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

Theme 4 – How will we know systems are working?

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.

Having asked how inspection, scrutiny, and regulation should be carried out, the call for evidence and events then asked a series of questions on what information people would find useful to assist in making decisions about care and support.

The first question in this theme asked:

Q10: How can we ensure that people and their families who require care and support, have the information they need about how providers are performing to support their decisions about care and support?

A total of 85 call for evidence respondents across all sub-groups commented in response to this question. The same issues also tended to be raised at events.

A need for accessible reporting

A key theme from call for evidence respondents across all sub-groups, and from events, was of the need to provide reports that are accessible to everyone and which are provided in a range of different formats. There were suggestions for reports to be available online as well as in hard copy, and the provision of easy read reports including more use of graphics. There were also a small number of requests for summary versions of the full report, again provided in an easy read format.

There were a few references to the need for reports to be accessible to all in terms of language used as well as being provided in alternatives such British Sign Language (BSL) and in different languages. Two HSCPs referred to the need for information that is accessible to those with sensory impairment.

A small minority of call for evidence respondents, across most sub-groups, suggested there should be a duty on social care providers to provide the most recent inspection report to people receiving social care supportand their families, as well as providing information on the role of the regulator, the performance of the social care provider and details of any changes or actions required by the regulator following an inspection. One service providing social care support felt that services like theirs should do more to allow access to information for people with greater communication needs. There were also a very small number of suggestions for services offering social care support to use standard templates to provide information to people receiving social care support and their families. An attendee at an event noted that services offering social care support vary in terms of the level of information they provide to people receiving social care support and their families, with some being good at sharing reports but others less good. There were also a few comments from call for evidence respondents and from events that some information provided is out of date.

While a number of comments focused on inspection reports, there were a small number of comments from call for evidence respondents on the need for access to improvement plans, performance indicators and quality improvement frameworks.

A few attendees at events also commented that there is a need for better communication around where and how to obtain information about how providers are performing to support their decisions about care and support. One respondent suggested this could be the responsibility of Public Health Scotland, while another respondent suggested a television advertising campaign was needed.

The use of websites

There were references from a small minority of call for evidence respondents – primarily individuals, HSCPs and advocacy organisations – and from some events on the use of websites in providing information to individuals and their families who use social care support. Most of these were general comments on the need for information that is easily accessible via a website(s) and there were a small number of suggestions for a single source public website that is available for people receiving social care support and their family members.

A small number of respondents referred specifically to the Care Inspectorate's website, with suggestions for greater promotion of this website as a source of information that can help people to make choice on social care. There were also a small number of suggestions for the Care Inspectorate website to record updated information in real time as well as providing the results of satisfaction surveys. A few call for evidence respondents across most organisation sub-groups, commented that information about how providers of social care support are performing already exists through Care Inspectorate reports or on their website.

While websites are clearly perceived to be a useful source for information, there were a few comments from call for evidence respondents that some websites are difficult to navigate, are not clearly signposted or do not present information that is easily accessible or presents information from the perspective of people receiving social care support or their family members. An event attendee commented that some people receiving social care support or family members will be digitally excluded.

The involvement of people receiving social care support and their families

There were references from the call for evidence and events to fully involve people receiving social care support and their families in decisions about their care and support or to involve them in any changes to the processes of inspection, scrutiny, and regulation. One representative organisation suggested using the Charter of Involvement^[8] to see if people receiving social care support and their families feel included and respected.

Allied to this issue, there were a few comments from call for evidence respondents of the need to make more use of advocacy services, third sector organisations, peer networks or local networking services that can reach out directly to local communities. It was felt these could provide support and advice. An attendee at an event noted that there is a need for inspection, scrutiny, and regulation processes to work in partnership with trusted services to disseminate information and hold information sessions within the community.

There were comments from a few respondents – mainly individuals – of the need to obtain feedback from people receiving social care support and their families. A variety of methods were suggested including questionnaires, briefings, online events, drop in hubs and surveys. There was also a suggestion from an event that there should be a channel to the regulator for feedback on complaints and appeals.

Other suggestions from call for evidence respondents and event attendees for ways in which information could be provided to people receiving social care support and their families included:

• An advice helpline
• Inclusion of people receiving social care support and their families in the inspection process
• Annual reports demonstrating inspection activities that have taken place
• Public information campaigns
• Information on how services are delivered or how to access regulatory bodies to obtain information
• Promotion of what service providers are doing and positive reinforcement of what they are doing well

Final comments

While respondents focused on formal channels of information, a small number – mainly representative bodies – felt that some decisions about care are made on word of mouth recommendations and that people receiving social care support and their families are less concerned about inspection reports. The importance of word of mouth as an information channel was also highlighted by some respondents attending events. For some, this may be attributed to a lack of choice of local facilities, a lack of awareness of regulation within the sector, a need to take the first option offered (in what may well be a crisis situation) or a lack of awareness of the availability of inspection reports. An attendee at an event noted the importance of personal contact and a capacity to visit a service beforehand as well as word of mouth and qualitative feedback.

Small numbers of call for evidence respondents and those attending events raised other issues. These included:

• A National Care Service could set out core principles for regulation and scrutiny, which would provide clarity to people receiving social care support and their families
• There are online tools such as Care Opinion which allows people receiving social care support to report and share personal experiences of care, and which could be used to access information
• The need for the inspection to pick up on, and to share good practice
• The use of social media (for younger people receiving social care support) such as Facebook, Instagram or tik tok

The next question asked:

Q11: What information might that be?

A total of 64 call for evidence respondents commented in response to this question, with a significant minority of these referring to information provided by the inspection process or inspection reports. Some comments echoed those from the previous question.

The inspection process and inspection reports

A few call for evidence respondents and attendees at events noted the importance of having the most recent inspection report available, in an easy to read version and accessible format. This included references to an easy read version of each report and the provision of reports in a range of different formats, to meet different needs. Once again, there were a small number of suggestions for a brief summary document of inspection findings that includes information on the ethos, aims, grades, strengths and areas for improvement, along with details on how to access further information if required. There were also comments on the need to ensure that all information provided is up-to-date. Although most respondents focused on inspection reports related to specific socialcare providers, one provider of social care services suggested it would be useful to be provided with general reports on the state of care across the sector as well as on the performance of different types of services providing social care support.

Respondents to the call for evidence and at events referred to a wide range of information that could be provided in inspection reports. This included:

• The purpose of inspection and the process of inspection
• An overview of the service providing social care support and the services available; location of setting of social care support
• Performance (past and present) to allow for comparisons over time. One respondent noted that information on performance will vary across different services who provide social care support, depending on the type of care and support provision; national and local information so that performance can be compared across different social care providers
• Outline of strengths / where services who provide social care support are 'getting it right'
• Outline of weaknesses and where services who provide social care support are 'getting it wrong'
• Areas for improvement / improvement plans; how services who provide social care support have responded; and progress made against these; achievements against targets
• Outcomes of inspection process
• Compliance with legal requirements
• Management / staff turnover within providers of social care support services; staffing levels (grades, roles, qualifications and experience)
• Complaints and enforcement activity; appeals process
• Contact point for the regulator
• Case studies in relation to lived or living experience, provided by people receiving social care support and their families; for example, whether the quality of care provided meets the expectations of people receiving social care support
• Qualitative information on whether relationships are warm and supportive, whether residents are comfortable, and the day-to-day routine
• Information on how assessments are made and waiting lists
• The role of SSSC and what they regulate

As noted by a representative body:

"The principles within the Social Care (Self-Directed Support) (Scotland) Act 2013 are clear that individuals should be provided with enough information to enable an informed choice. This could be details of the service provided, inspection activity and outcome, number of registered workers, engagement opportunities for those using services, and future plans for service development."

The involvement of people receiving social care support

As at the previous question, there were a number of comments from both call for evidence respondents and those attending events, about the need to involve people receiving social care support. Comments included a need for engagement with people receiving social care support so as to ascertain what information would be most useful to them. There were also a few suggestions for the inclusion of lived experience of people who have previously received social care support and the provision of feedback from people currently receiving social care support and their families so that potential users of social care support and their families can obtain an up to date picture of a specific service they might be considering.

The regulator

There were a few comments to the call for evidence on the need for information on how to access the regulator's website, with a suggestion that regulator websites should be easily navigated and have clear signposting as well as providing a clear explanation of their role in the inspection, scrutiny, and regulation process.

Additional information provision

There were a small number of requests in the call for evidence for information on what is available locally, along with contact details for these providers of social care support and what to expect from them.

Q12: How can we make data collection and sharing better?

A total of 73 call to evidence respondents commented in response to this question.

A single digital system

A key theme emerging in response to this question from call for evidence respondents was of a need for a single shared digital system or platform with all required information, as each organisation at present has its own IT system and there is little consistency in terms of the data collected. This issue was raised by a large minority of respondents across all sub-groups and cited by small numbers of attendees at events. A single shared system would reduce duplication of effort, remove administrative burden, help to streamline current data collection and reporting arrangements, enable users to focus on meaningful data and priority areas, and allow for service and system wide improvements. There were some suggestions that changes to data collection are being made already, with one regulator referring to information sharing agreements already in place between some organisations. Another regulator referred to a new framework with Sharing Intelligence of Health and Care Group (SIHCG) and another suggested adoption of the Scottish Approach to Service Design (SatSD) that focuses on a user-centred approach. One proviso in relation to the collection and sharing of data was that current local systems in use would need to be updated and properly resourced in order to ensure they can collect the required data.

One HSCP referred to the Improvement Service taking forward a project to try and simplify data submission arrangements across local authorities. An organisation in the 'other' sub-group noted:

"To assist in improved data collection, we need to develop a single system, with the ambition of reducing duplication and minimising the administrative burden and which effectively:

• - Supports the service provider to manage and report on performance
• - Collates evidence to inform scrutiny
• - Provides a Learning Management System for staff training and continuous professional development
• - Records and aggregates training needs
• - Sends notifications and required data to scrutiny bodies, commissioners and Scottish Government."

There were also a few suggestions for more collaborative working from call for evidence respondents and from events. This included regulators sharing more information and working together using a joined-up approach, and with deeper collaboration and stronger relationships between social care support providers.

Linked to the issue of a single digital system, there were again comments on the need for any data to be accessible.

Two organisations providing social care support suggested that the set up of a single regulatory organisation would allow for the central collection of data, align data sharing and allow for better sharing of information across agencies.

Development of a strategy

Alongside suggestions for a single shared digital system, there were a few calls – mainly from HSCPs and representative bodies responding to the call for evidence – for a national digital strategy for the public sector that would allow for better communications and information sharing. The involvement of the regulators in discussions about datasets and collecting data would help to develop this strategy, although it was suggested by an organisation in the 'other' category that there is firstly a need to map current data collection so there is a good understanding of what is currently available and what is required by the different regulators. To aid this, there would need to be consistency across the data collected and consistent definitions.

The need for accessibility

The issue of accessibility was raised again at this question by all respondents (call for evidence and events), with references to the need for easy to navigate and clearly signposted websites and for information to be accessible to all. It was also noted that it would be important that individuals providing data have a clear understanding of how their data would be used, and for those working with the data to understand how to use the data to reach positive outcomes and improvements to service delivery. One representative body responding to the call for evidence noted:

"Data held about registered social care services by the service and workforce regulators is not currently linked. The regulatory bodies could significantly improve the social care data available by sharing what they already hold from inspection visits, annual returns, and registrations in an accessible and up to date format."

Collecting data

A small minority of respondents referred specifically to the approaches used for data collection. There were suggestions for more regular surveys (such as quarterly surveys on the social care and support workforce or among people receiving social care support), for a combination of quantitative and qualitative data to be collected so as to provide a full picture of the service provided, and utilising a variety of different formats. There were a small number of comments that there is currently a lack of timely data, with one organisation providing social care support suggesting that there should be ongoing data collection so as to track and monitor performance outwith the inspection process.

Concerns over data collection and sharing

A few respondents outlined concerns they had in relation to data collection and sharing. These revolved around the inoperability between different IT systems and the level of funding that would be required to set up a collaborative approach to data sharing, and also that some organisations may be reluctant to share data. One representative body also cautioned over pressures currently facing the sector in terms of the time needed to collect information or participate in engagement sessions; and another that increased demands to collect data will lead to increased demands on administrative staff. As noted by an advocacy organisation;

"Currently there are 32 different systems in health and social care. This can result in an inconsistent picture of the current social care profession and difficulty gathering accurate equality and evidence data. This proves difficult to evaluate who is accessing social care services such as minority groups and to understand and address any differences in their experiences. To achieve an inclusive service focused on equity of access and quality of provision, more understanding around personal characteristics and needs is required. Introducing regulation and data sharing that is universal for all social care services would rectify this and contribute towards continuous service improvement."

An individual at an event noted that some providers of social care support are subject to multiple inspections which creates a lot of duplication of effort and can be time consuming.

Q13: How do we make sure regulation, inspection and scrutiny supports good practice for people accessing care and support?

A total of 70 respondents commented on this question in the call for evidence. Many of the topics raised were noted by respondents to the call for evidence and those attending events.

Two key themes emerged in response to this specific question. The first, noted by a significant minority across all sub-groups as well as being mentioned at events, commented on the need to define, identify and highlight good practice. There were a few comments on the need to focus on creative, flexible and innovative working practices rather than focusing on poor service delivery or elements of the service that do not work as well as they should. This would help to ensure continual improvements to good practice as well as ensuring all services offering social care support can adhere to good practice. It would also ensure that people receiving social care support and their families would know what good practice should look like.

The second key theme, noted by a significant minority of respondents across all sub-groups and from respondents at events, focused on the need to involve people receiving social care support and their families. In this way, the system of inspection, scrutiny, and regulation would fit people receiving social care support, rather than expecting people receiving social care support to fit the system. Ways in which to involve people receiving social care support included active involvement at all levels such as management meetings and peer inspections. A commitment to co-design systems with people with lived or living experience alongside provision of accessible information would help to develop social care services that meet their needs as well as highlight good practice. It was felt there is a current lack of focus on developing relationship-based practice that aims to facilitate support and positive outcomes by involving users of social care services in their own care plan. A representative body felt that strategic evaluation of the process of inspection, scrutiny, and regulation should draw on data collection and intersectional analysis of people's experiences of health and social care, to ensure evidence-based responses that target groups of people who do not have equitable access to care. In summing up, a representative body commented:

"Having people with lived experience involved in all aspects of regulation, inspection and scrutiny will encourage good practice through its very nature. People with lived experience can create clear guidance on how to conduct inspections and encourage best practice. Positive outcomes following inspection can be shared with the public to show the aim of inspection is to continually improve. Positive examples could be shared in training new inspectors and amongst teams. Discussions should also be had when things do not go well in order to learn from mistakes made and improve practice. Peer support organisations can share examples of good practice through their information channels. They could also hold workshops with special interest groups and in local areas, reaching out to under-represented groups. Different channels should be used, keeping in mind that not everyone has access to the internet or finds it the best way to receive information."

There were also a few references to the need for inspection reports to be accessible, to provide insight on the current system and opportunities for changes and to frame the results in the context in which care is delivered while acknowledging the challenges facing the sector.

Individuals involved in the social care sector

While much of the focus at this question was on the involvement of people receiving social care support and the use of good practice, a significant minority of respondents also focused on the role of inspectors and the need for good professional practice during their involvement in inspection activities. This issue was raised in responses from all sub-groups to the call for evidence as well as at events. Comments included the need for:

• Clear guidelines for inspections so that all interpret the outcomes in a consistent way; and a thorough and systematic approach to the grading system
• More regular visits to local authorities and services offering social care support
• Inspectors to be visible outwith the formal scrutiny and inspection processes, having regular contact and observation sessions
• Creating a better dialogue between inspectors and providers of social care support
• Well trained inspectors with up-to-date and relevant knowledge and skills for each of the inspections undertaken and the different service types
• An environment that supports learning
• Higher levels of transparency in the inspection, scrutiny, and regulation process
• The embedding of PANEL principles in all practice
• Less focus on procedure and policy and more on developing relationship-based practice and supporting positive outcomes
• Offering higher levels of support to organisations, working in partnership and understanding the ethos of different organisations

While the role of inspectors is clearly important, a small minority of respondents across all sub-groups and those attending events, also focused on the way the social care and support workforce should carry out their jobs. These included references to high quality training so that the social care and support workforce has the right skills at the right time and in the right place. There were also calls for ongoing and continuous improvement in terms of skills development. Some very specific skills were outlined by respondents and these included specialist training to help develop understanding of mental health issues, stigma and discrimination. While a number of responses focused on specific skills and training, there were also a few references to other skills such as the need for staff to be kind and compassionate.

Across the social care and support workforce as a whole, there were a few comments on the need for a system that is rights-based and works for the benefit of the people receiving social care support, rather than focusing on a specific registration category. One organisation felt there is a need to improve workers' knowledge and understanding of legislation, regulation and standards. There was a reference to the need for a change in attitude so that the social care and support workforce views inspection, scrutiny, and regulation processes as positive and to their benefit, rather than being process driven and could be challenging for many.

Final comments

There were a small number of comments made by one or two respondents to the call for evidence and at events. These included:

• Better promotion of the health and social care standards
• Strengthening codes of practice so that providers of social care services adhere to the Care Standards; for example, currently there are no statutory obligations on these to ensure anyone in the social care and support workforce attains the qualifications required for their registration
• The setting up of a national body to focus on benchmarking and the sharing of good practice
• Offering clear definitions of what is meant by inspection, scrutiny, and regulation
• Reframing inspection and scrutiny as one tool within a broader system that is focused on supporting continuous improvement
• The need to address questions of resources, responsibilities and relationships
• Having a collaborative approach across regulators and with the National Social Work Agency, using information gathered through scrutiny and inspection to highlight best practice and promote joint working
• Offering a 'Trip Advisor' style site for the rating of services offering social care support
• A transparent and easy to use complaints system, that offers anonymity to complainants

The next question in the call for evidence focused on the social care and support workforce, and asked:

Q14: How do we make sure regulation, inspection, and scrutiny supports good practice for people working in care and support?

A total of 63 respondents to the call for evidence responded to this question. To an extent, some respondents raised the same issues to this question as they had to the previous question, and a few respondents set the context for their response in terms of the challenges in the current landscape facing services offering social care support. These include a reduced labour pool, high inflation, recruitment and retention issues and higher wages being offered in other less pressured working sectors.

Issues that were raised at the previous question included the highlighting, identifying and sharing of good practice; and for inspectors to be well trained with up-to-date knowledge; for inspection reports to be accessible and focus on positives rather than problem areas or to offer a better balance between providing positive feedback and highlighting areas for improvement. There were also a few requests for clearer explanations on the role of inspection (and the inspector) and regulation activities. There was a request from a representative body for the quality framework for inspections to be amended to require inspectors to examine services providing social care support against required national Fair Work standards. A service providing social care support suggested that regulations should ensure that there are terms and conditions in place to support the social care and support workforce and that these could be part of the inspection process.

The need for culture change

There were a small number of references from call for evidence respondents and events on the culture change that is needed within the sector so that the inspection process is not seen as a burden but as an opportunity to reflect on challenges, successes and learning. It was felt that a greater emphasis on collaboration and support would help to bring about the required change in culture. Furthermore, while there needs to be a recognition that regulation is important, an approach focusing on good practice and innovation within the health and social care sector would encourage rather than discourage individuals from working in the social care sector and thus help to address the existing recruitment and retention issues.

The role for care services

A small minority of respondents focused on roles that need to be adopted by services providing social care support, although some may already have taken these roles on board. There were a small number of references to the need for services offering social care support to support meaningful training for their social care and support workforce, offering support for continuous professional development (CPD) and learning so that there is a culture of learning, and support that ensures staff have the necessary skills to perform their role well. It was also suggested that regular meetings between managers of services providing social care support and their staff to discuss areas of development would be useful in supporting their staff, alongside a commitment to this from senior leadership.

The social care and support workforce

Linked to the previous point, a small minority of respondents to the call for evidence and some of those at events focused on the need for resources, training and support to be provided to the social care and support workforce. This included access to good quality continuous professional learning (CPD), opportunities for CPD that reflect the skills needed to perform their job well, management support and encouragement and paid time for training. There was one reference to training on mental health issues and societal issues such as racism. Training and CPD would also demonstrate that the social care and support workforce is respected and valued and offer a valuable contribution to their employer. A small number of respondents – mostly individuals – referred to the need for the social care and support workforce to be offered secure contracts with fair pay and terms and conditions. There were also a small number of references to the Fair Work standards which offer all individuals an effective voice, opportunity, security, fulfilment and respect.

A few respondents commented on the need to involve the social care and support workforce more, for example by having systems in place to obtain regular feedback from them on their experience, and in involving them to a greater extent in the inspection processes.

A small number of respondents noted the need for services providing social care support to have robust disclosure policies and whistleblowing protection for their staff. A similar number also suggested support should be provided by regulators for social care service staff. This included ongoing consultation and feedback and involvement at all levels of the inspection.

The next question in the call for evidence asked about providers delivering care and support.

Q15: How do we make sure regulation, inspection, and scrutiny supports good practice for providers delivering care and support?

A total of 55 respondents to the call for evidence commented in response to this question. Again, responses echoed many of the points raised by call for evidence respondents and at events at the previous two questions. These included:

• The need to highlight and share good practice
• Involving social care support providers in the inspection, scrutiny, and regulation processes, for example, by building trusting relationships based on mutual respect
• The provision of support outwith the inspection process
• The provision of consistent advice and a consistent approach across the inspection process
• Working collaboratively with social care support providers and involving them in any developments in inspection, scrutiny, and regulation. There were also a small number of references to the need to involve the social care and support workforce and people receiving social care support
• Building good relationships with providers of social care support and reducing the fear and anxiety felt by many about the inspection, scrutiny, and regulation processes
• Ensuring reports are set in context and recognise the challenges of funding and staffing
• Changing focus to support improvement, with a greater emphasis on collaboration rather than scrutiny
• To consider the terms and conditions offered to the social care and support workforce and ensure they are standardised to help improve recruitment to the sector and provide career options to those in the social care and support workforce
• For services providing social care support to all work to operate at consistent and high standards

In summary: Theme 4 – How will we know systems are working?

Respondents outlined a number of ways to ensure that people have the information they need about how providers of social care support are performing, to support decision making about care and support (Q10). These included inspection reports that are accessible to all and include easy read and summary versions in a range of different formats and channels. There were also requests for a duty on providers of social care support to publish and provide the most recent inspections report. A single source public website that provides all the required information was also suggested. On existing websites that provide information, this needs to be clearly signposted and provide cross-references to other sources of information. Involvement of people receiving social care support and their families would also help to ensure they receive the required information they need. A wide range of information was outlined as necessary (Q11).

Respondents outlined a number of ways data collection and sharing could be better (Q12). There were references to a single digital system or platform to help reduce duplication and administrative burdens, improve consistency in data collection and streamline data collection and reporting requirements. Some respondents would like to see a national digital strategy that would allow for better communications and information sharing. This would also be helped by more collaborative working and ensuing that all data is accessible to all users.

Respondents noted some concerns over data collection and sharing, for example, the current inoperability between different IT systems and the funding that would be needed to set up a single data collection system.

Respondents identified a number of ways in which regulation, inspection, and scrutiny could support good practice for people accessing care and support (Q13), for people working in the social care sector (Q14), and for providers delivering social care support (Q15). These included defining, identifying and highlighting good practice and placing a greater focus on positives and less on negatives in the inspection process. There was also a desire for inspectors to focus on developing relationship-based practices and supporting positive outcomes, with more collaboration and support for organisations.

It was seen as important to involve people receiving social care support and their families in co-designing inspection, scrutiny, and regulation processes.

There were also calls to ensure that training for the social care and support workforce provides people with the skills needed to carry out their job effectively.

Creating a culture change so that inspection, scrutiny, and regulation is seen as an opportunity to reflect on challenges, successes and learning; a greater focus on the positives was seen to be needed.

Ensuring care providers support staff training requirements and provide access to high quality training and continuous professional development, was perceived to be important for those working in the social care sector.

There were calls to adopt a more collaborative role between regulators and care providers, with support provided on an ongoing basis outwith the inspection regime. This would help to build good relationships and create a more positive view of inspection, scrutiny, and regulation.

Finally, there were requests for a consistent approach to inspection, scrutiny, and regulation.