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

Theme 2 – What needs to be inspected, scrutinised, and regulated?

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 paper explained that in Scotland, there are three main organisations that regulate and inspect social care support. These are:

Care Inspectorate – is a scrutiny body which supports improvement and regulates and inspects care services in Scotland to make sure they meet the right standards. They also jointly inspect with other regulators to check how well different organisations in local areas work to support adults and children.

Healthcare Improvement Scotland – is the inspection and improvement body for health but it carries out a number of strategic and thematic inspections with the Care Inspectorate, for example, inspections of Health and Social Care Partnerships.

Scottish Social Services Council – is the independent professional regulator for social workers, social care and early learning and childcare practitioners. It sets the standards for their practice, conducts training and education, supporting continuous professional development.

The next question asked:

Q2: Do you feel there are services that are not currently subject to inspection, scrutiny, and regulation that should be?

As shown in the following table, a majority of respondents who expressed an opinion felt there are services not currently subject to inspection, scrutiny, and regulation that should be. Greater proportions of individuals thought this than organisations.

(Percentages might not add to 100% because of rounding)

All respondents who answered question 2 were then asked to say which types of services should be subject to inspection, scrutiny, and regulation, why they should be inspected, scrutinised, and regulated and who should be responsible for this.

Which types of services should be subject to inspection, scrutiny, and regulation?

A total of 66 call for evidence consultees commented at this question. Among these were small numbers who made a response other than 'Yes' at the previous question. A very wide range of services was quoted by consultees and at events, but only a few services came up repeatedly in answers and discussions. The most frequently discussed service – mentioned by a large minority of respondents across all sub-groups and at events – was personal assistants (PAs).It was noted that there were currently discussions taking place regarding the levels of inspection, scrutiny, and regulation needed for this role. A few respondents were against further scrutiny. There were concerns that this may deter people from becoming a personal assistant, or because the role is very specific to the person receiving support.

A significant minority (comprising mainly the same respondents who discussed personal assistants) cited people employed using self-directed support (SDS). Inspection, scrutiny, and regulation should cover, for example, outsourced services for the third sector or how the introduction of SDS in terms of advice is being delivered. Similarly, a very small number of respondents cited self-employed social care workers.

A significant minority saw a need for further scrutiny of unregistered social care providers or some professional groups who provide social care support which sit outside regulation requirements. Consultees gave a wide variety of examples^[5] including agency staff, independent care centres, para-professional roles, independent consultants, independent counselling or therapeutic services, advisors used by regulatory bodies, non SSSC-registered managers, social work assistants and cooks in care homes.

A few respondents viewed all services operating in the health and social care sector as requiring more inspection, scrutiny, and regulation, while two individual call for evidence respondees saw a similar need for local authority social work services themselves. A small number of respondents thought the forthcoming National Care Service would need regulation and inspection.

A few respondents each identified other service areas as requiring inspection, scrutiny, and regulation:

The regulators themselves (specifically the Care Inspectorate (CI), Healthcare Improvement Scotland (HiS))

Third sector organisations (in instances where these are not collaborating with statutory partners); care at home services or placements (mainly by individual respondents / lived experience / unpaid carers) with mentions of poor personal experience or feedback; community health services (e.g. nursing, healthcare assistants and services for those with sight or hearing loss not included in present national arrangements)

There were also a large number of social care support services mentioned by only very small numbers or single respondents, or at one or two events only, as follows:

• Nannies
• Older unpaid carers of adult children
• Contact centres for family contact^[6]
• Family support workers (e.g. beneficial to register with SSSC)
• Community outreach groups
• Alcohol / drug services^[7]
• Harm reduction services
• Advocacy organisations / services / providers
• Mental health services (inspection needs clarification)
• Unpaid adult carer centres
• Organisations providing support for victims of modern slavery, those in the asylum system and survivors of trafficking
• School care settings (e.g. private residential schools which house care experienced children)
• Playgroups (e.g. those running just under the 2 hour cut off for inspection)
• Childcare agencies
• Child activity services / out of school care services (e.g. football camps, those run by leisure trusts and those where parents are not present)
• Early years services (Early Learning Centre sector, intervention services Early Start, Sure Start, etc.)
• Services for children with additional support needs (ASN)
• Tutoring services / home school education services
• GP surgeries
• Hospital to home services (set up by NHS / health authorities)
• Acute health services
• Dementia services (meeting centres, etc.)
• Pharmacies
• Training and skills providers
• Secure care transport provision
• Foodbanks

There were also a few comments (largely made by respondents who did not answer 'yes' at the first part of the question) stating that the priority should be to clarify and streamline inspection, scrutiny, and regulation processes to make it easier for people to navigate. Similar numbers, mostly representative bodies, felt it would be better to resource and properly support services (for example by improving individuals' skills) in order to improve them, rather than bring in additional regulation which could also create extra bureaucracy.

Why these services should be subject to inspection, scrutiny, and regulation

A total of 63 call for evidence respondents replied to this question, including a small number who did not respond 'Yes' at the first part of question 2. Most gave their answers from the point of view of the benefits to people receiving social care support, rather than specifically relating to reasons for inspection, scrutiny, or regulation of the services they mentioned at the previous question. Three dominant themes emerged.

Firstly, a large minority from across the broad spectrum of respondent types and events felt that all services should have the same level of inspection, scrutiny, and regulation. The advantages were seen to be consistency of standards across the care service profession (e.g. the same standards for domestic / private / residential settings as for care homes, and for agency staff as well as the directly employed) and the provision of assurance of care quality (e.g. in terms of equality, inclusion, and human rights). A service provider commented:

"It seems incongruent that multiple care services who provide care, too often the same people, have different regulation requirements. For instance, a person may use a harm reduction service for drug use where that service may not be regulated or inspected but then that same person attends a stabilisation service which is regulated." (Service Provider)

Secondly, it was thought by a large minority (again from across all respondent types although this was not mentioned at events) that an adequate or improved standard of care and support would be provided to vulnerable people receiving social care support such as victims of trafficking or exploitation. A representative body noted an inspection scheme already exists in England and Wales, without giving further details on this scheme.

Thirdly, similar numbers across all sub-groups thought that further inspection or regulation would help to drive improvements and encourage best practice across services. This would result in more training and skills development and increased continuous professional learning (CPL) opportunities.

A significant minority of mostly individuals, representative bodies and regulators noted increased protection of vulnerable people. Similar numbers from a broad mix of respondents saw further inspection, scrutiny, and regulation as helping with safeguarding (i.e. ensuring the safety of vulnerable people receiving social care support). Small numbers – mainly representative bodies and social care providers – identified advantages in terms of staff safety, safer recruitment processes, induction and support, and other staff vulnerabilities (e.g. not getting paid).

Very small numbers outlined advantages arising from:

• Helping with the instigation of improved complaint procedures
• Provision of accountability and transparency
• Informing the understanding of, and ability to, monitor and manage issues and risks

A few respondents gave caveats on how any further regulation should be implemented. Several representative bodies, other organisations and individuals wanted regulation and inspection to be a supportive process. They felt that the language currently used tends to promote a power imbalance between inspectors and the people receiving social care support and providers of social care support.

Furthermore, small numbers of comments suggested that regulation should involve giving recognition to or acknowledging the value of staff roles, and urged that all scrutiny is relevant to circumstances, with comments that this does not suit all scenarios (e.g. clubs, activities).

A few respondents wanted to see increased registration requirements as a result of increased scrutiny and regulation. However, similar numbers raised concerns about the possibility some staff could move from registered to unregistered roles to avoid scrutiny.

A few representative bodies and individuals made arguments as to whether or not personal assistants (e.g. directly paid under SDS option 1) should be inspected, a topic also discussed at events. It was suggested that extra protection and enhancement of services to people receiving social care support would be provided by extra regulation, although this could reduce an individual's right to choose. It was also felt that an outside agency providing inspection, scrutiny, and regulation might be seen as being in contravention of the principles of independent living. A small number of mentions were made at events and among consultees about making use of proportionate regulation in these situations.

A few representative bodies at events were concerned about the risks of losing staff due to further registration and qualification requirements.

Who should be responsible for undertaking inspection, scrutiny, and regulation?

A total of 54 respondents answered this question. By far the most common response from a large minority of respondents (mainly individuals and representative bodies and a couple of HSCPs / local authorities) was the Care Inspectorate (CI). Reasons for this centred around the Care Inspectorate already having responsibility for quality of care provision and improvements over a variety of specified services. Most of those referring to this organisation mentioned it in isolation although small numbers did mention it in combination with another organisation. A representative body and an individual thought responsibilities could lie jointly with the CI and Healthcare Improvement Scotland (HIS), while an HSCP / local authority and an individual thought regulation and inspection should be shared between the CI and the Scottish Social Services Council (SSSC). A small number of respondents simply said that the relevant or existing regulatory agencies should be in charge without specifying which ones.

A few respondents each supported the following taking responsibility:

• Employers / social care providers (to engage / play a role)
• SSSC (for additions to the register / registration, or suitability of individuals to be employed)
• The Scottish Government (e.g. Ministers)

In addition, a few respondents requested a single inspection and scrutiny body, with an HSCP / local authority viewing the relationship between the CI and SSSC as often overlapping. Similar numbers wanted to see an independent body in charge, with suggestions that inspection should be independent of the regulator, the regulator independent of government control, and that the body should be answerable to government and the public.

Small or very small numbers of respondents supported a role for the following:

• People receiving social care support / relatives / the public / social care and support workforce staff / unpaid carers
• The National Care Service
• Local government / local authorities
• Health and Social Care Partnerships (HSCPs)
• Subcontracting the role to sector specialists (e.g. third sector childcare organisations, Personal Assistant Network Scotland)

Other organisations that were mentioned (mainly during events) by only one respondent in connection with roles in regulation included:

• The Mental Welfare Commission (MWC) – to ensure care and medication plans are appropriate
• Trading Standards
• Office of the Public Guardian
• Chief Social Work Officer
• Health & Safety Executive (HSE) - for workers health & safety
• Scottish Human Rights Commission - for human rights-related issues

Further comments (mainly at events) were made about the regulation, scrutiny, and inspection landscape being very complicated and in need of simplification. This included too many bodies involved in inspection, and conflicting advice from different bodies (e.g. between CI and HiS) and from the same body at different times. In connection with this, there was a query over the interface between regulatory bodies. Finally there were a very small number of requests for clarity over the effects of regulation on the implementation of the National Care Service.

In summary: Theme 2 – What needs to be inspected, scrutinised, and regulated?

A majority of respondents felt there are services not currently subject to inspection, scrutiny, and regulation that should be (Q2). A wide range of services were mentioned by consultees, but only a few cropped up repeatedly (Q2a). Services provided by personal assistants (PAs) were most frequently raised, though a few respondents were against further scrutiny of personal assistants as they may be less likely to take on this role if there is further scrutiny. Unregistered services providing social care support which sit outside regulation requirements were also cited as needing further scrutiny, with a wide variety of examples given.

When asked about why these services should be subject to inspection, scrutiny, and regulation (Q2b), a large minority thought that all services should be subject to the same level of inspection, scrutiny, and regulation to ensure consistency of standards and assurance of high care quality. It was also thought that this would lead to improved standards of care and support to people who use social care support. Further inspection or regulation was predicted to help drive improvements and encourage best practice across services. Increased safety was also seen to be an advantage.

The Care Inspectorate was seen as the organisation most suitable for taking responsibility for undertaking inspection, scrutiny, and regulation (Q2c). This body already has responsibility for quality of care provision and improvements over a variety of specific services. Smaller numbers advocated other bodies to take responsibility such as employers and social care providers (in an engagement role), the Scottish Social Services Council (SSSC) (e.g. for suitability of individuals to be employed) and the Scottish Government.