Health and Sport Committee

Meeting date: Tuesday, August 25, 2020

Official Report 674KB pdf

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Pre-budget Scrutiny 2021-22

We move on to agenda item 9, which is an evidence session with the Care Inspectorate. This is one of a series of evidence sessions that we are holding with health and care bodies, which will contribute to our 2021-22 pre-budget scrutiny.

The committee’s approach to scrutiny of the budget reflects the approach that was recommended by the budget process review group. It entails addressing budget implications throughout the year and bringing that information together to inform a pre-budget report for consideration by the cabinet secretary.

This year, the committee agreed to undertake pre-budget scrutiny of the 2021-22 budget while considering the impact on health and social care of Covid-19 as well as the settlement for the current year. Today, we will hear from the Care Inspectorate on its work, including its budget, work in relation to its statutory roles and the impact and implications for its work that arise from Covid-19.

I welcome to the committee Peter Macleod, who is the chief executive of the Care Inspectorate, and Kevin Mitchell, who is executive director of scrutiny and assurance.

We will move straight to questions. I will begin, and then I will bring in colleagues in the usual way. How effectively is the Care Inspectorate fulfilling its statutory brief as set out in part 5 of the Public Services Reform (Scotland) Act 2010, which is to protect the users of social care services, encourage a diversity of services, promote the independence of users of care services and identify and promote good practice in social care?

Thank you for that question, convener. Before I answer it, I would like to put on the record my acknowledgement of the loss and tragedy that has occurred as a result of the impact of Covid-19 in Scotland. In the care sector, there has been loss of life and there are many bereaved and grieving families. That is also the case for staff members, who have worked selflessly and have also lost their lives.

Given my role in the Care Inspectorate, it is important that I acknowledge that tragedy and its impact. Having spent 30 years in the sector and having come to my role in the past 18 months, my acknowledgement of that is heartfelt. It must remain a focal point and something that drives us forward to change and learn. I hope that it is acceptable to you that I have put that on the record, convener.

You outlined our key responsibilities under the Public Services Reform (Scotland) Act 2010. Members will be clear that, within the scope of the act, a number of responsibilities, powers and duties are given to the Care Inspectorate. They range from the ability to register services—to give the final say to a service being created in the first place, from childminding services right through to care homes for adults and older people—to the powers and duties in relation to inspection. No doubt we will return to that issue this morning.

We also have a number of powers in relation to the cancellation of registration, the making of conditions and variations to it, and improvement and enforcement activities. That can go right up to the cancellation of a service and therefore its closure. The statutory underpinning of the Care Inspectorate allows us to fulfil the full range of functions.

I absolutely acknowledge that the unprecedented situation that Covid-19 has presented, not least in Scotland’s care homes, has led us to continue to reflect, with the Scottish Government and other partners, on whether more should be done or changes should be made to some of the legislative requirements and powers that I have outlined.

It is clear that legislative changes have already been made since 2010. For example, oversight of strategic commissioning and planning is now a responsibility of the Care Inspectorate. How have that change and other changes that have been made to your remit over the past 10 years impacted on the organisation?

They have impacted positively on the organisation. In part of my career, I was a director of social work, and I believe that commissioning and examining integrated services at local partnership level is critical. We have completed eight such inspections in recent years.

If your question is about the impact that those changes have had on our budgetary and resource availability, I note that we have received some additional resource through business cases that we have made to the Scottish Government for specific requirements such as the expansion of early learning and childcare and some resource in relation to justice services. In recent weeks, we received additional resource to increase the numbers and capacity of our inspector workforce and to recruit to fill vacancies. We have had responsive support in a resourcing sense, which has enabled us to focus on priority areas of risk.

You have direct income in addition to the funding that you receive from the Scottish Government. Is the balance of Government funding and direct income right or about right? Are there opportunities to increase the level of direct income to offset increasing demands on Government funding?

The proportion of funding is one third income generated to two thirds grant in aid from the Scottish Government and the Parliament. Almost £12 million is generated in fees from registered services, which can be up to £13,500 a year for a large care home service, for example.

We have been taking forward with Scottish Government officials a review of not just the level of fees, but the definitions of services, because I believe that they require to be updated to reflect the current picture of services in Scotland. One of the dilemmas regarding the fees that are raised is how much they impact on services in the social care sector that could already be quite stretched. There is a fine balance to be struck.

Early in the Covid-19 crisis, we deferred fees collection across the sector that we regulate in order to relieve some of the burdens on services that were clearly struggling under the demands that Covid-19 brought.

Good morning, Mr Macleod and Mr Mitchell. There has been a marked decline in inspections of care homes for adults over the past five years. Why is that?

[Inaudible.]—that we inspect, Mr Stewart. In particular, we changed the methodologies of inspection back in 2014-15 to be much more outcome focused in the way that we inspect. We now look not just at the size of the rooms or other more straightforward service requirements, but at the experience of the people who receive those services, the relationships that they have to support them, and whether those services are responsive to their needs and are achieving the outcomes that we all seek for the individuals concerned.

It would be correct to say that we have developed an intelligence-led model of inspection, which means that we rigorously target our inspections on those services that most need to be looked at and those where we believe that improvement is most urgently needed. Despite the fact that there has been a reduction in the number of inspections over recent years, because of that targeting of inspection and our taking of a risk-aware approach, over the three years up to 2019 we had to take action—unfortunately—to close nine care services in Scotland, using the powers through the sheriff courts that I mentioned earlier.

We are proportionate in what we do. We target the right services that require inspections, outwith the statutory inspections that we need to undertake.

I will move on to return inspections, the number of which has also fallen dramatically over the past five years. Why is that? Has that happened for the same reasons that you have just outlined?

The number of return inspections is determined by the improvements that we find require to be put in place. Because we have targeted, in a more risk-aware way, services that are in most need, we have been able to deal with matters quickly. I have mentioned the example of cancellations of registration.

We also have services that do not need inspection continuation or follow-on visits from our improvement team. Over a number of years, our focus has been much more on building resources around improvement services, so that we can assist services that might be experiencing difficulty to improve before we need to take enforcement action against them. Such action is often based on a risk to individuals; we would prefer to be preventative and improving in our approach. There is a mix of reasons for the decline in the number of continued or repeat visits, but that is a principal reason.

What specific monitoring was carried out with regard to residents who were discharged from hospitals to homes during the Covid pandemic? I am thinking, in particular, of homes with poor inspection reports.

I again return to the fact that I have long experience in the social care sector; I am a former director of social work. As you will be aware, there is a very clear and defined process for how the decision to discharge somebody from hospital is reached. That will involve a medical person in the hospital setting making the clinical judgment that somebody is ready to leave hospital. A view will be taken by the health and social care partnership in assessing the needs of the individual as to whether, for example, they should be placed in a care home. Critically, the care home requires to ensure that it is equipped to deal with the individual’s needs and to make the decision to admit them or accept them for care.

Our role is to ensure that we provide proper guidance and direction to services, particularly on infection prevention and control practice. We would not be directly involved in the grading relationship; it would be a matter for the partnership and the care service, alongside the hospital service, to determine where the individual would be best placed.

I am of course aware that the Cabinet Secretary for Health and Sport has recently commissioned Public Health Scotland to examine a number of cases of individuals who were discharged from hospital into care homes. We await its examination and findings and any further learning and actions that emerge.

11:15  

I will not drag you into political controversy, but it is clear that there was a Government move to clear hospitals of patients and put them into care homes during the Covid pandemic—there has been recent coverage of that in the Sunday Post. Was the Care Inspectorate brought into discussions about pandemic planning and the effect that that move would have on our care homes, which were obviously under a lot of pressure, particularly those that had poor inspection reports? Were you involved in discussions? Did you give advice, guidance and assistance to the Scottish Government in relation to that decision? I understand that clinical decisions were taken, but a wider, macro, Scottish Government decision was taken to clear hospitals and move patients to care homes.

I am aware of that debate, and it is clear what impact such decisions could have had. I repeat that our role as the regulator for Scotland’s care services is to advise and provide the right guidance, along with Health Protection Scotland and others, in the face of this unprecedented public health crisis. It is not our role to advise in relation to decisions around discharge of patients from hospital. I made it clear in my earlier answer that such decisions are a matter for the local area on a case by case basis. To answer your question, that is not a role—whether in an advisory or other capacity—that we have stepped into. It is for others to make a determination on how such matters were progressed.

Given the announcement by the First Minister of Scotland about a future public inquiry on Covid-19 and its impact on Scotland, we will await that inquiry and will be advised by its findings, particularly in relation to the question that you posed to me.

Could you explain the self-assessment process, which I presume provides feedback from residents to drive improvement in care homes in the future?

As you have described, the self-assessment process is there to give a sense of how the service thinks that it is performing and, in particular, of where it needs to improve. It is critical that it is only part of the picture. The process involves seeking views from those who have been cared for and supported and from their relatives. It is one part of the picture, and it is rigorously tested against the quality frameworks of the modernised inspection regimes that we have in place in Scotland.

It would be wrong to accept a self-assessment purely at face value. It is an aid to the service and to us, but we rigorously inspect every aspect of care, leadership, management resourcing and training, and, in recent times, we have inspected the provision and suitability of infection prevention and control measures. Self-assessment is only part of the picture that we build. If we find, through building that picture and through inspection and interventions, that things need to improve, we do not hesitate to take appropriate action.

Before I bring in Emma Harper, Brian Whittle has a brief supplementary to Mr Stewart’s questions.

Good morning, Mr Macleod. You can correct me if I am wrong, but I think that the phrase “clinical judgment”, which we hear all the time, pertains to the patient’s health and their ability to leave hospital. That judgment by the hospital clinician does not take into account the potential impact of moving the patient into a care home setting. Is that a fair assessment?

Increasingly, in my experience of that area of practice, those judgments are taken in the round. Clinicians look at the medical circumstances but, equally, they look at the circumstances of the individual. For example, when a judgment is made about whether a person, if well enough, is able to go home, it may be that their home circumstances are not suitable or, indeed, safe for that to happen and that, therefore, a care setting is the best option to take.

I think that I mentioned earlier that a part of the process requires a suitable assessment of the individual’s needs to be done by the local health and care partnership and for the individual to be matched with the needs that are determined through that assessment—in fact, such an assessment is statutory. In a sense, that is another form of clinical judgment or assessment.

As I have also said, an assessment and judgment are applied by a care home in relation to whether the individual can be suitably cared for in their setting and whether they have adequate staff, space and nursing support, for example, should that be required.

All an individual’s needs—not just their medical needs at the time—should be considered in the round, given all the different parts of the process.

Good morning. I want to pick up on the issue of inspections and self-evaluation. Are residents and their families involved in the self-assessment process? If so, how is the feedback that is received from residents and families used by inspectors to drive improvement?

Such feedback is, indeed, used as part of the self-evaluation process. I repeat that although that feedback is part of the picture and part of what we use in the improvement process, even more critical are the questionnaires, the interviews and the bringing together of groups of people, including relatives and staff members, that we progress as part of an inspection programme. That way, we are able to compare and contrast independently the self-evaluation against our findings.

I think that we always recognise—this is certainly my experience of running services such as care-at-home services for many years—that, sometimes, those who receive the service are more prone to saying that everything is fine if they are being asked by the service provider. However, if a person is making a comment to the inspectorate, they might want to share a slightly different view. Therefore, self-assessments are part of the process, but they can never be the whole of the process. The robust processes that we put in place and the conversations that we have with relatives, staff and those who are cared for are a critical part of how we find out what is going on in a service and the quality of care that it provides.

I understand that the evaluation and quality framework process covers seven questions, which are part of the self-assessment. They include asking about how people’s wellbeing is supported; how good the leadership is; how good the staff team is; how good the setting is; and how care and support are planned. A new question has been added about care and support during the Covid-19 pandemic.

As a nurse, I understand the process of assessing care homes, but the self-assessment process is new to me. I am interested in how we encourage that process to be robust, so that its quality marries up with that of face-to-face inspections.

There are a couple of ways in which we do that—and I note your past experience in nursing. First, we ensured that we developed our frameworks in conjunction with people in the sector, so that those people owned the frameworks and were part of how they were shaped. We did the same with question 7—the new question—which focuses on infection prevention and control and related matters.

We have also produced guides and guidance on self-assessment. If you go to our website, you will find various resources on that. My appointment with the Care Inspectorate was in January last year, and in the year up to lockdown we spent many days going around the country talking directly to services about how those resources should be used and how they tie into our quality frameworks and the questions—there are seven now; there used to be six—to which you referred. We encourage people to undertake self-assessments rigorously. As I said, that is part of the picture.

Question 7 is critical and means that services have to assess the robustness of their infection prevention and control. In the midst of a pandemic such as this, that is what we most rigorously assess. You will see that that is the focal point of our fortnightly reports to the Parliament.

We find concerns that we have to deal with, and we go back very quickly to deal with them. In the vast majority of cases, they are then resolved. We do that with public health, nursing directors and other partners in the system.

How do you provide guidance and training for your inspectors on assessing performance against the health and care standards, so that the approach is consistent throughout Scotland? Obviously, you carry out such training.

Yes, we do. We do that with partners. For example, on infection prevention and control, we work with NHS Education for Scotland. We also work with the providers of services—much of that has been done over the past year. As you said, the aim absolutely is to achieve consistency in how services are inspected.

The way in which we developed the quality frameworks questions to which you referred means that consistency is good. Equally, individual inspectors need to apply their judgment.

In recent years, we have introduced professional development awards; currently, more than 30 members of staff are on that programme. We have also involved Healthcare Improvement Scotland staff in joint inspections, which is important.

All that work, plus the new development programme, is about achieving the consistency of application that you talked about.

How are assessments fed back to providers? How often are unannounced inspections made?

There is of course feedback from assessments. We give providers an opportunity to look at and comment on draft reports, and then we publish the reports. We might or might not accept a provider’s comments, depending on the evidence that we find. It absolutely is a process of dialogue with the service, including about where things need to be done—and need to be done very quickly.

I think that you asked about follow-up visits. If so, I reference the more than 160 Covid-related inspections that have taken place, a large number of which required follow-up visits, because we identified immediate concerns about things such as infection prevention and control. Clearly, we have to take very quick action to ensure that such concerns are addressed in the way they should be addressed. That is why follow-up and continuation visits take place, particularly in the current context.

11:30  

In the self-assessment process, how often do services assess their performance as poor or failing? Is that something that crops up now and again?

That is a very important question. I would need to go and check the detail of the numbers. I think that the answer is that that happens relatively rarely. Some of the self-assessment models that we have introduced against the new standards are relatively new, and I get the sense from providers in the sector that they are still moving towards making a more accurate assessment of what they are finding for themselves.

I am often impressed with the honesty of services and their ability to reach out for assistance. That is the true hallmark of a service that is willing to learn and to deal with difficulty at the earliest stages. On occasions during this public health crisis, I have been humbled to see services come forward and say, “We need help,” particularly in the context of staffing. We have been able to assist services quickly and directly as a result of those requests.

I have some questions on leadership and accountability. How can the health and care scrutiny landscape in Scotland be improved?

We always strive to improve. During the Covid-19 public health crisis, we require to reflect, consider and change even more.

On how the landscape should change, we need to reflect on how we can continue to work as closely as we have done during Covid, when support has been wrapped around care homes in Scotland, with directors of public health, directors of nursing, the Care Inspectorate, health and social care partnerships and providers working together to ensure that homes have been as well supported as possible. For example, we produced the safety huddle tool, which service providers and partnerships now use daily to assess staffing levels and how safe and adequate care is.

The landscape of the future is therefore one that is integrated in the interests of the people in Scotland who require care and support. We are governed by the legislation that the convener mentioned and, should it be the will of the Parliament to revisit the legislation and change the regulation landscape, we will want to make a central contribution to that work.

It is about taking a more integrated approach. For example, we now inspect care homes with Healthcare Improvement Scotland inspectors and public health personnel. That has happened for the first time, and it happened by necessity, because of Covid-19.

Has what is in “Social services in Scotland: a shared vision and strategy 2015-2020” been achieved? What should be the focus of the strategy for the next five years?

To a large degree, the shared vision and strategy has had to be informed by the Covid-19 circumstances that we have faced. I think that that means that we have to stop, pause and reflect. At the Care Inspectorate, we are about to go back to our board with a refreshed view of our corporate plan. We do that by necessity; we cannot have the worst public health crisis in living memory and not change what we do, not least because of the tragedy that we have seen unfold in Scotland’s care sector, as I said at the beginning of this part of the meeting.

We must reflect and change, and I hope that the submission that I have given to the committee shows that we have changed very rapidly, acted safely and implemented very different systems. We have already changed, and I think that we will change more and in a more integrated manner.

What is the role of the office of the chief social worker in relation to the Care Inspectorate? How does she complement and add value to your work?

The office of the chief social work adviser works very closely with the Care Inspectorate, and we very much complement the work that we each do in our different functions. I know Iona Colvin very well, and I regularly meet her, as do members of my senior leadership team. In fact, during the Covid crisis, we are sitting together on the leadership team for children and families for Scotland, and we deal with matters to do with social work and social care that we identify through our inspections. We share intelligence and deal with priority matters that require to be addressed and changed, including where risks have emerged in services. We work together very closely and in a complementary way across a whole range of functions in social work and social care.

Given the Care Inspectorate’s multiple roles across such a range of services, does it have the capacity to lead the sector to a sustainable future?

We act as both a recipient and a collector of information from our inspection activity across the range of functions to which you refer. That is an invaluable source of information that allows us to explore what is required for now and the future.

On the sustainability of care, we already have the Scottish Government reform of adult social care programme, and we are part of the leadership arrangements for that. It examines issues such as fair work, resourcing and the current care services in place in Scotland. Therefore, we are very well placed, and we would wish to advise on and influence what the future can hold for care services in Scotland.

There are well-known challenges in the sector, but they are also challenges that I see in my work across the British isles and Europe. We need to address those challenges in the most practical way possible, but we should address them in a way that addresses the needs of individuals as they see how their support needs being addressed best by our services, and not necessarily by what we determine is best for them.

Finally, how does the Care Inspectorate currently demonstrate leadership skills? What are the essential elements of a sustainable care sector?

On our leadership role, I have referred to the fact that I have over 30 years of experience in the sector. My absolute commitment is to the care of people—that is what I have spent my life engaged in. Fortunately, I have been able to influence positively to some degree some of the changes that have occurred over the years in conjunction with talented people I have worked with.

On the leadership role and sustainability, we will have to look at all the available options to us for the future of the care sector in Scotland. I believe that the home care sector should be and requires to be a mainstay for Scotland’s population that is in need of care and support. Equally, we can reflect again on how the measures that have been put in place around the self-directed support legislation for Scotland are promoted. They have recently been reviewed.

At the core of the issue is how we continue to integrate health and care services. They should be further integrated with housing and technology options in order to allow people to live as long as they can safely at home and retain their independence where that is possible.

My question is about integration and whether the joint inspections with Healthcare Improvement Scotland are joint in name only. Some of the evidence to the committee makes the point that, although there are joint inspections, there are different approaches and advice that flow from those. I also wonder whether the Care Inspectorate is visible enough at the integrated authority level, and therefore whether there is a truly joint approach.

I believe that there is a truly joint approach. I referred earlier to the eight partnership inspections that have taken place across Scotland. I also cite the fact that I have recently developed a proposal, which I have shared with partnerships and with the Scottish Government, to change the way we do those joint inspections so that they focus much more on the experience and outcomes of the individuals who receive services from the partnerships.

We often focus on the strategic and planning aspects, as part of the inspection duties that the Public Services Reform (Scotland) Act 2010 placed on the Care Inspectorate in respect of integration. However, we can broaden our perspective beyond that to look much more at the lived experience of those individuals who receive care and support, and consider whether that support is suitable for their needs or whether it can be improved. In answer to Mr Rennie’s question, I say that we are already changing, and we have already engaged with partnerships on the suggested changes that we propose to make.

We always strive for visibility. I, too, was interested in some of the comments that were made in evidence to the committee. Again, however, we are not necessarily a champion for the sector; we are there to report on what we find without—to be frank—fear or favour. That also might mean that some of the things that we say are not necessarily palatable, because they require things to change, improve or become safer. Nonetheless, I accept entirely that we can change and move forward in the way that Mr Rennie describes. Visibility and profile are part of the new inspections that we propose on an integrated basis.

That is helpful. You acknowledge that some of the evidence that the committee has received is pertinent to the issues at play here. The fact that you are changing the inspection system and seeking more visibility is clearly a good thing.

My next question is on the viability and sustainability of the sector. There is no doubt that the pandemic may have a financial impact on an awful lot of social care businesses, which may fail even though they provide good-quality care. In your organisation, do you have the expertise to be able to provide support and advice on the business failure—or business success—aspect, as well as on the quality of care? If not, are you planning to change that? The climate will get a lot more difficult for those businesses, and we may need a greater focus on that.

I believe that we have some of the expertise and capacity that is required. We have already had some active discussions—I, along with my leadership team, am about to consider a paper that looks at something that, in England, is called market oversight. I work closely with the chief executive and senior officers of the Care Quality Commission, as I do with others who are in similar positions across the UK. After the failure of Southern Cross—as Mr Rennie may be aware—legislation was brought forward to create that facility within the regulator in England. There are active discussions on that, both in my organisation and with colleagues in the Scottish Government.

I accept that the current situation impacts on the sustainability of services, to which you referred. We are actively exploring capacity in my organisation in order to make it more robust, and we are working with Scotland Excel, the Convention of Scottish Local Authorities, Scottish Care, the Coalition of Care and Support Providers in Scotland and others to ensure that we understand and can map the care sector and its vulnerabilities relating to sustainability.

11:45  

If you are in discussions with the Government on that issue, do you need more powers through new legislation in order to carry out the functions that you have indicated are being carried out in England and might be necessary in Scotland?

I am not sure that we necessarily need legislation. We need the ability to map and consider what is happening in the care sector. I share with the committee the reassurance that, in relation to care providers that operate across the UK—in Scotland and England—we have close working relationships with regulators such as the CQC that allow us to share information in order to provide that assessment.

My considerations have not reached the stage at which I can say definitively that more powers are required, but I am certainly considering what we need to do to undertake the work that we have discussed as a result of Willie Rennie’s question.

The Care Inspectorate has a role in ensuring improvement in services and advising on them, but it also polices care in Scotland through its inspection and enforcement role. Do you accept that there is a tension between those two roles? If so, how do you resolve that tension in practice?

I very much understand the tension between inspection and enforcement, and improvement. The two roles can work in tandem, but they have to be separate, so that the staff who carry out the first role are not always the staff who carry out the improvement role. I have referred to the fact that we attempted to strike that balance through some of the early changes that we made to our model. By improving early, we can prevent harm and poor-quality care. In that sense, the two roles are part of a continuum that should be embraced by Scotland’s regulators and, as you say, are part of the legislative make-up of the Care Inspectorate in Scotland.

We must always be alert to that tension and ensure that we deal with the matters that we need to deal with urgently, including safe care. We can balance the roles, and we do so through our improvement strategy, through how we train our staff and through recognising that we sometimes need to enforce immediate action to improve care.

You want to further what is described as a collaborative approach to quality in the care sector yet, at the same time, you have to regulate the sector. Are you content that the Care Inspectorate is able to do that?

I believe that we are able to do that. My journey has meant that I spent many years being inspected before I became the accountable officer who visits the process on services. It has been a learning journey and, over many years, it has taught me that the best services are those that take responsibility for monitoring their care, ensure that they know where improvements should be made and then take action to make them. In that sense, there is a spirit of collaboration.

However, as we have seen during the pandemic, collaboration sometimes has to be compromised by the urgency to take action in the face of need and, indeed, in the face of safety and protection. That is why we have taken some of the actions that we have outlined in the reports to Parliament.

There is a balance to be struck, but I believe that we can and do strike it. That is evident in some of the comments that have been received in submissions to the committee.

If rules and compliance are required, who should set those rules? Should that be the Care Inspectorate?

I think that the Care Inspectorate should do that. It depends on what rules and standards are being adhered to. We require to be cognisant of various pieces of legislation in setting rules and standards, including adult support and protection legislation and protection of children legislation. There are various legislative frameworks around the needs and the services that are provided in Scotland’s care sector, including, of course, early learning and childcare. I think that we should be, in a sense, the moderator and the body that judges how those standards are met. Equally, we strive to define those standards, based on the experience and the lived experience of those who receive care.

A number of different aspects form the frameworks that we use. I am confident that those frameworks are robust, but they are always under development, and we seek to learn and understand, not least during the experience of Covid-19 in Scotland.

Finally, what are you doing to raise the profile of the Care Inspectorate as an organisation with the general public and to raise the profile of the care sector?

I was interested to read the comments from many in the care sector about raising the sector’s profile through the work of the regulator. As members can see, the publication that I have submitted to the committee gives an overview and seeks to share understanding of what has happened in the care sector, or one particular part of it, through Covid-19. That is one very recent example of how we are raising the profile of what is happening in care. There are many publications on our website and elsewhere.

I do not believe that we are the sector’s champion. We can be that to some degree, but there is an inherent tension in regulating and enforcing action where that is required, and championing at the same time. I am not sure that those are in equal balance.

I accept that there is more that we can do and say about the sector. That is something that I have very much taken from the evidence that has been presented to the committee. I will work very closely with partners to understand and take that forward. However, given the level of activity across the 12,500 registered services in Scotland that we are involved in, I believe that we cover and discharge our duties across all sectors in the way the legislation intended us to.

Good morning. I am well aware of Peter Macleod’s history of delivery in the sector, because we worked together in Renfrewshire Council.

My question, which is about the effect of the Covid-19 pandemic on the Care Inspectorate’s activity, follows on from David Torrance’s questions. Many respondents have been very positive about the support that your officers have provided. What have you learned about your role and functions during the pandemic?

We have learned that we must act quickly to change in the face of an unprecedented set of circumstances. That means that we must apply judgments and decisions that are based on the best evidence possible, including on when it is safe or not safe to inspect because of the risk of our inspectors spreading Covid through care services.

My submission to the committee today illustrates one particular learning point. We changed the contact levels and the scrutiny models that we employed, and we put in place red, amber and green status notifications to ensure that care services could alert us if they were experiencing difficulty with staffing levels. We also put in place virtual technology solutions to ensure that surveillance and examination of care settings was possible even when it was too dangerous to undertake site visits.

I am glad to hear of the positive comments, Mr Adam. The main learning for us is that, while we must guide as clearly as we can, we must also scrutinise and understand what is happening in care services and—critically—provide assistance to those services when they need it.

We have seen an awful tragedy unfold. It is the worst time in my 30-year career in social services. We have been able to seek assistance and get staff into a service urgently when they were needed, through partnerships or other means. We were also able, on almost 400 occasions during the pandemic, to put personal protective equipment into services where it was desperately needed, where the equipment was available and where it was possible for us to do so.

The main learning is that we should never, ever stop being determined to do the best we can. We should adapt quickly and use the best advice to do so, but we should always keep a focus on the individual who needs care at the heart of what we do.

That is the first time that you have ever called me “Mr Adam” in all the years that we have known each other.

Older people in residential care remain vulnerable to the pandemic. How do we apply any learning in the months ahead as winter approaches?

The learning is already there. As I mentioned, we have changed the wraparound support that we provide to care homes, and it is essential that that support remains in place. Early on, I, along with others, gave advice on how those arrangements could be put in place to best effect; I worked with the director of public health, for example, to that end.

We need to ensure that we are picking up intelligence. We changed our intelligence model to target those services that are most in need. For example, we were able, for the first time, to draw on weekly assessments by the director of public health in Scotland, as directed by the Government in mid-April, as a source of information, as we could look at what they were saying about specific care homes. We used that information alongside other evidence such as complaints, previous inspection history and a variety of other measures of intelligence.

We have learned that we need to ensure that there is proactive wraparound support in place. We can understand as early as possible if there are difficulties emerging, and the service provider can seek to remediate the situation. Moving forward, we can look in particular at how infection prevention and control measures can be most robustly put in place. Just last week, we received new UK clinical guidance on infection prevention and control, and we will put that in place very quickly with agencies such as Health Protection Scotland.

We also have to look at how the design of care services in the future will be influenced by the realities of how Covid-19 is spread, not only in the care sector across society. There is much learning to be done, but we are already doing that. I am part of the mobilisation and recovery group; I am able to contribute centrally to the group, along with other leaders across sectors in Scotland. Our learning, and our influence and advice, is front and centre for the care sector in preparing for any future eventualities around Covid, flu or anything else that tests us.

Finally, Peter, following on from what you have just said, how will the Care Inspectorate advise services on maintaining the balance between infection control and respecting personal outcomes, recognising that care homes are primarily people’s homes, not hospitals? Do you think that the balance was and is right?

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The fact that the coronavirus has resulted in such a loss of life around the globe, tragically often targeting older members of our communities and indeed those in care settings across the world, causes us to reflect on the balance and the focus, and on how we ensure that infection prevention and control is even more robust in the future. We have learned much about the sustainability of the sector and its ability to cope with such an event again, but we must be determined to continue to learn and focus on the elements that make care safer.

You ask about balance. I am now confident that all parts of the services that are working together to get care supported and to get it through the virus pandemic are clear about the balance that needs to be struck. Somebody’s home is not a hospital, with very few exceptions—there are those in continuing care. We must therefore ensure that care homes are homely environments or as like home as possible, striking the balance that you mention.

Over the course of the Covid-19 pandemic, we have rebalanced that, but we must keep our eye on the risks, the concerns and the impacts to life and limb that arise from Covid.

Mr Macleod, I have been considering your earlier answer on clinical judgment and the fact that clinical decisions result in patients being discharged into a care-home setting. What involvement did the Care Inspectorate have in developing that emergency protocol whereby local authorities did not have to carry out the normal assessments of individuals being discharged and consulting the individual. What was your role in developing that strategy?

I do not believe that we had a direct input into the development of that protocol. I understand its origins, with a requirement to consider assessing need very rapidly. I would need to explore whether there is anything further that I can add in response to Mr Whittle’s question, and I could then come back to the committee.

Thank you—that would be appreciated.

I am a wee bit surprised. Surely the Care Inspectorate must have a role in discussions about the impact of protecting the national health service by moving people out of hospital into care settings. I would be surprised if you were not consulted.

I will go and check what the level of discussion and involvement was. I would go back to the point that our role is to ensure that guidance is given to the sector on how it manages infection prevention and control—along with Health Protection Scotland and other bodies. I have already explained the process by which decisions for discharge are made. I am clear about the protocols that I have shared with you from my knowledge of practice. On the question of consultation, I will go and check and come back to the committee on what our contribution was. If it was more directive than I have suggested, I will correct the record.

Thank you—I really appreciate that. We might be able to highlight that there is a gap in knowledge. As I said earlier, surely, if we are discharging people from hospital into a care home setting, we should be taking cognisance of the impact on that care home. The committee would appreciate your following up on that issue.

The remits of a number of bodies seems to cross over significantly. Is there an argument for the Care Inspectorate and the Scottish Social Services Council to merge or, at the very least, to have a much closer working relationship?

We are co-located in our Dundee offices. We work closely together and liaise regularly—indeed, there is an element of shared services between the organisations. We have distinctively different but complementary features. The SSSC is the workforce regulator and we regulate the services, their quality and the standards that providers aspire to meet.

I do not think that it is a matter for me, given the legislative frameworks that operate between the organisations and on which they are founded, to give you a judgment on that, because I consider that we already work closely together. For example, the publication that I gave to the committee for today’s session has joint statements by the SSSC’s accountable officer and me on recommended practice. That is evidence of our joint work.

It would be a matter for Parliament to reflect on the legislative frameworks that are currently in place to discharge the key duties and functions for which we are responsible and whether there should be legislative change following that review. I consider that the two bodies work closely together, and that that works in the interests of the sector that we serve.

Most of the questions have been about care homes, but I want to ask about care-at-home services. I thank you for your submission, and for your awareness of and involvement in the home-care sector. How has the Care Inspectorate been ensuring that those in receipt of care at home and other support have been safe? How has the Care Inspectorate been ensuring that staff providing care at home have been safe and are following guidance?

We have been closely monitoring care-at-home services. In fact, we are just about to complete an inquiry into care-at-home services.

There are just over 1,000 stand-alone care-at-home services, and more than 1,000 additional services providing housing support. Some 16 per cent of notifications of Covid cases—around 169—were received from those services. That provides evidence of the monitoring and awareness that we have of what is happening in them. We received many inquiries about, for example, the supply of PPE and practice around care at home.

We have received responses to our inquiry from almost all health and care partnerships. We are about to publish a report that will give clear detail that will answer your questions. The report will guide us as to what additional inspection, intervention and other means we need to employ to ensure that that part of the sector has responded and will continue to respond to the increased challenges of infection prevention and control.

I bring in Kevin Mitchell, who is our executive director, to comment.

On our work at the outset of the pandemic, our significantly increased contacts with services included care-at-home services, just as they did care homes. Those contacts were on a weekly basis at least, and often more frequent if the need arose. We continued to monitor notifications from those services, to monitor complaints and to deal with them, and to analyse on a daily basis—seven days a week, morning and afternoon—the data that we received through notifications of outbreaks and deaths. The enhanced contact with services that Peter Macleod described included care-at-home services, which made up part of the almost 36,000 contacts that we had with 6,700 services between April and July. It was very important that we did that. As Sandra White has highlighted, supporting the services and signposting them when support was required, and providing advice and guidance, was part of that contact and it included, critically, care-at-home services.

Peter Macleod has alluded to the investigative work that we are undertaking because we are aware that, in some areas, care-at-home services were scaled back at the outset of the pandemic. That inquiry, which is almost concluded, will give us a national picture of the impact of the pandemic on decision making on care at home. It will look at how care at home was prioritised during the pandemic; it will monitor the impact on changes to packages that were delivered and how engagement has—or perhaps has not—continued with service users; and it will also look at the recovery plan.

We hope that that information will give us a sense of what we need to focus on and where. That work informs our intelligence-led, targeted and proportionate approach to inspection, which Peter has also alluded to.

Thank you. You referred to a review of care at home services, if I heard that correctly. Is that to be provided to the committee, please.

When, roughly, will the inquiry be ready for publication, and can the committee receive that? A very important issue that you touched on is self-directed support and, obviously, councils supply home-care support as well. There is quite a myriad of providers. It will be very interesting to see exactly what comes out of that report. Thank you for the detailed response.

We have received comments from various people, including anonymous ones, about complaints about care-at-home services and the Care Inspectorate. How have you dealt with complaints, anonymous or otherwise, about standards and quality of care during the Covid-19 pandemic? Will those comments be included in the inquiry report that you are going to put forward?

The performance data that I have supplied shows how we have dealt with a very large number of complaints and turned them around quickly. After this meeting, I can provide to the committee more detail on where those complaints were specifically around care-at-home services.

What we do with complaints is follow them up. We talk to the provider of the services. As we indicated earlier in our evidence, visiting services would present a real risk of our staff spreading Covid-19, so we have sought information in the round, from health and social care partnerships and others, about any complaints or assertions of poor practice that have been made known to us. We compare that information to the history of complaints that we have in relation to the individual care service. We then make a judgment and take a decision about what action is required.

I am aware of a number of complaints, including anonymous ones. On the specific question of whether those will be included in the report, we will look at whether they can be, given that the report should be published sometime in the next three to four weeks. It might provide further contextual information on some of the questions that you have put to me this afternoon.

I have no more questions. Thank you for your helpful responses.

That concludes our evidence session. I thank Peter Macleod and Kevin Mitchell for taking part and for answering so many questions. I look forward to receiving the additional information that has been referred to.

12:15 Meeting continued in private until 12:37.