Joint Committee on Health and Children Meeting
on Tuesday 16th December 2014
Opening Statement
by
Mr. Tony O’Brien
Director General
Health Service Executive
Good evening Chairman and members of the Committee.
Thank you for the invitation to attend the Committee meeting this
evening.
I am joined by my colleagues:
• Mr. Pat Healy, National Director for Social Care
• Dr Philip Crowley National Director Quality & Patient Safety
• Ms.
Marion
Meany,
Head
of
Operations
and
Service
Improvements- Disabilities, Social Care
Introduction – Aras Attracta
Aras Attracta, located on a 13 hectare site, in Swinford, Co. Mayo
is a residential, respite and day service for adults with an
intellectual disability. It currently provides 100 residential places95
for residents and 5 respite places.
Background to HIQA Inspections at Aras Attracta
Aras Attracta was the subject of a HIQA Investigation and Report
in February 2014. This followed on from information received by
HIQA including information on the death of a resident at the centre.
On foot of the Report, HIQA made 59 recommendations. All of the
Recommendations have been implemented including a significant
programme of training and development for staff training (423
hours to date in 2014 (including over 100 hours in Unit 3) in
relevant topics, including amongst many others Adult Protection,
Crisis Prevention & Intervention Management, Care Planning,
Trust in Care, has been implemented in the facility by the HSE.
The facility received positive reports from the Regulator on
subsequent unannounced visits in May 2014 which clearly stated
that, ‘inspectors found the provider and person in charge with
the support of staff had significantly improved practice in
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relation to these areas and the specific issues identified on
the last inspection had been addressed. The inspectors also
found that in response to a required action from the previous
inspection, the provider had put in place an effective
management system and this had resulted in a significant
improvement in the provision of quality and safe care for
residents’.
It is therefore a matter of the most serious concern to the HSE that
the totally unacceptable behavior and attitudes towards residents,
as seen in the RTE footage, continued in Unit 3 until the
allegations were uncovered and made known to the HSE.
The HSE became aware of the situation in Unit 3 on receipt of a
formal letter of complaint from a student on work experience
placement at the Centre. The student worked in the facility for ten
weeks from September to November including three weeks in Unit
3.The HSE immediately acted on the written complaint.
Subsequently it emerged that that the student was an undercover
reporter for Prime Time Investigates Producers in RTE have told
the HSE that it took a number of weeks and the placement of a
fixed camera before any unacceptable behaviour became evident.
This highlights the challenges in detecting such unacceptable
practices, attitudes and behaviours..
Once the HSE became aware of the serious allegations, it initiated
an immediate three-level set of actions as follows:
At the first level: the most immediate priority has been to
guarantee that a safe and caring environment exists for the
residents of Unit 3. A number of immediate actions have already
been taken at Aras Attracta, these include:
- Personnel against whom allegations were made have, without
prejudice, been “put off duty”. A total of 13 staff have been put
off duty.
-
An Garda Síochána and HIQA were notified
- Mr. Christy Lynch, CEO of KARE has been appointed as
Independent Chairman to conduct a full and thorough
investigation into the matter;
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Practice Co-coordinators have been assigned to Unit 3 to
-
supervise practice and implementation of care plans, and to
provide assurance to management.
- External expert advice from Scotland, originally engaged
following the first HIQA inspection, has been reengaged to
support the service at Aras Attracta responding to the needs of
the residents at Unit 3.
- At the second level: A full assurance review has also been
commissioned of all of the Units in the Aras Attracta facility
under the independent chairmanship of Dr. Kevin McCoy,
assisted by 3 independent experts within the field. The group
will review the programme of work already implemented on foot
of the reports from HIQA and HSE Audits to establish their
effectiveness, identify the gaps that arose and make
recommendations for further improvements for each unit at Aras
Attracta.
In addition the output from the Review Team will help to inform a
system –wide programme of improvement and assurance for all
residential centres, including a mechanism for input from service
users and their families, staff at all levels throughout the sector and
academia.
At the third level: The HSE has initiated a system-wide
programme of measures to assure that the quality and safety of
services delivered by 90 Providers in the 908 designated
residential centres for people with disabilities, is in line with the
requirements of the regulations and standards as inspected by
HIQA. In this regard, a 6 step programme, will be implemented and
monitored by a National Implementation Task Force for Disability
Residential Services, led by Pat Healy, National Director Social
Care.
National Implementation Taskforce: The National
Implementation Task Force will drive the implementation of the
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programme and development of long term sustainable and
evidence based safeguarding practices and training programmes
specific to residential settings.
Implementation of Safeguarding Vulnerable Persons at Risk
of Abuse - National Policy & Procedures: The new policy which
is for all HSE and HSE funded services builds on and incorporates,
existing policies in HSE Disability and Elder Abuse services and in
a range of other Disability Service Providers. It will provide a
consistent approach to safeguard and protect people with
disabilities and older people from abuse and neglect, The Policy
defines the types of abuse and who is at risk of experiencing such
abuse. It gives direction in the area of recognizing abuse and how
complaints can be made, as well as the procedures to be followed
to invistege any claims of abuse. An dedicated office for the
implementation of the policy has been established, building on
previous work undertaken in the area of elder abuse.
Advocacy: The HSE will work in partnership with key internal and
external stakeholders, families and service users to develop and
implement a Volunteer Advocacy Programme similar to the model
being developed for older persons drawing on experience of other
models of advocacy currently in use by Disability Groups. The
HSE will support the development of service user/family councils
that will concern themselves with the welfare of all residents and
will seek to protect resident’s rights and to enable them to
participate in matters that affect their daily lives. These councils
will be independently chaired and will empower service users and
their families and will focus on quality development based on
service user needs.
Evaluation and Practice Improvement: This will involve
undertaking an evaluation on the transfer of Standards of Care into
practice in services provided by the 90 service providers who
deliver residential services in over 900 designated residential
centres regulated by HIQA. In collaboration with service users,
staff – locally and nationally will devise a quality improvement plan
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to support the sustainability of good practice throughout Disability
services around the country. The team, have extensive knowledge
and competencies in the area of Intellectual Disability and
provision has been made to expand the Team in 2015.
The recommendations of the McCoy Review in respect of Aras
Attracta and the broader system wide programme of improvement
and assurance will be implemented.
The National Summit, held today, which both I and Minister
Lynch addressed, had participation not only from the HSE and
the DOH, but also from HIQA, the NDA, National Advocacy
Services, the CEO’s and senior management from the 90
providers, voluntary sector representatives and advocacy groups.
The output from the summit will inform the work of the National
Implementation Task Force which held it’s first meeting this
afternoon following the summit. The system wide reform
programme will be included in the operational plan for the social
care division in 2015 and further summits to review progress are
scheduled March and June of 2015.
The membership of the National Implementation Task Force, the
Investigation Team chaired by Mr. Christy Lynch and the
Assurance Review Team chaired by Dr. Kevin McCoy are attached
for the information of members.
Steps are also being taken with the appointment of ‘Confidential
Recipient" for staff in HSE and hse funded services for vulnerable
persons. I am pleased to announce that Leigh Gath has agreed to
take up this important role. The role - of which the finer details
have yet to be finalised - involves acting as a confidential recipient
for whistleblowers (including both staff and clients) in relation to
safeguarding concerns and issues of alleged abuse, negligence or
other mistreatment. Leigh has been an objective critic of the HSE
on disability matters over the past years. Both staff and clients can
be reassured that she will be an important champion for people
who may be concerned, for various reasons, when they make
complaints. The Terms of Reference for the role are currently
being agreed.
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As Director General of the HSE I wish to put on record again that
what was viewed on the RTE Primetime Programme falls well
below the standards that we expect in the health services and
displayed an absence of dignity, respect and human kindness for
the most vulnerable of the people for whom we care. Such
standards should not and will not be tolerated in the HSE.
At the centre of many of these examples of poor practice is the
individual responsibility of staff members. I urge all members of
staff of the HSE, without fear or favour, to blow the whistle on any
instance of misconduct, disrespect, or abuse towards residents,
clients, patients or any service user should they ever witness it.
On behalf of the HSE I again wish to apologise unreservedly to the
residents concerned and to their families for any distress
experienced at any time in relation to poor standards of care
provided to them in Unit 3.
This concludes my opening statement and together with my
colleagues we will endeavour to answer any questions you may
have.
Thank You.
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