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What happened to the HSE's proposal for its own undercover investigations in care homes?

Back in 2014, then director general Tony O’Brien said it was time to look at these sorts of measures to protect vulnerable clients.

Image: RollingNews.ie

THE HSE HAS rowed back on proposals for the installation of CCTV and the use of undercover investigations to crack down on abuse or neglect at care homes.

Following an RTÉ Prime Time investigation into the treatment of residents at Mayo’s Áras Attracta in 2014, then-director general of the HSE Tony O’Brien said it was time to look at these sorts of measures in the interests of its vulnerable clients.

Footage from the undercover investigation by RTÉ showed one resident, who has severe intellectual disabilities, being dragged along the floor and repeatedly denied use of the bathroom.

It also showed residents at the care home being slapped, kicked, prodded, struck with keys and generally roughly treated.

In a letter O’Brien wrote to senior HSE staff in 2014, he also stated that it was “clear that sending undercover workers/reporters into care settings has a certain value in exploring practices that otherwise may have continued for longer than it should”.

He said he had asked the Social Care division to discuss with him how the HSE can incorporate such an approach. 

Speaking to RTÉ’s Seán O’Rourke after the programme aired, O’Brien said the HSE now needed to “do things that in the past we wouldn’t have considered doing”.

We’ve placed the necessary notices to obtain the appropriate advice from specialists as to how we take this forward in terms of both undercover, open filming which is more straightforward, where it can be done in the open and with everybody knowing about it.

“But where we have specific reasons we need to know whether and in what circumstances we can engage in covert filming in order to protect the interests of people who are in fact the most vulnerable clients we have.”

Undercover investigations

TheJournal.ie asked the HSE whether the proposal for its own undercover investigations had ever been progressed and the reasons a system like this is not currently in place. The HSE did not address those queries in its response.

Instead it made reference to the new safeguarding policy and procedures it launched in 2014 as a response to concerns of abuse in service and community settings. As part of this policy, Safeguarding and Protection Teams (SPTs) were set up in each of the nine community healthcare areas.

“Their main focus is to co-ordinate consistent responses to concerns of abuse and neglect,” the HSE said. 

The HSE said there are now over 1,700 designated officers across the sector with specific lead safeguarding roles within their own service. They can conduct assessments and investigations to establish whether abuse or neglect has occurred. 

These designated officers include HSE staff such as nursing personnel, care assistants, advocacy workers, hospital consultants, social workers and managers of disability services. 

The assessments they can carry out are not covert probes as described by O’Brien back in 2014, where undercover workers would be sent to a facility to expose bad practices. 

The use of CCTV

Just weeks after the Prime Time programme aired, the HSE issued a tender for the design and installation of ‘surveillance and security solutions’, which it said was needed “to protect vulnerable clients”. 

In January 2015 it said it had concerns about the privacy and dignity of residents, but denied that it had abandoned plans to monitor practices in social care facilities using CCTV and undercover investigations.

At the time, a HSE spokesperson told TheJournal.ie: “We have to make sure that we dot the i’s and cross the t’s and make sure that a) it’s not illegal, b) it’s not impractical and c) it doesn’t cause a bigger problem than it solves.”

Almost five years after the RTÉ investigation, the HSE still has not put in place any version of CCTV monitoring or a system for undercover inspections or investigations. 

The HSE this week told TheJournal.ie that it did explore the use of CCTV monitoring within residential facilities. 

“This would be a new measure, not previously undertaken, and the HSE is very conscious of the potential difficulties in relation to privacy and data protection,” it said.

Research has shown that there is limited evidence on the effectiveness of CCTV as a means of preventing abuse and of increasing the safety of people living in residential centres. 
In its response the HSE referenced a review carried out by the UK’s Social Care Institute for Excellence, published in 2014.

This review concluded that, overall, there was no definitive evidence about when – and when not – to use surveillance. It also found that there was patchy evidence on the effectiveness or impacts of the different methods. 

It did identify some benefits of using CCTV such as:

  • The use of footage to build up a picture of what led to a negative event like an accident;
  • It can complement traditional staff models;
  • Awareness of surveillance could have a positive impact on staff behaviour.

However it also found that there was potential for misuse of CCTV by staff and that staff may change their behaviour out of fear that their actions, such as engaging in therapeutic touch, could be perceived in a negative way when viewed in footage. 

The HSE said it will continue to monitor research and evidence in this area as well continuing to liaise with a range of other bodies and stakeholders in relation to this complex issue.

The National Disability Authority (NDA), an independent statutory agency which operates under the aegis of the Justice Department, is opposed to the use of CCTV in care homes. It pointed out in a 2015 report that good care practice may be lost because staff are more guarded and residents may act differently because they are afraid their behaviour could alarm staff. 

It recommended that the factors that will transform the culture in residential settings should be examined before CCTV is considered. 

“If negative attitudes, culture and practice are not addressed through strong leadership and management of change, abuse is likely to continue off camera.”

Continued failings

The country’s health watchdog Hiqa has continued to identify serious failings in social care facilities across the country since the 2014 exposé at Áras Attracts. A report published this year found over half of HSE-run care homes that were inspected in 2018 failed to meet garda vetting requirements.

HSE nursing homes were much more likely to be non-compliant. 

The Hiqa review also noted that nearly 20% of all nursing homes inspected were not fully compliant with training and staff development regulations. 

The watchdog has received a number of complaints this year alleging abuse in care homes, including numerous claims about residents who have bruising. Details of these complaints were released to TheJournal.ie through a Freedom of Information request earlier this year. 

One concerned person who wrote to Hiqa claimed a resident at a nursing home had “suffered unexplained bruising on the face”. 

Another complaint stated the relative of a resident with dementia lifted the resident’s clothing to find bruising on their arm. Staff advised that it “must be a sprain” and the relative took the resident to hospital, where they were operated on that evening. The complaint said family were informed the incident was “unwitnessed”. 

In another incident, a relative reported that they noticed blood on bandages used to cover an ulcer and discovered the blood was actually from a fresh cut. 

When relative touched resident’s arm to try hold her whilst investigating the fresh cut they were in pain. Resident transferred to [redacted] hospital and tests confirmed they had two fractured bones in their arm and a lot of bruising under their arms. 

The concerned person alleged that “staff cannot give an explanation as to how these injuries occurred”. 

Hiqa does not have a remit to investigate individual complaints. However, all unsolicited information, which can be received from anyone concerned about a centre, is used to inform the watchdog’s monitoring of each residential centre.

‘Protect vulnerable people’

Fine Gael TD Fergus O’Dowd has said the HSE needs to be “more vigilant and should use every possible means within the law and GDPR” to ensure services and fit for purpose and the people providing them are “competent and caring”. 

He battled with the health watchdog last year for the release of information about how it dealt with nursing home complaints. O’Dowd revealed that none of the complaints Hiqa received over a three-year period had been forwarded to the Ombudsman for investigation.

Speaking to TheJournal.ie he said the State should “weed out” anyone involved in the type of abuse seen at the Áras Attracta facility in Mayo.

“I used to work in a bar – years ago – and the company I worked for had a number of pubs. They employed people [secret shoppers] to come into them and look at the quality of the customer service. 

It’s important to invest in staff upskilling, getting people up to date with the latest professional standards and also getting people from the outside to come in and openly or discreetly ensure standards are what they should be.

“I think anybody would welcome that, it doesn’t mean they have to do it every day but whatever we need to do to protect vulnerable people, we should do.”

Sinn Féin’s health spokesperson Louise O’Reilly said it is “telling” that the HSE does not appear to have explored its own proposal for undercover investigations in the aftermath of the Prime Time programme. 

“When the glare of publicity is shone on the HSE the will say they will take action but the minute the light goes off them they don’t progress what they said they’d do,” she said. 

O’Reilly said any move towards covert assessments should be done in consultation with disability groups and with workers.

“A worker who is doing the job diligently will want to know everything is being done to a high standard so I think you would find workers are very willing to help come up with mechanisms to ensure incidents like those at Áras Attracta aren’t repeated.

The exact format would have to be worked out, it can’t be something that’s designed to catch people out, it has to be designed to ensure top quality care and safeguarding. 

She said the HSE needs to take action on staff shortages and move away from using agency staff, who are less likely to notice ongoing abuse because they may move between care homes.

“It’s the staff who are there all the time who will see what’s going on because they have the capacity to view what’s happening long-term,” O’Reilly said. 

“The HSE has had nearly five years now and the approach has always been reactive, they need to change, to be proactive to ensure this doesn’t happen again.”

- With reporting by Hayley Halpin

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