Adult Social Care and Health Select Committee Minutes

Tuesday, 14th September, 2021
4.00 p.m.
Jim Cooke Conference Suite, Stockton Central Library, Stockton, TS18 1LD
Please note: all Minutes are subject to approval at the next Meeting

Attendance Details

Cllr Evaline Cunningham(Chairman), Cllr Clare Gamble, Cllr Jacky Bright, Cllr Luke Frost, Cllr Ray Godwin, Cllr Lynn Hall, Cllr Mohammed Javed, Cllr Steve Matthews, Cllr Paul Weston
Ann Workman, Emma Champley, Gavin Swankie, Peter Otter (A&H); Darren Boyd (FD&BS); Gary Woods (MD)
In Attendance:
Cllr Ann McCoy (Cabinet Member for Adult Social Care); Judith Mackenzie, Debbie Howe (CQC)
Apologies for absence:
Cllr Jacky Bright
Item Description Decision
AGREED that the minutes of the meeting on the 20th July 2021 be approved as a correct record and signed by the Chair.
AGREED that the Care Quality Commission (CQC) Inspection Results - Quarterly Summary (Q1 2021-2022) report be noted.
AGREED that the information be noted.
AGREED that the Rosedale update report be noted and that a future update be provided to the Committee.
AGREED that:

1) the content within the presented Action Plan in relation to the recently completed Scrutiny Review of Hospital Discharge (Phase 2) be approved;

2) the required responses from both South Tees Hospitals NHS Foundation Trust (STHFT) and Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) to those agreed recommendations directed at ‘local NHS Trusts’ be circulated to the Committee for approval once received.
AGREED that the information be noted.
AGREED that the Adult Social Care and Health Select Committee Work Programme for 2021-2022 be noted.


The evacuation procedure was noted.
Councillor Evaline Cunningham declared a personal, non-prejudicial interest in relation to agenda item 8 (Action Plan for Agreed Recommendations - Scrutiny Review of Hospital Discharge (Phase 2)) as she was currently a Director of Eastern Ravens.
Consideration was given to the minutes from the Committee meeting held on the 20th July 2021.
The SBC Quality Assurance and Compliance Manager presented the latest quarterly summary regarding CQC inspections within the Borough. Nine inspection reports were published during this period (April to June 2021 (inclusive)), and specific attention was drawn to the following:

• The Maple Care Home: A focused inspection was undertaken to review the key questions of ‘Safe’ and ‘Well-Led’ following concerns being raised regarding the management oversight and staffing levels at the service. The inspection found that not all risks were adequately addressed, with issues identified in relation to fire drills, investigating allegations of abuse, and infection control measures involving the initial screening of visitors. Members were informed that a Provider Assessment and Market Management Solutions (PAMMS) (quality assurance tool) report was published in July 2021 which also highlighted the need for improvements - this would be included in the next quarterly report (Q2 2021-2022).

• Roseworth Lodge Care Home: Prior to the CQC inspection, the provider had identified issues with their management of medication - as a result, a new audit tool was implemented. Whilst significant improvements had subsequently been made, the CQC found that some medicine stock counts were incorrect - an Action Plan was being put in place to correct these concerns. The provider has been referred to the medication optimisation team for further support.

• Oxbridge House: A focused inspection was undertaken to review the key questions of ‘Safe’ and ‘Well-Led’, and the subsequent CQC report highlighted several concerns in relation to leadership, auditing systems, care records, management of medicines, and completion of fire drills. Prior to this latest inspection, issues had been raised via a PAMMS assessment in August 2019 and a monitoring visit in February 2021. Despite Action Plans being put in place, the failure to address concerns over a long period had seen the Council place the service under the Responding to and Addressing Serious Concerns (RASC) protocol. An enhanced level of contract monitoring will be put in place, and the home is currently under a four-week embargo on new admissions (which will remain until sustained improvements have been made).

• Piper Court: A focused inspection was undertaken to review the key questions of ‘Safe’ and ‘Well-Led’, and the subsequent CQC report highlighted several concerns in relation infection control, care records, management of medicines, and completion of fire drills. Due to the overall rating of ‘inadequate’, the CQC placed Piper Court into special measures. A four-week embargo was imposed to assess the level of concern and consideration of risks - identification of further concerns resulted in Piper Court being referred into the RASC protocol in June 2021. An eight-week admissions embargo was now in force with enhanced monitoring in place.

Referencing the placing of providers into the RASC protocol, the Committee asked for clarification as to who can make such a referral - in response, Officers stated that the process can be initiated by a number of key stakeholders if there is evidence that people are at risk, including the Council (e.g. Quality Assurance & Compliance Officers), the CQC, other visiting professionals, or family members. On a more positive note, the Cabinet Member for Adult Social Care (also present at this meeting) drew attention to the awareness of issues at Piper Court prior to the CQC inspection, a sign that the systems in place for Council oversight of local providers was working.

Noting that both Oxbridge House and Piper Court had undergone focused inspections, the Committee questioned when the CQC would be carrying out full inspections in light of their latest findings. Members were informed that the CQC were in the process of changing their inspection regime which would be further outlined in the next agenda item. In the case of Piper Court, any provider rated ‘inadequate’ would be re-inspected within six months.

The new PAMMS Assessment Reports section (Appendix 3) of the quarterly summary was noted, with two reports published between April and June 2021 (inclusive) - Allington House Care Home and Green Lodge. Members were pleased to see improvements being evidenced at these two dementia homes, both of which had been upgraded to ‘good’ from their previous PAMMS rating of ‘requires improvement’. It was also noted that neither setting had experienced embargoes during the COVID-19 pandemic (though a ‘requires improvement’ PAMMS rating would see a period of enhanced monitoring).
Care Quality Commission (CQC) - Update on Regulatory Approach

Representatives from the CQC had been invited to this meeting to address previously-raised Committee concerns around visibility in care homes during the pandemic, the robustness of the infection prevention and control focused inspections, and the future regulatory approach. Led by the Lead Inspectors for Stockton-on-Tees, a presentation was given which detailed the following:

• CQC role and purpose: The independent regulator of health and Adult Social Care in England which makes sure services provide safe, effective, compassionate, high-quality care and encourages improvement.

• COVID-19 journey and what has been learnt: The pandemic forced the CQC to adapt so it could support providers to focus on the emergency. The overarching approach is not changing though - the CQC will continue to monitor services and carry-out risk-based inspections, and will always consider if action is proportionate to risk and the pressure on a service.

COVID-19 had reinforced the importance of capturing the voice of service-users and their loved ones, as well as listening to providers to better understand the challenges they were facing. Robust information-sharing remains critical and strong working relationship with the Council helps this. Good integrated health and Social Care endeavours noted (e.g. hospital discharge to designated settings), along with recognition of the incredible efforts of the care sector over the last 18 months.

• New strategy for regulation: COVID-19 affected the CQCs ability to inspect all services and provide the necessary assurance to the public of their safety. As such, whilst the core purpose / role is not changing, the CQC will work differently - regulation will be more relevant to how care is delivered and more flexible to manage risk and uncertainty, enabling quicker and more proportionate responses as the health and care environment continues to evolve.

Full realisation of the strategy will take time and will be based on four key themes to strengthen health and care systems, and reduce inequalities: people and communities (regulation driven by people’s needs / experiences and what is important to them), smarter regulation (providing timely and high-quality information and more proportionate responses), safety through learning (creating stronger safety cultures and valuing everyone’s perspectives), and accelerating improvement (enabling access to support to help improve quality of care where it is needed most).

• Communication with care homes around changes to practice: Press releases / guidance issued via website and regional engagement teams, Inspectors at regional level attending any provider or Local Authority forums they were invited to, and regular information-sharing meetings with Councils at which any regulatory changes could be discussed and then passed onto care homes. At national level, regular meetings with representative bodies (e.g. Care Provider Alliance and ADASS) to help disseminate messaging.

• Focused inspections - how the inspection and reporting format was agreed: Always been available as a tool to focus on specific areas of risk, but use became more relevant during the pandemic where the CQC had to balance managing risk with time onsite. Report format constantly reviewed and evolving - previous public and sector feedback resulted in reports becoming more streamlined and easily accessible.

• Developing the approach to monitoring 2021-2022 (smarter monitoring): Real progress made in using data and insight to monitor services since March 2020. From June 2021, further progress around three key areas: being more targeted in regulatory activity (ability to better monitor risk), bringing information together in one place (to make better decisions about risk and the appropriate response), and developing elements of how to work in the future (including the provision of more up-to-date views on risk).

The ‘Smarter Monitoring’ approach will involve monthly reviews of all data / information the CQC holds about services to help prioritise activity. If no evidence for a reassessment of rating / quality, a short public statement will be published on a service’s webpage. If evidence is found of the need for reassessment, further monitoring will be conducted including a call with the provider (note: a monitoring review will not directly change ratings) - an inspection may also be carried-out which will lead to a re-rating of the service. This process will be continuously reviewed.

• Communication with services and the public statement: Examples included of the CQCs public statement template and the communication (email) sent to the service provider. Reminder that information on sharing experiences and concerns with the CQC is on the top of every services’ page.

If, once any monitoring activity is completed, the CQC are assured of the quality of care, then the service may be eligible to have a public statement published in the next monthly information review. If monitoring leads to an inspection, no statement will appear on the website, but an inspection report will be published.

• Vaccination as a condition of deployment: From the 11th November 2021, all care home workers and other visiting professionals will need to be fully vaccinated against COVID-19 (unless they have an exemption or there is an emergency), and registered persons will need to ensure they do not allow anyone entry into a care home unless they have been vaccinated or have an exemption. These requirements form part of the fundamental standards and will be monitored from November 2021 and enforced in appropriate cases (possibly via fixed penalty notices or a breach in regulations requiring action). Registered persons will not be required to show a record of the evidence itself to inspectors, but will need to provide evidence that systems and processes are in place to ensure individuals who enter the premises are fully vaccinated.

• Sharing insight - reports from CQC: Monthly ‘insight’ reports produced to highlight pandemic-related pressures on sectors the CQC regulates - latest edition includes information on COVID-19 death notifications in individual care homes.

The Committee thanked the CQC representatives for a very informative presentation which demonstrated the challenging times experienced and reflected on lessons learned and opportunities for better and more efficient oversight. Whilst there remained a lot of anguished people out there, Members were reassured by the CQCs emphasis on seeking-out the voice of those using services and their families / carers, and also noted their own personal experience of good communications with the CQC.

Responding to a query on whether the organisation had caught-up with its inspection programme, the Committee heard that it was not possible to compare the current situation with pre-COVID times as the CQC had adapted the way it was now working. However, contact had been maintained with those providers demonstrating the greatest levels of risk, and those with less risk were still being monitored.

With regards the focused inspections on infection prevention and control (IPC), Members raised concerns over the unacceptable inaccuracies of reports in the early stages of the pandemic when apparent ‘cutting and pasting’ of content from one to the next led to different care home names being left in another providers’ report. It was acknowledged that the CQC had started to use standard phrases in reports, but that they remained specific to a setting and were now in a format that provided greater clarity around statements and key information. It was also noted that readers had historically tended to refer to the ‘summary’ section of a report, hence the move to streamline content.

The use of the IPC focused inspections was further explained, with the Committee informed that these were undertaken when providers had experienced a COVID-19 outbreak. Time onsite was kept to a minimum to limit the risk to all (including to Inspectors), with inspections taking a matter of hours rather than days. Members felt this was not long enough, and also commented that the reports published following such inspections gave the reader very limited detail on how the CQC was ‘assured’ that appropriate measures were in place. It was re-iterated that a decision was made to produce succinct reports, but assurance was given that evidence to back-up CQCs view existed behind the overarching grading and further details were included when the CQC was not confident about a particular IPC aspect.

With regards the new ‘Smarter Monitoring’ approach, the Committee queried if there would be a default timeframe for a mandatory inspection as there seemed to be the potential for some providers to go a very long time without one (assuming no concerns were flagged). Members were informed that, whilst in theory this could occur, all providers would have to be re-assessed at an appropriate time. This new approach would be refined along the way, and dip samples on those homes that only require public statements (i.e. no evidence of the need for re-assessment) will occur to ensure the CQC are getting things right.

A number of queries were raised in relation to the impending requirements around vaccinations. The definition of ‘fully vaccinated’ was probed, something which the CQC would continue to be guided-on by the Government, but that currently meant being double-jabbed. In response to concerns around those staff who refuse to get vaccinated and the potential for workforce shortages, it was noted that providers cannot force their workers to get a jab, but that this would obviously have consequences as a result of the Government’s (not CQCs) stance. Staff had until Thursday (16th September 2021) to receive their first dose (in order to receive their second dose in time), and providers had long been aware of this - the Council and its partners continue to try to educate and dispel myths around the vaccine via Provider Forums. Reference was also made to the anticipated booster vaccinations - Members expressed the hope that these were distributed equally to all residents within a setting (not prioritising those who were registered to their own GP as opposed to the designated care home GP).

In light of the change in regulatory approach, the Committee asked how providers and service-users had influenced this thinking. The CQC had worked hard to reach-out to services throughout the pandemic, and on a local level, have very good relationships with care home managers. Obtaining the voice of residents, their relatives and staff is a key part of the inspection process (direct quotes are included in reports), and experiences can be shared via a form on the CQC website (with negative submissions followed-up on).
Further to the verbal statement provided at the last Committee meeting, the SBC Director of Adults and Health, supported by the Cabinet Member for Adult Social Care, presented an update report to the Committee following the recently-published CQC inspection of Rosedale which resulted in its overall rating being reduced from ‘good’ to ‘requires improvement’. Key developments were highlighted as follows:

• A Task and Finish Group was established to respond to the recommendations made by the CQC, and an Action Plan was created covering a number of key domains including resource and support, care planning, medication, infection control, and staff / staff views / culture. The Group meets fortnightly to review progress against the Action Plan.

• The Council referred Rosedale into the Responding to and Addressing Serious Concerns (RASC) protocol (as it would do for other providers). Subsequently recommended that Rosedale be closed to admissions to allow time for the CQC requirements to be met.

• Two Assistant Manager posts are currently being recruited to; one post will focus on service and staff governance, and the other will focus on resident experience and care planning. Due to the volume of activity seen within Rosedale, additional senior support is required. Additional night staff are also being recruited (though this was not raised by the CQC as an issue).

• Rosedale will be refurbished in February 2022 - this was due to occur in 2020 but was delayed due to the pandemic.

The operational challenges faced by Rosedale were detailed along with difficulties in recruiting and retaining a Registered Manager. The acuity of residents within Rosedale was also noted, with an increasing number of those aged 70 or over requiring two-to-one care.

A total of 17 applications had been received for the two Assistant Manager posts - this was a very good response considering the well-publicised national concerns around the recruitment of Social Care staff, and an encouraging indicator of a desire to work in the Borough.

Concern was expressed around the impact of the existing embargo in terms of discharge from hospital into the community. Members were assured that additional beds were available across the Borough to mitigate any shortfall from Rosedale, and it was stated that there had been no delayed discharges due to the present restrictions on Rosedale admissions (it was noted that the partnership-working within the Integrated Discharge Team (IDT) and Integrated Single Point of Access (ISPA) between health and Social Care staff had helped in this regard). In addition, an alternative ‘designated setting’ (for COVID- positive patients) was available within the Borough.

The Cabinet Member for Adult Social Care commented that Rosedale staff were devastated by the CQC rating, particularly after the extensive efforts they had made during the pandemic, and would need supporting during this time. Whilst there was much fatigue across the care sector following the challenges posed by COVID-19, the focus was very much on lifting the current embargo, and assurance was given that what was required to achieve this was being put in place. In closing, it was stated that a further update report would be brought back to the Committee at a future meeting.
The Committee was presented with an Action Plan setting out how the agreed recommendations from the Scrutiny Review of Hospital Discharge (Phase 2) will be implemented and target dates for completion.

In respect of the first six recommendations, it was noted that the proposed actions / progress related to North Tees and Hartlepool NHS Foundation Trust (NTHFT) only from a ‘local NHS Trust’ perspective. Delays in the sharing of the Action Plan template meant that South Tees Hospitals NHS Foundation Trust (STHFT) and Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) had yet to provide their responses to these recommendations.

With reference to recommendation 3 (Local NHS Trusts develop relationships with Eastern Ravens in order to strengthen the identification, inclusion and support of young carers in the discharge process), the Committee Chair had since spoken to Eastern Ravens who were happy to carry out a follow-up survey to ascertain the hospital discharge experiences of young people and then compare how these may have changed from the feelings expressed in the survey they undertook as part of the review itself.

Recommendation 7 (A future update on the NTHFT Home But Not Alone pilot (due to re-start in June 2021) and the Five Lamps Home from Hospital initiative be provided to the Committee, including feedback from those individuals the initiative has supported) included details of developments around the re-started Home But Not Alone pilot as well as an updated impact report in relation to the Home from Hospital project. Regarding the latter, the Committee was informed that Five Lamps had been asked to submit a bid to the Better Care Fund with a view to continuing this service.
Further to the background briefing that was provided prior to the consideration of the review’s scope and plan at the last Committee meeting in July 2021, this first evidence-gathering session for the review of Day Opportunities for Adults focused on a submission from the SBC Adults and Health directorate. Presented by the Council’s Transformation Manager (Day Opportunities), and supplemented by a Community Day Options - Community Bases: July 2021 paper circulated prior to the meeting, information included:

• Accessing day opportunities: Services run by, or commissioned by, the Council can be accessed following an assessment and referral by a Social Worker. Alternatively, individuals with an assessed need will be offered the opportunity to access their personal budget as a direct payment - this allows people to use their budget to directly purchase opportunities from independent providers.

A referral to the Community Transport team for support with accessing services can be made if a person is assessed as needing help with travel. Day services commissioned by the Council have access to vehicles to facilitate attendance, and people using a direct payment can use their budget to independently purchase transport.

• Information and promotion: Social Workers support people with an assessed need to consider what they want to gain by using day opportunities and review available options. The Stockton Information Directory provides information on all local Council-run, Council- commissioned and independently provided services (where links to websites / social media accounts of the latter can also be found), and the SBC website provides further details of Council-run opportunities.

• User involvement and consultation: Various approaches are used by individual providers to collect feedback on services, including annual questionnaires, feedback boxes, and discussions as part of an individual’s annual review. A September to November 2020 SBC consultation found that, among individuals who use day opportunities, half of the respondents expressed a preference for doing more things in their communities.

SBC are currently working on a strategy to ensure that individuals who use Adult Social Care can be actively involved in the design, development and review of its work - this includes an ambition to establish co-production groups that can support the future development of day opportunities.

• Impact of COVID-19: The first national lockdown reduced access to day opportunities - as a result, the Council worked with individuals to determine their needs and arrange alternative support where this was required, and places within day services continued to be provided to individuals who would be at risk if the provision was withdrawn. Throughout the pandemic, services run by, or commissioned by, the Council remained in contact with people who would, under other circumstances, be accessing their venues - new approaches were developed to remotely support the wellbeing of individuals, including the offer of online groups, wellbeing calls and, in some instances, face-to-face contact in the community.

People using a direct payment to purchase day opportunities were contacted by the Council during the pandemic to determine their needs - where their usual day services were closed, some people chose to use their budget to engage in activities with friends, family or other providers.

• Alternative approaches to delivering day opportunities: Whilst day centres had traditionally been central to the delivery of day opportunities, a growing body of national guidance has emphasised the limitations of such an offer (e.g. restricting social inclusion and the development of relationships within the community, reliance on a ‘menu’ of activities that are not personalised, and a requirement for transport to access settings), as well as the benefits of alternative approaches.

Adopting a community-based model has long been promoted, an approach that can enable individuals to access activities that are meaningful to them, support them to be active and valued members of the community, develop confidence, skills and relationships, and empowering them to be equal partners in the design and delivery of local opportunities. This model can also open-up a wider range of choice (both within and outside the usual working week), create connections with others and enhance sources of natural support, and prioritises the Council’s role as a facilitator to unlock assets across communities and build barrier-free access. Examples of community-based day opportunities, both within and beyond the Borough, were highlighted, including support provided by the Council’s STEPs team (based in the Stockton Business Centre).

Attention was drawn to the often-interchangeable use of the terms ‘day opportunities’ and ‘day centres’ when they are actually very different (the latter being a part of the former), as well as the Council’s progress around this scrutiny topic over the years. Nevertheless, and certainly in light of events around COVID-19, this review offered a good opportunity to further develop the existing offer and bring new ideas to the table. The Committee welcomed the chance to scrutinise this area of Council activity which it acknowledged was a significant budget pressure that needed to be fully understood - it also chimed with the notion of ‘building back better’ pandemic sentiment.

Reflecting on the providers listed at this and the last Committee meeting, Members highlighted that the buildings which day opportunities are provided from appeared to be concentrated within particular areas of the Borough - ensuring a quality offer across all of Stockton-on-Tees should be a future priority.

Referencing the section (2.4) within the background briefing from July 2021 (included with these meeting papers) regarding services purchased through a direct payment, Members asked if it would be possible to obtain a list of all 20 providers (not just those used by than five adults) to better understand where money was being spent - Officers confirmed that this would be made available.
Consideration was given to the Committee’s current Work Programme. The next meeting was scheduled for the 12th October 2021 and would include consideration of the draft final report for the Multi-Agency Support to Care Homes during the COVID-19 Pandemic (Task & Finish) review, the latest progress update regarding the previously-completed Temporary Accommodation for Homeless Households review, and the next evidence-gathering for the Day Opportunities for Adults review.
The Chair had no further updates.

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