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Healthcare Inspectorate Wales’ response to the COVID–19 outbreak – August 2020

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Healthcare Inspectorate Wales (HIW) welcomes the opportunity to contribute a briefing paper to the Health, Social Care and Sport Committee as evidence to the Inquiry into the impact of the Covid-19 outbreak, and its management, on health and social care in Wales.

Background

During the COVID-19 pandemic our continued commitment and goal has been to check that people in Wales are receiving good quality care, which is provided safely and effectively, in line with recognised standards.

This document sets out the principles that underpin our approach during this period and the actions Healthcare Inspectorate Wales (HIW) has taken in response to the outbreak. It also sets out how we are adapting our approach to delivering our functions as the pandemic develops, and as restrictions are eased, to ensure it is both proportionate and appropriate.

In summary, our approach has been underpinned by four principles:

1. Reduce the burden and regulatory pressure of our work on healthcare settings at such a pressured time, whilst still delivering our statutory functions.

2. Maintaining an oversight of healthcare services and providing assurance to the public and Minister through a focus on intelligence and working closely with partner organisations.

3. Supporting the NHS, Welsh Government and other organisations directly in responding to the pandemic.

4. Preparing HIW to enable it to continue to deliver its purpose in the face of the current and ongoing challenges, whilst meeting our duty of care to HIW colleagues.

We have recently published a position statement which sets out how these principles underpin our approach during this period and the actions we have taken in response to the outbreak. The position statement provides further detail on our approach and can be found at Annex 1.

Moving from response to recovery

Prior to the easing of restrictions across Wales we were considering new ways of working which would give us flexibility and agility in delivering our role over the coming year.

We have designed a new approach that uses a three-tiered model of assurance and inspection which reduces our reliance upon onsite inspection activity as our primary method of gaining assurance. The new approach is in line with Welsh Government and Public Health Wales guidance to help limit the spread of COVID-19.

In summary, Tier 1 activity will be a “quality check” conducted remotely and will be used for a number of purposes but, at this stage, primarily where issues cannot be resolved via our standard concerns process and where the risk of conducting a routine onsite inspection remains high. Our standard concerns process can be found at Annex 2.

Tier 2 will introduce a combination of remote and limited onsite activity whilst Tier 3 will represent a more traditional, and full, onsite inspection.

We always reserve the right to conduct a full inspection at any time, but we expect the majority of our work to be Tier 1 quality checks in the coming months. It is difficult to be exact about how long this phase will last and we will keep it under weekly review and adapt as necessary.

We have had to move quickly to adapt as an organisation and this has not allowed us to engage externally on the new approach in the normal way. We have, however, made NHS Chief Executives, Welsh Government officials, independent healthcare organisations, professional and partner organisations aware of these changes in good time, giving them an opportunity to raise any issues ahead of starting the new programme of work.

Our new programme of work using our adapted approach commenced in early August the new approach to assurance and inspection is at Annex 3.

Focus of our work

The focus of our Quality Checks is on three areas: infection prevention and control; governance (specifically around staffing); and the environment of care. This aligns to the key areas set out in the NHS Wales COVID-19 planning framework and represents the areas we already know, through our work and through advice received from our Clinical Advisors, are crucial to safe, effective patient care. Each sector specific methodology will consider these three areas, plus other pertinent areas. So in GP services for example, we will also explore the interfaces between GPs and other parts of the healthcare service. Each methodology also includes specific COVID-19 considerations which will enable us to gain a picture of key issues pertinent to the safe operation of services during this pandemic. Our findings will be reported in the normal way but we also intend to highlight any additional themes that emerge across all of our work by the end of the calendar year.

I would be happy to provide further detail on anything contained within this briefing if required.

Alun Jones, Interim Chief Executive Officer

Healthcare Inspectorate Wales

August 2020

Annex 1

Checking people in Wales are receiving good care during the COVID-19 pandemic

Position statement - Published 19 Jun 2020

During the COVID-19 pandemic it is our continued commitment and goal to check that people in Wales are receiving good quality care, which is provided safely and effectively, in line with recognised standards.

This statement sets out the principles that underpin our approach during this period and the actions Healthcare Inspectorate Wales (HIW) has taken in response to the outbreak. It also sets out how we are adapting our approach to delivering our functions as we move through the pandemic, and as restrictions are eased, to ensure it is both proportionate and appropriate.

Our approach is underpinned by four principles:

1. Reduce the burden and regulatory pressure of our work on healthcare settings at such a pressured time, whilst still delivering our statutory functions.

2. Maintaining an oversight of healthcare services and providing assurance to the public and Minister through a focus on intelligence and working closely with partner organisations.

3. Supporting the NHS, Welsh Government and other organisations directly in responding to the pandemic.

4. Preparing HIW to enable it to continue to deliver its purpose in the face of the current and ongoing challenges, whilst meeting our duty of care to HIW colleagues.

How we are delivering these principles during the pandemic:

1. Reduce the burden of our work on healthcare settings at such a pressured time, whilst still delivering our statutory functions

a) Inspection and review programme

· A decision was taken to stop our routine inspection and review programme, and communicated on our website on 17 March 2020. This was consistent with a decision taken by statutory regulators across the UK, and arrangements were put in place to ensure the continued delivery of critical business functions. HIW stated at this time that it may still be necessary to use our inspection powers in a very small number of cases where there is clear evidence to do so.

· In the absence of site visits and face-to-face interviews, work on our reviews programme is continuing where possible.

· A report on the work undertaken so far on our National Review of Maternity Services will be produced, which draws on public and staff surveys.

· HIW is also continuing work with Audit Wales on its data review of Unscheduled Care, and will also be contributing to Audit Wales’ work looking at Quality Governance across health boards and trusts. Both of these work areas are in early stages and we will provide further updates in subsequent briefings.

· As we moved out of the initial phase of the pandemic, HIW initiated engagement calls with all Chief Executives of Health boards and Trusts across Wales. These conversations explored how HIW could continue to gain assurance while supporting the services most affected by the pandemic.

· HIW is in the process of planning a new work programme to commence during the summer, concentrating on those areas where we consider there to be the highest risk of quality standards not being met and where we can make the biggest difference. The new plan will also align with the early focus of the NHS Wales COVID-19 Operating Framework on key areas of harm and essential services.

b) Responding to concerns

· If our intelligence monitoring activity identifies serious concerns and indicates that there may be an imminent risk to the safety of people using healthcare services, we will continue to undertake inspection visits

· However, inspection visits will only be undertaken when other means of gaining assurance and evidence have been exhausted

· We are changing the way we work to deliver a robust assurance framework to proactively gain assurance on the quality and safety of healthcare services in a remote way. We will do this by making effective use of technology available to us and providers. We will also be continuing our ongoing and close engagement with providers, Welsh Government and stakeholders

· Where inspection visits are required, we will ensure that our staff are protected and do not pose a risk of infection transmission. This will be achieved in the following way:

1. Providing training to all inspection staff on key areas relating to the pandemic including infection control and prevention

2. Using our ‘inspection ready’ team to undertake any inspection visits

3. On the date of inspection, all staff attending will undertake a questionnaire and declaration, relating to their health and isolation status. This is to ensure staff who are self-isolating or displaying symptoms do not enter healthcare environments

4. PPE to the standards set out by Public Health Wales, will be supplied to our inspection team undertaking the visit. They will also have received training in how to don and doff this equipment.

c) Publication of inspection reports

· On 14th April, we announced a pause on publication of reports from inspections at NHS healthcare settings that took place prior to our decision to pause new routine inspections on 17 March. This was to further reduce the immediate burden of the publication process.

· Following dialogue with health board and trust Chief Executives about the reintroduction of the report publication, the process was restarted on 28th May. In the case of reports for primary care settings, we will contact them directly to discuss the most appropriate arrangements

· For independent healthcare settings, including dental practices that are registered to provide private dental services, each inspection report will be considered on a case-by-case basis in consultation with the setting.

d) Field Hospitals

· We are working with Welsh Government colleagues in a supportive function regarding temporary and field hospitals

· We will be supporting them in relation to health and care standards in these facilities, acting as an independent voice to support standards of quality and safety

e) Independent Healthcare

· HIW is committed to supporting the independent sector to continue providing safe and effective care during this pandemic, and enabling independent providers to play their part in maximising the capacity available within their hospitals to support the NHS

· We have been working with NHS partners such as Welsh Government officials to ensure this commitment is realised

· As part of the pandemic response the NHS has been utilising independent acute hospital capacity to support the NHS. HIW has focussed on the practical implications of implementing this arrangement, and the need for guidance for providers on how to maintain regulatory compliance. We have issued guidance on when and how HIW should be notified of planned alterations to service provision so that registration changes can be made

· We have also given a commitment that registration activity related to COVID-19 will be prioritised over other registration activity

· HIW will continue to work with the National Collaborative Commissioning Unit (NCCU) ensuring that enhanced arrangements are in place to monitor patient and staff safety in independent mental health hospitals at this challenging time. This includes assurance on business continuity arrangements and regular updates on staffing levels at all hospitals

· NCCU have established a command centre approach so that hospitals have direct access to support and advice. Any issues arising are shared with HIW

· Private Dentistry is another area where HIW has been playing a key role in ensuring dental practices that offer private only dental treatment are aware of the public health advice available to them. We have provided these dental practices with guidance from the Chief Dental Officer on the operation of urgent access centres so that they have the information they need to refer patients should they need to.

· We have also ensured that the concerns of private dentists are represented in our discussions with the CDO on easing the restrictions on dental practices.

f) Review Service for Mental Health

· We have amended the procedures for Mental Health Act Second Opinion Appointed Doctors (SOADs) during the COVID outbreak, including the suspension of physical visits by SOADs. The updated guidance and amended methodology for the service are available here.

g) Ionising Radiation (Medical Exposure) Regulations (IR(ME)R)

· We have issued guidance jointly with our counterpart regulators in England, Northern Ireland and Scotland. The guidance covered training, equipment testing, the position of temporary or former registrants as duty holders under IR(ME)R, medical physics, notification of significant accidental or unintended exposures and where to go for further information

· This notice is available here.

2. Maintaining an oversight of healthcare services and providing assurance to the public and Minister through a focus on sources of intelligence and working closely with partner organisations.

a) Information and Intelligence

· In the absence of routine inspection and review work, HIW is continuing to monitor and risk assess settings and services though established intelligence feeds. This includes monitoring of performance measures, analysis of serious incidences and public concerns.

· Our first point of contact and concerns functions remain fully operational

· HIW is also working with partners to monitor services in regards to COVID-19, including regular intelligence sources and data analysis

· Welsh Government information and reports are being reviewed alongside data dashboards and modelling to determine the issues and risks being faced by settings and services

· As part of this work we have escalated concerns around provision of Personal Protective Equipment (PPE) for independent healthcare providers and issued a joint statement with CIW on advance care planning and DNACPR use. The statement can be found on our website.

· Following the submission of local operational plans under the NHS Wales COVID-19 Operating Framework, we have written to all health boards asking them to provide us with details of how they intend to assure themselves that harm in all four areas set out in the framework is being minimised, particularly in relation to essential services.

b) Communications

· HIW has been liaising with Welsh Government and other partners over our communications response to COVID-19. A Communication Strategy has been implemented to support regular communication with key stakeholders and staff, including providers of independent healthcare and private dentists. We have created a special COVID-19 section on our website.

· Letters have been issued to update NHS Chief Executives on HIW’s approach during the pandemic, including the actions taken to minimise our impact on frontline services

· As well as communicating information about our own decisions and activities as outlined above, we’ve also cascaded information and guidance from the Chief Medical, Chief Nursing and Chief Dental Officers to registered settings

· We will continue to use our Twitter and Facebook channels to share and help amplify public health information from Public Health Wales and the Welsh Government

· HIW has also worked with the NCCU to write and disseminate a letter to independent healthcare providers. This letter included how HIW’s work was changing in light of COVID-19 and gave answers to common questions around COVID-19. This letter included links and guidance on topics such as PPE and financial support for businesses.

3. Supporting the NHS, Welsh Government and other organisations directly in responding to the pandemic

· We identified staff from across the organisation who could be released to work for the NHS, to fulfil roles with the pandemic response team for Welsh Government, or released to the Army Reserves

· Our Clinical Director, on secondment from a Welsh NHS Trust, returned to the Trust for a period of three months to provide support.

4. Preparing HIW to enable it to continue to deliver its purpose in the face of the current and ongoing challenges whilst meeting our duty of care to HIW colleagues

· We are revisiting our broader work programme for the year ahead to ensure it is appropriate and recognises that the healthcare system will be responding to COVID-19 demands for some months to come. We are developing new ways of working that will give us further flexibility and agility in delivering our work over the coming year

· We have developed a draft reset plan which covers the restart of all areas of HIW business post pandemic.

· We are accelerating work on a number of key areas of improvement defined in our operational planning so that we can continue to strengthen the organisation.

· We have designed and implemented tailored training packages for all HIW staff on subjects relevant to their roles. This will ensure our people are supported to do the best job possible as the nature of our work evolves

· We have undertaken a robust risk assessment process to ensure that we meet our duty of care to our staff.

Annex 2