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An independent review assessing the regulatory processes of the Health Information and Quality Authority’s (HIQA) inspection of nursing homes has identified the changing profile of nursing home ownership from local to large corporations often located outside Ireland as providing new accountability challenges.
“Where ownership lies with parent or holding companies, often located outside Ireland, it becomes legally challenging to hold these parent entities accountable for regulatory failing at individual nursing home level. The Chief Inspector’s remit applies to the registered provider, the legal entity that operates the nursing home, rather than the corporate group or ultimate owner,” the report said.
The review was requested by the Minister for Health and the Minister of State with responsibility for Older People following the broadcast of a RTÉ Investigates programme about two nursing homes owned by Emeis Ireland, which showed revelations of serious concerns including fundamental care failings and shortcomings in terms of basic care and support to residents.
The purpose of the Review, which was conducted by Forvis Mazars, was to provide an independent assessment of the regulatory processes of HIQ, to identify areas where improvements could be made, and to consider whether the regulatory framework should be strengthened to reflect changes in the operating environment.
The Review found that overall HIQA’s Chief Inspector’s regulatory and inspection processes are effective, follow a standardised and consistent approach, and are carried out in a fair and proportionate manner.
It noted that the Chief Inspector placed a significant emphasis on safeguarding residents through its specific programme of safeguarding inspections and, in line with its legal remit, it sought to hold service providers directly to account given their primary responsibility for ensuring safe and effective care for all residents.
The Review also identified a number of areas where improvement is required, including:
– The inspection approach to culture and staff behaviour within nursing homes should be strengthened, particularly in relation to its relevance in terms of the lived experience of residents.
– A strengthened focus in all inspections on those areas that matter most to residents and their families. Areas for renewed focus include assessing
residents’ involvement in decisions about their own care, promoting residents’ independence, and ensuring that the care and support for residents upholds their rights.
-Requirement for regulatory reform in key areas, including ensuring that parent companies or nursing home groups can be held to account by the Chief Inspector.
CHANGING PROFILE OF OWNERSHIP
The Review also observed that “one of the most striking changes since 2009” in the nursing home sector has been in ownership patterns.
“Initially, Ireland’s nursing home sector consisted of a mix of private, voluntary (often religious or charitable) and public (HSE-operated) providers. Over the 17 years since, several trends have emerged,” it said.
There has been a sectoral shift, the report said, noting that “in 2023 private and voluntary operators provided five times more beds than public facilities with voluntary and HSE-owned centres declining both in number and capacity”.
In terms of consolidation, it said that “many smaller family-run community-based homes have closed, while large private groups and investment backed companies, including some owned by international investment funds or holding firms have expanded their footprint in Ireland.”
And it said that there had been a loss of smaller local homes, with HIQA’s 2024 Report on 15 years of Regulation noting a clear move towards larger centres with more beds, particularly in urban areas.
With “these structural changes came with new accountability challenges,” the review found. “Where ownership lies with parent or holding companies, often located outside Ireland, it becomes legally challenging to hold these parent entities accountable
for regulatory failing at individual nursing home level. The Chief Inspector’s remit applies to the registered provider, the legal entity that operates the nursing home, rather than the corporate group or ultimate owner.”
“This legal separation creates potential gaps in responsibility, accountability and financial transparency, particularly when decisions about staffing, budgets and closures are made at group level, but regulatory accountability for the nursing home lies with the registered provider.”
“In cases of insolvency or regulatory non-compliance, the Chief Inspector cannot hold anyone other than the registered entity to account, even where the evidence indicates that strategic and financial decisions are made elsewhere.”
“Through its engagements with the Department of Health and in published documents, HIQA has highlighted the need for greater corporate transparency, fit person assessments at group governance level and contingency planning to protect residents in the event of corporate restructuring, sale or closure.”
“The evolving ownership landscape presents one of the most complex challenges facing the regulatory system – how to ensure that the legal framework can be better aligned to the business reality of ownership so as to properly safeguard residents’ rights, care and support needs,” the review observed.
HIQA WELCOMES REPORT
HIQA CEO, Angela Fitzgerald has welcomed the recommendations of the Review, commenting:
“People living in nursing homes have a right to feel safe in their homes and enjoy a good experience and quality of life. Our role as a regulator is to ensure that providers meet their responsibilities to deliver safe, quality services and to protect residents. Where providers fail to do this, we use our powers to ensure that providers take action in the best interests of residents.
“As a regulator, we must always be open to critically evaluating what we do and how we do it. For this reason, we very much welcome this independent Review about our regulatory processes and how we do our work. We fully accept the findings and are committed to fully implementing the recommendations.”
“We hope that the positive findings about our processes and our regulatory model and approach will provide assurance to those using services, their families and the wider public. We fully accept that the Review also identifies where we need to improve and work is already underway in this regard.”
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