Health and Sport Committee

Meeting date: Tuesday, January 17, 2017

Official Report 538KB pdf

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Care Inspectorate

Agenda item 7 is an evidence-taking session with the Care Inspectorate. I welcome to the meeting Karen Reid, chief executive, and Paul Edie, chair, and I invite Karen to make an opening statement.

Paul Edie is going to do that, convener.

The Care Inspectorate is the scrutiny body that supports improvement and is responsible for inspecting and reporting on the quality of care that older people experience. We were formed in 2011 from the merger of the old Scottish Commission for the Regulation of Care and the Social Work Inspection Agency, with some duties also being transferred from Education Scotland at that time. As well as inspecting and reporting on the quality of care, we highlight good care and work closely with care providers to support them and help them to improve. However, when they are not prepared to improve and their quality of care is not good, we have extensive enforcement powers.

We work wherever possible with providers to support innovation in health and social care delivery, and we regulate and inspect a broad range of services. Around 14,000 services register annually with us, and almost 9,500 of them are children and young people’s services. We work collaboratively with a range of other partners including, among others, Education Scotland, Healthcare Improvement Scotland, Audit Scotland, the police, HM inspectorate of prisons for Scotland, the Scottish Social Services Council and NHS Education for Scotland, and we carry out joint inspections on how well organised services are in local areas and how well they work together in order to protect people and make a positive difference in their lives. For example, we carry out joint inspections of children’s services everywhere in Scotland which bring together professional inspectors from care, social work, health, the police and education.

Similarly, we work with Healthcare Improvement Scotland to inspect jointly the effectiveness of collaborative working between health, social work and social care services for older people and their carers. We also provide independent scrutiny of criminal justice social work across Scotland, and we are developing a positive working relationship with community justice Scotland as the new community justice model is being implemented.

Almost every one of us will use a care service at some point in our lives and, as a body, we believe that every person should receive high-quality, safe and compassionate care that meets their rights, choices and needs. We are also changing the way that we work. We are building on our experience of, and building close working relationships with, other scrutiny partners in order to deliver new models and methodologies that focus on new statutory duties on integration and strategic commissioning.

We are embarking on a transformation plan of our own organisation, and our priorities over the next couple of years include consolidating excellence, changing our internal culture, building a competent and confident workforce and collaborating with external scrutiny and care delivery partners and people who experience care, their families and their carers. We are also seeking to move away from a traditional compliance-based approach to a more collaborative approach and from a regulatory perspective to a more modern scrutiny approach that acts as a diagnostic to provide assurance and which targets improvement.

Critical to all of that will, I think, be the new national care standards, which will be crucial for the delivery of care and scrutiny. Although the standards, which are currently out to consultation, come from the Government, the Care Inspectorate and Healthcare Improvement Scotland have co-ordinated their development, and they have been created in partnership with people who use care services themselves, which is to be welcomed. Once the standards are completed, they will, I think, be the most radical anywhere in Europe and perhaps further afield, and they will have the potential to transform significantly the planning and delivery of care. They will apply to all settings, including the commissioning of services by integration joint boards, and they very much represent a move away from the traditional approach of minimal or technical inputs to an increased focus on outcomes and a person’s experience of care.

With that, we are happy to take questions.

Thank you very much. Alex Cole-Hamilton will begin.

Good morning and thank you for coming to see us. I have two questions, the first of which is on self-directed support. Obviously, we are still moving into what is something of an undiscovered country. Although the uptake has not been as great as people might have expected at first, it is still happening. Such support brings with it a great deal of very welcome choice and flexibility in the delivery of care to service users, which is in many cases directed by them. How has the Care Inspectorate found the implementation of SDS, particularly with regard to the response of the market to care-at-home services? How do you regulate and inspect such services and what is perhaps a broader range of providers than existed before SDS came in?

To date, we have undertaken 13 joint inspections of health and social care partnerships and, as you have said, we have found a variable picture with regard to the uptake of SDS. The Care Inspectorate actively supports people being able to make informed choices and decisions about their care, particularly with regard to ensuring that the care that they experience meets their needs, rights and choices.

Given the variable picture of the implementation of SDS that we have seen from the 13 joint inspections that we have undertaken, we are well aware of the need to do more work. As a result, we intend in 2017-18 to commence scoping a thematic review of self-directed support, and I would welcome the opportunity to report our findings back to the committee.

My second question relates to your work with other organisations, which Paul Edie touched on briefly.

When I was elected, one of the first constituency cases that I took up was the campaign of a person who had been badly burned in a bath in a care home. That was partly a failure of the care that she had received and partly a mechanical failure. What are your links with the Health and Safety Executive? Who holds responsibility for learning in such cases?

I recall the case, and I think that I responded to you about that tragic incident.

First and foremost, we expect every care provider to deliver safe, compassionate and high-quality care. Where that does not happen, we work with a range of bodies including the Health and Safety Executive. In that incident, we worked with the HSE to look at the details of the case.

Where the predominant focus is on the quality of care, the Care Inspectorate would be the lead investigatory agency. We bring in specialist support—on health and safety or on health, for example—wherever we require it. That is how we tend to work.

Critical to the incident that you described is the learning that came out of it. One thing that is very different about the Care Inspectorate is the statutory responsibility to support improvement that it has had since its inception in 2011. On the back of such an incident, we would work with the provider and ask it what has been learned and how it is supporting improvement and making sure that the changes that need to happen to ensure that people enjoy good-quality care across Scotland are in place.

Thank you.

It might be helpful—it would certainly be helpful for me—if you could describe the inspection process. I am sorry that we often dwell on negatives in order to exemplify our points, but often the experience of the people who come to us is negative. I was involved in the issue around the Pentland Hill care home. There was a catalogue of failures that ultimately resulted in the care home’s closure. How did we get to a situation where the police were involved? There were deaths at the home. The dogs in the street knew that there were serious problems in that establishment, yet it took an age to get to a position where it was closed down. I am sorry to give you a negative example but why did it take such a long time? On a more positive note, can you describe your inspection process—at what point do you involve different agencies, the person who runs the establishment and so on?

I welcome your focus on the fact that we sometimes dwell on negative areas, because I assure the committee that what we see across Scotland is, by and large, high-quality care.

On how we undertake inspections, over the past couple of years we have, as Paul Edie mentioned, moved away from the traditional approach to regulation, in which we focused on inputs, to one in which we look much more at collaboration to support improvement.

Scrutiny is a diagnostic that helps us to use our intelligence to delve in and to find out what is working well and what needs to improve. We have a range of mechanisms that enable us to form a picture of what is happening within the care service. For example, notifications come into us, because care service providers must tell us about particular incidents that happen within a care home or a care setting. We also get a lot of information through our complaints process; rather uniquely, our organisation has a statutory responsibility to investigate complaints, so complaints can be made to us by an individual in person or anonymously. I know that some committee members have been in touch with me to raise concerns and to make complaints.

11:15  

We take all that intelligence, as well as intelligence from our own scrutiny activities, and use it as a diagnostic to help us to home in on where the concerns lie. Some things particularly help us with the intelligence that we receive. For example, the Care Inspectorate might go into a service such as a care home once every 12 months. Many health and social care professionals, as well as families, are often in and out of those care services; we really welcome the intelligence that we get from, for example, district nurses. In the case of the Pentland Hill care home, we received information from nursing professionals that enabled us to be much more detailed in our scrutiny. Such information allows us to find out what is truly going on within a service and the quality of care that it provides.

To go back to the convener’s point about the time it took to close the service, we must always remember that when someone goes into residential care, it becomes their home. None of us in this room would like to have to move every time a care setting was closed. Equally, it is critically important to note that we have enforcement powers that we use wisely. When there is a risk to the life, health or safety of any resident, of course we will use those powers. Unlike our sister organisation down south, we support improvement at every single turn if it is possible and if it does not impact on the health, safety and wellbeing of vulnerable people.

We can issue requirements and improvement notices and we try to work with service providers and have on-going dialogue throughout our scrutiny process. There are no surprises: no provider should be surprised by the outcome of a scrutiny activity, whether it be an inspection or a complaints investigation, because we share information with them and ask questions about our findings and observations of practice all the way through the process.

We can apply to a sheriff, which is when delays can set in. The evidence base and the high level of tests that are required to close a service mean that we have to apply to a sheriff.

I also want to share with the committee that we have a responsibility to provide public assurance through our scrutiny activities, and we have a responsibility to support improvement. Under the regulator’s code, we also have the responsibility to sustain economic growth and community empowerment. All those fit together; we need to think about how best to support vulnerable people in Scotland first and foremost to remain in their own homes and receive high-quality care.

There have been other cases—very few, I hasten to add—in which an inspection has been carried out and the service has been given a “good” or “satisfactory” report, only for some horrendous practices to be exposed pretty soon afterwards. How does that happen?

That is a really important question and I welcome it. The Care Inspectorate cannot be in the services 24 hours a day, seven days a week, 365 days a year. When we go in and undertake scrutiny, we are evidencing our findings based on the intelligence process that I have just described.

However, problems can escalate quickly in a care setting. For example, a change of manager or agency staff coming in can compound problems and mean that a good service changes overnight and problems escalate. If a member of staff is not sure about how best to support an individual, or agency staff do not know the needs, choices and wishes of an individual, that can escalate quickly. That is why we sometimes see issues such as you describe, convener.

My question is in a similar vein to those I asked of the earlier panel. I believe that you have received 2,000 complaints, the majority of which were upheld. Are you concerned by the number of complaints that you are getting?

I want to put it on the record that I believe that every complaint is important. The Care Inspectorate inspects 13,678 care services, including 1,430 care homes. Are the majority of complaints about care services or care homes, or is it a mixture of both?

The vast majority of complaints that we receive are about care homes—particularly care homes for older people. Richard Lyle is right: in the past year we received 4,086 complaints and we investigated about half of those. There has been a 46 per cent rise in complaints made to us since 2011, when the Care Inspectorate was established. I would treat that figure with caution. We have undertaken significant public awareness-raising about the complaints process and have encouraged people to access it.

At every opportunity we encourage people to try to resolve their complaint with the service provider, but we recognise that that is sometimes not possible. That is one of the reasons why people can make a complaint to us in person or anonymously.

About 25 per cent of the complaints about care homes for older people focus on specific healthcare—on nutrition, medication, infection prevention and control and so on. We also receive complaints around staffing—about 16 per cent are about that. Communication also plays a big part and about 10.7 per cent of the complaints that we receive relate to it. We uphold about 75 per cent of the complaints that we receive about care homes.

Thank you.

You spoke about enforcement powers and said that you can apply to a sheriff. Is that a timely process? How often do you use enforcement powers?

We have served just over 30 enforcement notices on 21 services over the course of the last year. We tend to focus on improvement first and foremost, because whenever we can support a provider to improve a service, people can stay in their own homes. We are looking for improvement in the quality of care, people’s experience and the outcomes. We always try to support improvement, first because of the benefits that it brings to people who reside in the service, but also because of the economic benefits.

With your permission, convener, I will digress slightly to illustrate my point. Every day, our inspectors work with care services across Scotland to carry out inspections and support improvement. For example—and this is one of many examples—about 20 vulnerable residents with high-dependency needs in a care home in quite a deprived area in the north-east of Scotland were looking at having to move out of a care service. The care service had bumped along for a short time and we were not happy about its ability to improve. We had two choices: apply to a sheriff to close the service; or bring in the local authority and local health liaison co-ordinator to work together with our team.

The Care Inspectorate has a health and wellbeing improvement team with a range of professional knowledge of, for example, pharmacy, tissue viability, rehabilitation, dementia and so on, and we brought that team in to work with the service. Significant improvements were made in a short time, and the service has sustained those improvements. The net result was that 20 people remained in their own home, people living in a quite a deprived community in Scotland retained their jobs and suppliers continued to supply the care service. That is not a one-off example—Care Inspectorate staff do that sort of thing day in, day out.

You are in a very good position to study any pressures arising in the care service because of the move towards ensuring that people do not remain in hospital and in acute services. Is that growth in numbers putting increasing pressure on services, and is that increased pressure impacting on quality?

The benefit of being a scrutiny body that looks at the national picture, through strategic scrutiny, and at local examples, through regulated care service scrutiny, is that we can draw some of the conclusions that you are referring to. We work closely with Healthcare Improvement Scotland in relation to adults and older people and Education Scotland in relation to children’s services on looking at some of the outcomes of strategic commissioning across the integration joint board or community planning partnership. We are able to see what is happening in terms of some of those pressures and, equally, how those pressures are translating at local level and whether they are impacting on the experiences and outcomes of individuals. That is a precious golden thread for giving us a robust scrutiny and assurance regime, both at national and local levels.

It seems that there are more complaints about care homes than there are in respect of those who are being looked after at home. Why is that? Is it a cultural problem? Is it about engagement with you and ensuring that improvement happens?

It is a mix of all of those things. After people make the really difficult choice to place a loved one in a residential care setting, they will go in and visit, and on those visits, they will see and hear what is happening to their loved one. As a result, they are much more familiar with the issues and can think about whether that is the quality of care that they want for their loved one. Therefore, those people access the complaints process more quickly than those whose loved ones are cared for outwith that.

Personal assistants are not covered by the regulatory regime. Why is that, and is it at all problematic?

I cannot say why it is, but personal assistants are certainly not covered by the legislation. Of course, that poses risks, but—and it is really crucial for the committee to hear this—there is still a responsibility, through strategic commissioning and commissioning by local authorities, in relation to the use of personal assistants. We expect every local authority to undertake the necessary checks before they arrange for direct payment in relation to personal assistants, for example. People are—rightly—concerned about risk, but it is crucial to remember that there are checks and balances in the local authorities.

As the issue is critical, I will, if I may, digress slightly. We recognise some of those risks and, although we do not have a statutory responsibility to look at personal assistants, we have a statutory responsibility to look at adult support and protection, which traditionally has not had the same focus across Scotland as child protection. Next year, along with the thematic review of SDS, we will look at adult support and protection. That is by no means a coincidence. I would welcome the opportunity to come back to the committee in due course with the evidence that we find in the national overview of adult support and protection.

I have a number of questions about your relationship with Healthcare Improvement Scotland. In our earlier discussion with the ombudsman, we heard about a uniform complaints system across health and social care, which I think we can all see the sense of in this age of integration. From your submission, it is clear that you work with Healthcare Improvement Scotland and that there are new joint statutory arrangements for commissioning. However, I think that you would accept that you and Healthcare Improvement Scotland are very different bodies; it is a non-territorial health board and you are an independent non-departmental public body. Do you have any observations about the continuing operation of those two distinct regulatory bodies in the world of integration?

Yes, I do, actually. I have been asked that question a number of times of late. It is important that we consider the totality of both organisations’ roles and responsibilities. You are absolutely right that we have very different and broad remits. From the Care Inspectorate’s perspective, in addition to that small interface with Healthcare Improvement Scotland on strategic commissioning and improvement, we also have responsibility for social work services and 9,500 children’s services, as Paul Edie mentioned in his opening statement. We have lead agency responsibility for joint inspection of services for children, child protection, adult protection, multi-agency public protection arrangements, community justice, significant case reviews, serious incident reviews and deaths of looked-after children. I hope that that sets out for you that we have a significant range of statutory responsibilities, including a statutory responsibility to support improvement across the social care sector.

With Healthcare Improvement Scotland, we have mapped out the two bodies’ differing roles and responsibilities, where we have a small interface and how we add public value, which is the critical question. With your agreement, convener, I am happy to send that to the committee for information. In our relationship with Healthcare Improvement Scotland or Education Scotland, the key question is how the organisations come together to add public value and therefore ensure that the quality of care, learning and justice is what we would want across Scotland. I hope that that answers your question.

11:30  

I would like to add to that, because I sit on the board of HIS as well, and Denise Coia sits on our board. We employ a lot of inspectors and carry out thousands of inspections. HIS has things such as SIGN, the medical devices body, the Scottish Medicines Consortium and the Scottish health council. It carries out a wide variety of activities that are not about registration or inspection and although, as Karen Reid has said, the interface is important, it is quite small. HIS employs a handful of inspectors compared with us.

You talked about providing the committee with more information. The SPSO provided us with an analysis of the complaints about the sectors—well, it was obvious that he was talking about health. You cover a number of sub-sectors. Could you provide us with an analysis of the complaints about the various sub-sectors that sets out whether those complaints are about workforce issues, communications or whatever?

Absolutely. We have recently produced our five-year report on our findings in complaints, and I will ensure that the committee receives that.

First of all, I should declare an interest. Before I came to this place, I worked for eight years for the social care provider Aberlour Child Care Trust, which does exemplary work.

I want to ask about context. As someone who knows about the social care environment and, in particular, the higher-tariff-needs end of the spectrum when it comes to care home provision, I know that social care can be quite a visceral and frenetic environment. How does the balance work in, say, the context of a pattern of injuries at a care home for people with very severe behavioural needs, as a result of the use of passive restraint? Do your inspectors have sufficient expertise to understand the nature of the care that they are inspecting?

Yes. A couple of years ago, we changed the way in which we undertook our inspection activities, and we will also be changing our methodology in the coming months. Our inspectors now focus on their area of specialism. Previously, they had generic case loads; now they have specialisms. Only those with a background in adult services inspect adult services, and only those with a background in children’s services inspect children’s services. We play to the professional knowledge and skill that our inspectors bring.

Restraint, which you mentioned, is an interesting area. We are a member of the National Preventive Mechanism, which is a UK-wide body, and we regularly work with organisations such as the Mental Welfare Commission for Scotland when we believe that our intelligence tells us that there might well be some issues to do with the use of restraint. We reach out and get specialist expertise—I think that I mentioned that earlier in relation to the point that was made about the Health and Safety Executive. Similarly, if there are issues with regard to restraint that we are concerned about, we will reach out for specialist expertise. By and large, however, I am absolutely confident that the inspectors who work for the Care Inspectorate have the knowledge and expertise to conduct inspections and fulfil our statutory responsibilities effectively.

That is very good to hear.

My second question is about the point that you made about your role in relation to the death of looked-after children. Part of my work with Aberlour Child Care Trust involved seeking to influence the passage of the Children and Young People (Scotland) Bill. The big battle that we faced with legislators and, indeed, with all stakeholders was getting people to understand that our responsibility to looked-after children does not end with the removal of their supervision order. When that happens, they become care-experienced young people, to whom we still have a duty of care. Before that bill was passed, there was no knowledge of the life outcomes for care leavers and no mechanism to deal with the premature death of a care leaver, even though it is demonstrably the case that care leavers are far more likely to die prematurely than people who have not been in care. Finally, we managed to get included in the bill a provision whereby the Scottish ministers would be informed on the death of a care leaver. What role will your organisation play in helping to deliver on that responsibility and to disseminate learning and investigative work in that area?

When we are notified of the death of a looked-after child, we have a statutory responsibility to look into what has happened and what can be learned from the situation. Every death of a looked-after child is a tragic situation, and what we want on the back of that is for the partners involved—primarily local authorities, but the other partners, too—to take the learning from our review of a death of a looked-after child and to think about how we can make things better for looked-after young people in future.

We take the learning from our review and put it into practice in terms of improvement. We also have a link inspector who, as part of their role, works closely with local authorities and will soon work across the integration joint board. We expect our link inspectors to have conversations with the local authorities if there has been a death of a looked-after child and to support them in some of the improvements that they need to make. That is the added public value of an organisation that both undertakes the scrutiny element and supports improvement. That is quite unique and different from what is happening down south.

May I tease out one of the points in your answer, Karen? The looked-after child population in Scotland is such that, on any given day, we have 15,000 children in care, and the majority of those children are looked after at home. Because Aberlour did not deliver services for looked-after children at home, I am not really familiar with that aspect. What are your powers and responsibilities with regard to having some sort of oversight of those children? Given that their life outcomes are demonstrably worse than those of any other looked-after cohort, I imagine that there is probably a higher ratio of deaths in that cohort as well. Can you speak to your responsibility to children who are looked after at home?

Certainly, and I am happy to follow this up with a subsequent conversation with you if that would be useful.

As part of our joint inspections of services for children, we have a particular responsibility to look at outcomes for looked-after children, whether they be looked after at home or away from home. We utilise our responsibilities and discharge them through that process.

We have an update report, which I will be happy to share with the convener, on our first two years of joint inspections and some of the findings. The critical issues that we find around looked-after children in particular and child protection in general and around children on the child protection register include local authorities’ responsibilities to undertake appropriate assessment; chronologies, which is a big issue; and the ability to respond to immediate concerns and need. As well as being able to identify hot spots and what needs to improve in terms of delivering better outcomes for children and young people in Scotland, we also have a responsibility to help support improvement through our link inspector role, in which we work more closely with local authorities to ensure that they actually learn and share that learning.

The other thing that I would add for committee members’ information is that the Care Inspectorate website contains a hub setting out a range of good practice that we see during our scrutiny activities. We promulgate that good practice on our website. If you have a particular area of interest, I actively encourage you to go to our website and access some of the good practice that we see across the country.

I thank the panel for their answers so far, and I would like to expand on Alex Cole-Hamilton’s question about learning from experience and your reports. Earlier, we heard the ombudsman refer to the Francis report. One of its major criticisms was that there was no corporate memory in the NHS in England at that time, and I am keen to hear about how you disseminate your learning—both the good and the bad aspects—from your inspections.

You have talked in particular about the nursing home sector, where there is a high level of complaints. Nursing homes are often small businesses that are isolated and, perhaps, not as plugged into bigger support networks as the NHS is. How do you ensure that you disseminate your findings to those areas?

Every single inspection that we undertake results in a public report, which is available on our website. We also expect providers to share our reports with people who experience care and their families and carers. In the past year, we have produced 7,400 inspection reports at regulated care service level, and they are all available on our website.

As for learning, which you asked about, scrutiny is not, as I have said, a compliance-based process. We are not where we were perhaps five years ago; scrutiny is now a process of working with a provider to identify what is working well, to highlight good practice and to support improvement. Although scrutiny happens over a short time, we expect to have on-going dialogue—with no surprises about our findings—and support for improvement at the end of the scrutiny intervention. At the last count, we had made 12,000 to 14,000 scrutiny and improvement interventions, of which about 7,400 were actual inspections. The figures show that there is a significant focus on supporting improvement.

If we see good examples of practice that is working really well, we will, after undertaking two inspections, highlight that practice in the media. Similarly, if we see poor practice, we will not only take immediate action to support improvement or move forward with enforcement but give the information to the press. After two episodes of good practice or two episodes of poor practice, the information goes into the public domain.

Over the past 18 months or so, we have developed a strong relationship with Scottish Care. Given that the majority of care home providers in Scotland are in the private sector, we work closely with Scottish Care to support improvement and ensure that care home providers across the country can deliver high-quality care.

We have also beefed up our engagement with service providers through quality conversations, in which we can tease out some of the running issues and take soundings from various sectors as well as keep people in the loop on our thinking. We have also had some successful conferences. Indeed, Karen Reid might want to talk about our continence conference.

We were grateful to the chief nursing officer for providing part funding for us to run a conference that supported the development of a continence resource, particularly but not exclusively for people with dementia. The conference attracted more than 350 delegates and had a waiting list. There is a range of things that we can do to share information and promote our findings.

We tend to have our quality conversations with providers by sector type, so that we can find out what the issues are and how we can work more collaboratively. We all have the same goal in mind: we all want people in Scotland to experience high-quality, safe and compassionate care. A stick-based approach to compliance does not enable that to happen; undoubtedly the way to go is working much more collaboratively, sharing information and highlighting good practice.

I think that you said that 75 per cent of complaints are upheld—

Yes, in care—

Yes, in relation to care homes. Will a complainer have gone through the particular organisation’s complaints procedure before they come to you?

I do not have that information to hand, but I can check that and come back to you.

Earlier, the committee was quite surprised to hear from Jim Martin that 56 per cent of the complaints that fall into in his remit are upheld. In your case, the rate is 75 per cent. Does that alarm you?

The 75 per cent rate applies to complaints about care homes. I think that it is 67 per cent—

It is 59 per cent across care services.

Those are still quite high rates. Do they cause you concern and alarm?

They do. First, let me say that wherever we see a complaint, we investigate it, but we do not just leave things when we have published the results of our investigation; we work with the care provider to support improvement. Our involvement does not stop when we have undertaken a complaints investigation. We want to follow through and think about how to support improvement in a care setting, because that leads to better experiences and outcomes for individuals. That tends to be our focus now. We do not draw a line under things once the complaint has been investigated.

I hope that that assures the committee that, although the statistics might sound alarming, with 75 per cent of complaints about care homes for older people being upheld, we follow through and support providers to improve, regardless of the area in which they need to improve—it might be health, in which case we bring in our health and wellbeing improvement team, or another area.

Have you analysed trends? For example, care home providers tell us that they are under financial pressure. Is that an issue?

11:45  

We do not see that in the complaints that we investigate. We have analysed the sources of the complaints and found that they tend to come from family members or, indeed, staff who work in the social care sector. About a year ago, we ran a public awareness campaign and suggested that social care and healthcare professionals who do not see good-quality care in a facility that they enter have a professional responsibility to highlight those shortcomings to the care service provider and the Care Inspectorate so that the circumstances can be investigated.

The briefing that I said that I would send you on the five-year overview gives a range of distilled information about complaints across all kinds of care settings, including where the complaint came from, the type of complaint and whether the complaint was upheld. I am sure that that information will be particularly helpful to you. Again, I am happy to have further conversations about these issues either in the context of a committee meeting or with individual members.

I think that it is good that members of the workforce are approaching the Care Inspectorate individually. However, does that show that there is a shortcoming on the part of the owners, in that the staff do not feel confident about approaching them about a particular issue?

Not always, although there is no doubt that there are pockets of that. We could be talking about, for example, a nurse who is concerned about the quality of care in a care home and raises it with the care home manager but also comes to the Care Inspectorate. It is not an either/or thing.

So people do not have to exhaust the process before—

Not at all. We always encourage people to try to resolve complaints at the earliest opportunity with the care service provider, if at all possible. However, we recognise that, sometimes, it is not possible to do that. That is one of the reasons why we take complaints regardless of whether they have been through the care service provider’s process, as well as taking anonymous complaints.

We have taken evidence from social care staff about a range of workforce issues relating to their employment, and you have raised issues about agency staff. Obviously, there are implications for continuity of care—their concerns about continuity of care were among the first issues that the social care staff raised with us. However, on top of those are concerns about low pay, the lack of value that they see society placing on their work, insecure contracts and so on. Do you believe that those issues contribute to the feeling that the social care system is not as good as it could be? Do you think that we treat our social care staff fairly and value them enough?

To put the issue in context, more than 85 per cent of care services in Scotland have evaluations of good, very good or excellent. That is quite significant in terms of the quality of care that is being delivered. As you said, the things that tend to cause us the most concern are the really negative things that we find out about.

We evaluate the quality of staffing in care services in Scotland, looking at practice, qualifications and training, and we find that the majority of care services in Scotland are getting good, very good or excellent evaluations. That said, we know that there is an issue around the use of agency staff and temporary contracts. Those are specific issues for the Care Inspectorate only when they impact on the quality of care.

At the moment, because of health and social care integration, we have an opportunity to examine integration in action. For example, in the private healthcare sector, there is an opportunity to work more closely with the NHS in terms of nursing staff. There is also an opportunity in relation to recruitment and retention. Recently, we have been working with the Scottish Social Services Council, which is, as you know, the professional regulator for the social care workforce, to produce safer recruitment guidance. That means that we are looking at not only the recruitment process but the values and qualities that staff members bring to social care with regard to their ability to deliver both the clinical side of care and the value side of care—that is, their ability to be compassionate and nurturing, and to perform in a way that is much more in line with the new national care standards, which are out for consultation at the moment.

Do we treat staff fairly with regard to those workforce issues, pay and conditions?

Without a doubt, the progress that has been made in implementing the living wage is great. You will bear in mind that we do a retrospective look at quality of care over the past 12 months, so it is too early for us to tell, but we are not seeing the implications of the living wage. However, you should rest assured that we are looking to see whether the living wage has implications for quality of care.

We are pleased to see the implementation of the living wage and we want to see whether it results in any impacts on the sustainability and therefore the quality of care.

I am not sure whether the answer to my question was yes or no.

My question follows on from yours, convener. Again and again, constituents raise the issue of the 10 or 15-minute visits that many people who are being cared for at home receive. It is not really enough time. There are concerns around that, such as hearing aids being lost and people being left without their hearing aids properly fitted.

Is 10 or 15 minutes enough, in your view? If it is not, what should the Government and local authorities do to lengthen those visits, in order to improve care in Scotland?

It is very difficult to say whether 10 to 15 minutes is enough without knowing the context. For example, if the visit is primarily to ensure that someone is taking medication, perhaps it is enough time. If the concern is about the quality of personal care or an individual’s needs, rights and choices, it will depend. It is not easy for me to answer that without having a context, but I know that there is a particular issue.

Where we hear about hearing aids being lost and people not being treated particularly well, and where we see quality-of-care issues in some of the care that is delivered at home and by housing support services, of course we will take immediate action. Indeed, we would encourage you to encourage your constituents to lodge a complaint with the Care Inspectorate.

In your written submission, you note that you

“report publicly on emerging themes or trends in relation to the quality of care”.

Are you concerned about or aware of problems in care services resulting from extra pressures on increasingly limited resources? Is there an impact on the number of enforcement actions that you have taken or the learning that you recommend?

Five years ago, when the Care Inspectorate was established, the good, very good or excellent quality-of-care rate was probably around 80 per cent. We are therefore seeing an improvement in overall quality of care in Scotland, at a time when we recognise that there are challenges to the social care sector. However, with those challenges come opportunities, in terms of innovation. We are currently looking at the fact that the pressing funding constraints across Scotland mean that service providers are considering different care models. We are working with a large national care provider on the Buurtzorg model and different ways of designing, delivering and commissioning care.

We recognise that there are financial challenges. We recognise that both at a strategic level, in terms of our responsibility in relation to strategic commissioning, and with regard to the golden thread that I mentioned, which runs from strategic commissioning to the outcomes and experiences of care in a regulated care service. That puts us in a robust position as a scrutiny and improvement body.

There are funding challenges and improvement and innovation opportunities. We are watching the impact of the living wage carefully, and we are supporting care service providers to think differently about the models of care that they are designing and developing. I have no doubt that the care that we will see in the next three to five years will be significantly different from the care that we are familiar with today, in terms of the way in which it is designed, delivered and commissioned. The Care Commission is front and centre in empowering care providers and enabling that change to happen.

I take on board what you have said, but it does not really answer my specific question, which was whether the pressure on resources is one of the “emerging themes” that your written submission refers to and whether it impacts on, for example, the number of enforcement actions that you take or the learning that you recommend.

I apologise—I should have answered your question about enforcement actions.

We are not seeing a year-on-year increase in the enforcement actions that we undertake. That is primarily because over the past couple of years the Care Inspectorate has moved away from that traditional compliance-based approach to an approach that is about supporting improvement. At every opportunity, we try to work with a provider to improve.

With regard to some of the financial challenges and constraints that you mention, our work on supporting improvement has meant that we are not seeing an impact on the quality of care. However, we are not naive, and you can rest assured that when we see such an impact we will make that clear in some of the thematic statements that we make.

It seems that the issue of the new care standards has been kicking around for ever. What is the delay? I have another question on the back of that. Reducing health inequalities is a priority area for the committee. How will the new standards impact on that?

Around the end of 2014, the Care Inspectorate was asked to work with Healthcare Improvement Scotland on developing the new set of national care standards. Initially we developed a set of principles that were very broadly consulted on across Scotland, leading to more than 1,700 consultation responses, I think, which was absolutely fantastic. The principles were agreed and signed off by the cabinet secretary, and we have commenced a period of wide consultation and involvement of a range of organisations and, more important, individuals experiencing care on what the new national care standards should look like. The consultation closes on 22 January.

On the question of how the standards will address health—and, I hope, social—inequalities, the new national care standards are in my opinion perhaps the most radical and progressive set of standards to have been seen not just in Scotland or the United Kingdom but across Europe. Instead of 23 standards that start by saying “You should receive” this or that, the new standards are written from an individual’s perspective—in other words, they say “I experience” this or that. That is a significant difference.

We no longer have 23 standards and, I think, 2,402 indicators. Instead, we have four general standards, three standards for specific groups of people and a total of 177 statements. That will make things much simpler. It will be much easier for individuals to understand the quality of care that they receive and make it simpler for us to expand on where we are not seeing high-quality care or, indeed, where through our strategic and regulated care scrutiny work we are seeing inequalities, and to report on those issues publicly.

How will the new standards impact on inequality?

The standards will impact on inequality quite simply because, using our intelligence, we will be able to aggregate up what we are seeing in individual experiences across Scotland. Let me give a practical example of that. We will be able to evidence the quality of care that an individual receives, regardless of the care setting, and correlate that right down to postcode level through working with the integration joint board or partners on the board. That should in future give us a much more mature and sophisticated range of intelligence that tells us, for example, the postcode areas in which people are presenting most to their GPs. That will give us really robust information. Equally, we will be able to use that information from a children’s perspective with regard to looked-after children, children on the child protection register and that type of thing. I am therefore absolutely confident that the standards will go a long way towards addressing health and social inequalities across Scotland.

Thank you very much. I thank the witnesses for their attendance, and I suspend briefly for a change of panel.

11:59 Meeting suspended.  

12:01 On resuming—