the feedback from the public, by the number of people who got in touch with my office and with me directly, to share thanks that somebody had raised those issues so clearly and to look for a direct commitment to positive change in standards and certainty in nursing care. My office continues to receive regular calls for help and assistance, requests for meetings and, indeed, offers from families, carers and workers in the sector to share their experiences. In addition to all that information from people directly affected, I also took soundings from a wide range of stakeholders — professional, voluntary- and private-sector organisations, as well as people who live in care settings — to get their views on the recommendations that I am leaving with you today.

If the Committee is agreeable, I would like to take you through the 13 proposals for change, which, I feel, need not just urgent consideration but your leadership and your commitment to action. My advice is clear, and you have an opportunity to bring about real change. The recommendations of the independent review team fell into three categories: complaints and untoward incidents, whistle-blowing, and inspections. My advice is that a whole-system approach is required to improve outcomes for older people. The advice points that I will make fall into four themes: care standards and inspection processes, enforcement, whistle-blowing and protection and, indeed, changing the culture of care, and by that I mean the workforce — training, complaints handing, and the regional contract, among other things. If the Committee is agreeable, I will look at those recommendations.

Ms Keatinge: The first is that the rights, quality of life, dignity, needs and care of vulnerable older people should be at the very heart of planning, delivering, regulating and inspecting care services. It has to be their needs that matter most.

The second recommendation is a simple one: standards for the care of vulnerable older people should be clearly displayed and available to all service-users and their families and relatives — to everybody associated with nursing, residential and domiciliary care services, as well as to prospective users.

I recommend that inspection processes should be rigorous, with decisive and timely enforcement action taken when failings are detected, and those words are absolutely key: actions must be decisive and they must be timely. I also advised on the need for a ratings system for care homes and domiciliary care services, and, in addition to an overall rating, I advised that you should clearly identify any breaches of regulations or failures to comply, along with improvements that are required.

I advised on the need for clear and rigorously applied sanctions to be taken against care providers for non-compliance with the minimum standards. Just listen to those words: non-compliance with the minimum standards. Minimum standards are never what we should be aspiring to — never. Minimum standards are exactly what they say. Fall below those standards — they are the minimum — and you should be out of business. I also advised that persistent or serious breaches of regulation or compliance should result in decisive actions being taken without delay and within a clearly defined time frame. Those sanctions should include the deregistration of owners and managers, potential for home closures, financial penalties, as well as the suspension of new admissions to care homes and domiciliary care services while compliance issues are outstanding. I also advised that when there are serious unresolved failures of compliance and unacceptable standards of care, health and social care trusts should not continue to place vulnerable older people in those nursing and residential care homes or with domiciliary care services.

I have been with the Health Committee before in the context of the need for adult safeguarding legislation changes, and, again, in 'Changing the Culture of Care Provision in Northern Ireland', I am recommending clearly that we need new legislation to better protect older people from abuse. It should be enacted without delay and should include a criminal charge of corporate neglect, which would allow the prosecution of care home and care service owners who abuse and neglect older people in homes or services that they own and run. I also advised that there are a large number of people who pay for their own care. Health and social care trusts also make payments for people's care services. Whether it is health and social care trusts or individual older people who self-fund their care, they should be entitled to a refund of part of their fees for any time that a care home fails to meet the required minimum standards.

There are considerable pressures on people who whistle-blow and bring to the attention of the wider public or the regulator issues that are of concern to them. Whistle-blowers and older people or relatives who raise concerns about poor treatment or abuse must be better supported and better protected from unfair treatment. My advice is that we need a well-trained, registered social care workforce that is respected, valued and properly remunerated with opportunities for career progression. I am also looking at complaints procedures, safeguarding procedures and details of the operation of organisations that can assist complainants. At the moment, it is not clear to people generally whom they should complain to or how and what their rights are. Those processes and procedures must be made clear to all prospective and current service users, their relatives, and to the staff of care services.

Lastly, the contract through which older people occupy care homes must be reviewed so that, as long as somebody's care home can meet their assessed needs, they cannot have their right to remain there terminated without due process, reasonable due cause or reasonable alternative care being in place. In Northern Ireland at present, care home residents have what is called a licence to occupy. This licence provides much less legal protection than a lease or a tenancy, for example, especially in relation to eviction. In more and more casework coming through my office, I see threats and people being told that they will be asked to leave a nursing or residential care facility, often within a week, usually due to complaints or behaviours being raised by residents' families and not the behaviour of the older person or complaints raised by them.

On protocols, I would like to leave these advice points with you today for your further consideration. Action on the advice points is urgently required. The independent report was sought in September 2013 and published in July 2014. I met the Minister in November 2014. It is now October 2015. I revisit the "decisive and timely enforcement" phrase that I used. It is not possible for anybody to take timely decisive action if it is left too long. I have already provided the culture of care report to the RQIA, the health and social care trusts, the Patient and Client Council, and the Social Care Council. I continue to share it with people and organisations that bring similar concerns to me. The previous Minister committed to the full implementation of the recommendations in the independent review report. It remains of grave and serious concern to me, and to people across Northern Ireland, that there has not yet been comprehensive implementation and action. I seek your commitment to the whole-system change required to ensure better quality of care and more effective protection of older people in Northern Ireland.

The Chairperson (Ms Maeve McLaughlin): Claire, thank you once again for your robust and frank detail. To be clear, the formal guidance was submitted to the Minister in November 2014.

Ms Keatinge: I provided advice to the Minister in November 2014.

The Chairperson (Ms Maeve McLaughlin): And there has been no formal final response report.

Ms Keatinge: No. There have been bits of departmental correspondence to my office on a large number of those issues. I have had some updates and information, but no comprehensive or decisive overall action has been taken.

The Chairperson (Ms Maeve McLaughlin): I went through your report and found some quite stark examples. I will refer to just a few of them. It says on page 2, on the report on Cherry Tree House, that:

"The examples show that unacceptable practices and systems exist in care services. These failings must be urgently addressed so that older people can have confidence that they will enjoy an acceptable standard of care should the need arise."

Equally, on page 6, paragraph 2.6 states:

"Serious failings in the levels of care provided in nursing, residential and domiciliary settings cannot be allowed to continue."

Paragraph 2.8 states:

"These proposals require consideration and action by the Minister for Health, Social Services and Public Safety."

Those still stand.

Ms Keatinge: Absolutely.

The Chairperson (Ms Maeve McLaughlin): The four areas of advice that you documented — I know that you went through the 13 proposals — were changes in the regulation and inspection process; workforce issues and staff development; protection and support for whistle-blowers; and the strengthening of contracts under which an older person lives. Obviously they still remain.

Ms Keatinge: I am quite happy, if you want, to go through with the Committee the kind of feedback that I have had from the Department to give you a flavour of what has come back. Absolutely; that advice stands. We need leadership and action, and it needs to be comprehensive and decisive.

The Chairperson (Ms Maeve McLaughlin): Just for your information, last week the Committee agreed a review into care provision in nursing, residential and domiciliary care. I suppose that it goes without saying, but how we treat and care for our elderly population is a hugely important statement of any society. I noted that you used the word "shameful" and said that we were falling below even minimum standards of care. Just expand on that. Secondly, to touch on the issue of RQIA, it certainly feels at times that it is a part of the system inspecting another part of the system, if you like. I noted that, on page 7 of your report, you state that the:

"duty is underpinned by legislation however there is no direction within legislation on how inspections should be conducted".

That is something that comes up regularly on announced inspections as well. On those two issues, we are still falling below even the unacceptable minimum standards, and there is the RQIA issue.

Ms Keatinge: I stand by "shameful". The people who live in nursing homes or in residential care, or who receive domiciliary care, receive that care because they need it, because they are vulnerable, they are frail, they live with dementia, they are ill, or they are unable to fulfil the ordinary functions of daily living that somebody else would be able to fulfil. They need help. They have to be able to rely on those of us who are charged with service planning, service delivery, and protection to make sure that the very best services that can possibly be provided, so that those people can lead dignified, fulfilled lives right through to their last breath, are in place. If there are nursing homes — as we saw with Cherry Tree House — that, for eight years, fail to meet even the minimum standards, then those people are not being treated with dignity or respect; they are not being enabled to lead dignified and fulfilled lives. Instead, they are being warehoused in a system that grumbles along the bottom of minimum standards and where the improvements required are made and then fallen back on, so we end up with a report that says that, for eight years, there was a consistent failure to meet even minimum standards. I regard that as neither timely nor decisive. It is not respectful; it is shameful.

The Chairperson (Ms Maeve McLaughlin): Just on minimum standards, is the issue of staff ratios in our care facilities generally becoming more apparent? In cases that I have been directly involved in, certainly in nursing accommodation, the staff ratio is impacting on the level of care. Sometimes, I would go as far as to say, it is suggested that it can be neglect. Is that something that is apparent to you in that work?

Ms Keatinge: It is. There are no normative levels of staffing, as there would be, for example, in an accident and emergency department. However, on the standards and levels of staffing that are set and that a home says that it operates to, people repeatedly come to my office with information and clear evidence that, at particular times — at evenings, at weekends, if somebody has gone sick or if they have difficulty getting a member of staff in — the levels of staffing to which the home is expected to deliver are fallen below. When they are fallen below, the lack of dignity is incredibly obvious to everybody.

I was talking to a lady in a home not very long ago. She said, "Well, there are two staff on at night time, but if I need to go to the toilet, of course, they need to get a break, and they get a half hour break, so I have to wait half an hour, and by the time I have waited half an hour I have wet myself, and then I need to be changed and it's really embarrassing". So there may be two people on duty, but of course they need a break, which is not the same as two people being available to the older person who needs them. That is a procedural tick box to say that technically there are two people on duty.

Again and again in inspection reports we see cases where records are not kept properly by the home about how many staff were on duty and what the home does in the event that a member of staff does not turn up or they have vacancies. Staff shortages are a problem, but, generally speaking, it is one of the things that residents and their relatives say again and again: 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.

The Chairperson (Ms Maeve McLaughlin): I wanted to ask you about the RQIA and inspections.

Ms Keatinge: The RQIA has indicated that it is reviewing its inspection methodology, although there is no time frame for it to be published. It is critical that we have complete confidence that the system of inspection of homes and domiciliary care services picks up anything that is going wrong, either by intelligence or inspection, or through whistle-blowing or issues raised by relatives. It needs to be proactive in making sure that the action taken is decisive and timely and never rumbles on for years and years. If something is going wrong and the minimum standards are not being met, it has to be dealt with very quickly. Alternatively, that home should be closed down because the owner is not a fit person to run it. People should not be placed in that position of vulnerability. They are already vulnerable, and they need care and protection. The inspection system must absolutely reflect that.

The Chairperson (Ms Maeve McLaughlin): In your opinion, are our levels of care safe?

Ms Keatinge: That is a very difficult question to answer. The question should be: are older people safe in our care systems? As I said, there are some very good examples of care where people are treated incredibly well. However, there is a large number of homes that I would not want to live in, place a relative of mine in, or want anybody in Northern Ireland to have to live in. They are adequate and no more. In addition, there are homes such as Cherry Tree House that fall persistently below standard. Are vulnerable older people who need care always treated with dignity and respect? No, they are not. Are they sometimes treated with exemplary service? Yes, they are. The critical point for me is that nobody can be certain that, when they need care and the care facility door is open to them, it will be of the standard that is required, that it will meet their needs, and that it will be good.

Mr McCarthy: Thank you for your presentation, Claire. As always, you are very precise and to the point. It is sad that you are moving on, is that right?

Ms Keatinge: I am moving on. Thank you very much for saying that it is sad.

Mr McCarthy: Absolutely. You used the word "shameful"; I would say that it is disgusting, dreadful, intolerable and should not be acceptable at all. There are things that I wanted to speak to you about, the first being the non-response from the Minister. This started off in 2013, and you met the Minister in 2014. We are now in 2015, and yet you have had no direct response in relation to the problems that you have outlined to the Committee this afternoon.

Ms Keatinge: Indeed. I am disappointed. To go from 2013, when the report was commissioned, to now in 2015 on issues that took place in a nursing home over eight years previous to that, it is not possible, I suggest, for anybody to take action that could be described as timely when it has taken 11 years. It is not possible to call it timely action. I know that you all want better for older people; I am absolutely convinced that you do. I implore you as a group of responsible, able, committed politicians to take the decisive steps that are required to protect, invest in and secure the care that our older people need.

Mr McCarthy: Thank you very much. We had a meeting with the permanent secretary this morning, and he used the term "extreme difficulties" in relation to the financing of the health service. Some people used the word "crisis", and I used the word "shambles". What you have told us today convinces me more than ever that our health service, unfortunately, is in a shambles. I do not know who is in charge.

As you know, we have the hokey-cokey, in-out Minister. Things seem to be going from bad to worse. You said that we should have new legislation to incorporate that. I totally agree, and, if that is the way we should go, we should go down that road. You also said — I took a note of it — that the people who are involved in the abuse of older people should be out of business. Do you agree that they should not only be out of business but be prosecuted and brought before the court for abuse of elderly people?

Ms Keatinge: Yes. Absolutely, without question. In the very extreme cases, where there are charges like corporate manslaughter, owners of care facilities should be brought before the courts. It should absolutely be a prosecutable matter.

You asked me about the comments of the permanent secretary about the extreme difficulty in finance. I will be very direct with you: get over yourselves. Put older people first. There is nobody who started being 80 today whom, 20 years ago, we did not know would turn 80. It is a planning matter. Plan, decide, look forward. We know how many older people there are. We know what proportion of them are likely to need residential and nursing care and domiciliary care services. We know that already. Classically, in policy terms, there is what is called a structural lag in relation to ageing. We know the number of older people coming forward, and policy and practice tends to fall 15 to 20 years behind that. There is no need for Northern Ireland to be in this place. Whatever difficulties you have with finance, I am absolutely convinced that there is not a person in Northern Ireland who does not want that certainty for today's and tomorrow's older people. I say to you: get a hold of it. The permanent secretary may describe extreme difficulty in finance: it is his job to plan.

Mr McCarthy: OK. Thanks —

Ms Keatinge: Sorry. If I could just finish, I am no newcomer to the call for leadership and decisive action, and you will be familiar with the Donaldson report, which called for that same leadership. We are a small jurisdiction with a manageable number of issues and individuals. We could develop a health and social care system that works for older people and of which we all could be enormously proud, but it requires that leadership.

Mr McCarthy: Exactly. Almost finally, you mentioned in your report that you are not at all happy with the issue of whistle-blowing. Do you agree that, because of the inaction and previous experience in the Department, people are absolutely afraid to come forward about what is happening not only in homes but in other places? We know what can happen. People can lose their job if they open their mouth in the wrong place.

Ms Keatinge: Whistle-blowers are absolutely integral to gaining the intelligence and information about what is going on in homes. People who work in homes are in there every single day and are well placed to report any concerns that they have. They have to be better protected. Minister Poots issued very strong guidance in March 2012, in which he clearly emphasised the need for support and protection for whistle-blowers. He was very robust about it, but I have received no substantive response to the recommendations, and whistle-blowing remains a significant issue. In spite of the strong guidance that Minister Poots issued, people are terrified of coming forward and giving their information, and the anecdotal and international evidence quite clearly is that whistle-blowers are indeed victimised. They experience considerable difficulties having blown the whistle. Yet everybody associated with health and social care planning will talk up how important it is that whistle-blowers have access to somebody who they can talk to about their concerns and know that they will be acted on seriously. We need to look at how whistle-blowing information is handed over, who it goes to and who it is reported to, and we need very clear, decisive commitments on support for whistle-blowers.

Mr McCarthy: Do you agree that the term "whistle-blower" is not necessarily correct? In fact, it puts a label on somebody for simply doing their job.

Ms Keatinge: Absolutely.

Mr McCarthy: We should drop the term "whistle-blower" and give support to people in the institutions who see something wrong. My goodness, it is only common sense and decency that they should report it if something is not right.

Ms Keatinge: It is about common sense, decency and professional standards, and I certainly expect to see some improvements to that once the social care workforce is regulated and registered. That will come through shortly. "Whistle-blowing" is quite a strong term for people to use.

Actually, all that somebody is saying is, "I need to talk to somebody. Something is going wrong in the place where I am working. These people are not being treated properly. Something has gone wrong, and I have spoken to my manager about it, or the head of the home, or the owner, or whoever, and I cannot make any progress myself. I need somebody else who takes a salary for being responsible for the well-being of older people. I need to talk to that person, because somebody needs to take some action". "Whistle-blowing" is a strong term, and we can use it too easily. You are right: it is absolutely what we ask staff to do in the event that they see something that is not right.

Mr McCarthy: Finally, the document here talks about social care opportunities:

"savings opportunities in domiciliary care, day care centres and residential care will be progressed through the review of existing provision."

What is your attitude to that?

Ms Keatinge: Pass.

Mr McCarthy: In other words, rubbish.

Ms Keatinge: I have nothing at all that says to me that the savings are this much; they have been planned to be spent on these things; they are coming through on these dates; and these are the people who will benefit from them. I do not see it, so I am afraid that I cannot answer that question.

Mr McCarthy: An easy target. All right. Claire, I wish you all the best and every success in the future.

Ms Keatinge: Thank you very much, Mr McCarthy.

Mr McKinney: Thank you for your very frank and open analysis of the situation. Do you think that this is something that we all, as a Committee, need to share a concern over? I do not think that this is the narrowness of our Minister here; clearly, some of the issues that Claire is reflecting on predate some of our present problems, though they are affected by our present problems. I certainly would like to look at them in the strategic context. Looking after our older people has got to be our top priority. We will all be old some day ourselves. That is not a selfish context: we want to see the best provision for our older population. Of course, TYC recognised that very thing, that we would have a growing older population and that we would need to do something to mitigate that. So, the one constant for me is the Department. Can you reflect for me a bit more on why you think it is that you have not been hearing from the Department, despite the clear evidence and the clear action lines that needed to be followed?

Ms Keatinge: I have heard from the Department; I have heard from the Department at considerable length. The recommendations that I have provided to you have received a departmental response. A departmental response is not the same thing as decisive action. If I may, I will give you a number of examples. The Department has consolidated the replies to my office. The recommendations on Cherry Tree House were passed out to health and social care trusts, the RQIA, and the Regional Health and Social Care Board for different sorts of action. For example, while my recommendation is that:

"there should be clear and rigorously applied sanctions taken against care providers for non-compliance with the minimum standards."

I have received no commitment to change or to making sanctions clearer. I have just a review of inspection and quality assurance procedure, which is planned, with no clear idea of how wide-ranging that review will be or its time frame.

I recommended that:

"persistent or serious breaches of regulation and/or compliance should result in decisive sanctions being applied without delay and within a defined time frame",

including things like the deregistration of owners. In the response, that point was not directly addressed by the Department. It is instead a matter for the RQIA. It insists that it does apply appropriate sanctions as it sees fit in line with its current powers. I remain very concerned about that, and, indeed, I sought independent legal opinion from a senior QC in England who has acted both for and against the Care Quality Commission in England. The significant point in her advice for me was the timeliness of action that is required. If you leave it this long to act in relation to something that happened eight, 10 or 11 years ago, it is very hard to argue that decisive action is proportionate, if the current situation is satisfactory. So, timely action is absolutely required. Putting everything on the long finger, having another report, commissioning another anything and waiting for something to go round and round, results, really, in just a circular set of correspondence.

Mr McKinney: Do you make that point to them in your communication and say, "Look, guys, this is activity disguised as movement"?

Ms Keatinge: I do.

Mr McKinney: What do they say?

Ms Keatinge: They come back with something that is considerably shorter and often somewhat clearer. I then seek another meeting with the Minister to raise those issues of concern. It has not been helpful that I have had to brief three different Ministers of Health in a four-year term of office. The chain of accountability is not very strong. It does not appear to me to be good. By the time the advice and the information reaches the Department and is passed onto other agencies to come back to, something happens in that the urgency goes and the imperative for action seems to soften. It absolutely must not. The advice from that QC is simple: if you leave it too long, you cannot do anything so clearly about it. It is shameful — I will use that word again — to allow bureaucratic procedures and obfuscation to get in the way of action.

Mr McKinney: On the strategic side, TYC clearly foresaw that. It also explicitly demanded that data about the needs of that growing older population be available. We hear that they are doing a scoping exercise now. Are you aware of any evidence that they are actually assessing the scale of the issue or, as it is now, the problem?

Ms Keatinge: I am not confident that there is decisive, clear planning. As I say, we are a small jurisdiction with a small number of people. We know who our older population are. We know what their needs are. I have yet to see clear evidence of things like proper workforce planning, proper assessment of needs and people looking at what we mean by level of need in domiciliary care, for example. At the moment, if you are assessed as needing domiciliary care, you will only receive it from a health trust if your needs are critical or substantial. What happened to those early interventions that were promised in TYC, that we all know are the best thing and that older people call "that little bit of help"? What happened to all of that?

At the moment, you will only get domiciliary care if your needs are critical or substantial. That is a very grave situation indeed. People are very often struggling for many years, managing through depending on neighbours and friends. I hear about this widely from older people. I had a conversation last week with a lady in the Armagh, Banbridge and Craigavon Senior Network. She provides wide-ranging care support for an elderly neighbour but is very stressed about providing bathing and personal care for the lady in case she does something wrong. That lady is supposed to have two people help her wash and do those sorts of things. This is one person trying to help on her own because there is not enough care available. Those sorts of things are not good enough.

I have yet to see any evidence of very clear planning. I held what I called a domiciliary care summit a couple of weeks ago to bring together the regulator, independent providers, the statutory sector, people who use domiciliary care, their relatives and voluntary sector providers. What is it that we need to do? Really, bang your heads together: what is it that we need to do?

You need to start at the end and put the older person and their needs first. Work out from our older population and those who will become older what proportion of them are going to need care and what that care should look like. There are examples out there. There is clear evidence and clear standards of what the very best could look like. Then work out what you would need to do to recruit the staff who are needed, pay them properly, train them properly and give them proper respect and career progression prospects. You also need to look at what level of care you, as a Committee and as elected representatives, want to stand over. I do not think that you want to stand over a situation where you only get domiciliary care if your needs are critical or substantial. I think that you want older people to get that little bit of extra help and remain independent.

You need to work back from what the care should look like and then cost it. The approach at the moment is exactly the response that you got from the permanent secretary about the awful financial difficulties. Those are not as difficult as living in a nursing home that is inadequate; sitting in your own urine or faeces because your care worker has not turned up; living in a residential home that does not meet the standards; or, worse again, not getting any care at all because you are on a waiting list. It also does not help somebody who is waiting for aids and adaptations to their homes that there are substantial waiting lists for occupational therapy. Somebody can be discharged from hospital and have no proper bathing or toilet facilities. A couple of years ago in this job, I was contacted by somebody who was discharged from hospital and had a long wait for an adaption to their downstairs bathroom facilities. A lady in her 80s was trying to shower her husband in the kitchen in a child's paddling pool, and she slipped and fell and broke her hip.

All those things are manageable, and I implore you to put the planning and the systems in place. Do not prevaricate. Today's older people need your protection, and tomorrow's older people will only be certain and confident in this society if they know that that will be available to them.

Mr McKinney: We cannot ignore the present stuff. Some of that is strategic, and I believe that we need to move on that. I do not think that we, as a society and as a Committee, can afford to ignore that. Older people have contributed to society, and, in their vulnerability and frailty, we need to look after them. It is not just the emotive point. There is a hard-headed financial aspect of it in that, if you put in the early mitigations, as TYC foresaw, you will end up not having to pay for a hip operation or whatever. On the money side, it seems to me that something is about to happen around residential care. They have shut access to permanent or statutory residential, and we had correspondence last week from the independent sector that indicated that it will not be able to afford to do this anymore and may be in a position where some of them are handing in the keys. That, to me, appears to be a car crash. Do you have any views on that?

Ms Keatinge: Independent providers indicate clearly that, in domiciliary care — some say the same about nursing care and residential care — the rate that they are paid is simply inadequate to make a decent profit, pay decent salaries, pay decent wages to their care workers and provide decent levels of training and the right level of staffing. There are certainly issues with independent care providers who are failing to pay even the minimum wage at the moment in domiciliary care. Care staff are expected to travel between jobs in their own time and, therefore, are effectively being paid below the minimum wage. They also have to pay for things like uniforms themselves, which effectively takes them below the minimum wage. I expect HMRC, following its own investigations, to take action on that. The new living wage is very welcome to care workers and is much deserved by them, but it will inevitably push up the financial costs.

I say this to you: get a hold of it and plan for it. Do not panic. Do not flap about. Do not worry about it. Be decisive. Look at how much it costs. There are financial implications in providing the right care that our older people need, but we always hear about the financial cost of ageing. There is a financial contribution made by our older people too, and endlessly talking about the actual cost of ageing disregards the very positive contribution that older people make. If you add up the additional costs of ageing — the financial costs of an older population — and set that alongside the value of things like taxes paid by older people, the volunteering hours that they do, the care they provide for other older people and for children, often grandchildren, you will find that Northern Ireland will be £25 billion better off over the next 50 years because we are an ageing society, yet I hear persistently about the "cost of ageing" as though it is negative.

It is a challenge, but you have to rise to it and plan for it because, at the moment, the drive is certainly towards the independent sector in terms of policy generally. It has to be able to make a transparent profit and provide a good service, and we need to cost on that basis. Look at what model needs to be in place to work through how much it should actually cost to provide the kind of quality care that you can stand over and then offer that. I do not think that anybody will walk away from the business then.

Mr McKinney: Thank you, Claire. I have one comment. I had asked for the SDLP paper to be tabled. We invited a range of people in the sector together who had perhaps not normally conversed. Normally, in a process, you might find one or two saying that there are issues from their perspective with care for older people, but every one of them agreed that the whole system is broken. I thought that chimed well with what Claire Keatinge's report is saying. There is a chorus out there — we cannot ignore it — that is saying that not enough is being done about the care of our older people and that it is leading to the short-term crises. We need to get back to the strategic approach to deal with it in the long term.

Mr Buchanan: Claire, I again thank you for your support and your forthright responses to what you have been asked. Again, I commend you on the great work that you have been doing for older and vulnerable people in your role over the past few years. I wish you well as you move on.

With regard to your report, I fully agree with everything that is there. I am new to the Committee. This is my first day back on a Health Committee after some years, and I may well be covering things that have been asked before or whatever. I trust that you will forgive me for that. I see from your report that there are four areas of required change, comprising 13 proposals, and that is to be welcomed very much. Looking through it, there is nothing that we can disagree with. What I want to get clear today is this: are you telling us here today that the RQIA, which we hear so much about, and which is supposed to monitor all of these issues, either does not have sufficient powers to be doing what it should be doing or is not utilising effectively the powers that it has, and is therefore unfit for purpose?

Ms Keatinge: The job of the RQIA is both to regulate and inspect and to improve quality. It is in both of those areas. They do have limited powers and a limited budget. We need to be absolutely sure that your arrangements — government's arrangements — with the regulator are satisfactory to you. It is not an independent organisation; it has a direct relationship with government. You need to be sure that you are getting from it what you need. I think that there are steps, certainly, identified in the Cherry Tree House report where, in my view, action could have been taken more quickly and more decisively, and I think that the RQIA accepts that. But there are a number of issues on which they have limited powers and limited budgets and could do with further assistance, and I think that it would serve you well to look at the kind of regulation and inspection and quality improvement that you want to see in place and the degree of independence that you think you need to get the regulation that you want.

Mr Buchanan: OK. Thank you.

The Chairperson (Ms Maeve McLaughlin): On that point, Claire, on page 9 of your report, you talked about England, Scotland and Wales currently modernising and changing their regulation and inspection processes.

Ms Keatinge: There are substantial changes in England, Scotland and Wales in relation to care, and probably you have seen quite a lot of those in the Care Quality Commission. There has been a huge overhaul of standards, the introduction of large numbers of lay inspectors, a significant focus on the patient experience — the experience of the person who lives in the care settings — and outcomes for people. It is really about looking at the impact on quality of life and dignity of the residents.

I do remain unconvinced that this large-scale change that we need is happening in Northern Ireland, and the response that I received from the Department really focuses on existing legislative provision only. The single major change is coming from a source outside Northern Ireland, and in both Wales and England, certainly there are changes that are significant, but I do not see them here.

Ms McCorley: Go raibh maith agat, a Chathaoirligh. Thanks very much, Claire. Well done on a really good term of office. We will be sad to see you go, and I am sure that the sector will miss you as well.

Ms Keatinge: I am confident that the next commissioner will receive the same support from the voluntary sector and from elected representatives. Thank you very much.

Ms McCorley: I was actually just going to ask you. At this point, it is disappointing that we are in this place when you are leaving, and I wonder how that must feel for you, given that you have produced this report, and you were talking to the Minister 11 months ago and probably felt that something was going to happen, and now you are sitting here a year later, at this point. That is disappointing. Let me just ask you this: if there were even one or two things that you feel would be fundamental changes, if you were asked, what would be the things that you would like to see?

Ms Keatinge: I do have a substantial degree of frustration, because I am unclear at this point what it is that I could do to get government to take forward the advice that I provide. The Commissioner for Older People is charged with a statutory duty to provide advice to government. Advice is more than just being helpful; this is evidence-based, internationally credible advice, which I expect government to either take or challenge. Tell me that I have got it wrong. If you think that there is something in it that you do not agree with, say so. If not, take the advice and act on it. I only act in the best interests of older people; that is my only remit. If I have got it wrong, challenge me on it; but if not, act. I am frustrated by that circular set of conversations that has gone on. If you look at the report into Cherry Tree House, there were eight years of bad standards of care followed by three years to get to this point. It is far too long and it is very frustrating indeed.

The things that I would regard as priorities for action start with planning. Plan, plan, plan. We must put older people first. You should look at what it is you think the services and support for older people should look like. The second thing I would prioritise is looking at the workforce that we need. Where are we going to recruit it and how are we going to recruit, retain and reward that workforce and make sure that the respect and remuneration that care workers deserve is in place? If the planning is right and the remuneration, rewards and recognition of staff are right, then it is a good business to be in for commercial providers as well as for the voluntary sector, and it will deliver the dignified high-quality care that is required.

Ms McCorley: You are right, and I could not agree with you more. Workforce planning has been an issue in general that we have had to grapple with. As you say, you would imagine that it is an easy sector to plan for because you know what you are planning for. Your report makes it easy; you just need someone who has the will to do what is right for the older population and that is all.

You do not miss and hit the wall at any point. You are talking about non-compliance with minimum standards. That is verging on criminal, really, is it not? You are talking about crimes. It looks like that has either been ignored or somebody does not think that it is important enough to do something about it. Given the response that we got from the permanent secretary this morning, that report was not on the table. He was not aware of any detail around it, which spoke volumes as far as I could see. It did not give me any reason to feel that the Minister is prioritising this. I hope that I am wrong. I presume that the Minister will come back to work some day to stay, and I hope that he will. This Committee is committed to putting pressure on, at least, to ensure that something is done. We will be carrying out our own inquiry as well, and we look forward to any cooperation with that.

The faults in the system seem to be systemic. One the one hand there is a real need for whistle-blowing protection, and then you need a change in culture. The culture is obviously wrong when examples such as Cherry Tree House are happening. How challenging is it going to be to change the culture? How do you change a culture? Is it about changing mindsets?

Ms Keatinge: It is, Rosaleen. We are a deeply ageist society, and we remain so. We talk a lot about how much we care about, respect and like older people, but very often, alongside that, you still hear about the cost of ageing and negative attitudes towards frailty and disability. We hear it as a trouble and that, somehow or another, we do not know how we will meet the costs of caring for our older population or their health and social care needs, and we do.

This is a relatively small jurisdiction with a relatively small number of people, and I do not underestimate how complex or how difficult some of those changes may be. Nevertheless, the health and social care family is a large organisation in a relatively small jurisdiction, and I am convinced that it is possible to deliver excellence. I say that not because I am imagining it; you can go out in your constituencies and find excellence. I have been to places that are an absolute pleasure to go into, where you experience without question that the people who live there feel safe, secure, respected and part of the place that they live in; I have been in other places that meet the minimum standards but are not like that. I have gone into places where people are sitting in chairs that do not look very comfortable and their heads are lying to one side. The place is noisy and a bit smelly; there is a smell of food and a bit of a smell of wee and is not a place in which you would want to live, yet it meets the minimum standards. It is possible to deliver excellence, and we have a workforce that really wants to deliver excellence in service delivery.

I hear from large numbers of people working in the care sectors, such as domiciliary care, who are deeply distressed by having to try to provide intimate personal care to people in very short periods of time. I hear from care workers in residential nursing homes who are deeply distressed by the shortage of staff, by there not being enough people, by not having enough training, and by not being able to deliver the care that they want to provide.

Ms McCorley: It involves a lot of female staff who are poorly paid. That is something that permeates society. Women's work tends to be poorly valued and poorly paid. Women are taken advantage of in the workforce. Often, they will go the extra mile for a small amount of remuneration. We need to change that because it is not right. It is part of the culture that has to change. We have to value the work that is done by those people.

You have alluded to good examples and bad examples: what is the balance? Is there more of one than the other?

Ms Keatinge: It is hard to say. I can give you the formal information from the RQIA. There is a total of 471 registered nursing and residential homes; 268 nursing and 203 residential. There were a total of 1,336 inspections carried out; 771 in nursing and 565 in residential. The number of places where people could actually live in nursing and residential care is 16,146; 11,936 in nursing and 4,210 in residential. The total number of enforcement actions taken against nursing and residential care homes in 2014-15 was 26; 16 in nursing and 10 in residential care home settings.

Ms McCorley: So, 26 enforcement actions. The bar, then, is very low.

Ms Keatinge: The bar is low, and an enforcement action means that something is clearly and evidentially wrong and has to be addressed.

Ms McCorley: It has to be abysmally wrong really.

Ms Keatinge: No, it has to have been identified by the RQIA as not meeting the required standard.

Ms McCorley: Yes, but that is a required minimum standard.

Ms Keatinge: The required minimum standard.

Ms McCorley: And that is a low level.

Ms Keatinge: I will address your point about the undervaluing of female staff. You hear that again and again. It is a predominantly female workforce. However, it is a workforce that, in the main, likes the job, wants to provide care and do their best for people. Very often, we take advantage of that goodwill. Most care workers do not want to leave somebody vulnerable. They do not want to leave them in distress or stuck. To be very direct with you, when the financial squeeze comes, the pressure generally comes on front-line care workers rather than on managers. That is where the time pressure comes in.

Imagine yourself in a care home, trying to provide the very best care to somebody who needs support to go to the toilet or to be assisted to do something. There may not be another person to help you. You may have another priority where it is somebody else's turn to get a shower and you need to help with that. The pressure of knowing that you are leaving something undone that needs to be done, as well as doing what you have to do, is hugely difficult for care workers. There is the same sort of experience in the domiciliary setting. The personal care worker will go to someone's home. That person may need a little bit of extra time or something extra done for them. The care worker will, very often, try their best to do it but they cannot stay longer because, if they do, they will be late for the next visit. The next visit has only a limited amount of time attached to it, and that person is sitting there waiting for them. The direct pressure on those care workers is huge, and I think we do take advantage of them.

Ms McCorley: Yes. It is very unrealistic to expect people to go in and attend to someone without giving them the time to talk. One of the great needs that people have is a bit of a social interaction with someone. That should be factored into need, as well as physical needs and all of that.

Ms Keatinge: Absolutely.

Mr Easton: Thank you for your presentation. What you say is quite worrying. Cherry Tree House failed to meet the minimum standards for eight years. What is the current situation with it?

Ms Keatinge: The situation with Cherry Tree House is that it was subject to unannounced secondary care inspections in September and November 2014 and in February and July 2015. The first of those inspections, in September 2014, was undertaken following contact by a whistle-blower who expressed concerns about staffing levels, management of incidents and staff recruitment. Inspectors reviewed the staffing rosters and the recording of accidents and incidents, staff recruitment, care practices and management arrangements. They found that delivery of care was evidenced to be of a good standard, but a requirement was made on the induction plan for the acting manager, and a recommendation made that the registered provider continue to monitor staffing arrangements. At that inspection, the concerns raised by the whistle-blower were deemed unsubstantiated.

By November 2014, the inspection concentrated on continence management, which had been a significant issue in Cherry Tree House, and sought an update on the recommendations made in September 2014. That visit was brought forward following contact, again by a whistle-blower who raised the issues of staffing shortages, patient supervision, continence issues and breakfast times. The requirements and recommendations from previous inspections had been fully complied with, the delivery of care was deemed to be of a good standard, with processes in place to ensure effective management of continence care. Although the home was considered to be substantially compliant in relation to continence management, two requirements were made. However, an urgent findings letter was issued in relation to three requirements relating to wound and pressure ulcer care and fluid balance records. Other requirements related to updating care records in things like catheter care and updating care records in relation to wound and pressure ulcer care. Updated guidance on continence care and the replacement of carpets were required in some aspects of the home, so some level of continuing improvement was required.

By February 2015, the inspection again reviewed compliance with previous requirements. All seven requirements had been fully complied with, and delivery of care was evidenced to be of a good standard. Inspectors reviewed complaints, staffing, continence care and care practices. Two requirements were made in relation to the overall environment and management of complaints, and the recording of complaints was to be formalised. In relation to the environment, there was a requirement for further cleaning and for the bathrooms not to be used for storage.

By 21 July 2015, there was another change in management arrangements, and an inspection was undertaken to review governance and management, the standard of care and the update of the previous quality improvement plan. Both requirements from February had been met. At 11.30 am, patients were observed to have had their breakfast. Not all of them were up and dressed. The morning medication round was not completed until 12.10 pm. An urgent finding letter was issued to ensure that a management plan was provided for nursing and residential residents. The RQIA confirmed that the plan has been received.

The complaints record indicated a trend of common themes about the personal care of patients. The patient care records were reviewed by the inspectors. One record indicated a period of 15 days when there was no recorded evidence to support that somebody's wound had been dressed, when it should have been dressed every three days. Four requirements and three recommendations made, one of which was new and stated for the first time. There was a requirement that the management strategy and plan must be fully implemented. Further recommendations were that comprehensive monitoring reports should include monthly visits to the home by the regulator and that all personal protective items should be replaced regularly. So there are a number of ongoing matters, but none is an enforcement action; they are all improvement actions. There has obviously been quite a focus on Cherry Tree House. You can see that there have been a number of inspections by the RQIA, which is taking that seriously. There are some issues with the home, and complaints continue to be made.

Mr Easton: Thank you for that. Are there similar issues in homes across Northern Ireland, or are things better in general? Are you finding similar issues right across the sector?

Ms Keatinge: There are good and bad homes, as I have said. There are homes that apparently meet minimum standards and can continue in operation, but in which I would not wish to live and would not be prepared to place a relative. I think that we are not aspirational about the standard of care that we want as a society, and there is a level of tedium and very basic care provision that society continues to tolerate.

I think that there is good cause to investigate formally how satisfactory the real lived experience of people who live in residential and nursing care is. What is it actually like? What could we actually uncover if we looked at it? A large number of the complaints that come through are to do with staffing levels, not getting medication on time, wounds not being dressed, not enough staff to provide attention, not enough activities, not enough interesting things to do, and not enough person-centred responses to people's individual needs. I think there is good cause for an investigation to look very considerably and substantially at the real experience of nursing and residential care.

Mr Easton: On the RQIA, do you feel that it is maybe not — I am not putting words in your mouth, by the way — picking up things that it should, or do you not think that it is as robust as it can be?

Ms Keatinge: I think that the RQIA has a limited budget and limited powers. Its inspection methodology, how it actually carries out inspections, is under review. Certainly, there is a move towards many more unannounced inspections, so the home does not know that the inspectors are coming. It is picking up on some of the issues that I have raised with it directly, one of which is, if an issue has been raised at one inspection, it has to be followed up at the next one. It cannot just be that it was at that inspection, and the next theme is something else. I do think that review of the inspection methodology is important. You need to be confident that the RQIA has got the powers and the budget that it needs to give you and the population the assurance that is needed so that all of the social services and health services that it regulates and inspects are up to standard, and that, where they are not, decisive action is taken.

Mr Easton: Chair, we might want to get the RQIA up to have a chat about this as well. What it does with its inspections might be worth looking at.

The Chairperson (Ms Maeve McLaughlin): I think that what we are hoping to do from today is to drill down on the terms of reference that we will use in taking this forward. We are mindful of not duplicating the piece of work that is already there but how we look at the implementation of that work. We will be looking at all of that, Alex.

Ms Keatinge: The RQIA inspects to existing standards, and I think that the question of how high the standards are, how aspirational they are, warrants further consideration. We should look at really what is the best that we can provide, not just at minimum standards. Certainly, I will publish findings from the domiciliary care summit that I held, probably by the end of this month, and that will include a focus on some of the services provided by the RQIA.

Mr Easton: You have 13 proposals in your report. Has the Department come back to say what it is aiming to do specifically? Has it just been very bland, along the lines of, "We are looking at it"?

Ms Keatinge: It is more than, "We are looking at it", and it is less than decisive action. I will give you an example. This should be so simple to implement; this should be quick and easy. One recommendation in my report is:

"Standards for the care of vulnerable older people should be clearly displayed and available to all service users and their families and relatives for all nursing, residential and domiciliary care services as well as for any prospective users."

That is nice and simple. If you are considering admission to a residential or nursing home, you should have available to you the information that sets out what the standards should look like. The response from the Department says that a residents' guide is now to be produced as part of the new nursing home minimum standards. That reflects what is said in 'Changing the Culture of Care' about producing a shorter, easier-to-read version of the standards, but there is no commitment at all to print the documents, nor to take residents through what those standards should look like. So, there is some movement, but it is not decisive and it is not complete. Again, on the regulation and inspection service, I was recommending a rating service for care homes. We see that more and more: there are scores on the door if you go to a hotel. Certainly, other jurisdictions are looking at rating systems. The RQIA is considering a ratings system but we have no commitment to a deadline.

Mr Easton: Have you got somebody appointed to you in the Department who is trying to look at these issues and move them forward? Is there somebody who you specifically deal with?

Ms Keatinge: I should have introduced Emer properly: Emer is the head of legal and policy advice at the office of the Commissioner for Older People. Without question, the staff have wide-ranging connections and contacts with departmental officials, but there is not a nominated person, other than that I would expect a very swift and decisive response and, if things are not done properly or they are not to my satisfaction, the next stage is to give an opportunity to the Department to come up with the goods, and, after that, it goes back to the Minister.

Mr Easton: It is just my observation that there should be somebody specifically in the Department driving this forward and working with you to implement it.

Ms Keatinge: Whether there should be somebody in the Department driving it is probably a different point, to which I would say a hearty, big, fat "yes". Is there somebody who should be my point of contact? I am able to find the relevant points of contact myself but, yes, absolutely, in all the organisations, somebody needs to own everything that you decide you want action on and be accountable for taking it through with a costed and programmed timetable of the right quality and bring it back to you for decision.

Mr McGimpsey: Thanks, Claire. I am sorry that I missed the beginning of your briefing. I share the comments of colleagues that I am sorry that you are leaving your post; you have added a great deal of value to it.

We were talking about finances this morning with the permanent secretary, and we are going to go into finances again this afternoon. Of course, resource is the key in much of this. You said that most of the homes are privately run. As far as I can see, the tariff paid per patient or per resident does not meet the need and has not moved for a long time. It has been about five years since there was any real increase. As a consequence, it is very hard to maintain standards to do things such as having continuity of staff, which is one of the key things. If we are under-resourced, standards are liable to slip. If we have a proper resource, we have a much better chance of maintaining those standards. Have you any sense of what the tariff for a resident of a nursing home or residential home needs to be? Clearly, the state is withdrawing from provision and is doing it through private means. I will ask the question when we next see the Department's finance people. I always think that, if it is on a sound financial base, our aspirations can be matched.

Ms Keatinge: You need to spend some of the money to pay a really competent health economist to give you an options appraisal of what that looks like. There are really competent health economists out there. There is a gentleman from the London School of Economics who presented at the domiciliary care summit that I held a couple of weeks ago. There are a number of very expert health economists with considerable expertise in exactly this field. Pay the money, get the service and make a decision about what you want to do. You need a health economist to do that.

Mr McGimpsey: As I understand it, virtually no new residential or nursing homes have been built in Northern Ireland in the last number of years. Businesses in the private sector cannot borrow the money from banks and they cannot get a business case that stacks up when they multiply the number of residents by the tariff that is being offered. It is not a viable proposition in commercial terms, so the businesses do not happen and we do not get the expansion in the number of beds that we need to provide. At the same time, through DSD, we are not getting the number of supported-living beds and accommodation that we should be getting because, again, of the constraints of our public finances. We need some idea of where we need to be. We keep talking about money but it is about billing it down. A health economist will help us in that area.

Ms Keatinge: Without question. There are people who can model our population for you; they can look at the numbers and at different sorts of standards. They can factor in things such as rurality and cities and all sorts of things to give you very clear information about what the business model, the costing model and the remuneration model need to look like and what it would cost us. It is important to establish whether that results in a good business proposition. At the domiciliary care summit, the Association of Independent Healthcare Organisations indicated very clearly that significant providers in the domiciliary care market will not be bidding at the next tendering exercise because it is not economically viable. The organisations cannot provide the service that they legally need to provide, never mind want to provide, at the rate that is provided.

Mr McGimpsey: We have been expanding demand, but supply is static or even shrinking.

Ms Keatinge: There is a substantial danger. If the providers who are currently in place are not interested in contracting, who will come in and provide for that instead? How desperate will you and the trusts be to have a service on the ground? What are they going to settle for in the event of a challenge like that?

Mr McGimpsey: They end up cutting corners.

Ms Keatinge: You have to take a lot more care. There are good providers out there, and there is real need. Domiciliary care transforms people's lives, keeps employment local and is a good thing, but you need to know what you are planning for.

Mr McGimpsey: On the other side of it, we are not inventing the wheel. Other jurisdictions are looking at it. I always look at Scotland because I think that it provides very good models. I am not so sure about Wales and England because we get so much negative publicity very often, although a lot of it is politically driven out of England. Where do you think is the best model for us to be following? We have the integrated model of health and social care. Scotland, Wales and England do not have that, but is the Scottish model the best model to follow?

Ms Keatinge: The best model is to put older people first. Do not worry about anything else. It is a small population; put our older people first. We have integrated health and social care, and I sense that you are not planning to overhaul that. Just look at what older people need and then require whichever system we have in place to implement it. That is the right way round.

There are any number of possibilities and configurations of how the management and structure could be run, but there are a lot of layers of bureaucracy, administration and decision-making in Northern Ireland, all of which conspire to not putting the older person first. At this point, the increasing problem is safeguarding concerns. What is the protection for older people today, regardless of the system? There are more and more reports of abuse of older people. I have been with this Committee before, and I still advise very clearly on the need for new legislation on safeguarding and urge you to make sure that that is part of the next Programme for Government. It is absolutely imperative that the safeguarding legislation that is required be put in place.

Mrs Cameron: Thank you very much, Claire. This is not so much a question; it is a few comments. I think that most issues have been covered. First of all, not many people come before us in any of the Committees who can grip and hold attention as you do, so you will be much missed, certainly from my point of view. I am sure, for others, it is refreshing to have somebody who is so clear, concise and brave in saying it as it is, even though it is unpleasant to hear. None of us likes to think that our older population are living lives that are well below a standard that we would deem acceptable, so "Thank you" for that. I wish you well in the future wherever you go on to.

Ms Keatinge: Thank you.

Mrs Cameron: I was going to ask about the rating system, but you covered that. Recently, we have been dealing with the food hygiene rating scheme. It sounds like a brilliant idea to replicate that, although obviously in a much more detailed version. I presume that you would mean to physically display the rating. It is almost name and shame. Nothing drives improvement as much as a bit of public humiliation in some cases. That is why we have not seen the lower food hygiene ratings displayed because it is not yet compulsory. I think that is a really good idea to go forward with. It is something that could be implemented fairly easily, and people would have a general awareness of the conditions of facilities. Do you have any further comments on the rating scheme?

Ms Keatinge: The rating system is like anything else, Pam; it is never the answer to absolutely everything. A rating system would be based on an inspection or an observation on a particular date and time. Things can happen in between. If somebody gets a very good rating on a home, something can still go wrong on another day. It is not an absolute guarantee. In the same way as with food hygiene, it is an inspection on the day and then a recognition.

I would look at it not so much as name and shame, but name and aspire, or name and be proud. "We are a five-star facility. We care. We put older people at the very heart of our service. We meet all the minimum standards and more. This is what else we do. We do it because it is good for older people, good for our business and good for our workers." If you get organisations with that kind of ethos, they will be proud to display the five-star rating, the big tick or whatever it looks like.

As I say, it is not an answer to everything. It is not a panacea. However, it is something that would be very well worth having, along with inspection reports being clearly and readily available. The rating systems should include clear information about any outstanding enforcement issues that there are. I do not know about you, but if I were going to look at a home and I knew that there were issues to do with somebody waiting 15 days to have a wound dressed that should have been dressed in three days in an era when nobody should have a pressure sore anyway, I am not going to place a relative of mine in it.

The Chairperson (Ms Maeve McLaughlin): OK. Thank you both. As always, Claire, it has been frank, informative and extremely useful in focusing the minds of members. You can rest assured of our commitment to take this work forward. Following on from today, we will look at developing the terms of reference. As I said, it is not about duplicating the work that you have carefully produced; it is about implementing some of the recommendations that are coming from it and looking at the best way to do that. It is quite an eye-opener when we, as a society, have to reflect on words like "shameful" and on the fact that people are terrified to come forward. That should make us all sit up and take notice and not only that but, to use your words, take decisive action.

Ms Keatinge: I want to take this opportunity to thank all the members for your kind attention to the work of the office of the Commissioner for Older People. You were right to recognise the need for an independent champion for older people. I am absolutely confident that whoever is appointed to take the role next will continue to receive the same sort of support that I have.

I have intervened in a number of matters, but I held an event last week to launch my final advice to government. I have brought a copy of a consolidation of all the advices that I have provided to government over the four years. I intervened with the case of a lady who was having extreme difficulty in accident and emergency; she received very poor treatment and had a lot of difficulties with her care. She was extraordinarily ill. It was one of those cases that ended up all over the press, and her care was improved as a result of that. However, she had a very, very difficult time. The lady was 99 years of age. I went to see her in hospital. I also went to see here in the residential home where she then lived. It was a place where you would be proud to live yourself or to put any of your relatives. At 101 years of age, she came to the event that I held in the Europa last week to tell me, "You're the lady who came to see me in the hospital. I can't tell how lovely it is to live in the residential home that I live in now and how marvellous the staff are". That shows you how good residential and nursing care can be. Somebody who has been that ill can be supported and assisted to live a dignified, independent life and to get out and about and be part of society at 101 years of age. It is possible. We can do it. We should be so, so proud of the organisations that deliver that excellence and of the care workers who provide it. We should be so much quicker to sort out, fix and require poorer providers to up their game.

The Chairperson (Ms Maeve McLaughlin): Thank you very much. That should be a benchmark for us. I want formally to wish you every success going forward.

Ms Keatinge: Thank you very much, and good luck to you all.

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