Social care - Independent Review of Inspection, Scrutiny and Regulation: call for evidence analysis

Theme 1: A person-centred approach

When referring to respondents who made particular comments, the terms 'a small number,' 'a few' and so on have been used. While the analysis was qualitative in nature, with the consultation containing only a limited number of quantifiable questions, as a very general rule it can be assumed that:

'a small number' indicates up to 5 respondents

'a few indicates around 6-9

'a small minority' indicates around more than 9 but less than 10%

'a significant minority' indicates between around 10%-24% of respondents

'a large minority' indicates more than a quarter of respondents but less than half

and 'a majority' indicates more than 50% of those who commented at any question.

The consultation explained that a person-centred approach is about focusing care and support on the needs of the person receiving social care support. Also, to ensure that people's preferences, needs and values guide clinical decisions, and provide care that is respectful of, and responsive to them. This approach is supported by the PANEL principles of participation, accountability, non-discrimination, empowerment and legality, which are based on a human rights-based approach.

The following section provides more in-depth detail on these principles:

• Participation – people should be involved in decisions that affect their rights
• Accountability – there should be monitoring of how people's rights are being affected, as well as remedies when things go wrong
• Non-Discrimination – nobody should be treated unfairly because of their age, gender, ethnicity, disability, religion or belief, sexual orientation or gender identity; people who face the biggest barriers to realising their rights should be prioritised when it comes to taking action
• Empowerment – everyone should understand their rights and be fully supported to take part in developing policy and practices which affect their lives
• Legality – approaches should be grounded in the legal rights that are set out in domestic and / or international law

The first question asked:

Q1: How can we ensure that people with lived and living experience of care and support services are able / supported to contribute to inspection, scrutiny, and regulation processes? Please give us your views

A total of 93 respondents answered this question.

Supporting inclusive approaches

The most frequently mentioned theme (by a large minority of respondents across all sub-groups) centred on working with people with lived and living experience to share their knowledge and allow them to contribute to inspection and regulation processes. To do this, getting their involvement in decision-making, having an open approach and ensuring people are at the heart of all issues was recommended, along with assurances that participation will lead to positive action. Similar numbers of respondents also focused on the importance of meaningful engagement (ways of which are discussed below) via a variety of communication means and ways of interaction.

Supporting inclusive contributions

This was considered important, by a large minority including many representative bodies and social care providers, and by many people with lived and living experience at events. To do this, it was felt that the communication needs of people who use care and support services need to be taken into account. For example, people living with dementia or autism^[2] were mentioned, as well as those experiencing mental health issues, those living with sensory impairments and those with seldom heard voices^[3]; solution tools such as communication cards, tablets, software apps and 'talking mats' (a visual digital communication tool) were all suggested to help with interactions. An unpaid carer said:

"Ensure inspectors are able to access a range of communication tools used by those with communication differences and difficulties or ensure that where appropriate/required supported individuals receive support from those who know their preferred communication style well throughout the inspection process. Listen to the voice of the team around the supported person as they are often the experts in translating methods of communication. Provide easy read information to providers and supported individuals on the purpose of inspection and how people can contribute to the process." (Individual)

A significant minority of respondents called for flexibility in approaches, such as allowing time for responses to be made, visiting at suitable times to enable meaningful engagement, choosing suitable venues and listening to the supporting teams (e.g. staff, family members) of the individual concerned, to enable easy participation. Similar numbers emphasised the importance of including the views of all involved, with particular reference to people with lived or living experience such as family members, unpaid carers, those working in the social care sector and representative organisations.

A large minority suggested the direct input of those with lived experience in designing engagement tools or developing the inspection framework. This included areas such as the setting of standards as well as asking the questions that they themselves would ask during the inspection process. A service provider suggested that:

"This could include the opportunities for inclusion in regional, national or service specific groups which informed improvement in inspection and rules/standards." (Service Provider)

However, an individual with lived or living experience queried the basis of the question:

"Ask different questions as the assumption is that the person understands how government operates, e.g., in question 1 what does supported mean? Is it BSL interpretation or emotional support? What does contribute mean? Or is it "answer the questions?" or "attend inspections?" (Individual)

A significant minority wanted to ensure that the views of people receiving social care support were listened to and acted upon, while a few respondents noted the importance of people being able to raise issues in a safe way without concerns about possible repercussions. The latter point was mostly raised during events.

A significant minority, of largely representative bodies, noted their agreement with a human rights-based approach to facilitate involvement, with a few of these commenting positively on the use of the PANEL principles as a way of breaking this down. Slightly smaller numbers of respondents, though mentioned at a majority of events, agreed with a person-centred approach. It was noted that this would help with relationship-building as an aid to evaluation processes and assist avoiding traumatic experiences with inspectors, particularly for people with communication difficulties.

Forms of communication

Respondents outlined their views on the pros and cons of specific forms of communication. A significant minority, particularly at events, commented positively about the use of qualitative approaches including panels, citizens committees, focus groups and workshops. Similar numbers also mentioned speaking face-to-face or by phone, either in a group situation or by individual appointment.

A few respondents were in favour of the use of written surveys or questionnaires, particularly at a pre-inspection stage, to give people a chance to think about their responses before submitting them. The same numbers however outlined drawbacks such as the length of the documents, exclusion (as some people may find it difficult to respond), a lack of unbiased views being given and people asking staff in care organisations to complete them on their behalf.

Small numbers of comments (from a mix of respondents) suggested the use of electronic or digital systems (e.g. an online platform for people to input quality of care information), while the same numbers were against using these in isolation, citing digital exclusion issues and some older people needing support to use IT systems. Small numbers again suggested the use of feedback platforms or systems (e.g. for ad-hoc feedback). A Health and Social Care Partnership (HSCP) / local authority and a representative body suggested more use of observed practice where appropriate.

Other actions

Other actions to help people to contribute to inspection and regulatory processes were put forward. A significant minority were in favour of using independent advocacy to provide support and guidance, facilitate discussions, assist with completing forms and helping with input from seldom heard voices. Similar numbers wanted to see a change in language tone in documents, noting issues in relation to 'wordiness' which can be offputting, and a need for plain English and easy-read formats. There were also a couple of requests for access to translation services (e.g. for British Sign Language (BSL) users).

Concerns over a perceived lack of access to information about what to expect from services providing social care support were raised by a significant minority of respondents and frequently at events. It was felt that people needed to be made aware of information about the rights of those who use care and support services, about care plans for those using care and support services, about the differing support options available and about inspection details. Those accessing care and support services should also be provided with appropriate information accessibility tools.

The use of people with lived experience as lay or volunteer inspectors or peer reviewers was suggested by similar numbers. A few respondents wanted an effective feedback system in place to help track results and improvements from regulatory and inspection processes (this was a particular focus at events).

A few or small numbers of respondents wanted to see action to help involvement from specific stakeholders as follows:

• Children (e.g. embedding rights of the child, Getting it Right for Every Child (GIRFEC) approach, knowing who is coming to inspect in advance as they may not cope well with a new face or situation)
• Unpaid carers (e.g. contact through third sector organisations, visiting carers as they lack time)
• Those in rural or remote areas (e.g. with travel arrangements)

Inspection and regulatory processes

A variety of comments were made regarding the inspection and regulatory processes themselves. A significant minority cited the importance of having knowledgeable and skilled inspectors and regulators. Consistency provided by having the same inspector so that a relationship can be built was one part of this, given that one inspector can contradict another. There were also references to the need for knowledgeability about communication aids, tools and adaptations. A few respondents wanted to see the announcement of inspections before they take place, as they felt this would allow families and advocates to be prepared and it would make it easier for everyone to be involved as it would provide time to plan. A representative body however thought it best that inspections take place unannounced to establish a true picture of a service. A significant minority voiced concerns over sufficient resourcing in terms of staff, training and funding for the inspection and regulatory processes; this was particularly mentioned by event attendees.

A few respondents each made the following other recommendations about inspection and regulatory processes:

• Overhauling regulation of care (e.g. develop a national care plan, key quality indicators fail to fit a holistic approach, methodology needs to be overhauled to enable meaningful participation)
• Embedding or sharing good practice, or integrating a Code of Practice (e.g. processes should be, or are based on, Health and Social Care Standards, SSSC Codes of Practice)
• Enabling a transparent and accessible approach for involvement (e.g. regulatory bodies being open and accountable, telling people why they are there and how they can support improvement)
• Ensuring equality issues are not overlooked, bearing in mind that regulators, care providers, etc. may be subject to the Public Sector Equality Duty (PSED)
• Increasing the frequency of inspections of some services (e.g. more inspections for care at home services, more awareness / greater publicity concerning inspections and the regulatory role, more ability to challenge regulator judgements, or to seek help from the regulator)

Small numbers of respondents saw a need to review the current system or create an adequate complaints system. This was because of the potential for stigma to be associated with complaints terminology, the system not allowing for situations where a person may want to informally raise a concern or query rather than a formal complaints procedure, lack of easy navigation or resolution, and a need to make complaints materials available in different formats.

Very small numbers of respondents saw a role for quality assurance, with a social care provider citing the effectiveness of quality assessors. A small number perceived that there was too much scrutiny of care services. Conversely similar numbers thought that there is too little scrutiny.

Finally, there were a small number of calls from mainly individual respondents to ensure health services were included in social care planning, with complaints about a lack of service provision in certain areas (autism, learning disabilities). Remarks about current problems in the care industry (lack of consistent staff, demographic challenges and capacity issues) were also made by small numbers of respondents.

In summary: Theme 1 – A person-centred approach

• While some respondents to the call for evidence and the events spoke about a person-centred approach, others referred to a person-led approach. A person-led approach is seen to involve people more and was the preferred wording for some respondents.
• The most frequently mentioned theme was to work with people with lived and living experience to share their knowledge and thus contribute to inspection and regulation processes. To do this, it is vital that people are involved in decision-making and at the centre of systems of inspection, scrutiny, and regulation. It is important that engagement should be meaningful. A variety of different communication channels and ways of interacting would be needed to ensure inclusion of people with care and support needs.
• A large minority^[4] advocated direct involvement of those with lived experience in co-designing engagement tools or developing the inspection framework. This included areas such as standard setting and framing the questions that they themselves would ask during the inspection process.
• A relationship-building or partnership-building approach was commonly advocated at events to support people to contribute.
• When referring to ways in which to communicate with those with lived or living experience, there were positive comments about using qualitative approaches (e.g. panels or workshops).
• Other ways to enable involvement included using independent advocates for support and guidance and having a more user-friendly language tone in documents. Concerns were raised over a perceived lack of access to advocacy services, and a lack of information or education on what to expect from care services.