Policing by inspection

Inspections can be announced or unannounced

Inspections can be announced or unannounced

DETAILS of inspection reports produced by RQIA raise further questions over why the agency has never exercised its full powers of sanction.

The reports make for disturbing reading but the RQIA’s favoured tactic appears to have been increasing the number of inspections it carries out in problem homes.

Its position is in stark contrast to that of its sister organisation in England: the Care Quality Commission (CQC) which can and does act against homes it has concerns about. Under legislation CQC can issue a:

Statutory Requirement Notice

Notice of Proposal to cancel registration (provider and manager)

Notice of Proposal to vary condition

Notice of Proposal to impose condition

Urgent Application to Cancel Registration

Urgent Application to Vary Conditions

Prosecutions completed

Simple Caution

Warning Notice

The CQC operates under a system of “statutory requirement notices” which allows it to give care home providers warnings, fines or place restrictions on certain services. It can also stop new admissions to the residential care side of a care home if concerns lie in this area.

Since 2008 the CQC have issued over 500 statutory requirement notices and just under 150 notices of proposals to cancel registration – this means the CQC can “effectively close” a care home by removing its license to operate.

The RQIA was established under The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003.

RQIA effectively share identical powers with CQC except for the power to issue a simple caution or a warning notice.

There are two separate approaches to enforcement taken by RQIA. One relates to services regulated by RQIA, such as nursing homes and adult and children’s residential care homes, day care settings, domiciliary care, nursing and voluntary adoption agencies and independent health care services.

The other relates to actions RQIA may take as a result of its review or inspection activities in the statutory sector (health and social care (HSC) hospitals, trusts and agencies).

In terms of regulated services in Northern Ireland, RQIA conducts a programme of annual inspections at all registered health and social care services on a minimum of two occasions per year. During 2010/11 over one thousand of these were at registered nursing homes. Inspections may be announced – with the home receiving notice of the visit – or unannounced which can take place at any time with no advance notice to the home. Where RQIA is aware of an issue within a home, whether through its regulatory activity or other intelligence, additional inspection activity may take place.

When more serious issues are identified RQIA may issue a notice of failure to comply with regulations. To date they have done this on 55 occassions. This allows them to:

Enforce a closure of a premises by cancelling registration

pursue a prosecution

Impose conditions on registration, for example to cease new admissions to a service for a period of time

They have only ever enforced a notice of decision to apply conditions of registration on four occassions and in only two of these, RQIA specifically applied conditions ceasing admissions to services . To date, they have never pursued a prosecution or enforced the closure of a premise.

The Detail has learnt that the most commonly used powers of RQIA usually involve minimum enforcement, such as advice and guidance or recommendations based on minimum standards which usually result in an improvement notice being issued. The report will outline the areas of concern and how they can be approved. For example if furniture in the home is in bad condition, the report will recommend if this should be repaired or replace.

In November 2009 an inspection at Ratheane nursing home in Coleraine found increased evidence of infection in the home. As a result three monitoring inspections were carried out on 9th and 17th December 2009 and 18th January 2010.

Four months later during February 2010, concerns in relation to infection prevention and control practice were still present.

The inspection on 9th December noted that there had been little or no progress made in addressing the majority of infection prevention. The inspector noted that there was a lack of systems and processes in place to address the issues and deep cleaning arrangements had not progressed. Following this an independent nurse consultant was appointed to oversee and address the issues.

Subsequent inspections found that action plans had been developed and satisfactory progress and improvements were being made to address the infection prevention and control issues.

BREACH OF REGULATIONS

The RQIA can also make a requirement against a breach of regulation, for example to ensure the necessary improvements are being made; they can increase inspection activity for a period of time to monitor compliance.

On the 9th June 2011 a secondary unannounced inspection occurred in the Ard Cuan Nursing home in Portaferry.

The inspector was advised by the staff that the registered proprietor/manager was only available in the home for two or three hours per week but was always available by phone in an emergency. The inspector was not satisfied as this did not provide day to day management of the home on a full time basis.

Given the seriousness of the issues raised as a consequence of the inspection the manager was asked to attend a meeting with the RQIA to discuss the inspection findings. Fifteen requirements and twelve recommendations were made as a consequence and this included a significant number of issues that had been stated for a second or third occasion.

NOTICE OF FAILURE

The most serious power that RQIA have used to date is to issue a Notice of Failure to Comply with Regulations. This essentially places the home in a ‘danger zone’ and usually results in a series of follow-up inspections – but nothing further. Over the past three years (April 2008- present) notices of failure to comply have been issued on 14 occasions to nursing or residential care homes.

During an announced inspection at Bloomfields Nursing Home in Belfast in December 2010, 18 requirements and 13 recommendations were made and as a result of the serious concerns, a notice of failure to comply was issued.

The private nursing home has been inspected seven times since November 2009 after repeated failures to comply.

Previous inspections from January 2009, November 2009, July 2010 and September 2010 had already highlighted concerns regarding ongoing breaches in regulations at the home which had not been fully addressed and which the inspectors noted as “disappointing and concerning.”

The December 2010 inspection identified that there were poor systems in place to promote and make proper provision for the nursing, health and welfare of patients in terms of meeting their assessed need. Inspectors were also alarmed at the level of staffing and skill mix provided and observed that while many patients were presenting later stages of dementia, this resulted in behaviours which were challenging to themselves and the staff, but which also had an impact on the safety and well being of other patients.

The inspector noted that these behaviours were not observed to be well-managed by staff during the inspection and had also resulted in an increased numbers of adult protection incidents involving other patients being reported to both RQIA and the HSC Trust.

A follow up inspection from in March of this year again noted that five of the previous requirements and four recommendations had not been addressed and by May of this year there were still three requirements and four recommendations outstanding. These are the last inspections to have been published.

LESSONS FROM THE PAST

This isn’t the first time an RQIA report has outlined worrying conditions with a lack of concrete action.

RQIA claim there regulation activity is underpinned by the principles outlined in the Better Regulation Task Force Principles of Good Regulation (2003). These are: proportionality; consistency; targeting; transparency; and accountability.

However, The Detail has had access to inspection reports from a case dating from three years ago when RQIA carried out over 20 inspections at Orchard Manor Private nursing home in the space of just six months. (see bottom of this story for July 2008 reports in full).

The inspection report for Orchard Manor Private nursing home had flagged up a number of issues

The inspection report for Orchard Manor Private nursing home had flagged up a number of issues

The Antrim-based home was issued with three separate notices of failure to comply (in March, July and October 2008). From April to December 2008, RQIA undertook a staggering 22 unannounced inspections (4 pharmacy and 18 care inspections), ten times the normal amount.

On the 1st July 2008 an inspection was carried out at the Antrim care home. The inspector noted that staffing levels were not adhered to and there was increased pressure on the staff to answer patients’ bells. They noted that one patient required a sample of urine to be taken on the 30th June but it was only sent off on the 4th July and tasks relating to patient care which were highlighted in the diary did not appear to have been completed by nursing staff.

They concluded that staff morale was low and there was poor teamwork between the trained nurses and the care staff. The report also noted that upon entering the building there was a foul smell and floors had not been vacuumed and tables were noted to be dirty. A further inspection 5 days later highlighted that there were still significant concerns regarding:

- Staffing levels

- Record keeping

- General communication between staff

- Staff morale

- Care practices

- Infection control

- Management of wound care

- Competency and capability of staff

It was the opinion of the inspector that urgent action was required by senior management. However, a further unannounced inspection on 10th July noted that there were still fifteen requirements and three recommendations outstanding.

During this inspection one inspector observed that while a registered nurse was taking blood from a patient in the lounge, the procedure was not carried out in line with good practice guidelines and when the inspectors discussed this with the nurse she felt she was competent in this practice.

The inspectors also observed another registered nurse re-dress a wound that had previously been seen by one of the inspectors. The procedure was undertaken in the treatment room which still required cleaning as stated in the 6th inspection. The nurse did not follow correct infection control procedures and wound care management. The inspectors noted that there disappointed that the Deputy Manager who was present, did not intervene.

In December 2008 the proprietors of the home took the decision themselves to close, but this was not a direct result of an RQIA ruling. In fact, despite undertaking almost 2 years worth of inspections in the space of just six months they failed to issue a ruling to cancel registration or to prosecute for specified offences.

So why were more serious steps not taken sooner?

In a statement RQIA said:

“to ensure the necessary improvements are being made in line with our requirements as a result of regulatory activity, we may increase inspection activity for a period of time to monitor compliance. Where necessary, we may escalate enforcement actions against a provider in proportion to the level of risk to service users and the seriousness of the breach of regulation. RQIA also follows up on enforcement action to ensure that quality improvements are achieved.”

The Cancellation of Registration of a registered person – may be commenced by RQIA at any time, it can be used where other actions have failed to ensure compliance and quality improvement by the establishment or agency. However, RQIA has never used this power.

Furthermore an urgent procedure for cancellation or imposing/changing conditions on an establishment/agency – may be taken via application to a Lay Magistrate for an order, if RQIA believes there is serious risk to the life, health and wellbeing of any service user and urgent action is required. Again, this has never been done.

The use of prosecution for specified offences is also an important part of enforcement: to punish wrongdoing, to avoid a recurrence, and to act as a deterrent to others.

None of these actions were taken in the Orchard Manor case or have ever been used by RQIA. In a statement to The Detail RQIA said:

“RQIA takes the issue of notices of failure to comply with regulations very seriously, and we have found that providers generally respond in a positive manner thus achieving significant improvements for the users of health and social care services in Northern Ireland. To date RQIA has not had to enforce the closure of a premises or pursue a prosecution. However, a number of services have voluntarily closed as a result of enforcement action, where they were unable to comply fully with relevant regulations and standards.”

At an unannounced inspection at Belfast care home Clifton House in June 2009 (see below story for full report) two notices of failure to comply were issued after serious concerns had also been raised following inspections on the 13th, 15th and 28th May of that year.

In the inspection reports from the 13th and 28th May issues were raised with regard to specialist seating and wheelchairs. However, there was no evidence that this information had been acted upon by the nursing staff or the homes’ management.

Inspection report for Clifton House from June 2009

Inspection report for Clifton House from June 2009

At 14:45 on 17th June 2009 patient A was observed by the inspector seated in a wheelchair in the lounge very close to the television screen. Patient A was observed to have “slid down” from the wheelchair. The patient’s feet were on the floor and the lap belt, which had been tied in place, was observed across the patient’s upper chest. The registered nurse on duty stated that they had “only left the patient five minutes ago.” The patient’s care records identified that there was a risk from the lap belt when the patient was seated in a wheel chair.

Information provided in the communication book indicated that patient A’s relative visited the home on the 16th June and was upset to observe the patient to be incontinent. During this inspection the inspector also observed patient A in the wheelchair and she was unsettled. The patient had been incontinent and their clothing was wet.

Inspectors were concerned that despite the patient’s high risk of falls, and the risks identified by placing the patient in a wheelchair, management and nursing staff had failed to provide adequate supervision to address the identified risks. Inspectors were concerned that nursing staff had also failed to recognise incontinence as the reason why the patient may have been restless and uncomfortable.

Inspectors also flagged up worrying issues about another patient from this inspection. On 13th May 2009 the inspectors requested that Patient C’s GP be contacted and informed of recent changes in the patient’s health status. When the patient’s care records were examined it informed the inspectors that the GP visited Patient C on the 14th May 2009. The GP was informed that the patient had vomited “brownish fluid.”

The GP requested that specific investigation be obtained. However on the May 28th inspection, there was no evidence to suggest that investigation requested by the GP had been carried out. This was flagged up, but again on the 17th June 2009, five weeks following the request, there was still no evidence that the samples had been obtained and the GP’s requests were effectively ignored while the patient’s health deteriorated.

During 2009-10, a total of 27 inspections took place at the Benn Suite, Clifton House. These included 18 care, 8 pharmacy and one estates inspections. An inspection in November 2010 noted that all requirements within the home had now been been met with the exception of one.

VALUE FOR MONEY

At the moment RQIA is taking £4.5m more out of the already stretched health budget than it was only five years ago when it was first established.

In 2005/06 RQIA received grant aid from the Department amounting to just over £3m (3,123,592) and the total expenditure for that year was £3,83m

At the end of the financial year for 2010 the RQIA had a total expenditure of £6.94m, the gross figure for staff costs amounted to of £5.43m. This is up from the gross staff cost in 2008/09 of £4.50m. The increased figure included additional funds received from DHSSPS on the transfer of the duties of the Mental Health Commission to RQIA on 1 April 2009;

By 2011 RQIA’s remit had grown significantly with even more money being spent by the regulatory body, this accounted for the addition of the regulation of a number of services. At present 1,132 services are registered with RQIA, with a further 300 services currently undergoing registration including including residential family centres and a wide range of independent health care services including certain laser treatments, and private dental practices; To undertake these additional duties RQIA has received additional funding in the region of £1m.

The new figures produced in RQIA’s latest annual report show that as of March 2011, its total gross expenditure had increased once again reaching almost £7.5m.

A recent job advert placed by DHSSPS Public Appointments Unit for a non executive member of the RQIA stated that “the member needs to have experience of Financial Management in an organisation with an annual financial budget/turnover of at least £30 million.”

DHSSPS are responsible for the recruitment of board members to all its non departmental public bodies – the appointment of Board members for RQIA is the responsibility of the Minister for Health. RQIA currently has three vacancies on its board, and RQIA’s Chief Executive, Glenn Houston is currently on a wage that falls between £100 K– 105K per annum, up from £95K-£100K in 2009/10. Back in 2005 the chief executive’s pay band fell between £80-85k per year.

RQIA has had a number of chief executives since its establishment on the 1st April 2005. Mr Brian Coulter was the Chairman of the Authority from this point until his resignation on 31st December 2005. At a Public Board meeting on 12th January 2006 Dr Richard Adams, a member of the Board, was elected by the other members of the Board as Deputy Chairman and to act as Chairman.

The Chief Executive of the Authority during 2005/06 was Mrs Stella Burnside.

RQIA’s accounts show that the pro- rate figure for the pay band of Mrs. Burnside from the1st April to 17th September 2007 fell between £50-55k. The former Chief Executive took voluntary early retirement with employer consent with effect from 17 September 2007. She received the pension and lump sum entitlements arising from her service under the HSC Superannuation Scheme. Since she retired before the age of 60, the RQIA made a single payment of £90,489.94 to the Superannuation Scheme in respect of the early payment of these benefits.