We have received apologies from Deputy Healy, Senator Bradley, Deputy Quaide and Senator Harmon.

The purpose of today's meeting is to discuss the Health Information and Quality Authority, HIQA, 2024 annual report on designated centres for people with disabilities. On behalf of the committee, I extend a warm welcome to the representatives of HIQA: Mr. Finbarr Colfer, chief inspector designate; and Ms Ciara McShane, interim deputy chief inspector of social services and disability.

I will begin, as we always do, with a note on privilege and housekeeping matters. All witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against a person or entity by name or in such a way as to make him, her or it identifiable, or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction I may make. The evidence of witnesses physically present or who give evidence from within the parliamentary precincts is protected, pursuant to both the Constitution and statute, by absolute privilege.

I remind members of the constitutional requirement that in order to participate in public meetings members must be physically present within the confines of the Leinster House complex. Members of the committee attending remotely must do so from within the precincts of Leinster House.

I call Mr. Colfer to make his opening statement.

I thank the Chairman and members for the invitation to appear here to discuss HIQA’s Overview Report on the Regulation of Disability Services in 2024, which was published on International Day of Persons with Disabilities last December.

I am joined by my colleague, Ms Ciara McShane, who is interim deputy chief inspector with responsibility for registered residential centres for people with disabilities. As the chief inspector designate within HIQA, I am responsible for the regulation of designated centres which provide residential services for people with a disability. We regulate by registering centres, conducting inspections, reviewing and risk assessing information received from the service, staff, residents, their families and advocates about the care being received. We also meet residents to hear their views. Where we find risk to residents, we take the necessary enforcement steps to drive improvements.

HIQA’s regulatory role is essential to support service providers to deliver safe, high-quality care. By the end of 2024, there were 1,655 registered centres offering 9,246 residential places. Since the commencement of regulation, the number of centres and residential places has grown each year. It is anticipated that this trend will continue in order to meet the ongoing need for residential services.

Our inspectors carried out 1,042 inspections in disability services in 2024, and found that most centres provided a good standard of care and support to people with disabilities. Overall non-compliance levels across services decreased in 2024, with 78% compliance across regulations. This means that most providers are providing a good level of service that meets the basic requirements of the legislation, with many striving to exceed those requirements.

We have been the independent regulator of residential disability centres for more than a decade now. In the 12 and a half years since regulation and inspection of centres began, we now have fewer residents living in congregated or larger campus-based settings and more residents living better lives as active members of their local community. In 2019, there were 2,914 registered places in congregated settings and at the end of 2025, there were 1,941 registered places. This is a reduction of approximately 33%.

Since we began regulating, one consistent theme that we have seen is the importance of good governance and management. Where we find services that are well managed, we also find residents who are enjoying a good quality service that promotes their rights. Staff are supported and have the necessary resources to provide the best possible care to residents. The inverse of that is also true. Instances of poor governance result in poorer quality outcomes for people using services. In recent years, we engaged with and worked with providers to focus on ongoing improvements in governance in their centres, including through webinars, roadshow events and a national conference which we had in collaboration with providers and the HSE. Over that time, we saw incremental strengthening of governance in designated centres, with a reduction in non-compliance to 14% in 2024 from a high of 25% at the start of the programme. In that time, we also placed additional focus on a human rights-based approach to care. In 2024, 82% of our inspections found staff had received training in human rights. In speaking to residents, many tell our inspectors about examples of how this human rights-based approach has increased their independence and the positive support they receive from staff in their centres.

While we see excellent standards of care and support daily, we also know there are situations where residents do not receive good quality care and support. A small number of providers have had difficulty improving the quality of care and support in their centres. In some, while improvements have been achieved, the providers have failed to sustain those improvements, and this has had a negative impact on the quality of life of their residents. We use our regulatory powers to drive improvements in such cases. We regularly engage with providers, and we understand there are challenges in the sector impacting on governance, staffing and delivering new accommodation. While we recognise these challenges, as a regulator we must continue to put our focus on people using services and whether providers are delivering safe, good quality care and support to those residents.

We engage closely with providers and people using services. We are committed to listening to feedback and have open dialogue and communication. We regularly engage with residents outside of inspections to hear their views about both the service they receive, and what we can do to improve as the regulator. We are committed to acting on their feedback and are improving the accessibility of information that we provide to residents. We continue to engage with the Department of Children, Disability and Equality on the regulatory framework and in reviewing potential areas for reform, such as the introduction of provisions to allow providers to respond to the need for emergency accommodation for people with disabilities who are in crisis. I would like to assure the committee of HIQA’s continued commitment to promoting and protecting the rights of people with disabilities to live safe and happy lives. I am committed to continuing to work with residents, their families, friends and advocates, providers, staff, Government partners and other stakeholders in working towards this end. I thank members for their attention and we welcome any questions.

I thank Mr. Colfer. I invite members to ask questions and we have a rota. The first person who has indicated is Deputy Toole and she has seven minutes.

I thank the delegation for meeting with us. I thank HIQA for their highly valuable work, and particularly with relevance to this committee, HIQA's role in safeguarding and ensuring compliance with all of the regulations. I will ask all my questions first and then witnesses can answer.

The report is excellent, particularly the appendices which show that there has been a substantial improvement in the compliance percentage and, thankfully, a diminishing percentage in non-compliance.

A statistic in the report on governance and management stood out. On page 15, there is the post-Covid evaluation and HIQA's work in 2023. Does HIQA, as a statutory body, have interactions to report to the Covid-19 evaluation committee? I ask because HIQA's observations are highly important.

On governance failures where there is serious or persistent non-compliance, what are the most common governance and oversight weaknesses that HIQA has identified in designated centres? Does HIQA have adequate resources? There is compliance on paper and compliance witnessed by residents. HIQA has had face-to-face interactions at 13 sites out of the approximate 1,600, which is about 0.8%. Does HIQA have adequate resources to have more face-to-face interactions with residents, families, representatives and guardians?

Finally, and this has arisen in previous meetings, I raise the emergency and out-of-hours provision of service or lack thereof. Is HIQA feeding into a process with the Department and perhaps with colleagues in the HSE? What is happening there? Is there a sense of urgency about rectifying the situation? Many public representatives have cited examples where families have a bereavement or force majeure but there is no service and it feels like a cliff edge, and it falls to volunteers or the community rallying around. I am not going to mention governance and management. As there may be a second round I will reserve until then mentioning another issue that I wish to raise.

I might take some of the questions and then ask my colleague to talk about the resources and interacting with the families of residents and other stakeholders.

On the observation around post-Covid, what we found during Covid was that, for good reason, the number of people going into centres was reduced. That included managers and other personnel from the providers' main office going in and looking. Providers became dependent on verbal and written reports from services. What we found when we were doing our inspections during and after the pandemic is that while that weakness may have been sufficient on a short-term basis, because it was so long, the information that providers were getting was not reliable. There was a significant issue for providers in a lot of centres around their understanding of the quality of care being delivered.

Providers recognise this as well. We met with providers and we set up a national conference in collaboration with providers and with the HSE to look at how we could drive improvements and reassert good governance in centres. We did see a significant improvement following those measures.

In terms of the Covid evaluation committee, we link with our parent Department, which is the Department of Health, and we have provided a significant amount of information to the Department to make available to the committee. We have been available to clarify any issues around that as they have arisen.

In terms of the emergency and the out-of-hours piece, this is an issue that has been in place since commencement. There was a question on the right decisions of providers in circumstances where residents are at risk – to themselves or others. That could be along the lines of parents passing away. We have also seen it in established designated centres where people's needs change and they become more distressed and upset and end up either harming themselves or others in the house and providers have had to take emergency action to respond to those kind of scenarios, to keep the person safe, and other people safe. We have had active engagement with the Department of Children, Disability and Equality on this. That Department is working to develop provisions for the Act and we have been feeding into that process. In the meantime, we recognise that while it may be a breach of the Health Act, that in the small number of situations that do arise, people are acting in the best interests of the person and keeping them safe by taking those measures. Generally, providers are very open with us and tell us what is happening. We then engage with providers and they regularise situations as quickly as possible once the measures have been put in place. There is active work at the moment in terms of giving consideration to provisions to rectify the gap in the legislation.

Is there a timeline for that project work?

I would not be aware of what the timeline is. The Department of Children, Disability and Equality are leading on that. In recent months in particular we have had a number of conversations and discussions with the Department and we have given them information about the incident rates.

What about adequate resources, human, IT, and fiscally?

I am sorry, could the Deputy say that again?

Is HIQA adequately resources in terms of human resources, fiscal and IT resources?

In terms of resources, we have ongoing discussions with the Department. This is a sector that is continuing to grow. When I started in the sector, back in 2013, there were 920 centres. There are almost 2,000 centres now. It is an area that continues to change and grow. Also, since then the UN convention has been ratified and there have been changes. The Department does engage with us. For example, last year the Department gave us additional resources in acknowledgment of the changes and the growth in the number of centres. Currently, we are satisfied that we have the resources, but that is an ever-changing landscape. We continue our engagement with the Department on that.

In relation to interaction with resources, the Deputy asked about the interaction with residents and other stakeholders, I might ask Ciara to talk about that.

I am sorry but we have run out of time. We can come back to it in a few minutes but we are going to move on to the next person – Senator Murphy O'Mahony from Fianna Fáil, who has seven minutes.

I welcome both witnesses here this morning. I thank them for the great work they do. Sometimes, HIQA does not get great press for being strict, but it is obviously a good thing to be. I acknowledge the work they do.

With regard to congregated settings, I note that they said there is a 33% reduction since 2019. Is the plan to get rid of them altogether? What are the opinions of the witnesses on that, in the sense that when this started there was a lot of talk about people being happy and that this was their home. They did not know anything else. If someone is obviously happy in a congregated setting, what is the rationale for moving them?

Overall, there is a policy to move people from congregated settings. There is not a regulation requiring congregated settings to close and there is no regulation preventing congregated settings existing. Since 2013, what we have found is that there has been a significant difference between the compliance levels, the quality of life, and the safety of residents in congregated settings than in community residential services. Our view is that it has been a good development to see people moving to the community. I might pass the question over to Ciara to talk about the difference between people's experience in congregated settings and when they move to the community. She can elaborate on that piece. We have seen improvements in the quality of life for people and compliance levels in congregated settings, but there is still a differential. There is still a higher level of non-compliance in congregated settings. Does Ciara want to speak to that?

We have found while regulating the sector in recent years that those living in community-based settings have a much better quality of life in that they are living in and among their community. They are living in smaller numbers as well, in terms of people they perhaps would like to live with and enjoy living with, as opposed to the large campus-based congregated settings with institutional-type buildings. At the commencement of regulation, a number of individuals were sharing bedrooms, not through their own choice. We find that those living in the community do thrive. They are building new relations and feeling more involved. We have a lovely example in the north west of the country where a large congregated setting has now mostly decongregated and those residents have chosen where they live and who they live with. For example, now they are more in control of their daily routines. The large setting lends itself to a rota that is designed to meet the needs of staff as opposed to the needs of residents, but now a lot of residents living in community-based settings are leading out on their own day. They are having a really good quality experience like the Senator and I would in our community. They know their shops, their shop assistants and their neighbours. They are attending education and employment.

Are they actually saying they are happier? Would they voice that?

They are. Even their families talk about their lives being magical or say that they are now living a full life. That is really indicative of an increased quality of life and good outcomes for residents living among the community.

That is good to hear. It was said that HIQA works with residents and their families. Could the witnesses expand on how they do this and perhaps give an example of a change that was made because of that engagement?

While we are on inspections we meet with residents throughout the process. We speak with them and we seek their views on how they find the service they are receiving. If family members are there, we also speak with family members. Outside of the inspection process, we also have organised residents' forums. We have been doing those for a number of years. We organise forums to meet groups of residents who self-advocate outside of the inspection process. We have also moved away from doing those on-site in their home, for example, or in an office of the provider themselves.

We have invited them to our office at their request and met with them there. We have met with them in hotels. We have held some of the classes with residents, which creates an atmosphere where they can have open, transparent conversation with us around the inspections and around the service of which they are in receipt. In terms of the question about what changes we have made on the back of that, one, for example, was that residents told us they did not enjoy inspectors they do not know coming to the door unannounced early in the morning, which we can all appreciate, I am sure.

Fair enough.

I know I would not necessarily enjoy that.

You would not fancy someone-----

Working with the residents, we developed a leaflet that is sent to the residents as part of our announcement pack telling them who their inspector will be and what he or she looks like. It has a photograph of the inspector so that when he or she does arrive, it is not an absolute stranger. They may recognise the inspector from before and if not, at least now they know the face of the person arriving. If it is an unannounced inspection, we also carry those with us in our work bags and we hand them over to the residents to show them that this is who we are, this is our name and photograph and why we are here. We just communicate with them very clearly throughout the day on the purpose of the inspection to keep them at ease.

That is good to hear. Their involvement is so important.

It is crucial.

Yes, and outside an inspection is a great time to engage with them.

I will fit in one more question. Mr. Colfer noted that some providers achieve improvements for a while but fail to sustain them. What could be done to improve this?

I am conscious of the time but very quickly, we continue to monitor. We continue to drive improvement. We use our powers, where necessary. We have put restrictive conditions on centres. We have in a very small number of cases had to cancel the registration of centres. Our objective would be to use the regulations to drive improvement and for providers to sustain improvement.

I thank the witnesses.

I thank everyone. We will move on to the next person. I call Deputy Carrigy from Fine Gael.

The witnesses are very welcome. To follow on from the Senator's point, Mr. Colfer mentioned the fact that HIQA had to cancel registrations. In documentation in 2024, there were notices of a proposed decision to cancel 20 designated centres. Mr. Colfer might tell us what happens to those centres post that and to the residents who are ultimately the most important in those centres.

With regard to the inspections, it is getting a balance between strong enforcement and stability of care to the residents. That is where I want to try to see where that balance is because I have seen in my home area that HIQA inspections - it seems to me from the outside looking in, maybe in inspections on centres for the elderly - have got an awful lot stricter in recent times. Things that were in place previously were acceptable but now are suddenly not acceptable.

We had a case in our local St. Joseph's Care Centre in Longford where the physiotherapy service was based there for the people of Longford but also for the residents within the care home. It was a massive advantage for anyone being there to have that facility on site yet because of a door, an inspection closed that down, which did not make sense to me. We had to try to relocate things to make sure we maintained that service for the people of Longford until the extension to the care centre.

I know I am slightly going off track, but what I am saying is that there are the consequences to some of the decisions HIQA makes, which have negative consequences to the patients on the basis of a strict line in whatever regulations it has. With regard to care centres for those with disabilities, where is the line? A I said, HIQA issued notices to 20 to cancel registration. Where is that now? Where are the residents? What effect had that on the residents and their families?

I thank the Deputy. In relation to the cancellation, the Health Act sets out a process that gives the providers a right of reply and appeal. When the Deputy refers to the 20, that is where we issue a notice of proposed decision, so providers make representation to us then to say why. That notice will include why we are making that notice. Generally speaking, it is after prolonged engagement with the provider to try to use regulation to make changes. When we issue that notice, a provider can make representation to us, and we will give consideration to that. In a majority of cases, that representation sets out an action plan that the provider is going to take to improve the quality of their services. In five centres in 2024, the provider failed to make improvements and there continued to be issues around the quality and safety of care for residents in those centres. We are very cautious using that power because we are very conscious of the impact it has on residents. It does cause distress and upset to residents and to their families and loved ones. It is only something we take where nothing else has worked to drive change. In those circumstances, the HSE takes over the operation of the centre. In all of those circumstances, the house did not close down. Residents were not moved out of their homes. They were maintained in their homes and the HSE then sought another provider to come in and operate a service. In each of those situations, we found significant improvement in the quality of care of residents following a new provider coming into offer the service.

In relation to inspections, again, I do not have information on the one the Deputy is thinking about in his constituency. We are, however, quite conscious of the need for consistency and transparency. We have an assessment judgment framework that we have developed for our inspectors, which gives them guidance on how to weigh up the evidence and the quality of service and guidance on the appropriate actions. We make that available. We publish it on our website. We make it available because we believe that it would be helpful to providers. They are free to look at it and make their own assessments and judgments as well. Where we do make findings in relation to centres, providers have a feedback process wherein they can come back and correct any factual inaccuracies, or, if they do not believe that the findings are proportionate, there is a mechanism for providers to come back and do that. The reason we have those frameworks is to drive consistency in the way that inspectors do their business and also transparency so that providers can see how it is we do our business. Often, when we see situations where a decision has been made, there are other factors involved and often, there is a lot of discussion with providers before getting to a point where we are saying that there is an issue with it. I do not know the specifics of the situation the Deputy is talking about but, generally, they are the kinds of frameworks we put in place.

It is in general; it is not just in one. However, I wonder if there is a different mechanism because reports are put up there-----

Yes.

-----and on simple things, it is seen as a negative. There are X number of patients, we will say, between the four different centres in Longford - maybe 300. If there is any sort of a negative thing, the conversation goes on about how they are not being looked after properly. That is among families. That is what I am hearing, where it is far from the case because I go and visit them on a regular basis and I have family in a number of the nursing homes. Some of the reasons could include, and Mr. Colfer knows himself in that area, that they are struggling to actually get the workforce.

Yes.

A significant amount of the workforce to be able to maintain a service is coming from outside the country.

That is a fact. That could be part of the explanation for the communication issues and so on. These things are put into the public domain as a negative for those centres and it causes frustration for families who are wondering if their loved ones are being looked after properly. This is something I hear. Does HIQA examine those issues, particularly workforce issues because all of those settings are struggling to maintain the correct staffing levels?

We are aware of the challenges around recruitment and retention. Our focus has to be on the quality of care for residents. We use the regulations and the national standards to set out what is expected in any centre, be it Longford, Wexford or Waterford. What we try to do is drive improvement. We have engaged with providers where there are issues around recruitment and providers have given us their plans on how to drive forward improvements. We will work with providers in that regard but we will also call out that, because of the recruitment issue, there has been an impact on the quality of service for residents.

I am working on the basis that it is a positive that there has been a reduction in non-compliance to 14% in 2024 from a high of 25%. However, there are different levels of non-compliance. There can be a technical issue that needs to be resolved or there can be an abject failure to look after some of the most vulnerable members of our society. We need to determine what we are talking about in this regard. Is some of this non-compliance incredibly serious? What sort of percentage are we talking about?

Ms McShane may be able to provide some practical examples but when we are looking at governance and management, we are looking at how it impacts on the quality of people's lives in designated centres.

Rightly so.

Generally speaking, we start with the quality of life. We meet the residents, see what they are doing, see what their day is like and where we find deficits, we then look at whether the provider is identifying issues itself. Our best scenario is where we go in and find that there are deficits but the provider has already, through its own governance arrangements, identified them and is taking action. Unfortunately in a lot of cases when we go in and we find deficits, we find that there is not adequate surveillance of the centre and providers are not identifying what is going wrong. It is our inspectors who are identifying deficits for the providers. When we talk about governance and management, we are talking about it from the experience of the person living in the centre. We assess how the governance and management structures of the organisation support the staff to deliver good quality care to residents. Ms McShane would be able to explain that in more practical terms and give the Deputy some examples.

Is Mr. Colfer reasonably happy with the means by which HIQA carries out its inspections? Does HIQA have sufficient powers to do all that it wants to do? Previously, the authority has said that it could do with greater powers in the inspection of nursing homes. Would that also be the case for these designated centres?

Could I ask the Deputy to repeat his question?

Does Mr. Colfer believe HIQA has sufficient powers in relation to how it carries out its inspections and assessments?

We use the powers we have and we keep them under review regularly. We engage with the Department regularly on our powers. A review is being undertaken at the minute looking at the powers available to the chief inspector. We anticipate that we will have further engagement with the Department on whatever recommendations come from that review. In March 2025, for example, following engagement with the Department, changes were made to the regulations concerning person-in-charge arrangements and other matters to strengthen our ability to use regulations. Another example would be where the Health Act was amended to reduce the timeline for decisions to take effect. What we were finding was that decisions were being made but because of the appeals and the representation process, it could be three months before they actually took effect so that was changed. We keep our powers under constant review and engage with the Department.

While there may be more needed that can be added, the powers HIQA has at present are sufficiently robust. Is that correct?

There is always room for improvement.

Yes, there is always room for improvement. I accept that.

There is always room for improvement but-----

What I should have said is that there is not any great deficiency at the minute.

In relation to disability centres, we are using our powers with effect.

I will go back to my previous question when I spoke about varying levels of severity in breaches. What sort of percentage are we talking about? I am referring to serious situations where a designated centre would have needed to be shut down and where there were serious breaches that were not only impacting the quality of life but were at the severe end of that.

In terms of the serious breaches, we have a provision under section 59 of the Health Act that enables us to go and seek a court order, there and then, to close a centre with immediate effect. We have not had to do that in recent times in the regulation of disability services. In terms of -----

When Ms McShane says "recent times", does she mean in the past three or four years?

I will ask Mr. Colfer whether we have used section 59 since commencement of regulation.

Yes, in the very early days we did but I will have to check the date that we did the last one. It is four or five years-----

That is all very positive.

It is four or five years, I would say, since we have used that power.

We use our powers more regularly in cancelling the registration of a centre, which takes time, and the refusal of a renewal of registration. We do that where we see impact for those living in a centre, where they are not receiving a good quality, safe and effective service. We do not do it lightly because of the impact it can have for residents. We usually take a stepped approach to how we get to that point. We may, in the first instance, issue a warning letter to the provider.

If the providers work with HIQA, these are generally scenarios that could be salvaged but are not----

The providers are given all opportunity to demonstrate how they come into compliance. We can afford them time to come into compliance, once that is done in a way that actually will remove the risk and meet the needs of residents. Where they can do that, and do it in a timely way, our actions are reflective of that. Where providers-----

Can Ms McShane give us a couple of examples of what would lead to this?

We had a provider in the north west, for example, who had an individualised service. During an unannounced inspection, we found that the person living there was not in receipt of a safe, effective service. The staff were not supervised appropriately or sufficiently skilled to provide the necessary care and support. What that meant was that the mental health needs of the resident, their anxieties, autism and other disabilities were absolutely heightened, magnified and made worse by the staffing situation that was there. We gave the provider an opportunity to demonstrate how it could come into compliance. The provider gave us an action plan. We went back out and inspected again, against that action plan and ultimately, the provider had not made significant change. The resident was still in a state of distress and we issued a notice of decision to cancel that centre. The HSE has since gone in there under section 64 of the Health Act and has taken over the operation of that centre. The resident is now living a fuller life, the staff are now supervised and are skilled appropriately to meet that resident's needs. He is less anxious and more content in his day-to-day life.

That is HIQA doing its job and making sure that people are in an appropriate setting. I am interested in the number of providers who comply with the rules HIQA is applying to them versus those that end up losing their licence or registration

In 2024, we had five providers that had their registration cancelled. They were unable to demonstrate how they could come into compliance with the regulations but, more importantly, how they could improve the quality of life for the residents living in those centres.

How many would have been able to deal with HIQA and come into compliance?

We issued 20 notices of proposed decisions, so 15 out of those 20 were able to demonstrate that they could come into compliance.

In light of repeated non-compliance in some HIQA designated centres, why do serious issues continue to arise? Are HIQA's enforcement powers and timelines adequate to protect residents in a timely way?

Serious issues occur because these are human services and things change in services. For example, we had one large organisation with a very strong history of providing very good services and then a new CEO came in, along with a number of other senior managers. Within a very short space of time, we saw a very significant deterioration in the quality of service. In that circumstance, our response is to try to use regulation to drive improvement and ensure people continue to get the service they are getting and that it is of the quality they deserve, to which they have a right. In that particular situation, the provider had a number of centres that were at risk of being cancelled. Rather than going down the route of individually cancelling those centres, we engaged with the provider at company level and required it to look at its governance structures, executive arrangements, the competencies of its board and how it was going to use the review to drive improvement in the delivery of care. We are approximately a year and a half into that programme of work and we are now in situation where we are looking at normalising our regulatory engagement with that provider. We are seeing that its services have improved. Serious issues happen because things change, managers change, etc.

How does HIQA ensure consistent inspection standards and enforcement across all designated centres, including smaller and rural services, such that people with disabilities receive equal protection regardless of location? That question comes from my having spent many years on a former health board. We used to make unannounced visits to all houses to which people had been moved out, especially Alvernia House, which was attached to St. Vincent's hospital in Portlaoise.

Ms McShane might tell the Deputy how we do that.

In terms of our approach on consistency, as Mr. Colfer referenced earlier, we have an assessment judgment framework, which is a tool for our inspectors to look at how they assess against the regulations. That tool is available on our website to the public and to providers, which means they know how they will be measured in terms of the regulations. Regardless of whether a resident lives in a rural, suburban, congregated or community-based setting, the regulations are the same. We apply them in the same manner and hold the providers to account in the same way.

I refer in my question to State providers. How often does HIQA visit them?

That happens, on average, two times in a three-year cycle. However, if there are higher levels of non-compliance, we are in those centres more often. Some centres, for example, could have up to six or seven inspections in a three-year cycle.

Are other visits carried out by other authorities, such as were done by the health boards?

The HSE has a service level agreement with the services it funds, in respect of which it may have its own arrangements in place.

In such cases, is it the HSE's own staff going to those centres? Under the former health boards, doctors and public representatives who were members of the boards would make those visits. I wanted to check that because I was a member of a health board for many years.

Providers may have their own internal audits, which would involve their own managers, for example, completing audits. We complete our inspections under the Health Act 2007. There are other agencies, such as the Health and Safety Authority, that may complete inspections.

How does HIQA verify that providers have fully and sustainably addressed inspection findings rather than applying short-term measures? How is accountability enforced when failures are repeated?

As I referenced earlier, some providers make improvements and we continue to monitor them. In some cases, however, they do not sustain those improvements. In that case, we will give the provider an opportunity to establish good practice and ensure good-quality care for residents. If the provider fails to do so, we will then go into escalation. That can mean anything from issuing a warning letter to putting a restrictive condition on its registration or, ultimately, if there is ongoing concern for residents, cancellation of its registration.

I like to visit nursing homes and I know a lot of people who are in them. I take this opportunity to say that, by and large, the staff go above and beyond the call of duty in looking after people. I want to acknowledge that. Sometimes, my eyes are opened as to how good and personal the care is that they provide to their patients.

I thank Deputy Aird.

Before we move to the second round, I have a quick question. In his opening statement, Mr. Colfer said there was 78% compliance across the regulations in 2024. When will the 2025 figures be available? Can the witnesses give us an idea of the level of compliance in terms of whether serious and minor instances of non-compliance are all included in the same figures? I would like to hear about the level of small versus major non-compliance.

On the Cathaoirleach's first question, we have the 2025 figures and they are in and around the same as those for 2024, with compliance levels of 77% and non-compliance at 8%.

In terms of what is the distinction between, for example, sub-compliance and non-compliance, the latter is something that has a sustained and clear impact on the quality and safety of care for a resident and a higher level of risk associated with it. An incidence of sub-compliance might, for instance, be a documentation issue whereby a care plan was not updated in line with the requirements of the regulations, assuming that failure to update did not have a significant impact on the resident. If the failure did have a significant impact, that might be deemed to be non-compliant.

Is there information on the number of non-compliant providers that are still non-compliant today?

I do not have that figure to hand.

Is that reflected within the figure of 77% Ms McShane mentioned for 2025?

It depends on when we go back to those centre and do a follow-up inspection. After those follow-up inspections, we then make a determination as to whether the providers have come into compliance or have moved down to a sub-compliant level. As each inspection occurs and each report is published, we get a greater sense of how the provider has improved since the previous inspection.

Will Ms McShane clarify the term "sub-compliant"? Does it refer to where a provider is non-compliant and is being given time to become compliant?

It refers to where there is a lower level of impact or a finding of a smaller breach of the regulations.

I thank Ms McShane. We now move to the second round of questions, with five minutes for each speaker. The first person indicating is Deputy Toole.

I hope I will not need the full five minutes as some of my questions have been answered. Not to dwell on it, but it is important for us for learning and dealing with policy, regarding governance failures where, for example, registration had to be cancelled, what are the main issues? Will the witnesses drill into that in terms of governance and, in particular, management? Is it related to vetting, recruitment or, God forbid, fraudulent qualifications of persons being recruited? I would like more information in that regard.

Second, are there any trends in compliance or non-compliance as between services for children with disabilities and services for adults, or are there common themes?

Third, I bring an issue to the witnesses' attention on which we might confer later. It concerns a vetting query that was raised. The HSE reference number is HSENOPD801. Another one is a protected disclosure, reference number-----

The Deputy is drifting into individual cases.

They are a matter of public record and are with the relevant offices.

The Deputy may continue.

The second one, a protected disclosure, is reference number 2025/PD17.

More particularly, to go back to the governance pieces, what areas are they in?

Before the witnesses respond, those are individual cases and they can be discussed afterwards. The witnesses do not have to respond to those questions, although they are welcome to, if they wish.

I am happy to get a response afterwards. I have raised them at Leaders’ Questions previously.

I will take the first question. I will ask Ms McShane to talk about the trends between children and adults. In relation to the protected disclosure, we are precluded from discussing protected disclosures, particularly specific protected disclosures. The Protected Disclosures Act prevents us from discussing those items. We provide information at a higher level in relation to global protected disclosure responses and issues arising.

In relation to the governance failures, we would never contemplate taking action, such as the cancellation of a service, solely on the basis of something like Garda vetting or the other matters mentioned by the Deputy. We would engage with the providers and require them to take action. In some cases, we have asked providers to ensure that the people they have employed, and whom they do not have Garda vetting for, are not on-site while the Garda vetting is coming through. Garda vetting is one of the core indicators of whether a person is suitable to work in a centre. It is a very serious matter.

Generally speaking, when we get to a stage where we are issuing a warning letter to a provider, or where we are taking specific actions such as telling them that we are giving consideration to either attaching a condition or cancelling their services, it is in relation to matters that impact on residents. For example, in one of the services, a resident had very complex needs. Consistency in the delivery of that service was really important. What we found when we went out on inspection was that staff did not have the qualifications or experience to provide the care to the resident, and there was very poor guidance for staff on how to interact with that resident. Items like that impact and cause distress for residents. We will certainly take enforcement action on those. If there are other matters, we will look at ways of managing them and look at how we can provide the provider with the space to correct.

For all of our inspections, we produce an inspection report. In that report, we outline what the non-compliances are and the impact on residents. Providers have an opportunity to tell us what they are going to do to rectify it. That is how the vast majority of our inspections are managed. Providers respond, and we then check whether they have implemented the actions, and not just implemented the actions, but whether that has been effective. As for the examples given by the Deputy, most of those would be managed through that process.

Ms McShane may wish to talk about trends.

Regarding the Deputy’s query on children and adults, the regulations are the same for both children and adults. Certain aspects of the regulations specifically call out areas that we need to focus on for children who are in receipt of support, for example, education facilities, play and communication.

In terms of our findings for both children and adults, it is important to acknowledge that most providers are providing an excellent service. For example, we were in a service last week in Limerick. It is a respite service for young children with life-limiting conditions who have very medically complex needs. We found excellent service provision there. The families described the service as being life-saving. It was meeting the needs extremely well for those vulnerable young children.

Areas of concern we would see in some centres where children are provided with care and support include communication, in particular, not meeting their communication needs if they are pre-verbal or non-verbal, and consistency in how staff apply care and support, in that not all staff would do it in the same way in line with a child's assessed needs. There is also the piece around continuity of care and having the same staff team that the young children are familiar with, and that they trust and feel safe around.

Similarly, with adults, we see that most service provision is at a really high standard. Where we have concerns, again it is perhaps about the assessment of needs not being up to date or their needs not being met specifically. For example, somebody might have behaviours that challenge, and there might be an overly and unnecessarily restrictive environment in place because of the way the staff team is set up and arranged. Those are the types of things we see.

I want to pick up on the points made by Ms McShane. Is that down to a lack of staff training or because people cannot avail of other services that should be provided by the State, such as occupational therapy, speech and language therapy or psychology?

There could be multiple reasons. It could be that the staff are not supervised sufficiently, and do not have the support of a management team coming in and highlighting gaps in the care they are providing. It may be that they are not appropriately skilled to meet the needs of the residents. It may be that there are changing needs for a resident in terms of complexity. Sometimes, those changes in needs can be quite sudden, and staff might not yet have adapted to the changing needs.

As we move away from congregated settings and all that was wrong, I have a fear, and it has been said to me multiple times, that we are overly emergency-reactive when looking after the needs of the vulnerable and those with disabilities, be they children or adults. I am talking about the more complex end. We could probably game-plan or work out how many places we need, but we do not always necessarily do that. I have been told that this suits those with bigger pockets at some level - some of the private, for-profit operators - whereas others say they cannot avail of this. If they knew exactly the timeline, and they were making an allowance across the State for, say, 200 new places, they would be able to ensure that the funding was in place and draw it down. In the long term, that would actually be cheaper for the State. However, from their point of view, they would still be giving the best of care, whereas in some cases, because of the way we deal with this, it probably suits private operators more. I am not sure if the witnesses can give a view on that, but I will ask the question.

In relation to the need for places, there is a challenge in meeting the capacity and demand. When we get an application for a new centre, generally it is because people need accommodation fairly urgently.

In fairness, what I am being told is probably fairly right, which is that the system could do with being less emergency-reactive.

If there were more capacity in the system, there probably would not be as many emergencies. There is a legacy piece there. I had been working in disability services for a long time before I came to HIQA, and this has been a challenge for as long as I have been working. From our perspective, we do not distinguish between the private provider and public provider, for-profit and not-for-profit.

No, HIQA has to concentrate on the care.

We concentrate on the care of the person. The Health Act sets out the criteria for somebody applying to register. We have to make sure they meet those criteria and they can deliver care. That is the perspective we are coming from. It does not matter to us whether it is a private provider or otherwise.

I get that. I also work on the basis that HIQA has come across good and bad, and they probably fall into all brackets. I come back to the idea of the registration being cancelled. In these cases, it seems they are sufficiently serious for HIQA to consider registration cancellation. If the provider is able to up their game to a significant level, they get across the board. I am thinking that these failures where registration is cancelled are incredibly serious. I do not completely understand, if HIQA is willing to meet them halfway, how they are not able to deal with it.

Are there a number of repeat offenders among providers which HIQA has had constant issues with?

Is it a constant issue?

I am asking two things. Does HIQA have issues with some of the same providers on a constant basis? It seems that for those which have their registration cancelled, it does not happen straightaway, but there is a process, so it must be incredibly serious. Can Mr. Colfer detail an example or two?

To the second part, yes, it is. We do not take that action lightly. It is usually when we have gone through a process of trying to use regulation to drive improvement and the provider has failed to do that. In relation to consistent issues with providers, we have a number of providers. I would say it changes. We are engaged with a number of providers at a very high level organisationally because they have a number of centres that were at risk of being cancelled. We engage with them, tell them that we are looking to cancel, and give them space to drive improvement, but that changes. For example, there is a large provider on the east coast that was in that position and was struggling. It looked like quite a number of its centres were going to be cancelled. That provider's centres are probably now some of the best in the country with the compliance levels it is now achieving. We went to that space and the provider responded. We are in that space with a number of providers at the moment.

We all know that the staffing pressures in disability services are fairly high. At the moment, how confident is HIQA that staffing levels are adequate to fully meet the standards of person-centred and rights-based care in the settings? When it is doing an inspection, how does it assess staffing adequacy of a centre?

We are aware of the challenges with recruitment and retention of staff. Our focus is on the experience of residents, so when we go into a centre, if there are issues with staffing, we look at how they are impacting on residents, what the provider is doing to address or mitigate that risk, and what actions it is taking to address the staffing issues. We find that many providers are very good at managing that and will recognise and have a plan in place. Other providers are not good at managing it and the impact on residents continues without sufficient mitigation. In those kinds of situations, we call that out and require the provider to take action to meet the need of residents. If the provider fails to do that, then we will go into escalation with that provider. We recognise the challenge. We have also engaged with providers which have a specific challenge in one or two of their centres. They give us their plan of action. We give them space and time to implement their plan of action to address the issues. We will still call out the impact on residents through non-compliance.

Regarding ongoing engagement with providers, what is their most consistent concern? Would HIQA meet the users of a facility outside an inspection time? Does it do the same with providers and how does that work?

We also initiated a provider engagement meeting for the providers outside the inspection process. It is an opportunity for the providers to share with us some of their own plans, whether they are about recruitment, expansion or meeting the changing needs of residents, or any other initiatives that they have in their service, for example a human-rights based approach training session for their staff, or whatever the case may be. That meeting is not focused on, for example, the aspects that they are not doing too well on. We will come with our own date and share that with the provider. It is an opportunity outside the inspection process and that pressurised environment where they can have a conversation about their aspirations, plans, strategy and where they see themselves going. We started that a couple of years ago and it has been very effective. We currently have 97 or 98 providers, so it is quite a large number to get through. We do it over a number of years. We might meet a provider formally once every couple of years in that way.

Is HIQA available, within reason, if providers want to meet it?

Of course. If, for example, a provider got a new chair or CEO, that person may ask to meet us. Only recently, I met a new CEO and a new chair of a provider. They wanted to get an understanding of regulation and our view of their organisation, and for us to get familiar with their roles.

It is important that everyone tries to be on the same hymn sheet.

That concludes our discussion. Is it agreed that we publish opening statements on the committee's website? Agreed. I thank Mr. Colfer and Ms McShane for attending today and for their insightful contributions to help our members with their questions.