World of Irish Nursing & Midwifery May 2019

42 Focus

Warning signs

The application of clinical governance to the Home Service Support provision in Ireland is flawed and an imminent risk to patient safety, warns Rachel Eustace

in this policy is unsafe and unworka- ble. Members are advised not to accept responsibility for the governance of the HSS as outlined in the policy. INMO direc- tor of industrial relations Tony Fitzpatrick is involved in ongoing negotiations with the HSE to reach consensus as to how to pro- vide a more constructive form of clinical governance for this service. This document needs to be carefully considered by all PHNs. It states that PHNs have oversight and responsibility for all clinical aspects of care delivered by home helps (and presumably HCAs) on behalf of the HSE. This is regardless of whether the care is delivered by HSE employees or private care agencies contracted by the HSE. PHNs are responsible for ensuring that home helps are competent and certi- fied. They also should delegate, orientate, supervise and monitor the care delivered by home helps. The NMBI (2015) states that organi- sations should put structures in place to support the delegation of care by nurses to HCAs. My view is that the HSE has failed to adequately do this and that is why the INMO is disputing this clinical governance document. Currently there is a state of limbo as to who has true clinical govern- ance over this service. Recent HSE figures show that 1,553 PHNs are employed in the Republic of Ireland. 10 The National Service Plan states that over 53,000 people will receive a total of 17.9 million hours of home care support. 11 This means that on average each PHN has governance over 11,526 hours of care provision funded by the HSE. The practicality of every PHN having true clin- ical governance over 11,526 hours of HSS, in addition to our other roles, is unlikely. In

information booklet says that help and sup- port with everyday tasks and personal care will be provided by HSE staff or external providers on behalf of the HSE. The staff providing the hands-on care are healthcare assistants (HCAs). These carers have different titles in dif- ferent areas, their role is poorly defined and they are not regulated. Their levels of training and qualification vary enor- mously. In the UK, 40% of HCAs were found to have no relevant qualification and were not being supervised sufficiently or consistently to ensure patient safety. 7 In addition, research in the community set- ting reported that HCAs are increasingly working alone without adequate supervi- sion and support. 8 My experience is that there has been a huge increase in HSS provision in my geographical area. I would question how well the HCAs delivering the services are being supported or supervised. The NMBI in its Scope of Practice Frame- work 9 describes delegation as “when the nurse who has authority for the delivery of healthcare transfers responsibility for the role to another person” ie. the HCA. When this happens, the registered nurse is accountable for ensuring that the HCA is competent to perform the caring role that they are delegating. In the case of the HSS delivery, the HSE states in its 2014 Home Help Services Roles and Responsibilities policy that the PHN service retains clinical governance of this service on behalf of the HSE. No attempt has been made to revise this document in line with increasing and changing service delivery. INMO stance on 2014 policy Interestingly, this 2014 policy is being disputed by the INMO. The union argues that the governance structure outlined

Patient safety is the biggest chal- lenge in healthcare today. 1 In the US, one study found that medical errors are the third-leading cause of deaths in hospital. 2 Sláintecare has placed safe, quality, patient care at the core of health reform. 3 Clinical governance is seen as a key element in improving patient safety. It is defined as clear lines of accountability: knowing who has what roles and responsibilities. 4 My own background is in public health nursing in Dublin North and I am interested in how clinical governance applies to my daily practice, specifically the provision of Home Service Support (HSS). This was for- mally known as Home Help or the Home Care Package and is funded by the HSE in the community setting. Applications for this service and caseload management of clients in receipt of it form part of my daily practice. However, I had not considered its impact on patient safety or thought about who has true clinical governance over service delivery? In 2017 the Department of Health undertook a public consultation called Improving Home Care Services in Ireland: Have Your Say! In this, PHNs were identi- fied as the professionals the general public would most likely contact for information about HSS. Therefore, it is essential that PHNs are knowledgeable about the deliv- ery and structure of this service. On January 1, 2018 the HSE’s new National Guidelines and Procedures for the Standardised Implementation of the Home Support Service came into effect. This policy has streamlined the provision and delivery of this service nationwide. The service funding is now more transparent, and the application process is standardised nationwide. An examination of the HSS patient

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