The Leas Cross report list of recommendations
Each recommendation from Professor O'Neill's report is listed below together with a response that outlines the HSE's current position in respect of that recommendation.
Recommendations
Recommendation 1The Department of Health and Children and the Health Services Executive must in its policy, as a matter of urgency, clearly and formally articulate its recognition of the complex health and social care needs of older Irish people requiring long term residential care.
ResponseIn 2005 the HSE established a national steering group, Advancing the National Agenda, to oversee the standardised development of services for all older people including those in residential care. A working group on residential services is currently addressing the areas of Nursing Homes Inspections, Standards of care and dementia specific care. A report of current and future long term needs has recently been completed as part of an interdepartmental working group on the funding of Long Term Care. A national forum with HSE and Nursing Homes representatives is working on a number of quality initiatives including the development of service level agreements.
Recommendation 2The provision of this care (residential care) should be clarified formally in terms of adequate numbers of adequately trained nursing and Health care assistant staff, with adequate governance structures in terms of senior nursing staff. The minimum numbers of nursing staff should be calculated using a modern instrument such as the RCN Assessment tool or the Nursing needs assessment tool, and at least half of these Nursing staff should have a diploma in Gerontological nursing. A sufficient number of middle and senior grade nursing staff relative to the size of the nursing home will be needed to be added to the calculated tool to ensure an adequate care infrastructure. Directors of Nursing in all long term facilities should have the Diploma in Gerontological nursing or equivalent. All Health care assistants should have FETAC training or equivalent. Appropriate acculturation and Gerontological training should be provided for all non national staff.
Response
- The recommendation to use a workload analysis tool is in keeping with emerging DOHC policy. The Report of the Working Group to examine the development of appropriate systems to determine nursing and midwifery staffing levels was published by the DOHC in Sept 2005. This report makes recommendations, which include the dependency levels of patients and quality indicators. It is proposed to have a number of pilot sites across the country that would examine and pilot a number of workload analysis tools and ascertain their applicability and use in the Irish Health care setting. Agreement on these pilot sites will be determined between DOHC, Unions and HSE.
- The recommendation that at least half of nursing staff in residential care should have Diploma in Gerontological Nursing, while highly desirable, would be difficult to action over the short term. In the interim it may be more beneficial to have a combination of approaches that includes a stated proportion of staff having a post graduate course and a regular programme of clinical updates e.g. care of leg ulcers, diabetes, tube feeding etc and professional updates, scope of professional practice, code of conduct, report writing, incident reporting etc for all staff.
- In respect of the recommendation that all Directors of Nursing have a Diploma in Gerontological Nursing. This is desirable, however cognizance would have to be taken that current Directors of Nursing may have other relevant third level qualifications.
- In relation to cultural diversity, programmes are being rolled out in many of the HSE areas. Many HSE programmes are accessible to the Nursing Home sector.
Recommendation 3An electronic version of the minimum dataset should be made mandatory for all patients in nursing home care to assist in the development of individual care plans, the monitoring of quality and the provision of national statistics and dependency, morbidity and mortality
ResponseThe concept of minimum data sets is fully supported by the HSE as a means of improving information in relation to the services provided to all client groups both at local and national level. This is a complex and challenging area, which involves considerable work on standardisation of definitions and collection processes. Work has commenced on the development of a common assessment process and improved data collection within the ?Advancing the National Agenda? programme of work.
Recommendation 4Funding arrangements for nursing home care should be urgently reviewed by the Department of the Health and Children and HSE to ensure that it is matched to the provision of high quality care to older people in long term care.
ResponseWork is ongoing in respect of the procurement of high dependency beds within the private system and systems have been put in place to ensure that Nursing homes meet the standards required to provide this higher level of care. The funding for high dependency beds has increased significantly to reflect the appropriate nursing, medical and allied professional support required. The HSE has recently introduced multi-disciplinary teams for nursing home beds in some areas (Dublin). Further work on the development of cost models is required.
Recommendation 5The Nursing Home Legislation needs to be urgently updated to put the above provisions into place, to place the older person at the centre of its deliberations, and to adequately guide both provision of quality of care and quality of life, as well as providing timely and appropriate powers to the Social Services Inspectorate to effect change.
ResponseThe Department of Health and Children has indicated that new legislation will be published shortly.
Recommendation 6Pending the introduction of the Social Services Inspectorate, Nursing Home Inspection teams need to be immediately developed and staffed with relevant expertise to be able to detect poor practice patterns, and vigorously supported by the HSE in their recommendations. All written queries/concerns should have a rapid assessment and written response.
ResponseA national working group on Nursing homes inspections was established in 2005 and the first phase of recommendations has been adopted by the PCCC directorate of the HSE. Currently many of the areas are in the process of establishing full time dedicated nursing home inspection teams. In Dublin North East a Nursing Home Inspectorate Manager has been appointed to coordinate and manage the inspection and complaint processes for all nursing homes within this area. Additional inspectorate posts will be in place over the coming months. Better partnership working between Public and Private Nursing homes is currently being developed in respect of Practice development and training. Standardised assessment tools have been adopted and additional training is being commissioned. HSE Inspection reports on nursing homes are now available on the HSE website. A national complaints process is currently being implemented by the HSE.
Recommendation 7The Irish Health Services Accreditation Board process for long term care must be radically reviewed to reflect the realities of long term care in Ireland. This would include the determination of not only training but also appropriate numbers of nursing and health care assistants proportionate to the case-mix of residents, as well as congruity with MDS data from the nursing home.
ResponseThis is highlighted within the response on Recommendation 2.
Recommendation 8For those who are not looked after by the GP who provided their care while at home, the medical cover must be more clearly and unambiguously specified in the terms of relevant training (at least the Diploma in Medicine for the Elderly or equivalent), responsibilities and support from the HSE.
ResponseA working group between the HSE and ICGP is proposed to review the role of general/practitioner/medical officer in Nursing Homes, with a view to describing best practice and make recommendations regarding the way forward.
Recommendation 9Multi-disciplinary team support must be clearly specified in terms of both meeting need but also the facilitation of team work, and requires at a minimum: physiotherapy, occupational therapy, speech and language therapy, clinical nutrition and social work.
ResponseThrough the recent procurement of high dependency contracts, there are specific requirements for multi-disciplinary input such as physiotherapy, occupational therapy and speech and language therapy. These contracts are reviewed on a regular basis and paramedical input is measured to ensure a complete quantum of care for the client. Access to multidisciplinary team members in the primary and continuing care teams for clients in Nursing homes needs to be reviewed, gaps identified and an action plan put in place to ensure equal access, based on need for all older people regardless of location. The ongoing investment in services for older people and the development of Primary Care Teams will allow the HSE to make progress on multidisciplinary involvement over the coming years.
Recommendation 10Specialist medical support (geriatric medicine and Psychiatry of Old Age) needs to be developed to provide formal support to the medical officer, nursing staff and therapists not only in the care of patients but also in the development of appropriate care guidelines and therapeutic milieu. These services need protected access to dedicated specialist in patient facilities for appropriate assessment and support of those in long term care.
ResponseWhile there is some variation throughout the country depending on resources, access to a geriatrician is mainly through an out patient clinic in the acute hospital (referral by GP or medical officer). Only a small number of elderly care units have dedicated time or support from a Geriatrician or Psychiatrist of Old Age. It is acknowledged that the existing resource needs to be developed further, and that geriatrician led community teams will be a key element of future older persons care.
Recommendation 11Professional bodies with regulatory responsibilities for healthcare workers should clarify the highly specialized needs of older people in residential care in guidance to their members, with particular emphasis on the scope of practice of those who accept senior positions.
ResponseProfessional bodies with regulatory responsibility would need to respond directly to this recommendation.