Official Report: Minutes of Evidence

The Chairperson (Mr Gildernew): I welcome Mr Seán Holland, Chief Social Work Officer from the Department, and Mr Mark Lee, director of mental health, disability and older people. You are both welcome this morning, gentlemen. Please go ahead and brief the Committee.

Mr Seán Holland (Department of Health): Chair, it is good to be here. Hello, everyone. Thanks very much for the opportunity to update you on what is happening in the adult social care sector with particular reference to the impact that COVID-19 has had.

Since the outbreak in Northern Ireland, adult social care services have, as you will all be aware, been placed under immense pressure. Care homes have certainly borne the biggest impact of that in terms of infection rates and deaths, but domiciliary care, day-care services, supported living, family carers, unpaid carers and young carers have all been seriously impacted in the past few months. Media attention has, inevitably, focused on the care home sector, due to the high numbers of deaths recorded in the sector, but we increasingly see the impact of scaling back other services on families and communities, and that will be a crucial factor as we look to restart and recover from the pandemic.

Trusts have reshaped their services, and we have tried to prioritise a focus on reaching out to the most vulnerable. That has resulted in an intensive approach, but it has meant that many other families who would normally access the support have not been supported in the way that they normally would have been. The consequences of that are still emerging, and we are having to understand and respond to that.

Work is well under way to assess where we are, what the impact has been and how we can re-establish and recover services, but it will be hugely challenging and resource-intensive for the foreseeable future. There are probably three elements to that. One element is pent-up demand that has built up because we have not been responding to difficulties and needs that people have experienced because of the impact of COVID. The second element is trying to operate in this stage of the pandemic and trying to deliver a wider range of services but in the context of complying with social distancing and other factors, and that has an impact on productivity and capacity. The third element is the impact of COVID-19 creating new demand in itself, and that can be a variety of factors ranging from mental health needs being impacted due to people experiencing PTSD, increased anxiety and so on through to new social care demands that we are only starting to see emerging. There are consequences for some people who have been ill and have been left with debilitating conditions, and we do not know long those will last. Anecdotally, we are coming across people who were previously fit and well but will probably be reliant on care for a significant period.

We are putting in place some support for those who are providing unpaid care. We issued guidance for unpaid carers on 10 April, and that has been updated since. We have also tried to support people by participating in and supporting the use of a carer's ID scheme, which was launched on 8 June.

We continue to provide significant support to care homes. Personal protective equipment (PPE) has been provided in significant amounts. I think that some 17 million items have been provided to the care home sector and 27 million items to the social care sector overall — that is what we have provided to other providers in the non-statutory sector. On 2 June, the Minister announced a £11·7 million package of investment to support care homes. That had a particular focus on the enhancement of cleaning in care homes; the provision of new equipment to help with the clinical management of residents; facilitating communication between relatives and residents, which, I know, is an issue that the Committee has heard from others about; and sick pay for staff who will be unable to attend work should they become ill in the future. That was on top of a previous £6·5 million investment that was announced on 27 April.

Those funding packages are part of a wider and comprehensive package of financial support across the adult social care sector. As well as guaranteeing income for care homes and domiciliary care providers, we asked trusts, at the beginning of the pandemic, to ensure that, if they had contracts with voluntary and community sector organisations that, for reasons beyond their control, potentially faced an inability to deliver services in the way for which they were contracted, they continued to pay them as per the contract. We thought that it was important that we did not destabilise and potentially lose those organisations, which would be crucial to restarting that care when we came out on the other side of the pandemic.

We have also worked closely with colleagues in the Department for Communities, particularly on supported living. As you know, there is an arrangement of close cooperation between Health and Social Care and Communities, particularly its housing division, and we work in partnership to provide housing with care. We supported the work of DFC to secure £10 million to support that sector. In advance of it being able to secure that money, we included supported living providers in the arrangements that we had in place for accessing PPE from trusts.

We have also provided significant staff support to the care home sector. I think that that is unique in the United Kingdom. I am not aware of that happening in other parts of the UK. It reflects the integrated health and social care arrangements here that allowed us to go to our health and social care trusts and say, "You need to wrap your resources around care homes". To date, I think, they have provided some 17,000 hours of trust staff time directly to care homes, and that has been received positively by care homes. We are now at the point at which nearly all care homes rate themselves as "green" in red, amber or green (RAG) ratings in relation to staffing.

The Committee has previously heard from the Chief Medical Officer (CMO) about the programme of testing in care homes, and that work continues. As of Monday of this week, the information that I have is that 85% of residents and more than 15,000 care home staff have been tested. It is hoped that all staff and residents will be tested by the end of this month, and my understanding is that we are on target to achieve that. Nevertheless, there is much more to do.

The Minister recently announced a new framework for nursing, medical and multidisciplinary in-reach to care homes. That will be led by my colleague the Chief Nursing Officer, Charlotte McArdle. That partly recognises a long-standing change in the profile of people who live in care homes, in that there is a growing level of acuity of healthcare need, but it has also been exacerbated by the experience of the pandemic. Charlotte will also lead on a rapid learning initiative that is intended to assess which supports that were provided to the sector were most effective. That will be particularly important as we consider the possibility of future outbreaks, be they isolated to individual facilities or as part of a second wave or surge of the pandemic, of which we must acknowledge the possibility.

It is important that, where we can improve on our performance from our initial experience, we try to do everything within our power to make sure that we do so. The rapid learning initiative will be central to that.

Domiciliary care has also faced significant challenges. We supported that sector and tried to ensure that there was funding continuity when organisations were not necessarily able to deliver against their contracted hours, because there was a period when, for entirely understandable reasons, some individuals and families did not want to allow a carer into their home. Given that members of the extended network of support of those individuals were maybe not at work, they wanted to provide more care to carers. We felt that it was important not to destabilise those domiciliary care providers because we knew that we would need them as we moved into recovery, so financial sustainability was important for them.

The challenges facing the sector are reflected in the strategic framework for rebuilding services, which was published on 9 June. As I said, work is under way to develop recovery plans and to reconsider and refresh our surge plans should there be a resurgence of COVID-19.

I suspect that, if you were to talk to departmental officials for any area of our responsibilities, they would say exactly the same thing: services will not be normal for some time to come. That will not simply be "not normal" because of a lot of hand sanitisers, Perspex screens and social distancing: services will not be normal because we will not be able to return to capacity and productivity levels and manage both the increased demand and the delivery of services consistent with the social-distancing measures that will be required for some time. We must not use that as a an excuse not to do the very best that we can, but, equally, we must manage expectations for the public of Northern Ireland and be honest with them that, as we come out of the pandemic, there will be lasting impacts on our ability to deliver services.

As the Minister made clear, the challenge of COVID-19 has brought into stark relief an issue that I have discussed with you, Chair, and with many of your predecessors at appearances before the Committee: social care is an essential component of health and social care and should be valued in its own right, but it is also inextricably linked to the performance of our healthcare system. The sector has experienced many years of underinvestment. We have stretched the sector incredibly. We often talk about public money and value: there is not a pound in the public sector from which we extract more value than a pound spent on domiciliary care, to the extent that I think that we have extracted so much value that it is not sustainable in the long term. We really have to revisit our attitude, our approach and our funding to the sector. The Minister certainly believes that to be the case, and it will be a focus for the work that we need to do as we go forward.

That concludes my comments, Chair. Mark and I are happy to try to respond to questions. As always, if we are not sure of an answer, rather than wing it, we will say that we do not have the information but will follow up with a response in writing as quickly as possible.

The Chairperson (Mr Gildernew): OK. Thank you. I agree with your closing remarks that we have squeezed every penny out of that pound of spend on social care to the extent that it is creating significant problems. However, there is probably not a better spent pound for overall outcomes in terms of well-being and mental and physical health, and the value that the entire system derives in supporting people to live in their own home.

Mr Holland: We agree with you.

The Chairperson (Mr Gildernew): That is a fundamental point.

I recall first mentioning the care home sector to you on 5 March, when I asked about planning for care homes and what was going to happen. Coronavirus was looming, and we could see what was happening across the world. We all, including Committee members, have watched the horrendous impact of the virus on care home settings, and over 50% of deaths occurred in those settings. In that context, I was extremely dismayed recently to see that on, I think, 28 April, Richard Pengelly issued a letter to trusts stating that they were not to allow, while awaiting the return of a test or, indeed, a positive test, any delay in discharge to care homes. Is any work ongoing on the impact of that decision? Will that impact on how we deal with planning for a second wave, which you mentioned, and better protect care homes in any potential second wave?

Mr Holland: That, along with a number of decisions that were taken, will be considered and reviewed to see what learning can be extracted. I will take us back a little bit. It is important to be clear about some of the reasons why people are discharged from hospitals into care homes. First, it is important to recognise that the discharge is a clinical decision. The clinician who is overseeing the care of the individual will make the determination that someone should be discharged, and that is made knowing where they will be discharged to. Secondly, we have to recognise that, even in the best of times, it is not a good idea for people who are frail or, indeed, anyone, to be in an acute hospital for any longer than they need to be. Quite often, it is framed as a case of the system wanting to clear beds because it is expensive to have people in beds. That is not the primary motivation. The reality is that, when someone is in hospital for longer than they should be, even outside of a pandemic, their risk of acquiring a hospital-acquired infection is high, as is their risk of becoming increasingly frail and debilitated. The mobility of older people goes down the longer they are in an acute hospital. There is a whole range of reasons for always seeking to move people out of hospital as quickly as possible. Thirdly, it is also important to recall that we were looking at the collapse of acute healthcare facilities in other parts of Europe. Those facilities were becoming absolutely overwhelmed. We saw it in Italy, in Spain and in parts of France. It was certainly true that we felt that it was important to make sure that we were able to maintain an acute healthcare system that could respond to the pandemic. Finally, the guidance issued on discharge made it absolutely clear that people should be discharged to care homes only where a care home can adequately manage the care of that patient. That was based on the fact that, every year, care homes manage outbreaks of communicable diseases, ranging from gastroenteritis through to flu. At that stage, no one fully understood the particular qualities of coronavirus and how infectious it is and its routes of transmission. Based on the experience of care homes in managing outbreaks and infectious conditions every year, we said clearly in guidance that people should be discharged to a care home only where they can practise barrier nursing appropriately to contain the infection. We need to look back at all those positions and choices, but those were the factors and features of those decisions.

The Chairperson (Mr Gildernew): I want to pick up on a number of issues relating to that. First, we all understand the point about clinical decision-making, but we were not operating in a situation where clinical decisions were able to be made. Clinical decisions on bringing in people with red-flag cancer or people with other conditions had to be deferred. I recognise what you say about general infection procedures, but, in this outbreak, there were particular vulnerabilities for people living in care homes and particular issues with the transmission of coronavirus in congregated settings. The other thing — this is probably the most significant thing that I want you to reflect on and to answer — is that it was clear on 28 April that hospitals were not being overwhelmed by a surge. Therefore, why was that directive being reinforced in, I understand, bold print at that time?

Mr Holland: I would have to check the antecedence of that particular letter, but it was certainly not a change of policy. That was in place at an earlier point and people were being discharged from acute settings into care home settings.

The Chairperson (Mr Gildernew): Should the policy have changed? That is the point.

Mr Holland: We need to undertake an exercise to re-evaluate a range of decisions to see whether the evidence was there to support them at a particular point. Overall, I have set out why people were discharged from care homes and why people felt that that was reasonable. That will be subject to scrutiny.

The Chairperson (Mr Gildernew): OK. My second point is about developments this week. We had the series of incidents at Cherry Tree, Dunmurry Manor and Muckamore. We have also had the CPEA review. In the context of the rapid learning initiative, and the Chief Nursing Officer heading that up, I have questions about it. Many of the issues in those settings were to do with regulatory matters, but we need to bear in mind that those are people's homes. That social care and that social opportunity need to be reflected. How is the CPEA report linking in with the rapid learning initiative and when will it be published?

Mr Holland: OK. I will start with the point about the rapid learning initiative and the relationship between healthcare and social care and then address CPEA. I will ask Mark to add to the current status of the CPEA report.

Chair, you are right to point out that those are people's homes. The Minister, Charlotte and I have discussed that, and it is certainly not our intention to try to turn those facilities into subacute community healthcare facilities. There will certainly be social care and social work input into the rapid learning review and a framework for increasing healthcare support to those faculties. The way that it is best thought of is that people should be supported to live in their home for as long as possible with increasing levels of healthcare needs being met in that setting. When I say "their home" that could be their private residential address, a residential home or a nursing home. The key is not to turn them into healthcare facilities but to provide the in-reach and support that enables people to stay living in those homes. It is not about changing the character of homes and turning them into healthcare services; it is about providing in-reach that enables people to stay living there for as long as possible. Some of the findings of the CPEA work on Dunmurry Manor are with us for fact-checking, and we will certainly make sure that those are available to the team doing the rapid learning review. I know that we definitely have the safeguarding paper for fact-checking.

Mr Mark Lee (Department of Health): The CPEA has completed papers on different issues. One of the furthest progressed is on safeguarding, which we expect the final version of very soon. There is a paper on handling complaints that we expect to start going through a fact-checking process on soon. We also expect to receive one on regulation for fact-checking in the not-too-distant future. The progress of those reports has been impacted by COVID-19, but we will continue to press CPEA to bring them to us as soon as it can so that we can draw leaning from them.

The Chairperson (Mr Gildernew): You said: "as soon as possible". When can we expect to see reports being published?

Mr Lee: To some extent, we are in the hands of CPEA, which needs to make sure that it is completely happy with its reports to us. I hope that the safeguarding one will be in days rather than weeks.

Mr Holland: Before CPEA shares each of its reports with us, it has to clear them with the PSNI. You will be aware that there is a PSNI investigation into whether there were any criminal offences associated with what happened in Dunmurry Manor. They are trying to make sure that the material in those reports does not comprise any investigation or potential prosecution, and that has added a degree of delay. I spoke to the relevant superintendent in, I think, the past eight or nine days and emphasised the need for us to be able to act on those as soon as possible, and he fully accepted that. The PSNI also wants to be able to act on them as soon as possible, as it has an interest in those reports beyond its investigation. Safeguarding, in particular, is an activity that is jointly taken forward by many partners, and the police are critical to that. They are anxious to work with us to improve adult safeguarding in Northern Ireland on the back of the information in the CPEA report.

The Chairperson (Mr Gildernew): Finally from me before I go to members, in relation to the Regulation and Quality Improvement Authority (RQIA), what assurance can you give the public that there is a regulatory framework in place that provides safeguarding to the maximum standard and is world-leading, given the chaos in relation to the resignation? What can you share about what led to that resignation, and what is being done about that and about ensuring that we have a robust system in place?

Mr Holland: The first thing to say is that, obviously, the Minister has commissioned an independent review of the events that led to the regrettable resignation of the board of the RQIA. I will not pre-empt the findings of that review or speculate as to what those findings will be. I will say that the decisions that seem to have started that chain of events related to the suspension of routine inspections and the deployment of key staff within the health and social care system.

With regard to the first of those issues, it was really important to minimise footfall in and out of care settings — minimise, not eliminate. Some people have said, "Why did you stop the RQIA going to visit those facilities while other people were going in and out?". Those other people were staff delivering care, and you cannot stop that. That is not within your gift in terms of minimising, whereas stopping inspectors moving from facility to facility was deemed by the sponsors of the RQIA to be a reasonable step. When that was presented to me, I recognised that as being a step that had been taken by many other regulators in other jurisdictions. Certainly I think that, in these islands, every nation took the same step.

The second point was about the redeployment of staff. One of the most forceful messages that I heard about the pandemic was from one of the senior doctors in the World Health Organization, who talked about the need for leadership and for people to take decisions really quickly, without always knowing that the decision was going to be entirely the right one, that moving quickly was paramount. To do that, you need people of experience and calibre in the right positions. There was a judgement made that the chief executive of the RQIA should lead the Public Health Agency (PHA), that the medical director in the RQIA would support the Department's clinical team in leading the response and that Dermot Parsons would become the acting chief executive of the RQIA.

As I said, the Minister has commissioned a review of how those processes were handled and how the board was dealt with. All I will say is that, in my experience of the past 13 weeks, I certainly appreciated and felt it was critical that there were senior people in those positions. Mark and I had very close contact with the RQIA throughout that period and had a phenomenal amount of access to, and worked collaboratively with, Dermot in that role. It never once occurred to me that we were not experiencing a good service from that organisation because of those changes. That is a subjective view, but that is just my honest and sincere experience of the past few weeks. We worked incredibly closely with the RQIA, and Dermot provided very effective leadership in that time, in my dealings with him.

Mr Lee: Obviously, the safeguarding framework is not dependent on the RQIA's routine reviews to receive referrals, so care home staff, families and trust staff can make referrals if they are concerned about an individual and they think that there is a safeguarding issue. That has continued to be the case. One thing we have done as a result of the reduction in footfall of RQIA inspectors is to provide additional health and social care trust staff to homes. They have been provided with guidance and an aide-memoire of things to consider about safeguarding issues in care homes to make sure that they are as alert as they can be to any issues, to try to balance the fact that routine inspections have not been going in in the same way.

Mr Holland: One final point to add is that they were routine inspections. That did not mean that the RQIA was not prepared to go out and inspect a facility where it had cause to believe that there were live issues. I am sure that, before this session is over, you will ask about Clifton Nursing Home. That is an example of where, during this period, while routine inspections were suspended, the RQIA inspected that facility.

Ms Bradshaw: Just to pick up on the independent review of the RQIA board resignation, do you know who wrote the terms of reference for that investigation? Can you give us some insight into how that appointment process took place so quickly, just so we are assured of its independence and that we are not marking our own homework?

Mr Holland: I have to be clear: the sponsorship of the RQIA does not fall to me, and I have not been involved in that process at all. My earlier comments were about our experience of working with those organisations through the pandemic, but the process of changes to the RQIA's operation, and now the process of the independent review, do not fall within my remit. However, I believe that the Chief Medical Officer is appearing before the Committee next week alongside the Minister, and I am sure that they will be more than happy to clarify the points that you raise.

Ms Bradshaw: Just to clarify, would it be Minister and CMO level that would have written the terms of reference?

Mr Holland: I do not have an answer for you. I was not involved in the process. I am sure that they will be able to provide an answer. I do not know who wrote the terms of reference. I have not been involved in that at all.

Ms Bradshaw: OK. Thank you for that.

I know that you are here to talk about adult social care, but I want to raise an issue that was raised with me last night about looked-after children. We see that they are restarting parental contact, but there has been a delay in the guidance being issued for reconnecting with siblings. I am conscious that it is a very vulnerable group of people, and I would like to see those contacts being expedited. I would like you to intervene to bring that forward as quickly as possible.

Mr Holland: I will certainly check on the status of the guidance in relation to contact and write to you to update you on that. Understandably, a lot of focus has been on the people who are most vulnerable to the severe physical consequences of the pandemic, but, as time goes on, we are going to become increasingly aware of the impact on young people. People talk about sacrifice, but we do not properly understand the sacrifice that young people have had to make throughout this. I cannot remember what I did between March and June two years ago, five years ago or nine years ago, but I can remember what I did during those months in 1979, when I was 16. It is a really special time, and we have turned it upside down for young people. That is particularly the case for young people who are in care. Your question is well placed. It is a priority for us to try to respond to the needs of those young people, and contact is at the heart of that. I will write to you, and I will also pursue, in advance of the letter going to you, where we are with the guidance.

Ms Bradshaw: Thank you very much.

The Chairperson (Mr Gildernew): I should declare an interest as I was previously a social worker and, indeed, because of the fact that I am on a break from one of the trusts.

Mr Holland: And hopefully a future role at some point, Chair.

The Chairperson (Mr Gildernew): We will see if time allows. There is not a great deal of it at present.

Mr Easton: Thank you for your presentation and for the work that you have been doing. It is important to get that on the record. You mentioned the percentage of care home staff and residents who have been tested for COVID-19. Do you have figures on how many staff and residents, out of those tested, have had it?

Mr Lee: How many care home residents have been tested?

Mr Holland: Or positive results?

Mr Easton: No, how many have actually caught it.

Mr Lee: I may not be able to put my finger on that immediately.

Mr Easton: I will go on with another question while you do that.

Mr Holland: We get returns, and, rather than give you an inaccurate figure, we are more than happy to look at the data and write to you to confirm the figures. Is that for both staff and residents?

Mr Easton: Yes.

I am curious about the effect on social workers. From what I am led to believe, there has been quite an increase in different types of abuse. I am wondering how the staff — the social workers — are coping with that extra demand. I am also keen to hear from you about foster carers. Has there been a problem with getting foster carers due to COVID-19? If so, how are you coping with that?

Mr Holland: On the first point, the Chair recalled us talking at an early point in the progress of the pandemic. Unfortunately, at that stage, you will recall, Chair, that we had noted, from looking to other countries, that there were indications that, under lockdown conditions, abuse increased, particularly domestic violence, which in itself creates an abusive environment for children, but we also believed that there would be evidence that there was a greater risk of certain kinds of child abuse. The extent of that is not clear. One area in particular where, intuitively and on the basis of our understanding of research, it is not unreasonable to assume that there may well have been an increase is familial sexual abuse. That is not something that is easy to ascertain in the short term; it will probably be many years before we understand the impact of lockdown on that kind of abuse.

Certainly, we knew that there was going to be an increase in abuse from the beginning. Initially, the referrals about children in need dropped substantially. Again, that might sound like it contradicts the idea that abuse was increasing, but the people who identify children as being vulnerable and refer them require to see and interact with children. Children were no longer at school, they were no longer in youth clubs and they were no longer engaging in a range of activities; they were in their houses, and so referrals dropped. That picture has now changed, and we are seeing a surge — certainly, an increase — in the number of children who are being placed on the child protection register and the number of children coming into state care. That is a consequence. That will undoubtedly have an impact on social workers, who have done a fantastic job throughout.

We are beginning to get some case studies and some write-ups of some of the work that social workers have done. I hope to share that with the Committee at some point in the future, because it is good to share that kind of good practice and allow you to see it. But I also have to say that staff from every discipline have been impacted by this, and one of the challenges, along with the many other challenges that I referenced in the opening statement, is how we provide self-care and supported care for staff. There are staff who are going to be experiencing emotional turmoil and anxiety, all the way through to staff who, I am sure, will meet the clinical definition for things like PTSD after this experience. One of the things that we are looking at in our recovery plans is how we support those staff. We already have psychological support available through a helpline, and we are developing a significant number of online resources to help people to access things that will be of assistance to them.

The final part of your question was in relation to foster carers. I do not have up-to-date information about the foster care position, but I do know that foster care selection and recruitment were suspended due to COVID-19. That, given that we were already under pressure for foster carers, is going to cause us difficulties. Our response to that will need to be multifaceted. We need to try to make sure that we have capacity in residential children's homes, although that is not ideal and our first preference is always for a foster care placement. Secondly, we need to look at very quickly restarting family support services, because the most desirable outcome in this situation is to not need to take a child into foster care in the first place and to instead provide support to a family to enable it to cope with whatever difficulties it faces. Family support hubs continued to run in one form or another throughout the pandemic. We need to turn our focus to how we step up family support. Finally, we need to look at how we restart foster care recruitment and selection. That will be part of our recovery plan.

Mr Carroll: Thanks, Seán. I cannot always hear at this Committee: did you say 7,000 hours were supplied?

Mr Holland: I think it was 17,000.

Mr Carroll: Thanks for that.

As you are well aware, the police investigation into Dunmurry Manor began in 2018. You said that conversations are ongoing. At what stage is the investigation?

As the Chair said, in relation to the RQIA generally, there has been concern, if not heavy criticism, about Cherry Tree House and Dunmurry Manor. There are also serious questions about Muckamore Abbey. To be frank, people view the resignation of the entire RQIA board as a calamitous event. Nobody, either the Committee or the public, would dismiss the need for a robust and independent organisation to inspect health and social care. Over many years, however, there have been concerns about lack of action from the RQIA. People have commented to me that the RQIA is not truly independent of the Department. Will you address those points? Given the events not only of this week but of the last number of years, when do you think there will be a regulator in whom people can have trust and faith? People are scratching their heads, especially with events this week, and asking, "What is going on?".

Mr Holland: OK. Gerry, I hope that you will forgive me my first answer, because I know that it is a frustrating one. All that I can say about the police investigation is that it is ongoing. Although we liaise with the police about their investigation, it is in the most general terms. The police rightly do not discuss operational details with us. That is important, because although they are investigating an independent provider, it is part of the care system. It would be inappropriate of them to share operational details of the investigation with me. I know that it has been extensive and that they have committed significant resources to it. I hope that it will conclude as quickly as possible, whatever the outcome. The police would have to answer for the state of their investigation.

I will make a few points about the RQIA, some of which are general and others specific. My first point is specific — I echo the Minister's comments, which, I think, he made yesterday — that, while what happened with the board is regrettable, there is no reason for it to impact on the day-to-day operation of the RQIA. Certainly, as I said, through the pandemic, Mark and I have been working more closely with the RQIA than at any time in my career. Whatever has been happening with the board of the RQIA, I have not experienced its impacting in any way on the operation of the organisation.

My next point is a general one. We need to be realistic about what we can expect from any regulator. That is not a comment about the RQIA; it is about any regulator of any system. Regulators do not guarantee the adequate performance of a system, whether they regulate schools, healthcare, social care or anything else. Regulators give you a snapshot insight into how an organisation or system is operating at a point in time. Ultimately, the responsibility for the effective operation of a service lies with the people who provide that service. In the case of care homes, those are the independent sector providers. A regulator should be able to give us an insight into how well, or otherwise, providers are discharging their responsibilities, but not in a 100%, fail-safe way. Regulators go in on the day and see what they see: that is what they can report on. Unfortunately, the nature of abuse, in particular, is that it is, almost by definition, covert. People seek to conceal abuse, which is a challenge for any regulator.

The work of CPEA is considering the role of regulation in regard to the events at Dunmurry Manor, and I look forward to seeing the report on that. I have not yet received it, but I am sure that, when it is available and public, we will be able to answer that question more effectively. Mark, do you want to add anything?

Mr Lee: The Department had already been carrying out a review of regulatory policy to put in place a new regulatory framework. We understand that a proposed policy document that sets out the principles is still intended to be issued for consultation later this year.

Mr Carroll: People whom I have been speaking to are concerned that no information is coming from the police investigation into Dunmurry Manor. They want a speedy resolution. The problem with investigation and investigatory bodies is that, often, concerns are raised but, for the most part, nothing is really done; there are no sanctions or fines. That has been a repeated action with issues around RQIA, and that is a concern that a lot of people have.

Mr McGrath: I have taken a wee note of some of the things that you have said here today. You said that, during the pandemic, the RQIA provided a safe and effective function and that what has happened will not impact on the work of the RQIA. That could typify the problem with the board. You are saying that you do not need a board to be able to do the work and that what it did during the pandemic was proper, safe and effective, but the board felt that it had to resign because of what happened in that process. If those are the sort of remarks that are being made about the board, that really signifies to me that there are relationship difficulties between the board and the Department. If I were a member of that board, I would be very insulted by statements about it being grand in what it did throughout the process and, "We don't really need you to be able to do the work". I hope that you can qualify those to give a bit more —.

Mr Holland: I will do more than qualify them: I challenge them. I will rely on Hansard: I do not think that that is a reflection of what I said. In relation to the operation of the RQIA not being affected by the resignation of the board, I was referring to a ministerial statement; I believe that he was referring to the fact that the day-to-day operation is not directed by a board. A board has a very important role: it assures governance, it assures challenge to the executive officers of an organisation, and it provides a degree of accountability to the Department for the running of an ALB. However, it does not direct operational activity; that is not its job. I sit on a number of boards as a non-executive director, and it is always emphasised to me by the chairs who work on those boards that it is not our job to run the organisation. The role of a board is different from the role of executive officers, and I believe that that is what the Minister was referring to.

I am not giving a global assessment of the performance of the RQIA throughout the pandemic; I do not have that information or knowledge. All that I am saying is that I worked very closely with it, as did my colleague, and, during those encounters, it worked very effectively with us. I am happy to illustrate what we are referring to. One of the key things for us through the pandemic was trying to get information about what was happening. That is always a challenge because, on the one hand, you do not want to burden people with bureaucracy and filling in forms, particularly not when they are responding to a pandemic, but, on the other hand, you need to have real-time information to understand what is going on, how you can support a sector and how you can respond. The RQIA played a critical role in that. Mark can expand on that. We were able to get daily reports from care homes about how they were assessing themselves in terms of their staffing, outbreaks and access to PPE via the work of the RQIA. That is all that I was commenting on.

Mr McGrath: We had the former chief executive of the RQIA here at, I think, the very end of April or the very beginning of May; I cannot remember exactly which. Some of us challenged him about the visitations that were made to homes. We then asked for a breakdown of the visits that had taken place. Since that meeting with the former chief executive, visits to homes have shot way up. We have the list of dates broken down; we see that there was a series of remote visits and a handful of inspections, but, as soon as we raised that question, all of a sudden, the numbers increased. Maybe I have a suspicious mind, but that makes me suspicious; once we challenged something, all of a sudden, things changed. You mentioned Clifton House, into which there was quite a detailed 'Spotlight' investigation. All the interactions with it took place after we raised issues about RQIA in the Committee. The visitations all took place during May, and there was nothing during March and April. When the Department asked the RQIA to stop doing the visitations, it sometimes went to remote investigations. What was involved in a remote investigation that is different from an on-site investigation? Were you satisfied that, if a series of homes had issues, a remote exercise was able to help and was able to prevent people dying, which they inevitably did in some of those homes?

Mr Holland: I have to make it clear that this is not a case of trying to avoid the question, but I am not best placed to answer some aspects of your question. I am not the sponsor in the Department for the RQIA, and some of those questions need to be answered by the RQIA and its sponsor.

I will say something about the profile of the visits. I am not sure of the exact dates, but it is probably inevitable that, as the course of the pandemic changed, the profile of visits may have changed. You will be more cautious at the height of the pandemic, but, as community transmission reduces, you may feel — I am nervous because I do not want to speak on behalf of other people, who can answer these questions for themselves. That may be a factor in the visits.

In relation to Clifton House, it should be noted that the RQIA did conduct boots-on-the-ground visits before the lifting of the prohibition on routine inspections. It was still within the period when routine inspections were not happening, but, where there was an identified need, it did conduct frequent visits to Clifton House.

Mr McGrath: It did not do that during March or April, but, after we raised the issues here, the visits happened and the RQIA found the issues. I asked some of those questions because the RQIA wrote to us and named you. The letter states:

It details that it changed a lot of its procedures based on correspondence from you. I know that you say that you are not its sponsor, but it is clearly saying that, unless it means somebody else.

Mr Holland: If you share the correspondence with me, I will be able to clarify that point.

Mr Sheehan: Thanks, Seán and Mark, for coming in. I want to go back to the question that Paula asked about the independent review of the RQIA that has been established. Are you aware of whether the Department or the PHA commissions services from the individual who has been appointed to head this up?

Mr Holland: I cannot answer that with 100% certainty. I do not know the gentleman, and I have never had any direct dealings with the organisation. As I say, I did not set the terms and was not party to the selection. However, I am aware — I am fairly certain — that Onboard is an organisation that provides training to prospective non-executive directors across a range of organisations, and I imagine that that will have included people who are going on to boards of arm's-length bodies sponsored by the Department. I suspect that that is the case, but I would need to double-check. As I say, I have never had any contact with the organisation.

Mr Sheehan: OK. Thanks for that.

Moving on, hospital admissions from care homes dropped by almost a third from February to March, and there was another drop of a third from March to May. This is not just individuals; it is the number of admissions. It shows a considerable drop in admissions to hospitals from care homes. What would you put that down to, considering that we have heard that, if someone needs to be admitted to hospital, they will be admitted?

Mr Holland: My answer would be speculative at the moment. We need to analyse the data. People with clinical expertise beyond mine as a social worker will probably be critical in helping us to understand the situation. There is always a desire to make sure that people who are at the end of their life are not moved. One of the big challenges over the past number of years has been the number of people who die in hospital who probably should not die in hospital; they should be able to die in their own home or in a care home. It may well have been related to palliative care, but I do not know.

Where possible, you are trying to avoid movement around the system. Where you can care for people where they are, that is what you should do. Mark, perhaps you could add to that.

Mr Lee: It is difficult to say without a systematic look at it. I am aware that a number of trusts increased their in-reach into homes to make geriatricians or others available to provide support directly into the home. It is like an enhanced acute-care-at-home service that a number of the trusts already run. It was a change in the way that acute care was provided to try to avoid people coming into hospital and to provide that care, as far as possible, in homes. That would account for some of those changes. We would need a systematic look at it to fully understand all of the drivers and to what extent they were important in the change in those numbers.

Mr Sheehan: Some people would argue that decisions were being made that certain patients would not qualify to be put on ventilators, for example. If those were particularly frail or elderly people, maybe with co-morbidities, that decision would have been taken on site, in a nursing home, and therefore people would not have been admitted to hospital. I am just throwing that out there. You are saying that you do not have —.

Mr Holland: What I would say in response to that is that the decision about any course of treatment is made by a clinician who is supervising the care of an individual. There was certainly never any decision at a policy level to restrict people's access to certain kinds of treatment, nor could there ever be in that sense.

Mr Lee: We do have some figures for the number of admissions to hospital for COVID-19 —.

Mr Sheehan: Forgive me for interrupting. Seán, if there is only one ventilator and you have two patients who need ventilated, decisions are made on that basis; they are not necessarily made on a clinical basis. Obviously, there is a clinical input, but, when there is only one ventilator, someone loses out.

Mr Holland: Those would be decisions of prioritisation made by clinicians who were overseeing the resources available to them against the demand in front of them.

Mr Lee: We never reached that point.

Mr Holland: We never reached that point.

Mr Sheehan: It comes back to the issue that the Chair raised about acute hospitals. You raised the issue that we saw acute hospitals being overwhelmed in Italy and Spain and parts of France. We also saw care homes and the elderly being disproportionately affected in those countries, yet there did not seem to be any real action taken here to deal with that issue.

Mr Holland: I would dispute that. There were a number of actions. I recall the point at which the Department stepped up the response to the threat of the pandemic: it was the day we started activating plans for acute hospitals. That was the same day that we started asking ourselves what we needed to do to support care homes in the event of a pandemic. It was not the case that one started and then we subsequently got around to the other. There was a focus from the beginning.

For example, on PPE, the decision was made at a very early stage, before care homes were being directly impacted by COVID, where we recognised that there was going to be a need for PPE in the care homes. Care homes have a responsibility to provide PPE; they use it every day of the year. We recognised that there was a risk that they would be overwhelmed, because we knew that there was a risk that the virus would spread to care homes and that there was a particular vulnerability. We took a decision very early on in the planning that trusts needed to consider care homes as if they were part of their own organisations when it came to allocating PPE to them. Whether we were as effective as we wanted to be, whether it worked as well as we hoped, whether the virus behaved in ways that we did not fully understand, whether we properly or did not properly learn the lessons from other countries, I do not know. Others will be the judge of that, I am sure; I have no doubt about that. It certainly was not the case that we forgot about them. We started planning at the same time as we did for the acute sector.

The Chairperson (Mr Gildernew): You have mentioned the plan a couple of times, Seán, and we have seen the surge plans that were published for the hospitals. Can you provide the Committee with the plan for care homes at that point?

Mr Holland: The plan for care homes was incorporated in the trust plans.

Mr Lee: We received an adult and children social care surge plan from the Health and Social Care Board, I think, on 13 March. We commissioned it in the early stages of March, and that came back to us then. I am sure that we can find that and provide it to you. It is worth saying that the focus, at that point, was on freeing up staff to respond to the surge. It was really about saying, "How can we get staff free to respond where we need to respond?".

Mr Holland: In the early days, that was one of our primary focuses, because we recognised that, in the event of a pandemic —. We know that our system runs very hot; that is the phrase that we use. We talked earlier about how we have underfunded this system and how we extract a lot of value, so we knew that it was a fragile system. We recognised that one risk would be that, if significant numbers of staff became sick, how would we continue to run the service? In the early surge plans, that was a particular focus, although, as I say, PPE was also a very early focus for us.

The Chairperson (Mr Gildernew): That plan apparently deals with freeing up staff. I asked you, on 5 March, what plan was in place to protect care homes and the people in them. Can that plan be shared with us?

Mr Lee: Guidance was issued, including for care homes, on 27 February, and the next version was issued on, I think, 13 March. Further guidance, specifically for care homes, was issued to them on, I think, 17 March. That was the flow of the guidance, and it set out what we wanted care homes and trusts to do.

The Chairperson (Mr Gildernew): Was there a structured plan?

Mr Holland: That guidance clearly set out what we believed different parts of the system should do and how they should behave in the future. That constitutes a plan.

The Chairperson (Mr Gildernew): Can you get that guidance to us so that we can look at it?

Mr Holland: Yes.

Ms Flynn: Thanks to Seán and Mark. I have been lobbied, as, I am sure, other members have, about families' visiting rights in care homes. Are you aware whether there is legal standing in turning away a family or a carer who wants to visit their loved one in a care home? Is there any update on the funding reaching the sector for the use of tablet devices in care homes, if families cannot visit for a good while yet?

Mr Holland: It is ultimately for each individual care home to determine its visiting policy. However, we have referred to it in guidance and, basically, said — I look to Mark, as the person who drafted the guidance, for a more accurate description — that care homes need to take a risk-based approach and need to be very conscious of infection control measures and that we recommend that they absolutely minimise footfall in and out of care homes during the pandemic. That position reflected where we were when we were seeing more significant community transmission. I believe that there is a group looking at visiting policies in general and reviewing that position as we move into the next stage. However, I need to be updated on the work of that group.

The last funding package that the Minister announced included, I think, £2·2 million specifically for equipment. Some of that equipment was of a clinical nature, so it was to provide additional things to enable people to monitor oxygen levels and to make sure that everyone had adequate and appropriate thermometers. We also said that that fund could be used to access equipment that facilitated contact between relatives and residents, and I think that we specifically referenced tablets.

At the Minister's instruction, we are looking at opening up that resource to allow care homes, if they want to, to purchase equipment that might facilitate face-to-face visitation, but we want to make sure that that is only supported where there is evidence that it is a safe arrangement. We are working with our colleagues in the PHA at the moment, but we hope that that money will be able to support care homes.

I am sure that, like me, you have seen innovations from other places that are at a different stage in their pandemic journey and are further along in looking at innovative ways of facilitating contact. I saw Perspex boxes in the grounds of homes, different uses of screens, tunnels and so on. We are certainly interested in those ideas and, in principle, do not have a problem with the equipment money supporting those. However, we want to check with colleagues in the PHA that they are a good idea and do not carry additional risks. Mark.

Mr Lee: The guidance refers to nursing and residential homes implementing their existing policies on infection control at the home. As Seán said, this is guidance from us to them about implementing existing approaches, just as they would if there was an outbreak of vomiting and diarrhoea or whatever. As Seán also said, we are chasing up progress on the disbursement of the £11·7 million to see how far along we are in getting it out the door.

Mr Holland: It is important to note that, while this is the second tranche of funding, the two tranches have been very different. With the first £6·5 million —?

Mr Lee: Correct; yes.

Mr Holland: There was a very straightforward arrangement to disburse money. We recognised that people needed money very quickly, so it was a grant system. On the basis of the number of beds, you got £10,000, £15,000 or £20,000. That was a simple arrangement; all you had to do was specify how many beds you had and, bang, you had the money. This money is slightly different. It has to be against spend and has to be accounted for. I think that it was appropriate that, at a stage in the pandemic, we loosened arrangements and tried to look at a very speedy way of disbursing money. As we have moved on, it has been appropriate to make sure that the money is more targeted, can be accounted for and we are not simply throwing money at facilities to use it for whatever they need. The spend will be slower for this than it was for the original tranche.

Mr Lee: Based on a claim back.

Mrs Cameron: Thank you for your presentation. I do not underestimate the job that you and all the other healthcare workers in the system have in front of you. You are very much under pressure. You referred to a group that is looking at visitation: is there a name for that group?

Mr Lee: It is just a group in the Department. Colleagues from the Chief Nursing Officer's group and our team have been looking at that together and have engaged with experts in the PHA and others to think about what the new guidance on visiting should say.

Mrs Cameron: OK. I think that it was Pauline Shepherd who told the Committee that an average stay in a care setting is just 18 months. Given that and given where we are in the pandemic, regardless of what may come in the future, that risk is there and the pressure is there to protect the most vulnerable in society. How do you balance that with the need for visitation, which is vital? I am thinking about older people who have all their faculties and are relatively well. Contrast them with those who might be very confused and have medical conditions that leave them in a very bad place because they cannot see their loved ones and friends. I know that it is difficult, but I am anxious to see some kind of resolution. I understand that it is up to individual homes and that some homes are doing different things to allow that to happen because they want the best for their residents, but we need to find a solution, and we need to find it —

Mr Holland: Quickly.

Mrs Cameron: — urgently. Lives could be lost simply due to loneliness and confusion.

Mr Holland: Your point is very well made, and it illustrates a few issues. The first is that, sometimes, you are looking for the least worst decision, and there is a balance between recognising the importance of family contact and the absolute imperative of trying to protect an incredibly vulnerable community. As the questions have demonstrated, quite rightly, we know that this is a very vulnerable community. We also need to recognise that we are still learning about the nature of the virus, how it behaves and the speed of its spread. The majority of care homes have not had an outbreak, a number of care homes that did have an outbreak have recovered and come back and some care homes have been devastated by an outbreak. We need to understand all of that.

On your point about elderly people, I recall the Minister making a point at one of his press conferences, which reflected an irritation that I also felt. Early on in the pandemic, people were talking about who was dying or surviving. You kept on hearing that four people had died but they all had underlying health conditions or were all elderly. It was almost as if that did not count in the same way. I remember the Minister trying to make the point that you do not measure the value of a life by time.

The fact that someone might be relatively close to their death, as opposed to being a young person in their 20s, is not how you measure the value of a life. It is often in the last months of a life that people reconcile issues that have been going on in families for years or even generations. It is the time when people make peace; it is valuable time. We take your point, and we will make sure that appropriate impetus is given to the work on visiting — absolutely.

Mrs Cameron: I appreciate that.

My last question is about the pressure that social work in particular is under. In your presentation, you said that, basically, things will not return to normal any time soon. Would any change in social-distancing measures — from two metres to one metre — have a positive impact on services and allow some to resume?

Mr Holland: Yes, it probably would facilitate some services. Services that present a particular challenge with social distancing include day-care settings, where there is a fixed amount of space, and you are trying to provide a service to a fixed number of people, so social distancing impacts on your ability to operate. It is like the hospitality sector, where people have described the difference between two metres and one metre as being the difference between being able to operate at 30% capacity and 70% capacity. There would be a similar impact on services such as day-care settings.

Regardless of the rules about social distancing, the reality is that the virus is present in the community, which has an impact on how safely certain things that involve direct contact can be done. We talked about domiciliary care: that has continued, as has work in care homes, and people have received care, and there has been direct physical contact throughout. However, there are other situations where it is important to be physically close to someone. Two days ago, I was talking to both the outgoing and incoming chair of the Royal College of Psychiatrists about the need to innovate and use technology for remote working as a way to manage the challenges of social distancing. They said, "Yes, there definitely are opportunities, but remember that some of the services that we provide are about a relationship, which is developed not simply through the words we speak but by being in the same physical space with each other. It is about contact and the ability to read people's behaviour". The fewer the restrictions, the more the building of such relationships can be facilitated, which is a key part of an awful lot of social work activity.

Mrs Cameron: Absolutely. I will ask a supplementary question. You talked about the outworking of the pandemic and the rising number of children who are at risk, and you said that you are dealing with that. If all our children are back at school in as normal a way as possible and there is evidence that children are much less at risk from the virus than adults and older people, surely social distancing could be reduced to one metre in schools. I had better be careful that I do not ask you something too scientific; that is not your place. What is your opinion about the balance between getting children back to school, regardless of social distancing, because of risks other than the virus that they face in their life?

Mr Holland: The decision on safe distances is not mine to make; I defer to my medical and scientific colleagues to make that determination. They will provide advice, and decisions will be made on that basis. Those decisions need to take into account not only that advice but the advice that social interaction is incredibly important as part of children's development. It can have a lifelong impact on them long beyond childhood. Moreover, schools are incredibly protective. I am old enough to remember a time when the relationship between social workers in child protection and schools was not always necessarily a close one. That is not the case today. Schools and child protection services are absolutely intertwined and integrated. All schools have teachers who are specialist, well-trained safeguarding officers. The fact that children are at school is a hugely protective factor. There are risks and dangers associated with keeping children away from school one day longer than is absolutely necessary, but it has to be balanced with those other factors.

The Chairperson (Mr Gildernew): Is it also a factor that, while children do not appear to be as susceptible to developing the disease, they are quite capable of spreading it to their older loved ones, who are susceptible to it?

Mr Holland: I make the point that the Chief Medical Officer does not practise social work, and I do not practise medicine, so I will —.

The Chairperson (Mr Gildernew): Luckily, he is coming here very soon —

Mr Holland: He is.

The Chairperson (Mr Gildernew): — so we will address that then.

Mr Chambers: Thank you, Mark and Seán, for your attendance today. Seán, if I picked you up right, in your opening remarks you talked about the programme of testing all residents and staff in the nursing-care sector, and you indicated that you hope to have that process finished by the end of this month. It is, obviously, a huge task, and I recognised, from day 1, just how huge a task it is. Is this a one-off, or is there an intention for a second tranche to start again when that one finishes?

The Commissioner for Older People is on record suggesting to the Committee that he would like to see testing done twice a week. Would it be deliverable and practicable for that to happen?

I know that you alluded to this issue in Pam's question. A couple of weeks ago, the Committee received a very touching letter from a member of the public, who asked:

I know that you have talked about that. Last night, there was an item on TV — I do not know whether it was on Ulster Television or BBC —

Mr Holland: I saw the item.

Mr Chambers: — about a nursing home in, I think, Londonderry that had innovated a wheel-in screen that can be brought into a room, which is really quite a cheap option. The joy on the faces of the residents and their families was a joy to behold. Is somebody looking at and coordinating those options and trying to encourage the nursing homes, or is it down to money?

I want to put it on the record that I welcome your reassurance today that the routine work of the RQIA is continuing. Families with a family member in the care sector will welcome that reassurance this morning.

Mr Holland: I will start with the issue of screens and visiting. I will not repeat the points that we have already made about the importance of it. It is not a question of money, because, as I say, the Minister explicitly said to me that he wanted to make sure that the £2·2 million resource for equipment was available to care homes to deliver that kind of innovation, as long as our colleagues in the PHA advise that that is suitable, so we are working on that.

I saw the item, and, you are right: it was very touching. I go back to the points that Pam made and my response to her: time is really precious. We take that on board. We hope to have new information about visiting very shortly.

I am aware of the commissioner's position on the testing programme. Like me, the commissioner is not a scientist or a qualified medical practitioner. I understand where he is coming from, and I understand what he hopes to achieve. At an intuitive level, it certainly makes some sense. What will happen is that this programme of testing will be completed and the results considered by the Scientific Advisory Group, which will report to the Chief Medical Officer. The Chief Medical Officer will then provide advice to the Minister as to what we should do next on testing. That will be the process. I cannot predetermine the outcome, but my understanding of the process is that it will be based on the advice of the Scientific Advisory Group to the Chief Medical Officer. Is that correct, Mark?

Mr Lee: Yes.

Mr Chambers: Thank you.

The Chairperson (Mr Gildernew): Thank you, Mark and Seán, for your attendance today and for your presentations. We acknowledge the significant work that has been done in the care home setting. Unfortunately, we did not get to domiciliary care today, such are the concerns about care homes, but we all acknowledge the good work that has been done and the many steps that have been taken.

On behalf of the Committee, I extend our thanks to every one of the social care workers and domiciliary care workers who work under your direction, Seán, all of whom have been on the front line in very difficult circumstances throughout the worst and most difficult stages of the pandemic.

The Committee's key focus is the lessons learnt from the experience in care homes and how we can do things better in care homes in future. That is what we want to continue to work on, and it is the context of our questioning. I am sure that we will speak to you again in that context. Thank you for today, and all the best with your important work in the days, weeks and months ahead.

Mr Holland: Thank you very much, Chairperson. I wish to make one closing remark that is not directly related to the business that we have been dealing with today, and that is to say that we recognise that there will be mental health consequences from the pandemic. Mental health issues are dear to many politicians' hearts and rightly so. We have moved from a time when people felt that having a mental illness was something to be kept secret and to be ashamed of. A key thing in changing that has been the willingness of people in visible positions, including politicians, to stand up and acknowledge their own difficulties. I am eternally grateful to those who do so. Thank you.

The Chairperson (Mr Gildernew): That is well said, and we very much endorse that remark. Thank you, Seán and Mark. All the best.