Official Report 798KB pdf
The next item on our agenda is our periodic scrutiny of the work of the Care Inspectorate. I welcome our witnesses from the Care Inspectorate. Jackie Irvine is the chief executive; Edith Macintosh is the executive director of assurance and improvement, adults, registration, complaints and quality improvement; and Kevin Mitchell is the executive director of assurance and improvement, children’s regulated care and strategic scrutiny.
We will move straight to questions, and I will start. I am keen to hear how the scope of your work in social care has changed since the Care Inspectorate was established.
09:15
I have only been in post for nearly three years, so that was before my time.
To be honest, it has changed quite considerably. I transferred to the Care Inspectorate in 2011 from what was then Her Majesty’s Inspectorate of Education. With regard to the focus of our work, the legislation has remained largely unchanged, so we still adhere to the key principles of the Public Services Reform (Scotland) Act 2010.
One of the biggest changes in the scrutiny of regulated care services was the introduction of quality frameworks that began in 2018 for care homes for adults, and we now have a quality framework for every care service type.
If it is helpful to the committee, I will give a brief explanation. A framework is, principally, a document to support self-evaluation, but, in the interests of openness and transparency, we also use that document as the foundation for our scrutiny work. Indeed, it reflects health and social care standards, and they are kept under regular review. The most significant part is the deep and firm focus on experiences and outcomes that is entrenched throughout all the frameworks. Regardless of structure, changes and challenges—and there are many challenges for regulated care services and social work services in the round—and although we contextualise our findings, we hold dear to the firm commitment to report on experiences and outcomes for people. The framework also enshrines the health and social care standards, so there is a rights-based focus. We hope that, in due course, there will be an even stronger focus on rights, but the introduction of our quality frameworks has been the significant change.
Of course, the services have changed significantly, not least since the pandemic. They have challenges of their own with recruitment and retention, as well as with the cost of living. We have seen that over recent years and, even more recently, with the changes to employer national insurance contributions.
There is a context and a complexity, because services respond to the needs of communities. Services have got larger, not smaller, and that brings a level of complexity. There have been staffing pressures, which are quite acute in some areas, and you might want to explore that.
With regard to the services, more has been asked of us, which is good. We try to be helpful and supportive and do what we can with the resources that we have. Most recently, we have taken on oversight of child contact centres and, a number of years ago, we took over responsibility for adult support and protection. Although it did not happen right away when the Care Inspectorate was formed, we also took over responsibility for the inspection of social work services, including justice social work.
The role has expanded, the context is significantly different and the challenges are there. You could argue that challenges were always there, but they change with the times. One of the strengths of our frameworks and approaches is that we commit to supporting improvement through all our work.
Primarily, the legislation requires us to provide independent assurance. Whatever the context, and although we contextualise our findings and give credit where it is due, we hold firmly and dearly to our responsibility to report on experiences and outcomes for people who, in some cases, are the most vulnerable people.
That is really helpful in setting the context for the broad range of the work that you do with our citizens—from the youngest to the oldest—when they come into contact with the services that you monitor.
I will ask about your key corporate priorities. To what extent have you achieved them over the past four years? What has not been achieved and why?
Thank you for the question and for the invitation to be here today.
Our key corporate priorities are within our corporate plan, which is coming to an end this year. When I was applying for my job, I read the corporate plan and I thought that it was fairly extensive and broad ranging. Through a process of consultation with our workforce and the providers, we are moving into agreeing with our board a new corporate plan for five years.
A number of those priorities will continue, and the broad headings of our priorities will remain the same: high-quality care, realising the rights of people who experience care, and supporting our workforce to be as skilled and as adept as possible at doing inspections, scrutiny and improvement work. A number of things will run. We have already met our board, and its members are quite happy about those priorities. We are just developing them further and making them more fit for the future.
There have been a lot of changes, some of which Kevin Mitchell has outlined, but, recently, there have been even more. It is about making our work more flexible. This year, we will also look at developing a business plan to go alongside our corporate plan, so that we have a way of reporting on how well we have done from year to year, as opposed to having a standing corporate plan for three or five years. We want to do that business planning process so that we can account for that.
In rewriting or revising the corporate plan, one of the biggest pieces of work will be looking at our key performance indicators. We have acknowledged that they need to be updated and be much more performance based. They have worked well for us, but a number of them are at green, so we have to question whether they are the right performance indicators for us. Those performance indicators will be developed once we have our priorities, the plan and the detail of the work going forward.
You are talking about KPIs, performance frameworks and business plans, which is pretty high-level stuff. I want to get a bit more into the nitty-gritty of the work that you do. I am keen to hear what mechanisms you have in place to allow the board to alert or advise Scottish ministers on sector-wide issues, should you see patterns beginning to develop.
One of the things that we are very keen to do—and have done all along, although we developed other options to do it—is look at what the sector makes of us and how effective and efficient we are at providing that oversight and assurance. We have long-standing inspection satisfaction questionnaires for providers. We have developed them more recently, so that they—
I am sorry—maybe I am not being clear. I am asking about the mechanisms that you have as an organisation to raise concerns with Scottish ministers or other authorities about concerns or issues that you might see developing.
We raise concerns with our board, particularly when we see themes developing in inspection and assurance. We raise them with our sponsor team as well. As you are probably aware, convener, although our sponsor team covers everything, we work with a number of different directorates in the Scottish Government, so we have those separate conversations. In particular, we speak to the early learning and childcare directorate and the justice directorate. For example, in the past two years, we picked up an issue about supported accommodation for offenders, which needed to be more regulated. That was one of the things that we raised through those various channels. We said, “This is something that we need to do,” and we stepped in to do it without any funding, because it was of such a serious nature.
Thank you very much.
Good morning to you all. I am interested in hearing about how inspections are carried out. My understanding is that, previously, there was a cyclical approach to them, which was later changed to a risk-based approach. I will be interested to understand how the Care Inspectorate identifies risk. Is there a danger that inspection can sometimes come too late, such as when problems have already been reported? What data and information do you use to identify high-risk services?
I will talk about the change that we made in moving from a cyclical approach to a risk-based one, then perhaps Kevin Mitchell could talk about the data.
Until 2019, we had a cyclical approach to inspections, which meant that we went around the country, doing them in a set format. However, we recognised—and the cabinet secretary at the time shared our view—that if we went in to inspect services and set recommendations or improvement actions, we were not seeing whether those were being implemented or sustained until the next time that we went in to inspect. We therefore moved to having follow-up visits to make sure that recommendations had been acted on, that we could see evidence that they were working, that the service had made improvements and—the more difficult thing—that it had sustained them.
Once we had moved to a risk-based approach, we became aware—and the point has been reinforced since then—that although certain services might not be due for inspection, we might pick up information and data about them through complaints from the public or the workforce. We might also know soft information about aspects such as changes in an organisation’s management structure. There might be staffing issues, too. If we pick up on those things, that tends to add to our risk analysis, which might lead to prioritising the inspection of that service ahead of another that might be planned for that week.
It is a question of balancing those risks and then getting in to inspect a service. We aim to get in very early. For example, if we receive a complaint we can decide to go in there and then, and inspect on the basis of investigating that complaint, but we would still be doing an inspection. We also get notifications about various incidents that providers are required to tell us about, and we use those as the basis for inspections, too. An inspector will see how many notifications there are, whether there has been a spike in them or whether some are very concerning, in which case that would prompt us to increase the risk level and go in sooner.
Would changes to what you are hearing on the ground lead to unannounced inspections?
Most of our inspections are unannounced, but even if we are following up on a risk or an accumulation of data and information that we think indicates that there is a risk, we will go in unannounced.
I understand that services can answer self-evaluation questions. How does a self-evaluation translate into a grade such as “satisfactory” or “excellent”?
We very much encourage services to use our frameworks for self-evaluation, as I mentioned at the start of our session. When we go in to do an inspection we will gather any self-evaluation material that the service has done. It is important to say that there has to be an aim behind conducting self-evaluation—¬it should be done for improvement. That is why we promote self-evaluation as a means of achieving on-going improvement; it should not be done just for the purposes of inspection. If services have been doing that work, we will look at it. More importantly, we expect to see that any self-evaluation is based on evidence, but sometimes there is a failing there. If a self-evaluation is based on evidence that services can show us, we will take that into account in the inspection. However, we do not set out to compare our grades against those from the self-evaluation—that is, if a service has attached them; many do not.
It is more important that services identify for themselves their strengths and their areas for improvement, so that they understand them and are not waiting for inspectors to do that for them. If they have done so, and can show us the self-evaluation evidence, we will give due recognition to that in our report and take account of it once we have effectively validated what they have provided to us.
Self-evaluation is critically important, though. Inspection comes around only every so often, so self-evaluation is a much more powerful tool, as long as it is based on evidence and supports improvement. As a scrutiny body, we need to find a mechanism to validate self-evaluation, which we have done, and we should not simply accept responses at face value.
09:30
I will pick up on what you have just said. A lot of care homes and family contact centres need to be inspected, so what do you mean by “every so often”?
Jackie Irvine described the shift in our business model. We introduced it in 2019, and it was pretty helpful that we did, because we did not know then that we were about to face the pandemic. We accelerated the pace of that shift during the pandemic period. We have finite resources, but we aim to make the best use of them and target them where they are most needed. Using a risk-based approach means targeting those resources and returning to services quickly to make sure not only that improvements have been made but that they have been sustained over time. Changing our approach in that way enabled us to do so, and we built on that both during the pandemic and when we came out of it.
Clearly, if we are not taking a cyclical approach to inspecting services, which meant that we would go in to some of them simply because it was their turn, we have to be conscious—and we are—that, in the background, we must keep a record of when a service last had an inspection, so that we do not let it go too long without another.
There is a tricky balance to be achieved there, given our resources. As we are operating with public finances, we are committed to making the best use of those resources. The risk-based process allows us to do that, to follow up on our requirements more quickly, and to ensure that improvements are not only made but sustained over time, whereas previously they were often not followed up until the next inspection. Again, there is a balance to be struck there. Achieving that is a challenge, and I would not pretend otherwise. However, we aim to make the best use of our resources and to target them where they can have the greatest impact.
A final question from me. Does the Care Inspectorate delegate responsibility for quality assurance to local authorities or integration joint boards? How do you work with your partners to implement inspections or to have them deliver the changes that are required?
I will start off, and then perhaps Edith Macintosh could come in.
The primary responsibility for achieving improvement rests with services themselves. However, in all our scrutiny work we aim to support them to do that. Rather than taking a tick-box, regulatory approach, such as by going around with a clipboard, we give advice and signpost services to examples of good practice on our website and elsewhere. We might even put one service in touch with another that we know has dealt with an issue more effectively.
We do all that through our inspection work, but we also provide targeted improvement support where we think that it could be helpful, although we have limited resource for doing so. We might do that generically across a particular area of our work, or we might even do it with individual services. For example, if an early learning and childcare service is at risk of not meeting the national standard, we will take it on to our improvement programme, which specifically aims to ensure that it maintains or retains that standard and, therefore, the funded element of childcare provision.
Edith Macintosh might want to say more about that.
I am happy to add to that. Kevin Mitchell has explained a bit about our quality improvement support process. We have a couple of teams of improvement advisers that support improvement. As Jackie Irvine and Kevin Mitchell have already said this morning, all our work focuses on outcomes for people and supporting improvement—that is our primary aim. Of course, where we see care that is not good, we will not hesitate to take action.
Kevin described the early learning and childcare component. That is a grant-funded piece of improvement work that we have been doing for a number of years now. We have worked with around 500 early learning and childcare services through that improvement work and have seen a difference in the experience for children.
Another example is the care home improvement programme, which is a targeted piece of improvement work. We work closely with our colleagues in inspection and target services that have had a grade 3. We have worked with NHS Greater Glasgow and Clyde and, most recently, with NHS Tayside and NHS Fife. The first cohort of the care home improvement programme involved about 30 services. We have already seen a difference when inspectors have gone back to those services, with their grades having improved. That is an example of how we target our quality improvement work to support services that have a particular outcome from their inspections. We have seen a real difference.
When we have involved those services, we have seen a real appetite to improve and real dedication. I am sure that members will know about the challenges that are out there in the sector at the moment. Despite those challenges, services are keen to make improvements where they need to do so, and we have seen that in our work.
For the record, can you tell us what the grades are? Is it grade 1 for weak, grade 2 for unsatisfactory and so on?
It is a six-point scale. Grade 1 is unsatisfactory, grade 2 is weak and grade 3 is adequate—that is the grade that Edith Macintosh mentioned. If a care home tipped into that grade, it would be a priority for the care home improvement programme. Obviously, we then have grades for good, very good and excellent.
Across the services, we keep a count of the grades. As Edith pointed out, people are keen for improvement, and we see a lot of passionate, committed and dedicated work out there when we are on inspection. Although we see challenges, about 87 per cent of services across Scotland are achieving grades of good, very good or excellent.
I have a supplementary question, which is on self-evaluation. I totally understand where self-evaluation sits with organisations that are looking to deliver the highest-quality services that they can. I think that we would recognise that that is the attitude of the vast majority of services. However, we all know that some will try to game the system. How do you ensure that self-evaluation does not push back a potential visit? Was the development of self-evaluation in any way driven by finance and investment and your ability to deliver?
We do not mandate that everyone has to do a self-evaluation. As you say and as we have pointed out, that approach is for services that are keen to look at their improvement, and to prepare for inspection in some respects. They are preparing their view of what is going well and what needs to improve. However, we validate the self-evaluations. When a service does a self-evaluation, that does not prevent us from inspecting—we do not say, “We’ll not inspect them.” We go in and look for the evidence.
Sometimes there is disappointment, because our evaluation does not marry up with a service’s view. That will be fed back to the service, along with the reasons why we do not think that it has adhered to that, and evidence for that. Obviously, at other times, we agree with the service, because we have seen the evidence.
One crucial thing for us is our confidence in an area or a service’s ability to improve. If a service is open and transparent about the fact that it has improvements to make, we will be much more confident. If a service did not think that it had anything to improve, that would concern us. We are an improvement agency, and we all know that we need to improve as we go along.
There is no way for a service to avoid an inspection because it has done a self-evaluation. We encourage services to do that because it gets them and their staff acquainted with the quality indicators that we use and the evidence that we are looking for. We are looking for examples of good outcome-based practice for service users and people who use and experience the services.
I hope that that reassures you in some way. On your other question, the self-evaluation process was not driven by finances. It was about services asking, “How can we best place ourselves to improve?” The quality frameworks have done their job in that respect.
I do not expect you to know about every single inspection that the Care Inspectorate undertakes, but, in 2023, you went to East Park school, which is in my constituency of Glasgow, and rated it as very good. The finances of the school, which looks after children with very complex needs, are now under threat. Obviously, other places that you visit will get a rating that is not as good. Do your inspections and ratings skew the way funding goes in that poorly rated schools or places get more money to bring themselves up while very well rated schools might find themselves squeezed because they are so good?
We have no impact on what funding an organisation might get. However, we are aware that, for regulated services that are commissioned by, for example, local authorities or health and social care partnerships, the commissioning of each body will be slightly different. For example, some will look for a grade of good or above in their commissioning but, obviously, organisations commission in different ways, with some using more qualitative or outcome-focused approaches. It is a very blunt instrument to say, “You need to have a grade of good.”
As a social worker, I placed children at East Park, so I am very familiar with it. We would not have any impact on funding. Obviously, a place such as East Park will have a board of governors, which might take messages from our inspection. The board might be concerned about the quality, which I imagine would inform the need for reinvestment or investment to bring up improvement. However, we have no impact on that.
Good morning to our witnesses. My questions are on complaints and data collection. How does the Care Inspectorate decide what complaints to investigate and prioritise?
I am sure that the committee is aware that we are unique in having a complaints service in a regulatory body. We believe that our complaints function works very well. We have done a lot over the years to ensure that members of the public understand how to make a complaint if they wish to do so.
We gather a lot of data through complaints. Over the past few years, the number of complaints has risen. At the moment, we get around 6,000 complaints a year—it was slightly fewer over the past year, but it is usually around 6,000. That number has risen over the past few years, from around 2,800. We believe that we are doing a good job in promoting the opportunity to complain.
The information that we receive from complaints is important. We have a system whereby we risk assess our complaints, and we have pathways that we use to resolve complaints. That could involve anything from using the information and data that you referred to as part of our risk assessment for inspection, all the way to doing an investigation and then perhaps an unannounced inspection if we believe that there are systemic issues that we need to look at.
The information that we get from complaints is critical in informing our inspections. Kevin Mitchell spoke about the risk assessment process in our scrutiny work. If, through our complaints process, we identify issues that we believe need to be looked at through an inspection, we would reprioritise some of our inspections because of that.
The complaints process is critical to the work that we do across the board. It also informs our quality improvement work. Our report for 2024-25 was fairly typical of previous reports in that the trends tended to be around healthcare issues, with most complaints being on care homes for older people. The top three trends are healthcare issues, communication and staffing. Using the data on healthcare issues, we might work with particular services around issues—an example would be medicines management. We have done a lot of work on psychoactive medication in relation to supporting people with dementia.
The data is critical, as it informs our scrutiny and quality improvement work. Obviously, we can then report on and share data on the issues relating to care with relevant people.
09:45
It is important to say that, as well as complaints from families, relatives and so on, we get complaints from the workforce and staff in services. We have a duty to protect their anonymity so that their employment is not at risk. Those are the two main sources, but complaints come mostly from families, relatives and friends.
I was coming on to ask about that. How does the Care Inspectorate perceive any changes in the type and number of complaints received over the past few years?
The type of complaints tends to stay the same. They are about healthcare issues and tend to be primarily about care homes for older people. Issues with visiting in care homes are a very small percentage—currently about 1 per cent of all complaints. That is an example of the range of issues that come in. As I said, healthcare issues can range from medicines, tissue viability and nutrition to continence. They are always at the top of the list in our annual report.
When I came into post—it was too long ago now—the organisation was dealing with around 2,000 complaints a year and we are now dealing with in the region of 6,000. When the media see that, the first thing that we hear is, “Care has got so bad,” but that absolutely is not the case. I think that people just know where to come. Over the years, we have done a lot of work to profile our responsibility, which is actually unique in United Kingdom regulation—no other body has that responsibility. Believe it or not, we value it dearly, because how a service deals with a complaint tells you a lot about that service, and therefore we risk assess, we triage, and we give responsibility to the services that we know will act.
If somebody’s loved one needs something immediately, the best way to get that is by a phone call to the service and confirmation that it has been done. We will risk assess and triage complaints, but we will also fully investigate when we have to. It is a valuable tool. I would hate to lose responsibility for complaints, because it offers a richness of evidence. We regard every complaint as an opportunity to improve. Complaints tell us so much about a service and its leadership and management, as does how it deals with complaints, and we get confirmation of that. Ultimately, it is about supporting improvement.
The Care Inspectorate’s written submission states that it has upheld 73 per cent of the complaints investigated. What happens with those results for the complainant and the services concerned? How does the Care Inspectorate monitor any progress or actions taken?
We publish on our website information on any complaints that are upheld. There is always a response to the complainant. We always have a conversation with the complainant, unless they complain anonymously—obviously, it is slightly more challenging to resolve that. Any complaints that are upheld are on our website for the public to see.
Through our inspection process, we monitor any improvements that might be required following complaints. As I said, any information or data is put into the process of risk assessing services across the board. If improvements are found to be required through the inspection process, we also carry out follow-up visits to services to ensure that improvements are made.
Edith Macintosh just touched on the issue of anonymous complaints, which are very difficult for us to deal with. Quite often, when we get a complaint we will contact the complainant to be clear about the headings of the complaint and the main issues. We cannot do that with anonymous referrals. That does not mean we cannot investigate, but we have no feedback or way of clarifying exactly what the issue is.
In the past year, we have done a lot of work to promote the idea that people can make a confidential complaint. We guarantee that we will not share their details, but a confidential complaint allows us to have much more of an engagement with the person who makes the complaint and to address the matter much more quickly. That approach is having a good result so far. We monitor the types of complaints that we get in and whether they are anonymous. Two years ago, there was a fairly significant number of anonymous complaints. We have done improvement work to ensure that people can complain confidentially, and it appears to be working. We have done lots of poster work and campaigns, and we advertise within services and in various other places.
How does the data that the Care Inspectorate collects contribute to the national picture and policy to improve social care in Scotland? How do you engage with the Scottish Government?
As we gather information about quality—as I said, 87 per cent of services are doing really well—we notify the sponsor team in the Government of any particular incidents, in relation to risk, that happen in a service. They come across my desk—or my tablet—which is a good way for me, as chief executive, to keep a note of what is prevalent. At Christmas a couple of years ago, there were quite a lot of cases of older people being able to get out of a care home, obviously into cold weather, which was highly risky. We have reported on children leaving nurseries unattended—such incidents are notified through Government, so the ELC directorate is aware of them. We also then look at what we can do to prevent such incidents because, obviously, one child leaving a nursery is one child too many.
We have seen the number of incidents coming down, but we will produce guidance and immediately visit services where something has happened to look at their processes for keeping adults, older people and young people safe. That is how we use that kind of information—it is not necessarily a complaint; it is a notification to us that a serious incident has happened.
Good morning. Can I just check that you can hear me?
We can hear you, Mr Harvie.
Thank you, convener. Good morning to the witnesses. Will you say a little more about the pattern of complaints that have come in over the years and whether that has changed? In particular, will you say something about public expectations of and relationships to care services, which might have been significantly affected over recent years because of Covid? Have the events of recent years changed the kinds of issues that people have concerns about and raise complaints about, whether or not those complaints end up being upheld?
Thanks very much for your question, Mr Harvie. We have not seen much difference in the trends of complaints over the past number of years. The top trends are around healthcare matters, communication and staffing. A range of complaints come in, but those trends tend to be the top three.
What have become a bit more prevalent as a result of the pandemic are issues around meaningful connection for people and visiting, although we do not get many complaints about the latter—around 1 per cent of all our complaints are about visiting. However, during Covid and towards the end of Covid, one of the main challenges that came through in complaints was about people being able to have a meaningful connection with their loved ones and their being able to be citizens in their local community.
We have done a lot of work on that over the past number of years. We were funded by the Scottish Government to run our meaningful connection, visiting and Anne’s law programme, and we have developed resources, guidance and fact sheets around the issue. Two additional standards in the health and social care standards mean that services need to comply on visiting, and we obviously look at that in inspections.
Recently, we have not had a lot of complaints in the area of meaningful connection for people; it was more of an issue during and coming out of the pandemic. We responded to it and were able to support services, and we continue to do so. We listen to people’s loved ones, as well, to understand their feelings around visiting and meaningful connection. We all know that having that connection is so important for our health and wellbeing and being able to enjoy life, no matter our situation.
The reason that I ask is that I recently visited and had conversations with a care provider in my region, and they made the point that their experience—perhaps you can confirm whether this is felt more widely—is that people are entering residential care later in life as a result of changed attitudes and experiences in recent years. If people enter residential care later, they are more likely to enter at a more advanced stage of various conditions, including dementia. If that pattern becomes established, it will presumably change the pattern of complaints and peoples’ concerns. I assume that it is more likely that there are complaints from concerned family members about residential care than care at home services. Is that right, and do you anticipate that continuing to be a changed pattern?
That trend is already reflected in the complaints that we get now. I think that you are right. I agree with you and acknowledge that the situation of people coming into older people’s care homes now is much more complex. Often, people are almost at the end-of-life stage by the time that they come into a care home setting.
The challenges for care homes and care home staff are therefore even more significant, whereby they have to support people well, even though they have co-morbidities and really challenging situations, and they support many people at end of life. A lot of the data tells us that many people are being supported to end their life in a care home setting rather than in a hospital.
Care homes therefore need a host of different skills: supporting people at end of life, dealing with many different health conditions and caring for people living with dementia, as you said. The social care workforce faces many challenges and, when it comes to healthcare, our complaints data show that co-morbidities and associated complexities are now part of it.
My final question is about complaints that are not upheld. You have given us statistics about the proportion of complaints that you investigate that are upheld. Do you take lessons from, and bring into wider intelligence gathering, complaints that are not upheld? Even if there is nothing to investigate, do they tell you anything about peoples’ concerns and experiences?
We use information in our wider scrutiny work from all complaints, including those that are not upheld. Although a complaint might not be upheld, that information is put into what we call our scrutiny assessment tool, which we use to assess services. Absolutely none of the information is lost, and we always use it as part of our wider scrutiny work.
The Care Inspectorate’s vision is
“for world-class social care and social work in Scotland, where everyone, in every community, experiences high-quality care, support and learning, tailored to their rights, needs and wishes.”
Will that vision stay the same in the new corporate plan? To what extent has the vision been achieved so far, and are there any barriers in the way of achieving it at the moment?
We are very much looking at our vision as we review our corporate plan. We have always strived for high-quality care and equal access to care for people across the country. The vision will remain aspirational. It would be wrong of me to say that we have written it already, because we are engaged in consultation with our workforce and providers, and a question has arisen about how to measure what is world class. We know how our provider organisations and the other regulators across England, Scotland, Wales and Ireland, whom I meet regularly, are assessing and evaluating.
No matter what the wording is, the vision will still be aspirational, as we believe it should be. As Edith Macintosh has said, you want your loved one—or yourself, if you are the one receiving the service—to get the highest quality of care.
Are there any barriers to achieving that aspirational vision? Have you identified what is making it difficult for the Care Inspectorate to achieve it?
Something that we have already touched on and that I want to emphasise is the context in which the services are working just now. We know that there are recruitment and retention difficulties in staffing. We often engage with stakeholders and our provider groups through what we call quality conversations and normal quarterly meetings, and that difficulty is coming out strongly as a particularly challenging issue, which you will not be surprised about. It appears in other sectors, too.
10:00Inevitably, the ability to retain and have consistent staffing sometimes has an impact on the quality of care. I always imagine what it must be like to be a manager with a high staff turnover. You might have all your posts filled but, if you have a high turnover rate—which we have seen—your ability to keep your staff cohesive, clear about what they are doing and understanding their role is much more challenged.
As Kevin Mitchell said earlier, we appreciate the context, and we are trying to encourage our inspectors to illustrate the context but not to deviate away from a focus on outcomes in inspections.
That is one barrier. From our inspections, we know that what makes a good service is really good quality leadership and management. That is a key aspect.
It is helpful for the committee to understand that.
Thinking about the most recent corporate plan, can you identify any improvements in social care that you have been part of and have helped to drive forward?
I am struggling to do that on the spot, but what I think has improved is the development, through the corporate plan, of quality frameworks, which has allowed us to share responsibility. As I said, we still validate self-evaluations, but I think that the quality frameworks have helped services to understand what we are looking for, and what good care looks and feels like. I do not think that any service would say that they have no improvements to make, and that includes us. I think that the quality frameworks have probably been the biggest area of improvement.
I have already described a bit of the work that we have done around Anne’s Law, which I think has made a huge difference in services’ understanding of how they can support people to have that meaningful connection. We have focused a lot of work on medicines management. We have done a lot of work to support services around self-evaluation. Colleagues from Heath Improvement Scotland and the Care Inspectorate have worked together and run webinars for services to help them to do robust self-evaluations. We have had really good feedback from that.
We have resources available for the sector on a host of things, such as guidance and helping the sector to understand some of the national policy aspects. Those resources sit on our website, which we are redeveloping at the moment, so people have ready access to them. It is important for services to be able to access information quickly when they need it, particularly if we have identified areas for improvement. That is another area that is important in what we do. We work with the sector to develop some of those resources, so we need to understand their needs to be able to support them in different ways. Our interventions in that regard have had some good impact.
Let me explore a little bit further how, as an organisation, you are able to track, monitor and evaluate quality improvement. We have heard about some of the tools that you already use, such as self-evaluation forms and using complaints themselves as tools. What other tools do you have to track, monitor and evaluate improvement?
Edith Macintosh mentioned the care home improvement programme, which is very targeted. At the end of it, we evaluate how well participants have contributed. I go along to the awards ceremony at the end, at which participants talk about the programme and which can be quite outstanding. We also look at the outcomes of inspection after improvement work. I do not remember the percentages, but Edith can tell us.
In the first cohort, 86 per cent showed improvement in at least one of the key questions asked at inspection, and 57 per cent showed improved outcomes overall in the grading. We do the inspection and the grading, and then we focus our improvement work on services that have a grade of adequate. We intervene in relation to quality improvement. There is a mix: there are sessions with all the care services together so that they can share good practice and challenges; and we offer an improvement adviser who is dedicated to a service. At the end, we measure the impact.
As Jackie Irvine said, we hear from services via a survey, but we also have our colleagues in inspection measure the impact—not right away, but when the service’s inspection comes around—in terms of the outcomes from that improvement. The difference that has been made has been quite significant. We feel that it is a positive piece of work, and positive support for the sector.
It is also important that we share the results with the wider sector. That encourages more people to say, “There is something to be gained for us here,” and they will step forward for that improvement work much more quickly or enthusiastically. It is important that we share information in meetings of the wider provider sector, in our webinars and in quality conversations with the sector, so that they know what is available, what other people have tried and tested and what has worked. We hope that that means that services will continue to take up the offers that we put out.
I have a final question. It has come to our attention that the Care Inspectorate does not seem to be represented on the interim national care service advisory board. What involvement, if any, have you had with the board? What involvement will you have with it going forward?
I can speak about our involvement so far. One example in terms of the care reform aspect relates to our complaints process. We would not want to lose that, and it is mandated by legislation. We have met with Government colleagues to ask how it would fit with any complaints process that comes from the national advisory board. There is a similar point with regard to quality improvement. We are asking how we can do that more cohesively and effectively across the country with all the other providers, which also do different types of improvement work, where the gaps are and so on.
I appreciate that the decision about the advisory board is one for the Government and not one for me to have a view on. However, we have been involved and we will be keen to see, for example, how we play into providing, as we do already, that vision of the quality that exists out there, what the issues are—the very good questions that you and your colleagues have asked today—and how we can continue to convey that vision. I think that that will be done through the board.
We live in a world of artificial intelligence and digital technology, and I think that health and social care in Scotland is finally waking up to the potentially huge impact that new technology can have on the way in which we deliver services. How is the Care Inspectorate developing its digital technology offer?
You will have seen from our written submission that we were very pleased to get funding to take forward a new information technology platform for our service. We have a very outdated legacy system that is not joined up, with apps and different bits that do not necessarily speak to one another. They are a risk because, if they fall down, we lose all our tools and our information. We have done a huge piece of work on preventing cyberattacks and so on.
We have good governance around our digital platform. One of our board members chairs the digital approval group. We also have a project group. We have had a Scottish Government gateway assessment to make sure that the project is progressing—as you know, such projects do not happen overnight.
We have already presented an AI paper to our board and to partners that sit on the project board. Our approach is that we need to be progressive and we need a platform that is fit for the future, so we are keen to explore AI opportunities within that. On the other hand, we also need to be robust about any AI functionality that we bring in.
We see huge potential benefits. We have talked a lot today about data and how we learn from complaints and notifications about where the risks are. The big advantage of our digital platform coming in is that it means that inspectors will be able to see everything about a care service on one page, whereas currently, they have to look for it manually, which is not only very time consuming but how things might be missed. Another benefit—I hope that AI will help with this—is that providers will have access, through that platform and our website, to the information that they need to submit to us, so that process should be smoother. Also, families and relatives will be able to see that information. We felt that AI is in the early stages, but we want to step up now, because otherwise we will lose opportunities. We will look for expertise out there as we develop things.
One of the main reasons why the implementation of AI stalls relates to cascading it and encouraging its adoption both by your own people and by services. How are you making sure that that cascading is in place and that adoption is maximised?
We produced a fairly in-depth document on the potential of AI early on in the process—we did that last year—and shared it with our board and with the project board, which need to be confident that we are going down the right track with it. Thereafter, I would say we have been taking it easy so that people understand not only the potential, but that there will be robust protection. For example, in our cyber work, we have identified that people may be adopting apps that are not secure, and we do a lot of reviewing so that we are not putting ourselves at risk.
Bringing in a new digital platform, not just the AI element, can be quite unsettling for the workforce because it means doing things differently. AI will encompassed in that work. We also did a survey. I cannot remember what we called it, but it was a digital assessment of our workforce so that we know what training and development we need to put in place before we launch the new platform.
I want to ask about that. You put forward your ask for funding for a new digital platform—it was good to hear about that. However, you need about the same amount again for cascading, adoption and training the workforce.
That was part of our business case. Importantly, what came out very positively in our gateway assessment was that we are using our workforce—the people who do the job every day—to inform us about what they need. That is taking time, but the approach is achieving a balance between just delivering something and telling staff that they have to use it, and having them inform the process.
We also have built something into the end of the process. Once the platform is ready to go live, we will continue to have support from the provider for six months to work out any fixes. If things do not go well or need to be adjusted, we will have that six-month gap at the end, which is important. Most of those costs were built into the bid.
How will you evaluate the impact of the technology?
First, it will no longer be a manual system. The technology will allow us to produce data more effectively, more efficiently and more quickly, so we will be able to look at how much time we can take off those tasks. MSPs, Government sponsors and provider bodies often ask for data, and that process will become much slicker. We will probably do an evaluation with inspectors of how different the system is for them, and how much time can be taken off tasks.
The technology will also allow us to take a much more thorough and in-depth look at how long our inspections take and how much time we spend on different aspects of an inspection. That sort of information should all be within the platform.
My final question on this topic is about interoperability and compatibility with other services. In health and social care, interoperability across all platforms will be key as we go forward and develop the platforms and the technology. How are you making sure that that is happening?
That was not just part of the bid when we were making the case but a clear part of the remit when we appointed the provider. The platform must be flexible enough to achieve that interoperability in future. It is about looking around the corner and being fit for the future. It will not happen automatically, but the flexibility will be there.
10:15
I declare an interest as a practising national health service general practitioner.
In 2022, Kevin Mitchell highlighted the need for clear governance and accountability in social care while, in May 2025, Jackie Irvine noted:
“The statutory framework is dispersed across various pieces of legislation making governance arrangements complex.”
Would the Care Reform (Scotland) Bill, which comes before the Parliament today, have provided a great opportunity to bring all these frameworks together and allow guidance to be simplified for you?
The bill will, with the inclusion of Anne’s law, give us greater opportunities with regard to visiting, and we look forward to working with that. Our position is that we will provide assurance and oversight based on outcomes, no matter what the structure is. We are flexible in that respect, and our main aim will continue to be a focus on outcomes for people and on ensuring that their rights are realised, regardless of the structure. We already have that legislation in place for ourselves through the Public Services Reform (Scotland) Act 2010 and the Public Bodies (Joint Working) (Scotland) Act 2014.
Okay. I am just surprised—you just said that this was complex and difficult for you and now you say that it is all fine.
I am not sure what you are referring to. I cannot see the script in front of you with regard to what I said and in what context, so it would probably be helpful if you shared that. I am happy to come back to you on that.
Okay—that is fine.
Would the Care Inspectorate benefit from having any additional powers or authority?
The prospect of our having additional powers has already been considered. At the moment, we would need to issue a notice of improvement before we could move to enforcement through the sheriff court, and the potential proposal is that we go straight to enforcement without that improvement notice, although providers would still have a right of appeal.
Our enforcement actions have gone up slightly, but they are not as significant as I think people out there think that they are, simply because of that improvement angle and the need to sustain services. We are very conscious of our communities needing services and of demand rising, in some respects, and getting more complex, and, instead of moving very quickly to enforcement, we always go in with that improvement angle to see whether we can help the service provider improve what they are doing and keep them relevant and sustained. However, in circumstances where we saw a high risk to life or impact on services, we would go to enforcement.
Absolutely, and we would expect a stepwise process. However, you have said that there are some powers that you would like to have, and there is an amendment to the Care Reform (Scotland) Bill that seeks to get you more powers. Do you feel that that would be helpful or a hindrance to you?
From my recollection of what is in the bill, I think that it would be helpful. First, I must stress that enforcement is a last resort; we would much rather support the service to improve, because if we are talking about, say, a care home for elderly people, the nearest alternative might be many miles away or off an island.
With that caveat, what we have found frustrating is that the bar for us to close a service—which is that it must pose a serious risk to life—is very high. Even when we have absolutely clear and strong evidence that that bar has been reached, enforcement can sometimes take a long time.
Our biggest frustration is with improvement notices. When we serve an improvement notice, the legislation requires us to give the service sufficient time to make the improvement. The time that we allow has to be relative to the task that we set, and if services meet the requirements of the improvement notice, as they often do, the notice is discharged. However, we often see standards start to slip again after a little while, and we are back into that up-and-down cycle.
What is also frustrating is that, in court procedures, we cannot cite the evidence of the previous improvement notice. We therefore believe that it would be better to have sustained improvement as an element of any notice, so that if a service improves after receiving an improvement notice but then goes downhill again, we can act more quickly. I believe that an amendment to the legislation that allowed us to move to immediate cancellation without an improvement notice would achieve that aim. We would use such a provision very sparingly and as a last resort, but, from my understanding of the bill, it would allow us to take action more quickly in those kinds of frustrating circumstances.
After all, we are dealing with people and this is in the territory of seriously poor care. We need to be able to act in the way that we would all want to act if the people involved were our loved ones—we only want for others what we would want for ourselves or our loved ones. Therefore, we welcome what has been proposed if that is the means of achieving it. I stress again that it would be a last resort and used sparingly, but if we reached the serious risk to life bar, I would have no hesitation in using it.
I want to turn the clock back to Covid-19 and discuss any lessons that you might have learned, especially around inspections and communication, when it comes to how you might respond to another potential pandemic—which, we hear, is between 5 and 25 per cent likely in the next five years.
Gosh, there is so much learning to be had from the pandemic.
For me, one lesson was the very difficult balance that has to be struck when you are considering risk, particularly with care homes for older people. The risk has to be balanced against rights. Of course, our health and social care standards are underpinned by human rights—quite rightly so—and we understand that there are plans to have an even stronger rights-based approach. However, there is a tension there, because a care home is not a clinical environment but a home, and we learned that we had to balance the rights of the individual versus the rights of the community within that home and the risk involved versus the right to live a good life, even during a pandemic.
Visiting was very much a feature in that respect, and there were some real challenges to deal with. For example, infection prevention control was a key element of managing the pandemic, and services such as ourselves had not previously worked with the directors of public health in the way that we did during—and, indeed, subsequent to—the pandemic. That was a new partnership, and we developed other new and very valuable partnerships with a range of organisations such as health and social care partnerships. Under the new model, we were meeting regularly during the pandemic with those partnerships to exchange much more meaningful intelligence. We were giving them immediate outcomes from our inspections, which enabled them to provide support that might not otherwise have been provided and, in return, concerns that they might have had from their normal visits to services were being passed to us much more quickly.
We have retained that approach, because it is about good partnership working and good information sharing; indeed, we have talked about systems and the need for those systems to speak to each other. We also learned many things about how we record information, and we are hopeful with regard to the systems that we will get through the digital transformation. We have known—and shown—for a long time now that having the right data and intelligence to make good risk assessments and to be able to deploy inspectors and improvement support at the right time, in the right circumstances and in the right place, can prevent our having to take the strongest enforcement action with a service. Therefore, we need those systems.
We have also taken on board a lot of learning from how we maintained policy files, chronologies and so on during the pandemic. Those things were crucial; indeed, we recently facilitated a two-day session to allow all our managers to reflect on our own learning. There is learning for the sector, too. We continue to reflect on all of it, because we do not want to close our eyes to any opportunities for us or, indeed, services to improve.
We have been working hard to supply the UK and Scottish Covid-19 inquiries with evidence. After all, evidence is not about my view or Jackie Irvine’s view; it is the evidence that we gathered during the pandemic, and we are feeding it very comprehensively into those inquiries. Our most recent statement ran to 200-plus pages and four lever arch files of documents. We are keen to support that learning, and we have not closed our minds to what might come out of the inquiries, whether it be learning for us or for the sector. We have to be a learning organisation, and I think that we are. If it is deemed that we could have done things better, we will learn from that.
Equally, however, some things that we did during the pandemic were very successful. There was, for instance, the flexible response team that we put in place to help services to interpret guidance that was changing almost daily.
There is a lot that I could say. I could speak for hours about this, but I am sure you would not want me to do that at this particular juncture. We are very much taking the learning on board. Even at this stage, five years down the line, we are waiting not only to see what knowledge or support we need to give the inquiries, but to receive their recommendations so that all of us, ultimately, can deal better with anything of a similar nature. There is always room for improvement.
We are not the Covid inquiry, so we do not need to go into quite that level of detail.
My final question is about Anne’s law and its potential introduction later on today. Will it change the balance for you and allow people to have that family life?
Edith Macintosh is probably more aligned with this issue than I am, but I can say from my experience during the pandemic that there is absolutely no doubt that we have been strengthening our approach in this respect, even prior to the bill. We have put a lot of effort into working with services to help them to understand what is required.
What was helpful was the inclusion of two new standards in the health and social care standards, which made things very clear. However, that could be termed an interim arrangement, and we now have an opportunity to strengthen the arrangement in legislation to ensure that, in the future, people are not deprived of their right to connections with loved ones.
I suspect that there will still be responsibilities on directors of public health, who are the experts in infection prevention control and will undoubtedly, now and in the future, have a view on what should happen. However, I think that the legislation will give everybody a greater understanding of the need to strike a better balance with regard to risk—that is, the balance between risk and rights that I alluded to earlier and the need for more alignment in that respect. From my understanding of the legislation, it will help to support that balance.
I can add to that, convener, if it is all right to do so.
We are very supportive of Anne’s law and we do hope that it will enable a more consistent approach to be taken. In our inspections, we always look at wellbeing, and elements of Anne’s law relate to visiting and making meaningful connection. If we make requirements with regard to a service that is not adhering to the standard, we hope that Anne’s law will support the process and help to ensure that services step up to the mark and support visiting.
We ask services to complete a self-evaluation tool on visiting that we have developed, and, every time that we are out on an inspection, we look at that element as part of our core assurances. We welcome Anne’s law and hope that it will provide extra support to enable people to live a good life, no matter what their situation is.
Thank you very much.
I thank the witnesses for their attendance and evidence today, and I apologise to colleagues who wanted to come in with further questions.
I will briefly suspend the meeting for a changeover of witnesses.
10:29 Meeting suspended.