Governance: The Root Cause Behind Repeat HIQA Failings

Introduction

Despite years of regulatory guidance, revised standards and repeated inspection findings, governance remains a persistent point of failure in HIQA inspections of nursing homes.

Through our review of 25 recent HIQA inspection reports for designated centres for older people, HCI identified a consistent pattern: where governance and management systems were weak or ineffective, multiple areas of non-compliance followed. Fire safety, infection prevention and control, staffing, care planning and residents’ rights all deteriorated where governance failed to provide meaningful oversight.

This is not about a lack of commitment to care. It is about oversight systems that are not functioning as intended.

Governance Is Not a Standalone Regulation

Regulation 23: Governance and Management can often be misunderstood as an administrative requirement. In practice, it is the regulation that determines whether all other regulations can be met. HIQA often note the correlation between good governance and the overall quality and safety of the service.

HIQA inspections consistently demonstrate that governance failure:

• Allows risk to go unidentified
• Weakens escalation and decision-making
• Undermines audit and assurance
• Results in repeat findings across inspections

Where governance is effective, providers have the structures, systems and oversight mechanisms in place to demonstrate control even when challenges arise. Where it is not, issues persist, compound and escalate.

What HIQA Is Repeatedly Finding Under Governance and Management

In our review of inspection reports, HIQA repeatedly found that providers were not assured that care was safe, despite having governance structures in place. Audit systems did not reflect the reality observed during inspection, and senior management could not demonstrate how they knew risks were being controlled.

In several cases, audits failed to identify:

• Fire safety risks
• Infection control breaches
• Unsafe care practices
• Environmental hazards

This disconnect between assurance and reality is a critical governance failure.

Unclear Accountability and Escalation

Inspectors frequently identified unclear lines of accountability, particularly between PICs, CNMs, ADONs and operational management. Staff were unsure who was in charge, especially out of hours, and escalation processes were not consistently understood or applied.

High turnover in management roles further weakened governance, resulting in:

• Loss of oversight continuity
• Delayed decision-making
• Repeated failure to close out actions effectively

Governance structures existed on paper, but did not operate reliably in practice.

Incident and Risk Management That Did Not Drive Improvement

Another recurring theme was the failure to learn from incidents. While incidents such as falls or unexplained injuries were recorded, root cause analysis was inconsistent, and trends were not effectively analysed.

Risks were documented, but control measures were not implemented or monitored, and there was limited evidence that learning led to meaningful quality improvement.

From HIQA’s perspective, this represents a governance system that records problems but does not manage them.

Why Governance Failures Drive Wider Non-Compliance

One of the most important messages from the inspections is that governance failures rarely exist in isolation.

Where Regulation 23 was found non-compliant, inspectors almost always identified issues under other regulations, including:

• Regulation 28 (Fire Precautions)
• Regulation 27 (Infection Prevention and Control)
• Regulation 15 and 16 (Staffing, Training and Supervision)
• Regulation 9 (Residents’ Rights)
• Regulation 17 (Premises)

Governance is the mechanism that sets priorities, allocates resources, tests whether systems are working in practice, escalates risk when issues emerge, and verifies that improvements have actually been embedded. When governance is weak or ineffective, these functions break down — and risk migrates across the service unchecked, leading to repeated non-compliance across multiple regulations rather than isolated issues.

The Illusion of Governance

Many of the services inspected had governance meetings in place, maintained audit schedules, held risk registers and developed action plans, yet inspectors still found serious non-compliance on the day of inspection. This highlights a critical issue: governance activity does not equal governance effectiveness.

HIQA is looking for evidence that governance systems are effective at identifying risk early, challenge assumptions, drive timely action, and prevent repeat findings. Where governance exists primarily as a reporting exercise rather than an assurance mechanism, it offers little protection when an inspection takes place.

What A Good Governance Model Looks Like to HIQA

Elements of a Good Governance model include, but are not limited to:

• The governance arrangements are appropriate for the size, scope and complexity of the service provided.
• Clearly defined lines of authority and accountability, with role delegation in place.
• Managed by people who have been appropriately trained and have the required experience.
• Management roles are visible at all levels, and members report that they know them.
• Provides adequate resources to assure the quality and safety of support.
• An effective risk management model to manage service and individual risks both proactively and reactively.
• Appropriate controls in place for critical subcontractors / suppliers.
• An open culture of communication between staff and management.
• Members’ involvement is supported to design and improve the service provision.
• The service provided is reflective of evidence based best practice and is person centred.
• Quality and safety Key Performance Indicator’s (KPI’s) are monitored and formally reported to management so that they can drive continuous quality improvement.
• Robust continuous assessment, including an effective audit programme implemented to drive quality improvement strategy. Supported through benchmarking of current status and identification of required improvements.
• A Culture of Learning is embraced – learning from incidents, feedback, external issues – to improve the quality and safety of care and support provided.

Why Governance Issues Persist

The persistence of governance failures suggests that many providers continue to struggle with translating regulatory standards into practical, day-to-day operational systems, aligning internal audits with the real risks HIQA inspectors are identifying, and using quality and safety data in a meaningful way to inform decisions and drive improvement.

Governance can also weaken during periods of change or pressure, such as staffing challenges or management turnover, when oversight becomes less consistent and escalation pathways are not as robust as they should be. Without a deliberate focus on strengthening governance capability, services can appear compliant on paper while risk steadily increases on the ground.

How HCI Supports Providers

HCI has over 20 years experience supporting health and social care organisations, including nursing homes to build Quality and Safety Management Systems that effectively meet regulatory requirements.

Our supports for nursing nursing homes looking to strengthen their governance and management include:

• Reviewing governance structures and oversight arrangements
• Gap Analysis against National Standards and Regulations
• Implementing quality and safety management systems, including digital solutions that support real-time oversight
• Independent Quality of Care Audits
• Development of effective risk and incident management systems
• Providing HIQA Advice and Support
• Best Practice Policies and Procedures utilising Cloda
• Quality and Safety Data Analysis

The focus is on governance that works in practice, not just on paper.

Conclusion

The consistent governance findings across recent HIQA inspections are not a criticism of care intent. They are a warning about system reliability.

Governance remains the weakest link not because providers do not value it, but because it is often under-designed for the complexity and risk it must manage. Strengthening governance is not about preparing for inspection — it is about ensuring services are safe, controlled and resilient every day.

If your nursing home requires regulatory, quality or resident safety support then contact HCI at +353 (0)1 6292559 or info@hci.care to find out how we can help you.