Safeguarding in the Health Service Executive is managed within the framework of the Safeguarding Vulnerable Persons at Risk of Abuse; National Policy and Procedures.
The National Independent Review Panel (NIRP) was asked to review the application of the national safeguarding policy including safeguarding training, safeguarding practices, role of designated officer and role of social worker in the nursing home.
All safeguarding concerns must be reported within three days of an incident occurring by the staff or management at a local level (in this case the nursing home) through a preliminary screening form to the Community Health Organisation safeguarding and protection team.
This is to enable the Safeguarding and Protection Teams to provide advice and guidance around how to take the issue forward by way of investigation and safeguarding planning.
On 3 April 2020, the Director of Nursing in the home completed and submitted the preliminary screening form to the Social Protection Team within three days.
This was responded to by the Safeguarding Protection Team (SPT) in a "timely and appropriate manner" according to the report.
One of the primary roles of HSE Safeguarding and Protection Teams is to oversee the reporting of safeguarding concerns and the planned response by services.
They also work to assist An Garda Síochána with any investigations that they may carry out.
Where allegations or concerns are reported from within a residential or nursing facility, the role of the SPT is to review the preliminary screening report, the outcome of the assessment and then consider the interim safeguarding plan as required and, in agreement, finalise safeguarding plans with the service.
The SPT was involved in the case of Emily from the outset, giving advice on the requirement to provide a safeguarding plan when the incident first came to light.
It provided face-to-face sessions of training to the unit over two days in the summer of 2020 which provided staff, who were greatly upset by the incident, with an opportunity to disclose concerns.
The SPT was also commissioned by the Community Healthcare chief officer to carry out an in-depth review into the nursing home to identify if any other incidents of abuse of residents by Mr Z are alleged to have occurred.
The NIRP report noted that an integral part of safeguarding is communication between the various professionals and agencies involved.
"Different agencies and professionals tend to hold different parts of the story and it is only when everyone communicates with each other that the holistic picture of the concern is established."
The services involved in the Emily case were the nursing home, the safeguarding and protection team, the safeguarding and protection review team (SPRT), HIQA and An Garda Síochána.
Emily's family informed the NIRP that during the period immediately after the incident, gardaí were supportive of Emily and her family by helping them prepare for each stage of the criminal investigation and legal proceedings.
Emily's family was devastated that their mother had been assaulted in a home which she and they had chosen as a safe, secure and caring environment.
An Garda Síochána continued to support Emily and her family during the court appearances and subsequent sentencing processes according to the report.
While support with court proceedings was offered to the family by nursing home management, the family preferred to continue with the support of gardaí.
However, the Social Protection Review Team informed the NIRP team that following Mr Z's conviction, family members of another resident in the nursing home made a report to An Garda Síochána relating to concerns they had about their mother's presentation around Mr Z.
Gardaí did not inform the HSE'S safeguarding and protection team or the nursing home that they had received this report according to the NIRP.
Records viewed by the NIRP, evidence that all staff working in the nursing home received up to date HSE safeguarding training.
A year before the incident happened, in 2019, Inspectors from the Health Information and Quality Authority (HIQA) inspected the home and found the majority of staff had not attended training on safeguarding vulnerable adults within the timeline set out by the centre.
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However, the inspectors noted that the regular and agency staff members whom they spoke with were aware of the types of abuse that could occur and the procedure for responding to and reporting any suspected, alleged or actual incidents of abuse.
The HIQA inspection also noted that there were gaps in staff attending other mandatory training.
The HSE's Safeguarding Vulnerable Persons Awareness Programme is a mandatory three-and-a-half-hour session that must be completed every three years by staff working with vulnerable adults.
The overall aim of the training is to increase staff awareness of the different types of abuse, including sexual abuse, that may affect vulnerable adults and ensure that staff know how to report concerns.
The National Safeguarding Office informed the NIRP review team that since 2015, attendance at safeguarding awareness training had exceeded 80,000 across the HSE (including HSE-funded services).
From September 2020, awareness raising training was delivered online and the NIRP review recommended that they be in-person.
The NIRP review team liaised regularly with the Safeguarding and Protection Review Team (SPRT) throughout the review process.
The SPRT noted gaps in the residents' files such as safeguarding preliminary screening forms not being held on a resident's file.
The NIRP review team believed that as the name of the person "causing concern" was not recorded on the preliminary screening report there was no reason why these forms could not be held in the case file.
"It would be important for all staff caring for residents to be aware of any single or repeated incidents of alleged abuse," it said.
The SPRT also noted that when incidents occurred it was not evidenced in the file that the National Incident Management System (NIMS) form had been completed, making it difficult for staff, especially new or agency staff, to be aware of individual vulnerabilities.
The NIRP report was complimentary of the Multidisciplinary Team at the nursing home which included people from nursing, social work, a general practitioner, physiotherapy and occupational therapy each providing a specific service to the residents.
They worked together to provide support "as well as to challenge each other to ensure a holistic response to meeting the residents' needs".
When the sexual assault was first reported on 3 April 2020, the Multidisciplinary Team was immediately consulted by the Director of Nursing and promptly took the decision to take the allegation seriously and report the matter to gardaí.
"All members of the Multidisciplinary Team also demonstrated a professional approach to the NIRP review team with open and transparent reflections on the governance arrangements in the nursing home," it said.
"Each member of the Multidisciplinary Team provided helpful information relating to their experiences working in the home and helpful insights on the culture and atmosphere of the home."
The NIRP review team were "particularly impressed with the skills and leadership" of the Director of Nursing displayed throughout "what was an extremely challenging period of time".
The Director of Nursing encouraged staff to go forward to the review team and provide records and documents in an open and transparent manner.
"There is no doubt that the leadership skills displayed by the Director of Nursing in her approach to this crisis and the follow-up enquiries have helped to stabilise the nursing home and have restored confidence in the service," it said.
