ON 13 MARCH, the Care Inspectorate, the regulator responsible for the quality of care in care homes, suspended inspections of services and stopped all visits except “when absolutely necessary”. Few if any inspections then took place until 30 April, when the Care Inspectorate entered Home Farm care home on Skye. As a result of growing public concern about the death toll, the Scottish Parliament then intervened.
The Coronavirus (Scotland) (No.2) Act 2020, which came into force on 27 May 2020, required the Care Inspectorate to start inspecting care homes again and report to the Scottish Parliament every two weeks. This intention was to ensure the Care Inspectorate protected older people in care homes from Covid-19 more effectively. The first report – which summarises inspections at thirteen care homes, including Home Farm – was lodged last week, and while it represents an important step towards transparency, the report nevertheless leaves many questions unanswered and much to be done.
The inspections detailed in the report focus on the key components in a care home’s capacity to protect its residents in a pandemic: infection control, personal protective equipment (PPE) and staffing levels. To assist with this, the Care Inspectorate has now produced a methodology of how it will assess a care home against these requirements while respecting the rights of older people. This is welcome; had public sector pandemic planning been more effective, it is the type of resource that should have been available from the start of the Covid-19 crisis, not ten weeks later.
The report offers no explanation for why these 13 care homes were selected for inspection beyond “we have taken account in all inspections of the scrutiny intelligence we have, including previous inspections, complaints made to us, notifications made by the services, and information shared with us by health and social care partnerships and directors of public health”. A separate paper for the Care Inspectorate board meeting on 18 June indicates that the care homes were chosen after a joint risk assessment with directors of public health. The methodology underpinning this, along with the reasons why the Care Inspectorate decided to prioritise these particular homes for inspection, are not clarified any further.
The rationale for the inspections is important. Is the aim to understand what has gone wrong, to reduce the risks in care homes currently experiencing Covid-19, or to ensure homes are properly prepared in future? Is the choice a mixture of all three? The inspections summarised in the report cover a disparate set of care homes and circumstances. In several cases, it is difficult to ascertain what prompted the inspections, even after searching through past inspection records and media coverage. MSPs should ask for clarity about this so they can ascertain whether objectives are being achieved.
The importance of checking the preparedness of care homes for a pandemic is well illustrated, albeit not explicitly, by the inspection of Newcarron Court in Falkirk. The report records significant concerns with infection control, PPE and contaminated waste. One can understand why:the Care Inspectorate has issued no less than six requirements to the provider, Advinia Health Care, to improve the service. Back in April, the Sunday Mail revealed local hospitals had been negotiating with Advinia to admit older people, who were “highly likely” to have Covid-19, into this very home.
However, the report fails to explain whether those transfers happened and whether older people died as a result or whether quite separate events prompted the inspection. Whatever the explanation, the case shows some care homes were completely unprepared for Covid-19. It suggests the Care Inspectorate should have been ensuring good infection control procedures were in place before any discharge of potentially infected patients from hospital was considered.
Several of the care homes in the report have featured in the media due to the high numbers of their residents dying from Covid-19. The Care Inspectorate requires care homes to report such deaths, passing the data on to the Scottish Government – but has so far not made this information public. Families have been kept in the dark about what has been happening in care homes that concern them, a situation the report has done nothing to change: it does not record or explain the number of deaths in the care homes inspected, nor does it refer to past inspection grades. This limits its usefulness in terms of trying to understand what has happened in each home.
Unlike Home Farm, which had been rated poor, other care homes with high deaths featured in the report had previously been rated with much higher grades. For example, Whitehills in E. Kilbride, where the press revealed 23 older people have died from Covid-19, was inspected in June 2019 and judged “good” on two counts and “adequate” on three (not high quality care but above the Scottish average for care homes).
The recent inspection found that “staff to be knowledgeable in use of PPE and all staff had received COVID-19 training. The home had a good supply of PPE and this was available throughout the home for staff to access. The service had good infection prevention and control procedures in place and staff were assigned to work with either with those with COVID-19 or with those who were symptom free. The environment was very clean with good practice in place by domestic staff. Inspectors and public health staff were impressed with the cleanliness in rooms”.
Other examples include Drummohr care home in Musselburgh and Almond Court in Glasgow. Both had received good grades within the last six months and both were evaluated as good at infection control in the recent inspections. This raises the important question of how three care homes rated above average in their two most recent inspections could have suffered large numbers of deaths in-between?
There is a range of potential explanations, from inadequate infection control at the start of the crisis – for example, due to a lack of PPE – to ineffective shielding, exemplified by the number of infected older people being discharged from hospital. Unfortunately, the inspections, by focusing entirely on the present, cast no light on this (although individual inspectors may well have a good idea of the answers). Again, this makes the report of limited use for helping to inform MSPs or the public about what needs to be done to prepare for a second wave of Covid-19.
That is not to say the inspections were not needed. Drummond Grange at Lasswade had been rated very good when last inspected in August 2018. However it was selected, it was right to do so. The inspection “identified significant concerns relating to supply and use of PPE, infection prevention and control practices, including waste and laundry management, and staff knowledge of residents’ status relating to COVID-19.” The report adds these serious concerns have been quickly addressed, providing an illustration of how, if inspections had continued, they might have helped save lives.
Another group of care homes featured in the report were giving cause for serious concern before the Covid-19 outbreak; in fact, the two care homes with the worst grades appear to have improved significantly since their last inspections. Spynie Care Home, near Elgin, judged poor on four counts in October 2019 and previously issued with an Improvement Notice, was found to be operating to a good standard. Drumbrae, run by Edinburgh City Council, judged inadequate on three counts in January and subject to Improvement Notice, was “found to be clean and offered a safe environment. There was appropriate access to and use of PPE, and hand hygiene by staff was good”.
The rapid turnaround in both cases is welcome and offers some reassurance to families, but what explains this? Edinburgh City Council had failed to address no less than 10 requirements for over a year before being subject to the Improvement Notice. Has Covid-19 served to force some providers to find the resources necessary to address longstanding issues? If so, to what extent has that happened in the other 57 care homes for older people that had grades of inadequate or poor at the end of February? Without answers to these questions, how does the Care Inspectorate know which homes to prioritise next for inspection?
Home Farm on Skye, where ten residents died, is only briefly mentioned in the report; there has been no further inspection as such, only a monitoring visit. Separately, it has now emerged that NHS Highland discharged five older people into Home Farm, where serious staffing and infection control concerns had been documented by the Care Inspectorate in January, without tests. Had the Care Inspectorate undertaken a further inspection of the home before these discharges were allowed to take place, it appears that these deaths might have been averted. This is a good example of system failure where neither the Health Board, provider or Care Inspectorate appear to have taken appropriate action to shield residents from Covid-19.
Meanwhile, the Care Inspectorate has agreed to allow Home Farm a further two weeks to improve. Cancellation of the registration would require a full court hearing. That would make public the failings of all parties and the system as a whole and require significant extra resources in the short-term to enable Home Farm to be taken over.
Unless the Scottish Government intervenes, as they have the power to do, it appears unlikely to happen.
What should the Care Inspectorate be doing?
On 23 March, ten days after they stopped inspections, the Care Inspectorate board met. In over 200 pages of papers for the meeting, there was just a half page report from the chief executive on the Covid-19 crisis. Unfortunately, the minutes of that meeting and a further special board meeting in May, for which no papers have been published, are not included in the papers for their meeting on 18 June. That may be an accident, but it is not possible to ascertain how far the Care Inspectorate’s board may have questioned the decision to suspend inspections.
The papers for the meeting on 18th June again run to c200 pages, half a dozen of which concern the Covid-19 crisis. Although the crisis has taken up much of their chair’s time – he lists all the meetings attended with Scottish Ministers – the impression is that a large part of the Care Inspectorate has continued as normal, rather than addressing the largest crisis ever to face in care services in Scotland.
The report to the Board does narrate how, after starting to collect information on deaths and staffing in April, activity has increased significantly and is now far more pro-active: “We contact every care home directly in Scotland regularly and sometimes daily depending on individual circumstances. Up to 31 May 2020, our 300 inspectors had made 19,047 contacts with services, with 630 of these being virtual meetings”.
No attempt has been made, however, to assess what difference all this activity is making, how effectively public agencies are now working together or what needs to happen next.
Elsewhere in the board papers is information which hints at some big issues: “At the outset, the advice from directors of public health in Scotland was unequivocal in that inspection visits would present a real risk of introducing and spreading COVID-19 in Scotland’s care homes.” This is fundamental to understanding what has gone wrong and, if true, this represents a U-turn by public health. The reasons for that need to be made public.
It also begs the question: if public health and the Care Inspectorate stopped inspectors entering care homes because of the risk of spreading Covid-19, what did they do to prevent c1,400 older people being discharged from hospital to care homes without a test?
The board papers also reveal that “there has been a 34% increase in complaints for care homes for older people from 521 complaints between March and May 2019 to 697 complaints between March and May 2020.” Older people rarely complain and have had little voice in this crisis. But their relatives do and this increase in complaints, when those relatives have been denied access to care homes and cannot witness directly what has been happening, is likely to be highly significant.
Instead of a detailed analysis of these complaints, the board is asked to consider the same old quarterly performance reports. Which would the public consider the most important at the present time? Maybe board members should visit a few care homes, as soon as they can, and talk to residents, their relatives and staff about what really matters?
Together with the findings of the recent inspections, all this suggests that the Care Inspectorate, the body which has prime responsibility for ensuring that older people in care homes are safe, is still far from understanding what has gone wrong and what needs to change. That is almost certainly not the fault of the board or its staff, many of whom are very caring and able people. The failure is with our centralised, under-resourced and bureaucratised systems that did not prepare properly for a pandemic and don’t have the flexibility to respond to the Covid-19 crisis as a crisis – a system that keeps the people responsible for regulation distanced from what they are supposed to be regulating.
We need a fundamental review of the way regulation works for older people just as for younger people. But the immediate priority has to be an effective plan to protect older people in care homes from further outbreaks of Covid-19.The Care Inspectorate should using the inspection process ordered by the Scottish Parliament, not just to check on what infection control measures care homes have in place now, but to understand what has gone wrong and use this to help develop a proper plan for the sector.
Picture courtesy of Jernej Fulman