Nursing home residents may be left with no option in the future but to live in larger centres away from families, friends and local communities according to the Health Information and Quality Authority (HIQA).
The independent watchdog has published an overview report about its regulation of nursing homes over the past 15 years.
While it says significant progress has been made in enhancing the quality of nursing home care in Ireland, continued improvement is necessary.
One clear trend that has emerged in recent years is the move towards larger nursing homes with more beds, which has resulted in the closure of many smaller, local nursing homes.
This represents a loss of choice for residents and their families and, in the future, may result in residents being left with no option but to live in larger centres away from local communities and loved ones.
The regulation of nursing homes commenced in 2009.
It followed an investigation by RTÉ's Prime Time into the Leas Cross Nursing Home which was broadcast in 2005, and which prompted a national debate on how older people were being cared for in some nursing homes.
The scandal led to the establishment of HIQA in 2007 as the new regulatory body for social services.
This signalled a significant shift from the previous oversight system undertaken by the Health Service Executive, which up to then had only inspected and registered private and voluntary nursing home providers.
When HIQA inspectors began their work, they identified institutional practices, outdated premises and a prevailing culture of a medical model of care, which emphasised a clinical focus on residents’ healthcare needs but where their social needs, preferences, dignity and privacy came second.
Over the last 15 years, many providers have transformed their services and are now providing care that is more person-centred and where residents can exercise choice and preferences, according to the overview report.
Notwithstanding the progress made, HIQA has said there are significant challenges facing the sector.
In 2012, there were 568 active nursing homes in operation, which increased annually until 2019 when there were 585 homes.
At that point, the trend started to reverse and by 2023, 553 nursing homes were in operation.
The closure of smaller nursing homes has impacted rural areas according to HIQA, especially in the west of Ireland.
Registered providers have cited a number of contributory factors for closures including concerns around financial viability, the prevailing economic situation and increasing inflation and difficulties in recruiting and retaining staff.
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Undoubtedly, the Covid-19 pandemic, including burnout from coping with it, also had an impact.
While smaller homes have closed, the private nursing home sector has increased in terms of the number of nursing homes and the number of beds it provides nationally.
The voluntary and statutory (HSE) sector has seen a reduction in both.
Overall, there are over five times more beds in the private and voluntary sectors compared to the public sector.
The number of nursing home beds has increased by 12% since 2013 and at the end of 2023 there was a total of 32,314 nursing home places in Ireland, up from almost 29,000 in 2013.
The report notes that holding companies or companies registered outside of the State own a number of companies, each of which in turn owns several nursing homes in Ireland.
It says further reform of the regulatory framework is required.
The Chief Inspector and Deputy Chief Inspector point to the absence of a national strategy on how social care is to be provided, funded and staffed into the future to meet the changing needs of those that require care and the changing population demographics.
"As people get older, they must be supported to live active and fulfilling lives where their human rights are protected and promoted and in settings that are local and promote their independence as far as possible," they said.
They welcomed the recent commencement of the Health (Miscellaneous Provisions) Act 2024 and Patient Safety (Notifiable Incidents and Open Disclosure) Act 2023 which will strengthen the Chief Inspector’s powers within nursing homes.
