Coronavirus (COVID-19) care home outbreaks - root cause analysis: progress report November 2020 to September 2022

12. Inspection Arrangements

The RCA report considered the most recently published inspection reports for each of the four homes, all of which highlighted ongoing issues related to the cleaning of the environment, staff IPC practice including correct use of PPE, management of waste and staffing numbers as well as concerns about people social distancing, who cannot self-isolate due to living with dementia, and end of life care for individuals. This was not unexpected as inspections were being completed in high risk services where there were concerns about outbreak management in agreement with DPHs.

The report noted the statutory function of the CI to undertake scrutiny and assurance activities in care homes but emphasised the importance of additional expertise particularly of the clinical elements of IPC. During the pandemic HIS supported the CI to inspect some care homes. Inspectors were full partners supporting development of inspection tools, carrying out inspections, reporting on inspections and being involved in enforcement action. They worked together as part of teams who carried out inspections. The lead agency in terms of the legislation was the CI with the legal framework for inspecting care homes.

The report also noted that many care homes operate as part of wider Scotland or UK wide corporations. The culture, management process and impact of the overarching corporate approach or parent company impacted on the agility of the independent homes to quickly assimilate information and adopt measures. As a result, it was recommended that the CI consider ways to move beyond individual inspections to allow an understanding of the corporate culture management and approach. The CI operate a relationship manager system where each corporate entity /provider has a link contact who provides advice, guidance and feedback on the intelligence across the provider organisation this includes identifying areas for improvement and this does include management approach and governance arrangements. However, to undertake regulation of a corporate entity/provider group would require a change of legislation.

Recommendations:

12.1 Undertake a thorough review of the joint inspection process to ensure a truly integrated approach to inspection in care homes is in place

Progress

As noted in the RCA report, during the pandemic, a "joint arrangement" way of working was established between the CI and HIS linked to the functions that the CI carries out under Part 5 of the Public Services Reform (Scotland) Act 2010. There is now provision in the NCS Bill which sets out a clear legislative basis for HIS to provide additional clinical advice to CI inspections should any future joint working be required such as during a pandemic. It should be recognised that the CI has a Chief Nurse and Health and Social Care Senior Improvement Advisor in IPC who provide advice on health and clinical matters. They also employ multi-professional health workers to carry out scrutiny, assurance and improvement activities in registered care services. All inspectors are contracted to maintain their professional qualifications and skills and are supported to do this matter routinely.

The HIS updated standards for HAI and include all health and social care settings so the associated inspection processes undertaken by HIS and the CI are working to the same standards.

Alongside this, the CI undertook a number of actions relating to learning from outbreaks and inspections including:

• Revising the 'Building Better Care Homes' guidance 'Care Homes for Adults – The Design Guide'^[40] guidance taking into account information learned from outbreaks and learning environments.
• Development of a lessons learned plan based on intelligence gained from inspections to date – identifying common themes to shape quality improvement support. This resulted in targeted IPC learning events for the sector and ongoing learning events.
• Presenting to CPAG, DPH, PRASC, Scottish Care, Scottish Government, Nursing Directorate and other oversight groups lessons learned and outcomes from inspections.
• From the lessons learned, the CI developed two winter plans complementing the Scottish Government Winter Plan
• Developing early on in the pandemic Key Question 7 for use at inspection by HIS and CI staff in care homes. This covered IPC, Wellbeing and Staffing

IPC is a core assurance which is undertaken at all inspections as part of the CI quality framework. Having the Core Assurances l ensures IPC oversight in care services at every inspection.

By ensuring its scrutiny and assurance activity focus on health and wellbeing as well as IPC, CI aims to achieve a balance between IPC and general health and wellbeing, which includes the importance of connection for people.

The CI follow up any requirements with a further inspection in timescale to evidence improvement in care of people and publish those reports. They have also updated Quality Frameworks with learning from COVID and added quality indicator for IPC in Care at Home, Housing Support and Nurse Agencies.

Reviewing and publishing updated inspection frameworks for care homes and care at home from learnings from the pandemic. This includes quality indicators 1.5 in the Quality for Care Homes Framework^[41] to support IPC Practice as described earlier in Section 7.1. In July 2022 IPC policy and Standard Operating Procedure framework^[42] for CI registration teams to use was also developed to help assess prospective adult service applicants understanding of IPC. This includes highlighting good practice and key elements of policy forming and supporting S.O.P linked to SIPCEP and the education section of TURAS.

12.2 Ensure that relevant professional national IPC expertise is at the centre of the [inspection] process, to provide a consistent level of expertise and support

Progress

Clinical IPC expertise is provided through National ARHAI Community Infection Control Programme. National ARHAI work in collaboration with Public Health Scotland in the production of guidance and support for the sector.

More than 70 nurses work as inspectors at the CI alongside qualified social workers, allied health and social care professionals. All Inspectors received IPC training as part of their role. Pre pandemic the CI used the National IPC manual (2012) and HIS IPC standards (2015) as good practice guidance. Pre-pandemic, the Inspectorate reached agreement with HPS about a joint IPC post developed to ensure close working between HPS and CI and a review of practice and work. The person was in post when the pandemic started and a toolkit trial was planned. This work was paused due to the pandemic when the worker was recalled to their substantive post at HPS. Since then, the CI reviewed their structure and employed a Chief Nurse and established a Health and Social Care Improvement team including a Senior Improvement Adviser who has a focus on IPC across social care.

There has been collaboration on the development of national IPC and wellbeing resources. This work has been supported by the Chief Nurse and Chief Inspector of Adults along with the implementation and development of a Health and Social Care Improvement Team which comprises of several specialist Senior Improvement Advisors.

The CI have tailored their communication to different service types ensuring they can provide updates on guidance and good practice quickly which also helps learning and supports quality improvement. This was noted in the Scottish Government Winter Preparedness Plan 2021/22.

The CI co-chaired (along with CQC, RQIA And other European regulators) seminars for Health and Social Care regulators across the UK and Ireland to enable the sharing of lessons learned and collective experiences and work on next steps.

Early in the pandemic the CI put in place a COVID Flexible Response Team, transferring staff with relevant expertise to these roles to support the sector and the CI pandemic response. The team ensured guidance was shared with the sector and the COVID-19 compendium for social care was created and maintained. The team also collected and collated feedback from the sector and from enquiries received to highlight areas of guidance that required clarification or changed for application and implementation across social care. The CI participated, developed and delivered a number of learning events around IPC guidance and HIS IPC standards, oversight and practice with different service sector groups.

The CI Chief Nurse and Chief Inspector Adults meets with ARHAI regularly to review work, share intelligence and undertake joint programmes of work.

12.3 At present the operation of the wider company structure is out with the scope of CI scrutiny, and consideration should be given to extending its remit to corporate entities

Progress

The CI's intelligence team provide reports on provider (company) performance and have provided this to the Scottish Government and partner agencies to inform decisions. This information is publicly available in the CI Data Store along with performance at a local health and social care partnership level.

The current legislation does not make provision that would permit the CI to take action (such as cancellation of registration) from inspections against the wider company structure. The CI does not have the legislative powers to inspect or take enforcement action in this way and there would be a number of significant legal barriers to overcome in order to give CI the statutory powers to do so. However, whilst the CI cannot inspect wider company structure, the CI has in place a relationship manager arrangements for providers/companies. The role of the relationship manager was extended during the pandemic to include all providers of care homes with more than two services. The relationship manager takes an overview of a provider, using the performance reports provided by the intelligence team alongside other information about the provider and services it operates, and provides improvement support at a provider level. It enables the CI to share intelligence with providers/companies and where there are common themes or need for improvement. It provides improvement support from inspectors and improvement teams to support the provider organisation to improve across services.

Scottish Government has established an Independent Review of Inspection, Scrutiny and Regulation^[43](IRISR). The IRISR will look at how social care services are regulated and inspected across social care support services in Scotland to ensure that scrutiny keeps up with an evolving landscape and changing skills required of the workforce.

Going forward

• The Quality Frameworks^[44] for Support Service (day care) will be updated to include learning from COVID and have quality indicators for IPC.
• The CI should continue to monitor the impact of practices across whole provider organisations through the relationship manager, available data and intelligence.
• The IRISR will look at how social care services are regulated and inspected across health and social care support services in Scotland to ensure that scrutiny keeps up with an evolving landscape and changing skills required of the workforce
• It will be important to ensure formalisation of the process for ensuring IPC expertise availability between ARHAI and CI
• The CI continue to engage with subject matter experts as required.
• The CI collaborate with partners to develop and contribute to learning events for the sector and stakeholders based on intelligence and feedback from sector.