Dáil Éireann debate -
Tuesday, 14 May 2024

Vol. 1054 No. 1

Health (Miscellaneous Provisions) (No. 2) Bill 2024: Second Stage

Minister of State at the Department of Health (Deputy Mary Butler)

I move: "That the Bill be now read a Second Time."

I am very pleased to introduce the Health (Miscellaneous Provisions) (No.2) Bill 2024 to the Dáil. The legislation has two main aims. First, through amendments to the Health Act 2007, it will strengthen the regulatory framework for residential care services regulated under the Act. This includes residential centres for older persons, people with disabilities and children in need of care and protection. The ultimate objective of these proposals is to drive improvements for people living in these centres. These are some of the most vulnerable people and it is vital that we have a robust system of regulation to ensure they are receiving safe, quality care. Second, through amendments to the Nursing Homes Support Scheme Act 2009, it will widen the definition of those eligible to be considered as a family successor to a family farm or productive business assets under the nursing homes support scheme, or, as many people know it, fair deal.

I will begin by focusing on amendments to the Health Act 2007. The Health Act 2007 established the Health Information and Quality Authority, HIQA, and the Office of the Chief Inspector of Social Services. It also provides for a scheme of registration and inspection of the aforementioned residential services and for the making of regulations and the setting of standards on safety and quality in respect of these residential services. The Chief Inspector of Social Services, the regulator of these services, monitors compliance with these regulations and standards. There are three substantive provisions in the Bill to enhance the regulator’s enforcement powers and, consequently, to provide greater safeguards for residents. It is important to state at the outset that in general, there is a good standard of care across our residential services and good levels of compliance with regulations. However, as we all know, this is not always the case. We can see that in the inspection reports published on a regular basis by the chief inspector. In a recent annual overview report of monitoring and regulation of older persons' services in 2022, the chief inspector noted that although there was good overall compliance in 2022, "there are regulations with consistently higher levels of non-compliance over a prolonged period". For these instances, it is essential that effective enforcement mechanisms are in place.

The first of these enhancements will provide the chief inspector with a new power to issue compliance notices, which are an enforcement tool common across other regulated sectors. At present, the chief inspector’s enforcement powers centre on placing restrictions known as conditions on a registration or, in extreme cases, cancelling a registration. The chief inspector has described these as blunt instruments. Compliance notices will provide for a more timely and proportionate intervention where there is a breach of the regulations, focused on bringing a provider into compliance and driving service improvement. Non-compliance with a compliance notice will be an offence under these new provisions and may be subject to prosecution. It is important to state that this amendment is not introducing new requirements or increased regulation on service providers. It is simply providing the chief inspector with a further mechanism to ensure that the current protections for residents, as required under regulations, are adhered to and upheld.

The second enforcement provision relates to the power to enter and inspect premises. The chief inspector currently has the power to enter and inspect premises that are registered or are in the process of registering as designated centres. It is an offence to operate as a designated centre without being registered by the chief inspector. However, there is no explicit power for the chief inspector to enter premises which he or she suspects are operating as designated centres to establish if, in fact, this offence is being committed. To address this, the Bill provides for an amendment to the Health Act to provide a clear and unambiguous power for the chief inspector in this regard and will ensure the protections afforded to residents of registered centres are extended to those in centres operating outside the registration and regulatory system.

The third change being made to enhance enforcement arrangements concerns the timelines for current enforcement processes in the Act. At present, service providers have 28 days to make representations in relation to a proposed decision by the chief inspector to place a condition on registration or to cancel a registration and to appeal a decision of the chief inspector to the District Court. I want to make these processes quicker in order that the chief inspector can take timely action to safeguard residents. The amendment will reduce these timeframes from 28 days to 14 days. I believe that this is a proportionate measure and takes account of the fact that there is generally significant engagement between the chief inspector and the provider in advance of any proposed enforcement decision. The new timeframe also aligns with timeframes for other District Court appeal processes. The Bill also introduces new provisions in relation to the collection of key data from nursing homes. These provisions relate to nursing homes only. The majority of nursing homes are in private ownership and we currently do not have any centralised powers for the systematic collection of key data across the sector on a regular basis. This issue came to the fore during the Covid-19 pandemic. Access to good-quality, collated data on a sectoral basis is crucial to supporting effective national policymaking and service planning. These provisions are to address this gap. The amendments will provide a new obligation on nursing home providers to provide a defined data set to the chief inspector and will provide the chief inspector with new functions to collect, share and publish this data. The categories of data are defined in the Bill and broadly encompass information on the centre itself and the profile of residents and staff. This is the type of data available across other areas of the health service. It is worth emphasising that data will not be collected at the individual level, that is, the resident or staff member but will be in relation to the overall profile of residents and staff in the facility. Safeguards have also been included in the legislation to ensure that any data that identifies an individual will not be shared or published by the chief inspector. There is a small number of further minor amendments to the 2007 Act, which I will mention briefly later.

I will now outline the changes proposed to the Nursing Homes Support Scheme Act 2009. The nursing home support scheme, commonly known as the fair deal scheme, is a system of financial support for those requiring long-term nursing home care. Participants contribute to the cost of their care according to their means, while the State pays the balance of the cost. As Deputies will be aware, I introduced an amendment to the scheme through the Nursing Homes Support Scheme (Amendment) Act 2021, which extended the three-year cap that applies to the applicant's principal private residence to family farms and business assets, where a family successor is appointed. This family successor must continue to run the farm or business for at least a period of six years and have at least consistently applied to running the family asset for at least three of the last five years. This was a really important change to safeguard and protect the viability of family farms and businesses and it ensures that more family farms and businesses are handed down to the next generation. Since the introduction of the amendment, which came into operation in October 2022, there have been 301 applications, with 96 being successful. Since introducing these amendments, it has become clear that a small group of individuals with no close relatives have sought to benefit from this relief but cannot because they do not have a person who meets the eligibility criteria for a family successor, as currently provided for in the legislation. These proposed amendments to the fair deal scheme will ensure that the safeguards for family farms and businesses apply to the extended family, including cousins, great-nieces, great-nephews and great-grandchildren, further protecting the viability and sustainability of these businesses into the future. This is a really important change for individuals who do not have immediate relatives. There are also a number of technical amendments to the Nursing Homes Support Scheme Act in the Bill, which I will mention briefly later.

I will now provide a brief explanation of the sections of this Bill. The Bill is divided into three parts, with 35 sections. Part 1 is for the preliminary and general provisions of the Bill and contains only one section.

Section 1 contains standard provisions in relation to the Short Title and commencement arrangements. Part 2 provides for amendments to the Health Act 2007 and contains sections 2 to 19, inclusive.

Section 2 is the standard interpretation section and provides that the principal Act refers to the Health Act 2007.

Section 3 sets out amendments to section 41 of the 2007 Act to provide for new functions for the chief inspector to collect key data relating to designated centres for older people - nursing homes - and to inspect premises where he or she suspects the business of a designated centre is being carried out while unregistered.

Section 4 sets out amendments to section 49 of the 2007 Act to provide that any details of any fines or penalties imposed under the Act will be entered on the register of designated centres maintained by the chief inspector. This will enhance transparency.

Section 5 inserts a new section 51A into the 2007 Act to provide an express statutory power for the chief inspector to remove a condition attached to a designated centre’s registration without the need for an application by the registered provider as currently required. This will remove an unnecessary burden on the provider and speed up the process.

Section 6 is a consequential amendment arising from Section 5 and amends section 53 of the 2007 Act to provide that the chief inspector must notify the provider of the decision to remove a condition.

Section 7 sets out amendments to section 54 of the 2007 Act to reduce the timeframe in which a registered provider may make representations to the chief inspector in respect of a proposed decision regarding registration from 28 days to 14 days.

Section 8 provides for two amendments to section 55 of the 2007 Act. The first is another consequential amendment arising from section 5 to provide that the chief inspector must give notice to the provider of a decision to remove a condition, and the second a reduction in the timeframe from 28 to 14 days.

Section 9 amends section 57 of the 2007 Act to reduce the timeframe in which a registered provider may appeal a decision of the chief inspector regarding a registration to the District Court from 28 to 14 days.

Section 10 sets out amendments to section 65 of the Act in respect of the submission of information to the chief inspector by registered providers. It states that the chief inspector can request information necessary for the undertaking of her functions and that the provider is obliged to provide the information, and in the manner and form, the chief inspector considers necessary.

Section 11 inserts new section 65A into the 2007 Act to provide for the collection, sharing and publication of key data from designated centres for older people. It states that no data that can identify an individual can be shared or published. The section also inserts a new section 65B to provide that a registered provider shall not submit false or misleading information to the chief inspector, and it will be an offence under section 73 of the Act to do so.

Section 12 provides for transitional provisions relating to the reduction of the time limits from 28 to 14 days.

Section 13 inserts new sections 73A and 73B into the 2007 Act to provide that the chief inspector may enter to inspect a premises where he or she believes the business of a designated centre is being carried out, but which is not registered. It sets out the actions that the chief inspector may take and the circumstances in which the District Court may issue a warrant authorising entry to a premises.

Sections 14 and 15 are consequential amendments arising from section 13. Section 14 amends section 76 of the 2007 Act to extend the circumstances where the chief inspector may be accompanied by a member of An Garda Síochána to include inspections of unregistered centres. Section 15 inserts new section 77B into the 2007 Act, which mirrors section 77 to provide that a person shall not refuse entry, obstruct or impede an inspection or give false or misleading information in the context of such an inspection.

Section 16 inserts a new section 78A into the 2007 Act to provide for the serving of compliance notices on registered providers. It states that the chief inspector may issue such notices to the registered provider of a designated centre for older people or people with disabilities. It also states that the compliance notice will identify the area of non-compliance and a timeframe within which this should be remedied. It also provides that the registered providers will have the right to make an appeal to the District Court within 14 days. It finally sets out that a registered provider who does not comply with the notice within the specified date is guilty of an offence and liable to prosecution. Fines and penalties for prosecution mirror those currently in the Act. Details of any fine or penalties incurred by the registered provider under this new provision shall be entered on a non-compliance list maintained by the chief inspector, which may be published. This measure will apply to designated centres for older persons and designated centres for people with a disability.

Section 17 sets out amendments to section 79 of the 2007 Act to introduce the offence of providing false or misleading information under the new provisions in section 65A or under section 77B to refuse or obstruct entry to a person carrying out an inspection under section 73A

Section 18 sets out amendments to section 101(3) of the 2007 Act to ensure that there is a clear legal basis for the Minister to prescribe in regulations required elements of a complaints process for designated centres.

Section 19 inserts a new section 101B into the 2007 Act to provide the Minister for Health with regulation-making powers to prescribe the collection, sharing and publication of data relating to designated centres for older persons. Regulations will determine the type of data to be collected, shared and published and the frequency of the submission and sharing of the information as provided for by the new section 65A as described already. Part 3 provides for amendments to the Nursing Homes Support Scheme Act 2009 and contains sections 20 to 33, inclusive.

Section 20 is the standard interpretation section, which provides that the Act of 2009 means the Nursing Homes Support Scheme Act 2009.

Section 21 sets out amendments to section 14A to extend the categories of persons eligible to be appointed as family successors to a family farm or business, to include first cousins, great-nephews, great-nieces and great-grandchildren.

Section 22 provides for technical amendments to section 14C to clarify the circumstances in the appointment of a family successor in section 14C(4)(f).

Section 23 sets out technical amendments to section 14D with regard to a determination of a family successor in the case of members of a couple.

Section 24 amends section 14F to extend the categories of persons eligible to be appointed as family successors to a family farm or business to include first cousins, great-nephews, great-nieces and great-grandchildren.

Section 25 provides for technical amendments to section 14G relating to the death or change in circumstances of a family successor provisions to extend the categories of persons eligible to be appointed as family successors.

Section 26 provides for technical amendments to section 14H in respect of a change in family successor following the transfer of a particular family asset provisions and to extend the categories of persons eligible to be appointed as family successors, similar to those amendments in section 25.

Section 27 provides for technical amendments to section 141 relating to the repayment of an increase in State support provisions.

Section 28 provides for technical amendments to section 14K in the application by a partner of a family successor provisions.

Section 29 sets out technical amendments to section 14L in the application by a partner of a deceased person for the appointment of a family successor provisions and to extend the categories of persons eligible to be appointed as family successors.

Section 30 sets out technical amendments to section 14M in respect of a determination as to farm or business relief where a family successor fulfils an undertaking and the second person in a couple is entering nursing home care after the family successor has fulfilled the undertaking in regard to the first partner. Section 30(1)(d)(iii) currently sets out that this section is to apply where the partner has received three years of nursing home care after the expiry of the period of the undertaking. However, the requirement relating to three years of nursing home care is provided for by way of section 14M(4). For this reason, section 14M(1)(d)(iii) is deleted.

Section 31 sets out technical amendments to section 24A regarding notification of material change in the circumstances of a family successor provisions.

Section 32 sets out technical amendments to section 27A relating to the discharge of orders made under section 14B provisions.

Section 33 provides for technical amendments to section 32 regarding appeals against certain decisions of the HSE provisions.

An Leas-Cheann Comhairle

The Minister of State deserves a medal. I call Deputy Cullinane.

Deputy David Cullinane

We support reform of HIQA’s enforcement powers. HIQA’s current enforcement powers are blunt and we have been saying that for some time. We will support the Bill but the Government has been far too limited in its approach. I met HIQA officials on a number of occasions in recent years on many of these matters. The Bill provides for compliance notices for the Chief Inspector of Social Services at the authority. This is something I called for in a policy document I launched two and a half years ago. It provides for compliance notices to be issued to designated centres for older persons and people with disabilities and improvements to the enforcement system. The Bill also provides for improved data collection on nursing homes and to widen the definition of those eligible to be considered as a family successor to a family farm or productive business assets under the nursing home support scheme, which again we support.

HIQA published comprehensive proposals on improving its governing legislation and enforcement powers in 2013 and more recently in 2017 and 2021. The authority has been calling for these for a long time and it has taken far too long for the Government to act on them. HIQA has flagged that existing definitions fall short of legal clarity and that there are no specific clinical governance links, which resulted in confusion, resistance and adverse outcomes during the Covid-19 pandemic. None of this is addressed in the Bill. HIQA sought improved compliance notices but it also sought a more flexible enforcement system, which included failure to comply with notices and the ability to more robustly attach, enforce and direct implementation of conditions attached to operating licences. The ability to initiate and conduct investigations must also be addressed. Whether this legislation meets the authority's needs will need to be examined further ahead of Committee Stage. It has also called for a comprehensive social care policy and comprehensive social care services regulation. The Government continues to regulate home care, long-term residential care and other types of care separately. HIQA is clearly of the view that supported and-or assisted living and sheltered housing, personal assistance, day services, home sharing, hospice and living services are not covered adequately and should be included in a comprehensive regulatory framework along with nursing homes and home care.

I will make a number of points on the review of the regulatory framework and adult safeguarding legislation. The Government has not progressed an adult safeguarding Act, despite a comprehensive Bill presented by former Senator Colette Kelleher in the previous Seanad, which was reintroduced by Senator Frances Black. Safeguarding teams are a HSE function but they are managed differently across community healthcare organisation, CHO, areas, are often under resourced and do not have access or right to access private facilities. They must be invited by homes, which otherwise investigate themselves. This is unacceptable and has been for too long. Safeguarding teams and social workers need a legal right of entry. Again, this is something we proposed in our policy document some years ago.

We fully support adult safeguarding legislation. The Government’s term has been a missed opportunity because it has not progressed such legislation. Not only do we need safeguarding legislation but we also need a safeguarding authority. Furthermore, we need to look at safeguarding beyond health and through a much wider lens across a range of areas to protect our most vulnerable people. People at risk of neglect, coercion and abuse deserve a comprehensive legal framework for safeguarding in place to protect adults at risk of neglect, abuse, isolation or coercion. There are much broader safeguarding risks in society outside of healthcare settings that it could also address but the Government has ignored this whole area of vulnerable adults. The Covid committee, on which I sat, made a very important recommendation for a full review of the regulatory framework. The Law Reform Commission undertook similar work starting in 2020, which was published last month. I read their proposals last night. They have also published draft Bills in this area as well. This should have been undertaken much earlier as this has been an issue for the past decade. The Minister must expedite adult safeguarding legislation. There can be no excuses. We have to move in the area. Unfortunately it has been one of many areas in which the Minister and the Government have dragged their feet and not delivered.

The Bill provides for a legal right of entry where the chief inspector believes an unregistered centre is operating, but it does not provide a legal right of entry for social workers, safeguarding teams, or family or care partners. If it does, I would ask the Minister of State to point to where that is the case.

On care partners, during the pandemic, families were sounding the alarm of neglect and isolation but were not listened to by the Government. I met many of them over the past year and a half. By contrast, in the North, a care partner scheme was provided for, which ensured two family members could assist in the care and supervision of care of their loved one. The Government in the South has refused to entertain any such scheme, despite its success in the North, which is recognised by families and the Executive and was called for by bereaved families in the South.

The area of home care is possibly one of the Government’s biggest failures. There are currently no quality standards for the provision of home care. Current standards are not enforceable. The Government has not progressed legislation to regulate home care or provide a statutory home care scheme. It has started a pilot project that falls far short of what was committed to in the programme for Government. It took the Government several years to set up the commission on care. Many people who are experts in this area are very concerned about the model of the commission of care which the Minister of State has established.

With regard to the privatisation and consolidation of ownership in the nursing home sector, 80% of nursing home beds are now private; 38% of beds are operated by just 15 operators, of which 14 are funded by private equity firms. All of this has happened under the watch of successive Fianna Fáil and Fine Gael Governments, which have made this an unfortunate reality. Private nursing homes are independent and self-governing. This has continually been identified as a clinical governance concern but ignored by the Minister of State and her Government. The Government has failed to invest in public nursing home capacity and reverse this trend, and where it has opened nursing homes beds, these are being poached in some areas for step-down beds for hospitals, such as in Nenagh. Many nursing home beds across the State are now operating as step-down beds to support hospitals. There may be logic to that but it is all due to the Government’s lack of funding for these step-down beds in the first place.

HIQA has no legal powers to investigate individual complaints. The way the regulation is designed is that the authority looks at totality of the service. The provider has to do investigation themselves and provide findings to the HIQA. The authority has advocated change in this area. If not HIQA, which is a systems regulator, adult safeguarding teams should be responsible and resourced to investigate individual complaints in public and private nursing homes. Private nursing homes should not be investigating themselves.

I have long called for a comprehensive social care policy. The Department of Health should be called the Department of health and social care because social care has been left behind by successive Governments. The Department of Health does not have a comprehensive, integrated social care policy that considers social care in its totality alongside Sláintecare.

Disability services are inadequately regulated, as we have seen from HIQA's proposals. Decongregation has taken a back seat under the Government, which has not substantially progressed decongregation of intellectual disability services.

There are many elements of the Bill I support. Any advance is an advance but when considering all the lessons that should have been learned from Covid, all the reports that have been done by HIQA and all the expert reports from working groups established by the Government, we all know much more needs to be done to put in place proper regulatory systems, proper adult safeguarding legislation, proper enforcement bodies, an independent safeguarding authority and much more to make sure the most vulnerable citizens of our State are protected, and these are areas the Government has completely failed in.

With regard to nursing homes, unfortunately the Minister of State has presided over a system where more and more private capacity is coming in. Very little public capacity has come from this Government. It has been something the Government has ignored and it has allowed the private sector to dominate the nursing home sector. It promised us a commission on care. It took far too long for it to be set up and it will probably be the next Government that will have to look at the implications of that. Were I in the Minister of State’s position, I would change the terms of reference for the commission, as has been advocated by Sage Advocacy and many more groups. I met them today on this issue. The Government’s statutory home care scheme was much promised and a big part of the programme for Government. I suspect it took a back seat because the political will was not there to deal with it and because the resources were just not going to be committed to it.

That is the legacy of this Government.

Deputy Mary Butler

And of Covid

Deputy David Cullinane

Covid should actually have been the battle cry or the rallying cry to this Government to actually deal with these issues. The Minister of State is actually making the argument for me. Covid was the big disrupter that said to the State that we need to do more about adult safeguarding legislation, homecare and a statutory homecare but the Minister of State did not deliver and she has to accept her own responsibility for those failings.

Deputy Patricia Ryan

As Sinn Féin's spokesperson for older people, Sinn Féin and I give cautious support to this Bill that seeks to reform HIQA's enforcement powers. Yes, it provides for compliance notices and better collection of nursing home data but it does not go anywhere close to addressing the huge concerns around safeguarding and regulations.

The issues with HIQA have been ongoing since at least 2013 and the Minister of State has been in government for all of this time and still no real action has been taken. The Bill falls short on so many levels such as poorly defined terms, lack of legal clarity and no specific clinical governance. Calls from HIQA to strengthen its governing legislation have fallen on deaf ears. All of these ended ultimately in the tragic consequences of the Covid-19 pandemic. Where was the safeguarding then? There is not even a hint of any plan for a comprehensive social care policy or regulation. There is no joined-up thinking by the Government. Should the likes of supported assisted living, day services or sheltered housing not also come under the same umbrella of regulation as nursing homes? My view is that they should. After all, these services also care for our vulnerable and elderly citizens.

These vulnerable persons and all users of these services need to feel safe in the knowledge their safety and well-being will be absolutely assured. How can this be when the Government has failed yet again to move forward with the adult safeguarding legislation despite many opportunities to do so. Even the HSE safeguarding teams have no legal right to enter private facilities, which my colleague has mentioned. They must be invited in, meaning that private nursing home are effectively self-regulating. I find it very concerning that 80% of our nursing homes are private and almost half of these are operated by private equity firms. We cannot have a fox minding the henhouse situation with little or no regulation. We all know what happened when that happened with the banks. That cannot continue and it has to be sorted out.

The Government's abject failure to progress vital safeguarding legislation is yet another target it has missed. It has missed targets in housing, health and the list goes on. The Government has failed these vulnerable people again and again and they need and deserve to have a comprehensive legal framework in place that they can rely on for their protection. We do not have to go far back to find proof of these failures. Let us remember the Covid-19 pandemic - the Minister of State mentioned it and gave us an opportunity to discuss it - when nursing home residents died alone and without loved ones and front-line care workers struggled to cope, burnt out physically and mentally and often with defective, or worse, no PPE. Where was the safeguarding then? Where was the care partner scheme such as in the North? Why do we not have the same system here? It is badly needed and should be applied here. More importantly, where is the date for the Covid-19 inquiry? There is still no date set for it despite multiple requests. I asked the Minister of State for one last week and I have asked about the Covid inquiry four times this year already. No answers have been forthcoming.

We need clearer legislation; a statutory right of entry for safeguarding and social care teams; a comprehensive social care policy as set out by Sinn Féin's in our priorities for change in our health and social care document; safeguarding teams to be fully resourced and operating from the same page across all CHOs; and to tackle the clinical governance issues to end the practice of private nursing homes effectively self-regulating. What we need at this point is a change of government and a Sinn Féin government will do all of that.

Deputy Duncan Smith

We too in the Labour Party welcome this Bill. Transparency in healthcare is vital so that we as legislators know the areas that need improvement and can take action more swiftly, when needed. Amending the Health Act 2007 to give the Chief Inspector of Social Services new powers and to make amendments to existing provisions relating to enforcement, and the collection, sharing and publication of key data on nursing homes and complaint processes will provide the transparency we need to make informed decisions. It is particularly important in the context of our ageing population.

Safeguarding our older persons is an important responsibility. The new powers provided to the chief inspector in the Bill, which include issuing compliance notices as a complement to other important powers of the Act, the ability to enter and inspect a premises that is unregistered if there are reasonable grounds to believe the business of a designated centre is being carried on in line with the existing provisions in the Act for the entry and inspection of registered centres and a reduction in timelines for existing important provisions initiated under section 51 of the Act to expedite enforcement actions, are all significant steps in the right direction for safeguarding. The new functions provided by the Bill for the chief inspector to collect key data on nursing homes, the sharing of the data with the Minister, HIQA and the HSE as appropriate, and the publication of this data at aggregate level can be an important push towards change in how the nursing home sector can be managed and resourced. The Bill also introduces new regulation-making powers for the Minister for Health to prescribe the arrangements for the collection, sharing and publication of the data. This creates the ability for the Minister and his Department to take part in the type of long-term planning the sector desperately needs. I hope the Minister will utilise this mechanism to its utmost.

I have broader concerns, however, that the Government has been found lacking in its support for our older citizens and that an agenda for divestment over investment in long-term care, which has been prevalent since it took office, has been extremely damaging. Older people deserve proper care, support and the ability to live a happy and fulfilled life. We absolutely need to ensure nursing homes our citizens go to are of a standard we would expect for ourselves, for any of our family members and indeed for any citizen. This is vital. However, in doing so we cannot ignore the huge public appetite for people to want to age in their own homes as has been revealed in numerous surveys and is apparent in Government policy. Along with this type of legislation, we also need the Government to improve and resource our home care policies and home care resources.

I am deeply concerned following the ESRI report released earlier this year that found that 15 large private groups now control 39% of the almost 32,000 nursing home beds in the country. Caring for our older citizens should not be a profit-driven machine. The ESRI report concluded that it is vital as the needs of an ageing populations grow and evolve that policies harmonise financial incentives for nursing home operators with resident's needs. It is really as simple as that

The Bill is important in that the powers given to the Chief Inspector of Social Services point in the right direction. These types of measures are aimed at protecting residents and, of course, staff in nursing homes.

There is a huge problem with the number of nursing homes that have been coalesced into these large private groups. I have spoken about this many times, including on national media. The industry will say it that does not matter what the name is above the door but for me it does. The outsourcing and privatisation of our nursing home sector is not something that should expand. We need to see it rolled back and see greater State ownership and involvement. While I welcome the provisions of this Bill to improve regulation we need to see greater steps in the provision of new nursing home beds and nursing home care from the State. The State has the responsibility to prioritise the well-being of our older people. These individuals have contributed their entire lives to our society and deserve proper care. That is why we need to invest rather than divest, not only in nursing homes but also in our home care workers.

There are concrete steps to be taken alongside this legislation to ensure our older citizens are being looked after such as making working in a nursing home a more attractive job prospect for young people and young workers, ensuring better pay, conditions and clear career progression. The Labour Party is also calling for the appointment and resourcing of a commissioner for older people and ageing to address the urgent needs of our older citizens.

I have touched more generally on what has happened with regard to the privatisation of the sector more widely. It has led to increased problems with no continuity of care or indeed continuity of home care. We also have yet to see the delivery of a statutory right to care, which the Government promised. This is extremely important. The Bill relates to nursing homes but we have situations in the home care sector where an individual will have to have providers changed on them and the previous provider will provide list of things that will be done in terms of care in the home but when that individual gets a new provider, the list changes because there is not a statutory right to care and it is ultimately down to providers to state what element of care they will provide. It is quite frankly something that cannot continue.

I previously welcomed that the commission on care has finally commenced, which is important, but there are issues right now.

More importantly, they have been evident in the current model of care for a long time. There is an opportunity to make real progress in the sector, with a Government that is willing to make not only the right decisions, but also decisive ones. If we get statutory home care right and remove the policies of divestment and instead invest all across our care sector, including in nursing homes, together with a number of smaller facilities, we can bring more balance to the healthcare system. By doing so, we would take pressure off the hospitals that are beyond tipping point at this stage.

The Bill amends the Nursing Home Support Scheme Act 2009, which established the nursing support scheme under which financial support is provided to those availing of long-term residential care needs. The Bill changes the definition of those eligible to be considered as a family successor to a family farm or productive business assets to include cousins, great-nephews and great-nieces and great-grandchildren. This is something we need to examine further, in terms of the implications of these provisions. There are positive steps in the Bill and I hope better transparency and accountability will stem from it. The Government needs to do better more broadly regarding care for our older citizens.

Deputy Pauline Tully

While we will support the Bill, it is very limited and does not go far enough to protect people at risk of neglect or coercion and abuse. Currently, disability services are inadequately regulated. In 2019, a HIQA report on the first five years of the regulation of designated residential centres for adults and children with disabilities in Ireland found that significant challenges remain regarding the management and oversight of services addressing infrastructural deficits and safeguarding vulnerable people.

HIQA published three comprehensive proposals on improving its governing legislation and enforcement powers, the first in 2013, another in 2017 and the third in 2021. It has taken far too long to act on these proposals. In them, HIQA sought improved compliance notices, which I welcome and are included in the Bill. However, it also sought a more flexible enforcement system, which included failure to comply notices and the ability to move robustly to attach, enforce and direct the implementation of conditions attached to operating licences. The ability to initiate and conduct investigations must also be addressed. It is not clear if the Bill meets these needs and this must be examined further.

HIQA also called for a comprehensive social care policy and services regulation. While the Government continues to regulate home care, long-term residential care and other types of care separately, HIQA is clearly of the view that supported and-or assisted living and sheltered housing, personal assistance, day services, home sharing, hospice and living services are not covered adequately and should be included in a comprehensive regulatory framework, along with nursing homes and home care.

It is almost 13 years since the publication of the Time to Move On from Congregated Settings report in 2011, yet decongregation is still nowhere near complete. This has resulted in a number of service models being in operation. HIQA has highlighted that it is in something of a grey area and has stated that, in many cases, service providers can legitimately argue that they are not designated centres because the service users are not availing of care in the traditional sense. It has also highlighted the need to reconsider how services for people with disabilities are regulated, given the evolving models of care and support.

Disability advocates have expressed concern that HIQA inspections are predominantly focused on monitoring facilities in the absence of powers to investigate and decide on individual cases and complaints. There are long-standing calls for adult safeguarding legislation to be introduced, yet the Government has not progressed an adult safeguarding Act despite a comprehensive Bill presented by former Senator Colette Kelleher in the previous Seanad, which was reintroduced by Senator Frances Black. We fully support safeguarding legislation and the Government's term has been a missed opportunity in this regard.

People at risk of neglect, coercion and abuse deserve a comprehensive legal framework for safeguarding to be put in place. As I said, while I will support the Bill, it is severely limited in a number of areas and these need to be addressed. I hope the Government will take these concerns on board and consider proposals put forward which aim to strengthen the Bill.

Deputy Róisín Shortall

I welcome this long-awaited Bill to progress recommendations 14.4 and 14.6 of the Covid-19 nursing homes expert panel, which the Social Democrats will support. However, it is deeply regrettable that it has taken this long for the Minister to produce the necessary Bill. While these reforms are welcome, the Bill will not deliver fully on the regulatory reform recommendations from the expert panel published almost four years ago.

I appreciate that a consultation process was necessary, but that was completed in 2021. Why did it take another year for the heads of the Bill to be published? The Minister had the support of the Opposition and HIQA, which had called for greater powers for a number of years. When the general scheme of the Bill came before the health committee, we recognised its importance and the need to progress it quickly. That is why, following a briefing by the Department and having considered written submissions, the committee completed its pre-legislative scrutiny in one week. In a letter sent to the Minister, Deputy Donnelly, on 30 November 2022, the committee stated clearly that it considered this to be very important legislation, in light of issues that arose during the pandemic, and it had no recommendations to make.

That was a year and a half ago. What has delayed the Minister of State in progressing the proposal? Where are the blockages? It is very hard to understand why such important legislation has taken so long. We would have to ask whether this was because of lobbyists as it was certainly not because of the Oireachtas or regulator. The expert panel suggested a six-month timeframe for implementation of these reforms. It took the Minister just shy of four years, an incredible delay. This is only the beginning, of course.

The Minister, Deputy Donnelly, and the Minister of State, Deputy Butler, approved a two-stage approach to reform. The first phase, which is being progressed by this Bill, is only an interim solution to enhance governance and oversight of nursing homes. The second phase, we are told, will include a wider root-and-branch review of the regulatory model. It is this second phase that I am particularly interested in. Unfortunately, I do not think the Government shares that interest.

According to the fourth and final progress report on the implementation of the expert panel's recommendations, published in June 2022, an international evidence review of nursing home regulatory models had been commissioned to inform the second phase. When I raised this issue with the Minister of State, Deputy Butler, in November 2022, she said the review was nearing completion and would be published in due course. It is now May 2024, and we still have not seen that report. HIQA sent it to the Department in December 2022, but I do not think the Minister of State ever published it. I would like to think she did so, but I am not aware that she did. I ask her to indicate whether that has been published.

I would also appreciate it if the Minister of State could indicate whether the commission on care is the means by which she is progressing phase two. One would assume so, but we hear very little about this more ambitious phase. Where exactly are we at regarding this? If that is the case, the Minister of State is again way behind schedule, given that she told me, in November 2022 in reply to a parliamentary question, that stakeholder engagement around wider reform would begin in early 2023, which is more than a year ago.

The commission on care only held its first meeting in March. I outline these timelines not to be pedantic in any way, but because of the urgency with which this issue should have been treated and addressed. Overall, we must not forget the context in which these recommendations were made. In September 2020, HIQA appeared before the Oireachtas Special Committee on Covid-19 Response and called for more powers and regulatory reform, a plea that the regulator had been making since 2013.

As the deaths in nursing homes mounted, the need for reform could no longer be denied but it should never have taken this devastating loss of life for the Government to finally act. According to CSO data, between March 2020 and April 2022, almost 30% of Covid deaths occurred in nursing homes. An ESRI study, which examined the first three waves of the pandemic, from March 2020 to March 2021, found that 66% of all Covid deaths during that one-year period were related to nursing home outbreaks. Internationally, this placed Ireland second only to Australia, at 75%, in terms of the percentage of Covid deaths linked to nursing homes. One would imagine that there would have been a sense of urgency about that but a huge amount of time has been lost. This study into the deadliest period of the pandemic also found that larger, long-term residential care homes were three times more likely to have an outbreak than smaller homes.

Those shocking figures should have set off alarm bells in the Department of Health but in reality very little has changed. In public utterances Ministers and even the Taoiseach accepted that we need a new model of care but where is the model to match? Where is that policy we were promised by the current Taoiseach, the previous Taoiseach, Deputy Varadkar, and other Ministers? More and more small, independently-owned nursing homes are closing their doors while large operators, financed by international private equity, dominate the market. That is not acceptable and it is not in the interests of older people. The ESRI found that between February 2020 and December 2022, one in five smaller private nursing homes shut its doors, with rural areas hardest hit. A 2021 value-for-money review of the fair deal scheme rightly pointed out that the more the State becomes dependent on large chains, the less it is able to control costs, terminate contracts, remove residents from poorly performing nursing homes and ensure that standards are maintained. A 2021 HIQA paper, entitled "The Need for Regulatory Reform", also highlighted the risks involved in concentrating care within a small number of large providers. The variety of options along a continuum include supported housing and co-housing communities, of which there is a chronic undersupply. There are lots of other models that could be used for which older people are crying out. The whole spectrum of care needs to be considered, rather than the kind of approach the Government is taking in facilitating people who are more interested in ensuring a return on investment than what is in the best interest of older people. We should be moving towards a situation where long-term residential care is considered only when all other options along the continuum have been exhausted but we are a far cry from that reality. This Government seems, instead, to be focused on cementing the current over-institutionalised model of care by facilitating, even encouraging, its monetisation. All the while, we are told that Government policy is to provide a new model through home care but, again, the facts would say otherwise.

A statutory right to home care has been in development since 2018, after the Sláintecare report recommended ending the "over-reliance on market mechanisms to deliver new health care services by the expansion of public nursing homes and home care". The statutory scheme was supposed to be delivered in 2021. Then it was pushed out to 2023 but now, in 2024, we still do not even have the heads of this long-promised Bill. It is not even listed for priority publication in this Dáil term.

Deputy Mary Butler

The heads were approved today in Cabinet.

Deputy Róisín Shortall

I am glad to hear that because we have been waiting for a very long time.

While home care hours and funding have been increased since 2020, waiting lists remain stubbornly high. In February, there were over 5,500 people approved for a home care package but no carer was available. These staffing challenges have only been made worse by the regressive HSE recruitment freeze. That freeze is holding up so much delivery in terms of major healthcare. February's progress report on the implementation of the report of the strategic workforce advisory group showed that three of the 16 recommendations are on hold due to the recruitment freeze. This includes recommendation 11, that there be "a significant increase in the proportion of home support hours and packages provided directly by the HSE". This is just another example of this Government's short-sighted thinking leading to rampant outsourcing. The Minister has been promising the aforementioned significant increase for a very long time and it is really shocking that we have not seen movement in relation to that. Promises are being made but there does not seem to be any timescale in terms of what needs to be done in the best interests of older people.

Privatisation is now the cornerstone of this Government's elder care policy but it was not always this way. In 2006, funding to private home care providers stood at just €3 million. By 2019, the figure had risen to €107 million, while in the nursing home sector over the past 30 years, we have gone from a predominantly State-led service to one where approximately 80% of nursing homes are private. Undoubtedly, tax incentives in the early 2000s and the introduction of the fair deal scheme, which increased financial security for the sector, attracted more and more operators into the sector, especially from outside Ireland. This model, whereby the State is so heavily reliant on private nursing homes, is deeply flawed. In fact, it has become untenable. The pandemic has exposed severely lacking clinical oversight of these facilities and significant gaps in communication channels with the HSE. In May 2020, the then CEO of HIQA, Mr. Phelim Quinn, appeared before the Oireachtas Special Committee on Covid-19 Response. During the hearing he said that "the HSE did not know this sector" and that "private residential care for older persons has no formal clinical governance links with the HSE". That is a damning assessment of what the HSE was doing in respect of older people. As a result, there was no national clinical oversight of the care being delivered to some of our most vulnerable citizens during the spread of a deadly virus that was ravaging the places that so many of those vulnerable people called home.

It is unforgivable that the Government has taken so long to bring forward these interim measures.

Section 10 provides for mandatory reporting of key operational data to the chief inspector by registered providers, as recommended by the expert panel. Section 11 provides for the sharing of this data with the Minister and public bodies, including HIQA and the HSE. The publication of the data will be in aggregate form. In the course of the health committee's meeting with Department officials during pre-legislative scrutiny, many of us were shocked to learn of the complete absence of data collection. There is no national database of even the most basic information, such as staffing levels, bed occupancy or dependency levels. This type of data is extremely important in terms of regulatory oversight, service planning, demand projection and ensuring prospective residents and their families have enough information when choosing a nursing home. That certainly is not the case at the moment. It is bizarre that this is only now being provided for in legislation. There can be no excuse for the delay in progressing this most rudimentary measure.

Section 13, which provides a clear legal basis for the chief inspector to enter a premises that is not registered, is welcome. During pre-legislative scrutiny, Department officials confirmed this does not come up much in the nursing home sector but was brought up by HIQA in the context of disability centres, especially in respect of emergency placements. An explicit provision is needed for the avoidance of doubt should such a situation arise.

In terms of enforcement, the options available to the chief inspector have been repeatedly characterised as blunt instruments. Currently, the chief inspector can either place restrictive conditions on a centre, such as limiting the number of admissions, or cancel its registration, meaning it would have to cease operations or be taken over by an alternative service provider. This does not allow for positive action to be taken to rectify the situation. Prosecution should be the last resort. That is why the chief inspector has called for a more graduated suite of powers. Section 16 provides for that through the introduction of a new system of compliance notices. This will provide the chief inspector with a more efficient and proportionate set of tools to bring registered providers into compliance.

Another issue is HIQA's inability to investigate individual complaints. I accept that the Patient Safety (Notifiable Incidents and Open Disclosure) Act 2023 gives the chief inspector new powers to investigate serious incidents. However, that legislation has not even been commenced a year after it was signed into law. I received a reply to a parliamentary question today on this matter. All the Minister could say was that he intends to commence the Act at the earliest possible date.

Clearly, there is still much to be done. I do not doubt the Minister of State's intentions but there are serious questions over her delivery on these matters. This Bill is low-hanging fruit but the Government still managed to drag it out over most of its term. Older people deserve so much better than this. They deserve choice and a system that views care as a right, not a commodity. Much more needs to be done.

Deputy Jennifer Murnane O'Connor

Fianna Fáil supports this Bill, which it is of utmost importance. It provides for the amendment of two Acts, namely, the Health Act 2007 and the Nursing Homes Support Scheme Act 2009. The Bill gives new enforcement powers to the Chief Inspector of Social Services, including the power to issue compliance notices to enhance compliance with regulation in residential care homes and further protect residents. That is very important. The Bill is about further protecting residents.

The new amendments to the Health Act 2007 are a response to several key recommendations in the report of the Covid-19 nursing home expert panel. The report called for the enhancement and modernisation of powers and requirements within the regulatory framework governing nursing homes and the establishment of mandatory reporting to HIQA of key operational data by nursing homes to support service planning and policy development. The amendments to the Nursing Homes Support Scheme Act, which covers the fair deal scheme, will widen the definition of those eligible to be considered a family successor, particularly to family farm or productive business assets, to include cousins, great-nephews, great-nieces and great-grandchildren. That is really important. Lots of people have come to me about this. Under the Nursing Homes Support Scheme (Amendment) Act 2021, contributions from farm and business assets can be capped after three years in care as long as the family successor who is appointed will continue to run the assets for a period.

Having already introduced amendments to the fair deal scheme to safeguard family farms and businesses, it became clear there was a small group of farmers with no close relatives who were, as the Minister of State said to me, unintentionally excluded from the legislation. I really welcome their inclusion. The proposed amendments to the fair deal scheme will enhance the safeguards for family farms and businesses by allowing them to apply to extended family members, including cousins, great-nephews, great-nieces and great-grandchildren, thereby protecting the viability and sustainability of those businesses into the future. This is a really important change for individuals who do not have immediate relatives. I am knocking on doors at the moment, as is the Minister of State, and these are the issues that are raised with us daily. They often come up when I am talking to farmers and business owners. This Bill will drive improvements in the quality and safety of care for the benefit of residents, their families and the sector as a whole. In addition, the new powers in regard to data collection will enable more integrated national planning across the nursing home sector and improve overall transparency for current and future residents.

The Minister of State knows I cannot finish without mentioning County Carlow. That could not happen. She was down in Carlow recently to open a new dementia café. It is absolutely excellent. In the case of all the nursing homes and different care homes she is working with, she has been 100% supportive. Her home town in County Waterford is a dementia-friendly town. Now Carlow is the same. We are all working together to achieve it and I am on the committee. The work the Minister of State has done on this is really good. I knock on her door every day and she always listens to me. I really welcome that. These issues are ones people bring to me daily. I welcome the Bill. The Minister of State is welcome to Carlow at any time. Work like this is critical as we move forward.

An Ceann Comhairle

The next speaker is Deputy Conway-Walsh. She will have to say a few things about Mayo.

Deputy Rose Conway-Walsh

Absolutely. Mayo for Sam. As the Minister of State knows, I have repeatedly called on the Minister for Health, Deputy Stephen Donnelly, and the Minister of State, Deputy Rabbitte, to ensure there is accountability and proper oversight in respect of all care centres that HIQA deems likely to be designated care centres. For-profit organisations that care for vulnerable people in our society have been able to avoid accountability and proper oversight and governance for years. I welcome the progress that has been made in this legislation. It is a step in the right direction but only a very small step. It is vital that the Bill passes as quickly as possible through the Houses.

We had issues in Mayo in regard to individuals living alone in what were known as individualised services. We absolutely need a comprehensive social care policy. A loophole in the legislation was potentially used to avoid HIQA having oversight of care centres for years. I have been calling for a number of years for legislation to be reformed to close that loophole.

It is a crazy situation where we have the organisations saying that they can designate this or that, but it has to come completely off the table. There must be somebody in charge here. There must be accountability and governance. Every time we come in here and ask about people with disabilities or vulnerable people, we are told millions and billions are being spent. We need oversight, governance and accountability and we need it now.

I would also like to know how many claims that have been paid were because of substandard care in centres that were left outside the remit of HIQA. I hope this is only the beginning of a process whereby we give powers to HIQA. We need a lot more. Of course we need the resources to go with it to maintain standards in order that people in communities and those across County Mayo can have absolute confidence that the most vulnerable people in our county are looked after to a high standard.

Deputy Matt Shanahan

I wish to share time with Deputy Tóibín.

An Ceann Comhairle

Is that agreed? Agreed.

Deputy Matt Shanahan

In the main, no one doubts the Minister of State's bona fides in regard to the work she is doing here. I welcome the arrival of this Bill. The preamble of the Bill refers to its purpose in regard to two existing legislative measures. It amends the Health Act 2007 to give new enforcement powers to the Chief Inspector of Social Services in HIQA, which consequently will provide for greater safeguards of residents of residential care centres. That is obviously to be welcomed.

In addition, the proposed collection, sharing and publication of data is very important from the point of view of residents and their care plans. It is also intended to widen the definition of those eligible to be considered as the family successor to a family farm or productive business assets. That is something that has been highlighted in the fair deal scheme for some time. In the main, that is all good work and not to be faulted.

It is interesting that the background of the Bill suggests that it was the Covid-19 nursing homes panel that recommended the regulatory frameworks should be adjusted and that they needed modernising, and it called for the additional enhancement of the powers of the regulator. Many nursing homes did quite badly during Covid and some in the sector are still struggling to deal with the losses they suffered at that time, in particular private nursing homes. I note that the Bill will also give increased enforcement powers to the HIQA inspectorate to visit non-registered nursing homes. Again, nobody could argue with any of that.

Other speakers referred to the length of time it has taken the legislation to come before the House. As we all know, it is not easy to get legislation passed and through the Houses. Given that the Bill relates to the care of the elderly and disabled people, we should not delay it.

I welcome the Bill but I question whether it recognises the disparity between the private and public sector in terms of residential care settings. The Minister of State is no stranger to the issues of concern to the private nursing home sector. She is well aware in our city of Waterford of two high profile nursing homes that closed in the past two years, simply because of where the costs are going in the business. The operators state that the State is not providing enough funding to cover their costs. There is a very significant disparity between what a public nursing home is paid in capitation and what a private nursing home is paid. I am not sure why that is the case when the preponderance of beds is provided by the private sector. It seems to me that Government policy has created a rush to consolidation whereby large providers are able to make arrangements with the Department on the money they can get, unlike the small guys who cannot.

Another issue we have seen before that affects small nursing home operators is that it is unlikely that they can pay the remuneration offered in public nursing homes, ergo, when they change their staff they are then poached by the HSE. We saw that happen throughout Covid when it was a significant problem. One of the points we must recognise within all of the regulation, which of itself is not always a good thing, is that we need to have standards and compliance with them but the private nursing home sector calls for greater supports in addition to increased regulatory oversight. It will put up with unannounced inspections and all the rest of it but it asks for greater support and understanding of the challenges it faces. The Minister of State knows from our own constituency that there are small nursing homes in rural areas that provide a very beneficial service to their catchment area. It is great that the HSE can come in and say where nursing homes are not compliant and that it needs them to take on a few more staff or do X amount of capital works or whatever else. Everybody feels good when that happens. Staff have gone in and told those guys to tidy up and get going but what we find is that they cannot do it or they choose not to do it because of the costs involved and then we lose those beds. St. Brigid's in Carrick-on-Suir is a case in point. People who were previously able to visit relatives as they were very close are no longer able to do that and they have ended up having to do a circuitous round trip that could be ten or 20 miles. In Kerry, the distances involved could be 30 miles or 40 miles, or perhaps more depending on where a bed becomes available.

In the round, anybody would obviously support the positive developments in the Bill but we have still not addressed issues in the residential nursing home setting, and probably in the disability setting as well, namely, the difficulties involved for those who provide a private service. At times, there is a culture within the public system to label every private for-profit operation as being somehow malevolent and that it is only about profit and nothing else. The Minister of State and I both know private nursing homes where that could not be further from the truth. They have an excellent standard of care. They have directors of nursing and nurse managers who go above and beyond the call of duty to make sure that residents are properly looked after. They do not skimp but at the same time they are not getting the same amount of support from the State. That is a fact. It is not just the private nursing homes saying it. It is a question of why that disparity exists and why we are not trying to address it. I have not read all of the briefing documents but I am not sure it is included in this Bill. That is something we must address in the future because we cannot have a private sector providing 80% of the beds that we do not support, but we support the 20% of beds in the public sector to the hilt. I question why we are surprised at times when we lose private beds.

I will support the legislation as there is good work in it but we must do more. We must stop vilifying the private sector. I hear from time to time in this House when private residential care is being discussed the references to the "monopoly" and the private aspect of it and it is said that it is all for profit. If there is not a profit there, the business cannot operate. Therefore, the residents cannot be cared for in that setting unless the State is going to step in. We do not want it to do that because it often costs twice or three times as much – that is a fact of life – and if that was not the case, the State would have taken over the sector years ago. There is a place for both parties. We need regulation and enforcement but we must also recognise that greater support is needed for the private nursing home sector. That is what I am calling for.

Deputy Peadar Tóibín

Mary Bartley-Meehan lost her son and husband to Covid-19 in Kilbrew Nursing Home within just six weeks of each other. Ultan had dementia. He had carcinoma cancer, which resulted in tumorous wounds on his face and head. He had been a resident in the nursing home since 2019. Mary was shown a video of her husband before he died and it was quite horrific. The side of Ultan's face was discoloured with black, congealed blood. His nails were long and had become black as he had, unknown to himself, been picking at his facial tumours. As a result, these facial tumours became infected. Shockingly, his face had become infested with maggots. Shortly after these horrors happened to that man, he died in the nursing home. Months later, Mary went to the Department of Health, HIQA and the HSE to seek an investigation and justice for her husband and her son. She said that all of those groups refused to properly investigate what happened to her husband. It is now four years since Mary's husband died. It is four years ago today since she last saw him before he died.

I spoke to her today and she said, shockingly, every second night she has nightmares about that infestation. She told me she hoped she would not die before they say sorry. It is a horrific situation for anybody to have to deal with. She has gone through loved ones being poorly looked after in a nursing home at a significant cost during a very difficult time. She was prevented from being with them, protecting them, holding their hand and supporting them through their final days. Then the State basically washed its hands of it and said it was not able to help. It is astounding that this happened. I would like to know if the Bill starts to move towards allowing a situation like that to be investigated in future. Will the Minister of State address that in her closing remarks?

I spoke to personnel in the Ombudsman's office during that time. I asked if they would investigate what happened to Mary's husband. They said they could not and that they had no power under the law or ability to investigate it. That is incredible because we see the Ombudsman as the last port of call for citizens to investigate delivery of public services. The Ombudsman stated that unless there is a change to the Ombudsman's legislation, it will not be able to investigate something like this. While we are changing legislation, such as the two Acts being amended by this Bill, we should also look to change the Ombudsman's legislation to ensure the Ombudsman's office can investigate that. What happened to Mary Bartley-Meehan, her husband and son is absolutely wrong and it is absolutely wrong there has been no investigation and no apology in relation to what happened. I implore the Minister of State to see if anything can be done to achieve justice and to make sure Mary Bartley-Meehan does not pass away without receiving so much as a sorry from the State for what happened.

Deputy Mary Butler

Sorry to interrupt, but I did meet Ms Bartley-Meehan.

Deputy Peadar Tóibín

I appreciate that but I ask the Minister of State to meet her again to give that apology to her. It is important for her that that happens.

The whole situation around the Covid-19 crisis and nursing homes was incredible: 2,323 people died and 27% of all deaths during Covid happened in the nursing homes. They were the ground zero of Covid. The Government moved thousands of people from hospitals into nursing homes, many of whom were not tested for Covid. It had the effect of seeding Covid throughout the nursing home sector, which inevitably led to significant numbers of deaths in those nursing homes.

Staffing in nursing homes was chaotic. Nursing homes reported to me they were being abandoned in terms of staffing. A nursing home in Galway had all but two staff test positive for Covid during an outbreak in which it saw five residents die. I remember the manager of that nursing home being on RTÉ radio in tears, crying that he could not get the necessary staff. The HSE said to him it had no staff available. I remember other people getting phone calls from nursing homes asking them to come in and feed their loved ones. Other nursing homes put up Facebook posts asking if anyone could come in and help them. I also remember a freedom of information request which showed the then CEO, Paul Reid, did not respond to the Minister of State's request to deal with the lack of staffing for about a month, which was incredible. He also did not respond to Phelim Quinn of HIQA for at least a month in relation to that. Nursing Homes Ireland sought a meeting with the then Minister for Health, Simon Harris, but had no luck whatsoever. The then Minister for Health, who is now the Taoiseach, created a big press statement of a response, Be on Call for Ireland, where 77,000 people were asked to come and help this massive fight to staff our hospitals and nursing homes and only 400 were employed out of that.

I give credit to Majella Beatty and Care Champions for the hard work they have done in trying to get an investigation into this and to ensure families are able to accompany and support their loved ones in nursing homes in the future. That needs to be a basic right for anyone in a nursing home and their loved ones and family members. They are currently fighting in order that residents in Cherry Orchard Hospital will not be coerced into transferring to other locations. I ask the Minister of State to intervene in that situation if possible.

I understand about 50 families are suing the State through the State Claims Agency for wrongs done to them during the Covid time. It is incredible there is still no State investigation into nursing homes during Covid. I met the former Taoiseach, Leo Varadkar, in Government Buildings along with other political parties to discuss plans for a review into this, that is, a review that would not be able to compel people or papers and that would not look to speak to the former Chief Medical Officer or the head of the HSE. How you could not include those people in an investigation into what happened in Covid, I do not know. All the political parties here, to the left and right of me, agreed with the Government's plans until we piped up and said there must be compellability of people and papers. Only then did some of those parties ride in to support that objective. There must be an investigation. I honestly believe this Government does not want an investigation into what happened during the Covid crisis. It will do everything it can to stop it. I do not believe we will see one in the lifetime of this Government. The Government would like to cover up many of its actions in relation to nursing homes and hospitals during that crisis.

In the North of Ireland today, the British State is involved in an investigation into the Covid crisis. Most other European countries have involved themselves in such an investigation. We do not even have the terms of reference yet from the Government. We have no plans for an investigation. It is a major injustice to the 2,300 people who lost their lives in nursing homes at that time. Second, it means the State has learned nothing on how to deal with such a crisis if it happened again. That is the purpose of a State properly investigating what happened: it can learn from the mistakes it made and put in place new policies and procedures to make sure those mistakes do not happen again. We need a commitment to a full public investigation with the power to compel people and papers. That would send a clear message that the Government means business. I ask that the terms of reference be published before the end of this Government. Were the Minister of State to commit to that today, it would be an important step for the families.

I welcome that legislation is proposed that seeks to increase oversight of what happens in nursing homes. It has to be far stronger. We will table amendments to strengthen it in the future.

Nursing homes are in a state of chaos in this country. That is a fair statement to make because we have seen 50 nursing homes close in the past four years. The bed capacity in the State is not sufficient for its population and our demographic trajectory necessitates a trend, not of closing nursing home beds but of opening significantly more of them.

I agree with Deputy Shanahan on this point. I believe the bird will only fly on two wings. It will need public delivery of nursing home beds but will also need a private sector delivering into the system. People prefer to debate the ideology of this issue than the practical elements.

It is like saying "I want to climb to the top of Mount Everest" but they do not even talk about the base camps that need to be achieved before that. The extra provision of nursing home beds, whether public or private, is necessary now. I appeal to the Government to make sure that the provision of those services is feasible in terms of the funding that is available for those services, and that the staff in those services get paid a proper income. We hear too often that staff cannot be obtained for the services. The first thing to do if we want staff is to make sure they get proper pay and conditions, and then they will come.

Deputy Ruairí Ó Murchú

We have had much failure over many years in regard to the provision of the care of the elderly and we have not necessarily put in place those pieces that we should have. Everybody welcomes the greater level of enforcement powers for HIQA and the necessary reforms, and we will support this Bill. However, I do not think it goes quite where it needs to go. Of course, it provides for compliance notices for the Chief Inspector of Social Services and improved data collection, which is necessary so we have a notion of the needs and wants. However, HIQA has sought a lot more. It put in requests in 2013, 2017 and again in 2021 and made comprehensive proposals in regard to the powers that it needs. We need to see that.

As much as we need to see improved compliance notices, we also need a more flexible enforcement system. That will include failure-to-comply notices and the ability to more robustly attach, enforce and direct the implementation of conditions that relate to operating licences. We know the issues in regard to making sure HIQA has the powers in all the settings where it needs to be able to investigate, keep an eye on issues and make sure we are looking after our older people. We know everything that is needed with regard to safeguarding and there has been a failure concerning the legislative requirements in that area. This Bill is a start but there is a lot more to do. It goes without saying that we have had considerable conversations as to where the weaknesses are, not only in regard to elder care in residential settings but also in regard to home care. There is no shortage of proposals and no shortage of requirements to follow through on them.

I will also raise the issue of Dealgan House, where at least 22 people died from March to the middle of May 2020. The Minister of State met the families and is aware of the huge work they have done, sometimes facilitated by politicians. They put in a huge amount of work in regard to freedom of information requests, FOIs, and have engaged with every element of the HSE and with every official who deigned to talk to them, yet they still do not have the full information on what happened to their loved ones. We are still hopeful. We would like to see more information on the Covid-19 inquiry and whether we will be looking at a module in regard to nursing homes. Will we have something that can substantially provide what the Minister would have called a mechanism to provide these families with the answers that are required? We need to deal with any failures there have been and how we can improve things into the future. It is necessary that we look at everything and provide them with the best means to reach a point where justice meets closure.

Deputy Mattie McGrath

I too am glad to speak on the Bill. The aspects of the Bill include mandatory information provision. It mandates that registered providers of nursing homes and residential services, excluding those for people with disabilities, must regularly supply key operational data to HIQA, as drafted in the Bill. I have often spoken to HIQA. I do not have a lot of faith in HIQA, as the Minister of State is aware, and I have good reason for that. The whole saga of what went on in the nursing homes during Covid was diabolical. I am not blaming the nursing homes in most cases. The HSE literally abandoned them and hospitals sent patients with Covid into nursing homes without even telling them. Such carry-on was not bordering on criminal; in my opinion, it was completely criminal. It then denied them oxygen and the oxygen for those nursing homes was diverted and taken away from them. The HSE literally procured it without any legal basis. It just took it away from them and let them do without it.

The Minister of State is aware of a case that I wish to raise with the permission of the Ceann Comhairle. It refers to St. Conlon’s nursing home in Nenagh. I do not know it that well but having contacted many people, I understand there is a huge saga going on at St. Conlon’s. HIQA had condemned it but then gave it a licence for one year, and one year only, because it was waiting to get the new state-of-the-art St. Conlon’s nursing home built. That is now built and it is a model of state-of-the-art provision. The families, the patients, their advocates, the staff of St. Conlon’s and the community were looking forward to moving to this state-of-the-art premises. Everything was fine but, hey presto, because of the pressure on University Hospital Limerick, HIQA and everybody else decided that it was okay to take over the new building at St. Conlon’s as a step-down emergency department to try to put a sticking plaster over the fundamental problems at University Hospital Limerick, and they would override the licence issued, which was only in place for one year.

Sandra Broderick of the HSE said not to mind HIQA, she would tell it what to do. Imagine that. What power or what teeth does the Government have? How can the Minister of State, Deputy Butler, and the Minister, Deputy Donnelly, preside over an organisation when such a senior HSE official will say to not mind HIQA and she would tell it what to do? She said HIQA will do as she tells it. That is scandalous and outrageous. We have bodies and then more bodies set up for everything. They have an office with plush furniture, a CEO, a deputy CEO and God knows who else, and a brass plate on the wall telling the country who they are and that they are registered. Then, they are toothless, useless and fruitless. That is what they are if a department official or a senior nursing manager can say to not mind HIQA and that she would tell it what to do.

I know of many nursing homes that were closed down by stealth in the last 15 years, including a lovely one in Carrick-on-Suir. HIQA kept visiting them and visiting them, and then punishing them. The way it punished them was by cutting out so many beds, which restricted their turnover and they could not do the work they were asked to do because they could not get funding from the banks due to the limited capacity for financial return. HIQA closed that down in the time of the former Minister, James Reilly, and I have raised the issue before in the House.

At this point, I am talking about St. Conlon’s. HIQA had an order to close it down because it was not fit for purpose, so a new one was built, costing €50 million, which is not small money, and it was ready to go into operation. Now, because someone decided it would be taken over, the licence in place prior to the condemning of the old St. Conlon’s has now been issued again and it can carry on. HIQA will do what the management in the mid-western area want it to do because, in their own words, it will do what it is told to do. What kind of a body is that? What kind of a joke is this legislation that we are bringing in when we know what went on in nursing homes throughout Covid and at other times?

We have continuous daily and weekly lobbying by the private nursing homes, rightly so, against what the Government is paying the public nursing homes. It is scandalously unfair. It is discrimination. It cannot be legal that the Government can give so much per week for a patient in a public nursing home but give 30% or 40% less to the private providers. That is unjust and unfair in any walk of life. How are the private providers going to continue? They do not have the money to pay the staff properly and the staff are leaving to go into the public sector. It is discrimination.

Deputy Michael Collins raised in the House the case of a nursing home in west Cork that closed down. It is now being offered as an IPAS centre. Follow the money. If Government does not give fair play and a level playing field and does not ensure Departments pay private nursing homes the same rate as the public ones, there is an unjust imbalance. What is going on in Nenagh beats Banagher, and Nenagh is not too far from Banagher.

It beats Banagher to me that a place was condemned, a new building built and everything ready with patients, their families and staff so looking forward to going into it, and then because there is a problem in Limerick, HIQA can be instructed to turn a blind eye and say the old St. Conlon's is fine and the patients can be left there, even though it was under orders to close. Where do we go with that or how more clear could it be that it is so inadequate, not independent and can be manipulated? What confidence does that give to any of the families taking cases now against the HSE for the loss of lives and the degrading treatment of their loved ones?

Deputy Peadar Tóibín raised one case. I think the Minister of State said she is aware of it. It is so shocking that it happened but that happened in many cases, and not because in many cases the nursing homes wanted that to happen. It was because the HSE starved them of everything, seconded the oxygen, and seconded the different materials, PPE gear and everything else away from them. This was by order of the HSE, and it left them to fend for themselves. Then loved ones could not get in to visit them. It was the most cruel situation that ever existed and now the Government does not want it investigated. I attended a meeting here with other colleagues and the former Taoiseach about the Covid inquiry. There was a kind of laugh around the room. It was said that we cannot have an inquiry as Ireland is too small a place and everybody knows everyone. That is why I said all the time that we need an independent inquiry from without this country, and people who have no contacts with Ireland, who could come in and do a proper inquiry and investigation but, no ,too much might be found out then, and we might get to the bottom of something.

While there is a merry-go-round of cover-up and the Department's and HSE's mishandling, the buck stops at the Minister of State's table, especially with regard to elderly people, and indeed with the Minister, Deputy Donnelly and the Secretary General of the Department of Health.

An Ceann Comhairle

I thank the Deputy. I ask him to adjourn. When we come back, the Deputy's group will have 12 minutes remaining.

Deputy Mattie McGrath

Gabhaim buíochas leis an gCeann Comhairle.

Debate adjourned.