3-07-2025

(10.01 am)

Lady Hallett: Ms Hands.

Ms Hands: Good morning, my Lady.

My Lady, we’ll be starting with Dr Ruth Allen this morning.

Dr Ruth Allen

DR RUTH ALLEN (affirmed).

Questions From Counsel to the Inquiry

Ms Hands: Dr Allen, good morning.

Dr Ruth Allen: Good morning.

Counsel Inquiry: You are here today to give evidence as the chief executive of the British Association of Social Workers, or BASW for short, a role that you have held since 2016; is that right?

Dr Ruth Allen: That’s correct, yes.

Counsel Inquiry: And you have produced a statement for the Inquiry, which for those following is at INQ000572015.

I’d like to start this morning, if I may, with a brief overview of the role that BASW play in the adult social care sector of the UK, and their membership.

Dr Ruth Allen: Yes. So BASW, the British Association of Social Workers, represents social work across the UK. We have a paid membership where we provide support and advice and services too, and we have a wider remit to influence the development of good social work and to also promote social work across all the nations of the UK, and that of course includes adult social care but is not limited to adult social care.

Counsel Inquiry: And is it correct that you have about 22,000 members with approximately 40% working in adult social care and adult mental health services?

Dr Ruth Allen: Yes, that’s approximately correct, yes.

Counsel Inquiry: You’ve told us in your statement that social workers must be qualified and registered to carry out their role and that most social workers are employed by local authorities in England, Wales and Scotland, and health and social care trusts in Northern Ireland.

Dr Ruth Allen: Yes, that’s correct.

Counsel Inquiry: And despite social work being a devolved competence and there being some variations in guidance and policy, is it right that their statutory duties are broadly the same across the UK?

Dr Ruth Allen: Yes, they do vary. Social workers have slightly different functions, for instance in criminal justice and probation in some parts of the UK and not in others, but there are very common themes about – in relation to practice and the nature of policies but increasing divergence because the four nations – in the four nations it’s a devolved matter, predominantly.

Counsel Inquiry: And you have described in your statement how the adult social care sector, particularly in England, was in a markedly weakened state that impaired its ability to respond to the pandemic, and you’ve explained some of the vacancy rates in social work, for example in England it was at 8.3%, in 2019. Can you perhaps explain to us why this context is so important when we’re looking at the impact of the pandemic?

Dr Ruth Allen: Yes. So the adult social care sector generally was in a weakened state, not just social work, at the start of the pandemic. The absence of – the impact of austerity cuts on local authorities and other services where adult social care is delivered, the impact of a lack of the reform in policy that’s needed to put adult social care on a strong footing in England, but indeed similar issues across the UK, meant – and the lack of pandemic preparedness that we’ve also heard about that we found out about, really, when the pandemic came, we realised how unprepared both health and social care was to respond.

So all of those things have been important across adult social care.

For social work itself it’s a regulated profession. It’s a relatively small number in adult social care. In England it’s something like 23,000 adult social care social workers in a workforce of a million. But they – but the social workers hold very particular responsibilities, and accountabilities as well as skills, expertise and practices that are an absolutely essential part of the system which I’m sure we’ll come on to as well.

Counsel Inquiry: Yes, we will. Thank you.

You’ve referred there to it being a small workforce and you’ve described in your statement that that small workforce is predominantly made up of female older and more ethnic minorities, so how did that impact on staffing availability during the pandemic?

Dr Ruth Allen: Yes, so social work across the UK, in fact internationally, is very largely female. It’s currently about 87% women in social work in the UK, and there is a preponderance for an older workforce and a more ethnically diverse workforce. How did that impact? So certainly we know that women are – particularly perhaps women at different stages of life have different caring responsibilities to men – there’s certainly evidence around that – so may have also been particularly affected by the caring for people in their families and so forth that were also affected by the pandemic; obviously looking after children, home schooling, a joint responsibility, but some of that will often fall on women in the family.

So those were kind of some of the key issues. There are – it’s a very ethnically diverse profession. There’s a higher proportion of black and minority ethnic social workers compared to the general population, in the profession. And we know that there’s a lot of evidence that black and minority ethnic people were differently affected by Covid in a variety of ways, which I won’t go into but there was a lot of evidence in relation to the physical impact of Covid on people from different ethnic communities; also people in – where there was – people in ethnic communities who were also perhaps within their family working in particular occupations that may have left them more exposed to the virus.

So there were a whole number of interdependent issues which perhaps had an effect on the workforce.

Lady Hallett: Can I ask you to slow down, if you could. I’m a fine one to talk, but if you could slow down, it would be – (overspeaking) –

Dr Ruth Allen: I will. I have been told. Thank you.

Ms Hands: Thank you.

And we’ll descend into some of the detail but in terms of the workforce overall, what do you identify needs to happen to ensure that we don’t enter a future pandemic with the social care workforce in the same or perhaps even a worse state?

Dr Ruth Allen: So we need to learn the lessons from the pandemic for this profession and, of course, for all professions. So we really need to understand how the fact that we did have high vacancy rates, we had more turnover in the workforce actually since the pandemic, and there was that impact of going through the pandemic that affected other professions, as well, where we’ve seen particularly more experienced people leaving the profession.

So the importance of workforce strategies at national level to train social workers for adult and children’s work, and for other areas, to ensure that that pathway is well supported, that it is made possible for people to come into the profession. It’s very expensive for many people at the moment. And so we’ve got that pathway in for new people, that we’re supporting them properly and helping them to develop in early careers so they will stay, because we are concerned about losing experienced staff from the workforce.

So a resilient workforce will have all of those stages of the workforce well supported, represented, there’s decent policy that’s enabling keeping people in the profession as well as training them.

All of those things are not very secure in any part of the UK for social work, as for other – some of the other public professions.

Counsel Inquiry: Perhaps now bringing it back to social work more broadly, for those listening today who may not necessarily know what role a social worker plays in adult social care, can you briefly describe some of their key responsibilities for us?

Dr Ruth Allen: Yes. So over decades, social workers have accrued a whole range of statutory responsibilities, particularly where they’re employed by or working for a statutory organisation. This includes their roles in relation to safeguarding, or adult protections they refer to it in Scotland; in relation to mental capacity assessments and best interests, Mental Health Act, mental health assessments, in relation to – and then in relation to the adult social care legislation powers that exist in each of the nations, so in England that’s the Care Act. And they have specific responsibilities in practice and also in statutory guidance, in England particularly, in the leadership of social care, through principal social worker roles.

So they are there – much of what social work is about in statutory settings, in addition to building relationships, being able to do general assessments and support both individuals, families, carers, is to make sure that the rights of people are upheld in law, according to those duties that are placed upon them, and they work in a regulated profession. So they are working to regulatory standards they also have to uphold.

Counsel Inquiry: If we focus on the social care assessment, typically what will that involve and what might its purpose be?

Dr Ruth Allen: So the social care assessments, under all the legislation across the UK, is quite holistic. It will take account of the health needs, the disability needs, the wishes of the person. It’s very much focused on enabling people to find their own solutions and to identify what resources will help them and their families stay safe, get better, overcome their disability, whatever the issue is.

So it’s – the role of the social worker there is to advocate for people to live the best life they can. Often they will either be the gatekeeper of resources or the advocate for gaining resources that people may be entitled to. And there’s a very strong – I think in relation to this Inquiry, the protective role, the protection responsibilities of social workers need to be kept to the fore. So ensuring that people are safe and are able to keep themselves safe, wherever possible, and can be assisted in staying safe where necessary.

So there’s a diversity of responsibilities. There are others, but those are some of the key ones.

Counsel Inquiry: Thank you. And where will those assessments usually take place?

Dr Ruth Allen: Well, where social work happens is a very important point for us in relation to the Inquiry into Covid, because social workers are much more peripatetic than many health workers might be. There are other health workers who are peripatetic but …

They will often be working, obviously, in people’s homes, they will be going into people’s homes. They will be going into hospitals but – in some cases working in hospitals, but not – but often they will be going into hospitals. They may be going into prisons. They may be going into, obviously, care homes and working with people who are in placements of various kinds.

So social workers work in very much a kind of community settings, and even where they might be working more institutional settings, a lot of their function is to be that link to community, to ordinary life, to family, and so forth.

So, yes, so the assessments can be happening really in any of those contexts.

Counsel Inquiry: It may perhaps seem a question with an obvious answer but can they be taken remotely and are there any risks of them being taken in that way?

Dr Ruth Allen: If the assessments –

Counsel Inquiry: The assessments, yes.

Dr Ruth Allen: – the assessments are undertaken remotely?

So obviously social workers, like all professions, are becoming much more skilled and – in using technologies, and had to accelerate that during Covid.

The importance of being able to be in the room or to be in someone’s house, to be able to assess a living circumstance, to be able to be present with family to see – to understand the family dynamics, for instance, those things can only be partially replicated through remote – remote communications and through video links and so on.

There was a lot of work done during Covid time to try to extend that possibility, and to make the most of that, but it is essential that social workers have – are properly authorised and have the facility to go and meet people when they need to, and they need to use their judgment about when that’s important.

That includes going into care homes, where, for instance, their protective role is not just about the individuals they’re going to see but it may be about the institution. They are eyes and – very important professional eyes and ears on how an institution is operating.

So those are some of the balances and the – to emphasise the importance of in-person working.

Counsel Inquiry: I’d like to move on now to some of the issues or experiences during the pandemic.

So you have already referred to the fact that you discovered that there was a lack of preparedness, but you also refer in your statement to a lack of understanding of the social worker’s role and contribution that they could make, and that BASW made multiple requests for specific national guidance for social workers that really recognised this.

What guidance were social workers being asked to follow and what were some of the gaps that you were asking to be addressed?

Dr Ruth Allen: Initially I think there was virtually no specific guidance that really mentioned social workers. And what then subsequently happened when we were in communication with leaders in public health and so forth over coming months was that the general guidance for health and social care was the only thing that was available to help social workers, but didn’t really take account of the specificity of what they have to do, so the contexts in which they have to work.

So the – that – one of the other aspects of social work is – by no means in all cases, but you’re often going into a situation where your presence might not be welcomed, actually, or you’re going into a situation where things are very complex, and gaining access to somebody’s house because you’re concerned about the welfare of an adult or a child, for instance, you need specific kinds of guidance and help in relation to that, perhaps differently to – it will overlap with what nurses or paramedics or doctors need. Of course it overlaps. But we were clear that social workers were telling us that the tasks that they had to do, and also the guidance available to them from their employers at the early stage, wasn’t sufficient for them to feel confident that they were undertaking things in the right way. What could they not do because of their duties? How did they judge risk in that situation?

So there was – over the initial months in 2020, more guidance came out for health and social care generally, including for people working in the community, but it didn’t take account – it didn’t answer the questions that social workers needed answered, so we started to fill that space early on in response – using our own understanding of what was needed, really.

So it wasn’t – so we were able to do that, but that isn’t the same as having that statutory guidance to help people feel confident in their practice. That was also needed.

Counsel Inquiry: Yes. And can you provide some examples of the professional practice guidance that BASW produced to answer those questions that social workers were asking?

Dr Ruth Allen: Yes. So we – I’m just going to quickly grab a document, if I can find it. Yes. It’s my summary.

We did a lot of different kinds of guidance. Practice guidance in relation to home visiting, for instance; ethical guidance, because people were struggling with the ethics of what – how do I think through what I do and don’t do? Or the ethics of doing things differently, if I can’t see a child or an adult, how do I raise an issue? How do I understand the extent to which I am or am not fulfilling my duties?

That kind of thing.

We did guidance on working with digital tools, and we did guidance in relation to the role of Approved Mental Health Professionals and Mental Health Officers, capacity assessments. We provided a range of things.

Counsel Inquiry: And given the expertise that BASW was able to bring to that guidance, in your view, was it in the best position to be able to produce that guidance, and would you do so in future, or is your view that that should be national guidance in future?

Dr Ruth Allen: So I think, having reviewed a lot of this for this hearing, I think, you know, we produced some really useful guidance that was well received, that aligned with what the government was saying, it wasn’t contradictory, but it really augmented and where necessary, went in slightly different directions that weren’t being covered. So I think we were well placed to do that and we had a lot of feed-in because we had a running, open communication which ended up with about 2,000 submissions from social workers. So we were able to draw on that and use our own knowledge.

I think for the future, for pandemic preparedness, we would expect to see social work on the same footing as any other profession, being recognised for its role in emergencies and disasters, for which there’s quite an extensive and growing body of work, contemporary work around that. And then the – to, for instance, use some of our guidance and to work together with government and others to have things in place – the type of pandemic or emergency, each would be different, so it wouldn’t be exactly the same, but there are some principles I think we could draw on about what social workers need to know to discharge their duties that overlap but are different to some of the other duties of other public professionals.

Lady Hallett: Sorry to interrupt. I’m not quite following. How are you saying we should prepare for it differently? In other words, it sounds to me as if you were very much the experts in the field and therefore your guidance was particularly helpful to social workers, but what are you suggesting should happen in the future? Are you suggesting there should be more government involvement or government principles? I’m just not quite following what specifically you’re suggesting.

Dr Ruth Allen: Sure. So social work is represented within the governments. There are social work leaders in governments, chief social work officers with slightly different titles. So there is a context in which social work can be represented in, for instance, highest-level pandemic planning, highest-level disaster or emergency planning, what’s the role of the social worker? So I’m saying that that – I don’t – that wasn’t there. I don’t think that had been thought about previously in pandemic planning, and that could now be considered.

And an organisation like BASW, just like the BMA or the RCN or the colleges, the royal colleges, we’ve got lots of detailed knowledge and experience and expertise to share, and could inform that. So there should be a partnership, really, between government recognising the role of social workers and the experts who are in different organisations, can add to that.

Lady Hallett: That I follow, but Ms Hands was asking you about guidance. So you’ve moved on to the broader topic, which I totally and utterly follow, but I hope – it started off with questions about the guidance and whether there should be a different system.

Dr Ruth Allen: Ah, okay. Well, I think it’s a bit difficult to answer that because we were responding to the guidance that was needed in this pandemic at that point in time, and it would be different in the future. I think that in such a situation, we were well placed to provide guidance. It would have been better if we’d been able to do that in realtime, in more cooperation with leading officials, as well, so that we could further promote the guidance that we were putting out. Does that …?

Lady Hallett: I’m still not quite following you specifically. If I were persuaded that it would be right to make a recommendation, I have to be quite specific.

Dr Ruth Allen: Oh, okay.

Lady Hallett: Because otherwise it can’t be implemented.

Dr Ruth Allen: No, so I think – the profession – BASW as a professional body should be called upon to provide guidance in a situation like this, and to do that in conjunction with social work leaders within government and in other related parts of government in a situation of emergency or disaster.

In other circumstances, as well, but that’s the sort of circumstance. Does that …?

Lady Hallett: It’s basically – it’s greater collaboration between those who have the expertise like your organisation?

Dr Ruth Allen: Yes, yes.

Ms Hands: Thank you, my Lady.

You have provided in your statement quite a few examples of the changes to social work that were seen during the pandemic. I’d like to ask you about just couple of them. One of those is around the exceptional powers and arrangements in relation to some social work which were brought in with the Coronavirus Act, it gave local authorities discretion to disapply parts of the Care Act, and the equivalent in Wales, in relation to assessment and care planning in defined circumstances, and you’ve said that if there had been better preparation then it would have helped the implementation process, but you’ve also said that parts of that framework were unclear.

Can I ask what parts specifically your members found were unclear?

Dr Ruth Allen: Yes, I think one of the key areas which came with the, for instance, the easements legislation that was brought in in England, and I just want to make a slight correction on paragraph 38, where, just in relation to that, where it says, “In the end, formal easements were not introduced”.

That’s misstated there because we’re aware that they were enacted but they were hardly used. And I think the fact they were hardly used in a way is testimony to the fact that it was unclear how to use them, actually, in practice for local authorities.

Sorry, your question was about in what ways were these – the Coronavirus Act and the easements unclear?

Counsel Inquiry: Yes, I think you’ve said parts of the framework were unclear, and I was just asking you what parts specifically, what – (overspeaking) – you had?

Dr Ruth Allen: Yes, there was one specific area which, in relation to the – in relation to the Coronavirus Act and the easements, actually, which was related to the point at which how an assessment would be made that the provisions under the European Convention on Human Rights or under our Human Rights Act, that human rights were being breached. It was unclear how you would operationalise that assessment because it’s not an assessment that social care workers generally will be making. Local authorities certainly do have to consider whether their work is compliant with the Human Rights Act.

But it wasn’t clear how operationally, in day-to-day practices, people making decisions on the ground in real time would know, would understand how that might be the case. So that was one of the issues.

Counsel Inquiry: And were BASW consulted during the process of drafting of this legislation?

Dr Ruth Allen: Not the Coronavirus Act, but the easements in England. Yes, we were. And there was good collaboration with the interim chief social workers who led on an ethical – an ethical framework related to the easements. So we were – to be fair, we were consulted in relation to the ethical framework that the chief social worker – interim joint chief social workers worked on. So we were very involved in that. So that was where we were able to bring our expertise on ethics, and interpretation of law, and its implications for practice – (overspeaking) –

Counsel Inquiry: And was that – sorry, to speak over you. Was that incorporated into the framework?

Dr Ruth Allen: It was incorporated into the ethics framework, yes. We could see our work incorporated into the ethics framework.

Counsel Inquiry: I’m moving on to the topic of discharging of patients from hospital during the pandemic.

You have said in your statement that the vast majority of discharges will take place without the involvement of a social worker, but there are no national protocols in place for when a social worker might be called in or when additional support might be required at the point of discharge.

Did that lack of a national protocol have any impact on discharge decisions during the pandemic, in your experience?

Dr Ruth Allen: Yes, I think the issues around discharge became obviously quite complicated by the concerns around discharge without testing, and rapidity of discharge, which meant that, perhaps even more than prior, social workers weren’t necessarily involved or brought in to support that discharge. And it’s a really crucial area for – I know that discharge planning is a huge, ongoing issue about ensuring flow through hospitals, and freeing up hospital beds is a massive issue for the NHS and for social care, but ensuring that there is – good practice would say that you would be planning for discharge from the point that somebody arrives in hospital, not just in a coronavirus situation but that would generally happen, and there would be social work resource that would be able to use the powers of the Care Act, or the legislation in Wales, Northern Ireland or Scotland, to ensure that there’s a holistic – a proportionate and holistic consideration of what safe discharge would look like.

So, having clarity about the role of the social workers there would really help protect people’s rights.

Counsel Inquiry: And you have described in your statement how many social work teams were moved out of hospitals. So did that lack of access have any impact of whether a person underwent an assessment prior to discharge and were there any changes in rates of referrals, for example, that you were able to observe?

Dr Ruth Allen: I’m not sure about the rates of referrals, but – I couldn’t answer that specifically, but I think the process of speeding up discharge, which was already something that was being worked on – prior to the pandemic really hitting there was work going on in relation to that – but then implementing discharge to assess and implementing rapid discharge without assessment by a social worker, or perhaps even an overview from a social worker, was problematic. It added to the risks that were subsequently evident from that rapid discharge without testing that flowed through the system and the spread of infections into care homes.

Counsel Inquiry: And were you aware of any safeguards that were in place to ensure patients who were discharged during the pandemic prior to that assessment taking place in that procedure, whether they received a full assessment of their support needs once they’d been discharged?

Dr Ruth Allen: Well, there was – certainly in the earlier stages of the pandemic, there was the problem that social workers could not access care homes. They were not recognised as essential visitors into care homes.

And this is the point I was making about how social work – social workers are often the ones going into institutions. The institutions were locked down. And we ultimately had a fairly successful campaign, Test, Access, Rights, which was to ensure that social workers could be recognised for – in safe – safe visiting into care homes to protect people’s rights, because – to ensure that people’s capacity to consent to that, that placement, had been taken into – or – and best interests considerations, to ensure obviously that people were being protected from a health point of view, and to – also to consider the impact of people not being able to see their families on somebody’s health.

All of those things needed to – and others – needed to be taken into consideration for those people who’d been moved perhaps into a care home for – I mean, some people may have been going back to a care home but maybe into a care home for the first time out of hospital, and possibly rapidly.

So, for us, one of the key issues was whether or not social workers could access people to make those assessments.

Counsel Inquiry: And it’s right that that campaign was launched in November 2020, isn’t it?

Dr Ruth Allen: Yes.

Counsel Inquiry: And how quickly did you start to see the results or an improvement in the situation after that campaign was launched?

Dr Ruth Allen: And of course there were many others who were very concerned about this as well who were also working with other organisations and family members and so forth as well.

We had a quicker response in Wales than we did in England, as I recall. I think Welsh Government acted more receptively, and we worked with the minister there to ensure that this was recognised. It had gone on for a long time by then, and we had raised the issue in a whole number of ways.

And then, eventually, it was opened up in England. And similar processes were happening in the rest of the UK. I can’t recall all the detail, but yes.

So it was very necessary. But it was a long time coming, actually, because social workers were kind of locked out of being able to fulfil that role.

Counsel Inquiry: I think you’ve said in your statement that the access to tests in England certainly remained variable in March 2021. So were there still issues with the implementation at that point?

Dr Ruth Allen: I would have to the double-check on exactly when it came through, but it was – I think there were several months – I think the Welsh Government response was fairly quick after we launched that campaign, and collaborated with others, and it think it was several months later that we – but you’d have to check on the exact time point when it was – it changed in England. I will check that.

Counsel Inquiry: Just finishing the topic of the discharge to assess and hospital discharge. To your knowledge was there any auditing of the discharge to assess cases, either during or after the pandemic, to ensure that those that had been assessed through that – sorry, discharged through that process were then assessed?

Dr Ruth Allen: I’ve not seen any evidence of that being collated. I don’t know if that exists. I’ve not seen any – yes, I’ve not seen any strong data on that.

Counsel Inquiry: Has BASW observed any long-term impact of that?

Dr Ruth Allen: The – I mean, the long-term impact obviously included the fact that many people died in care homes, and – some 46,000, and there is a strong case to be made that that was – obviously there were many reasons for that, but that rapid discharge without testing – and also, especially in the early part, of course, a lack – generally, a lack of access to testing and irregular testing regimes in care homes and amongst case workers, all of those things contributed.

In terms of the – discharge to assess is still a key, kind of, policy area and has been funded, sort of, nationally and locally since the pandemic. So that work on – and there are – there is a case for discharge to assess, as a general model. There is a case for it. The key thing is the point of discharge has to be strongly assessed enough to make sure that initial move is good enough, or is good for that person. And then there needs to be very clear access to a social worker, and others, who can make, you know, the longer-term arrangements within a prompt way.

So it’s – getting the whole pathway right remains an issue, I think.

Counsel Inquiry: A review carried out by the Department of Health and Social Care into the discharge to assess model used during the pandemic recommended that in the future there should be the need for flexibility and local variation in implementation, but also emphasised that need for that holistic evaluation, which you started with at the beginning of your evidence today.

Do you agree with those suggestions for improving the policy in future, and do you think they can still be upheld during a future pandemic?

Dr Ruth Allen: Can you just go back to the first part of your point there, just the first bit of it?

Counsel Inquiry: Yes, it was about the need for flexibility and local variation in implementing policy.

Dr Ruth Allen: In implementing discharge to assess?

Counsel Inquiry: Exactly.

Dr Ruth Allen: Yes, thank you.

Yes, I think social care is very – social care processes obviously are managed through 151 local authorities in England and many local authorities elsewhere. So there’s a lot of – it’s very different from the NHS, as we know, in that regard. It’s very much locally managed and locally accountable.

I think the importance of learning from what works in particular communities – what might work for one community might not work for another community, to some extent – but in terms of other kinds of flexibilities, I think we just need to know what the evidence is for the value of discharge to assess, we need to see solid evidence of that, and then see what flexibilities around that evidence are – work for different communities.

Does that answer your question? I’m not sure if it does.

Counsel Inquiry: I guess the second part of it was around whether you think that those principles can still be in place during a pandemic, so if there’s –

Dr Ruth Allen: Oh, okay.

Counsel Inquiry: – advance planning that involves the discharge to assess model, perhaps some of the research that you’ve just suggested, do you think that those principles can still be upheld during a future pandemic with the preparedness in place?

Dr Ruth Allen: So the reason – I think this – I think this depends on the particular circumstance.

We had – so pandemic planning would need to take account of the sufficiency of beds, because that was one of the key issues we had, was we had far fewer suitable types of bed than many of our – many similar countries, which meant that our bed pressures were particularly high, as well as a very large number of people falling ill.

So, for pandemic preparedness we would need to be, I guess, modelling different flows of people coming through hospitals at different levels of hospital resourcing, and then looking at the extent to which we need the rapid discharge, because what we need – the perception was we needed rapid discharge to bring people through. That would almost certainly be needed again if we had something similar.

So we just really need to have the protocols of safety, the safety protocols around testing for – if it’s a pandemic, whatever the illness is. The protocols around how you assure people’s needs are properly and holistically assessed within a timely way; if it’s not in hospital, it has to be quickly afterwards. And to ensure that the principles that underpin the relevant legislation across the UK of holistic needs-led but also strength-based and people’s wishes being taken into – that can’t be – that can’t be ridden over. It has to be upheld through that process, even if you’re having to move people through the system quicker.

Counsel Inquiry: One of the issues that you have raised in your statement that you heard from your members was around that lack of access, preventing them from being able to build relationships, trust and rapport, with some of the people that they were working with and the impact that might have on the safety of their decisions, and I think BASW produced professional practice guidance on safeguarding for adults –

Dr Ruth Allen: Yes.

Counsel Inquiry: – to try and support its members with those decisions. So what measures were put in place, if any, to mitigate the risks faced by people that were needing care that perhaps couldn’t have that face-to-face assessment?

Dr Ruth Allen: I think – I mean, it was genuinely very difficult and a lot of things just didn’t happen, particularly in the early months, people were – social workers were still out working in communities, gaining – trying to gain access or making home visits, creating their own PPE if they didn’t – if they couldn’t get hold of any. They were visiting people at home, and trying to maintain relationships, sort of doorstep conversations rather than visiting, in people’s homes.

And then we provided some guidance to help people think through all of their options for sustaining relationships. So for instance, we were – one of the things with younger people particularly but others, as well, was that some local authorities were very restrictive on social workers being able to use things like apps to communicate, social media or – but that can actually work – that can work very well, but there were lots of safety concerns. Local authorities weren’t well – as well versed as they are now in technologies. So we were encouraging people to use technologies to work with their managers and so forth to try and do that.

So to use whatever we had, what was available, and think more creatively.

Counsel Inquiry: And did that raise any issues with digital exclusion or issues with communication that people might have had?

Dr Ruth Allen: Oh, I mean, absolutely. The need to move to digital was evident, and we were clear we needed to help social workers do that safely and optimise that wherever they could. So we tried to help with that. But it’s not, just not suitable for some people who were very, perhaps, cognitively impaired, people may find that difficult, people who have never used computers, people who don’t have access to it, they don’t have – they don’t have the devices, they don’t have data, all of the sort of usual digital exclusion issues would arise with that.

And it’s not – it’s not a … it can’t stand in place of human contact in all cases. It just can’t, because you can’t assess properly.

Counsel Inquiry: Yes. Thank you.

If I could perhaps ask you to just keep your answers just –

Dr Ruth Allen: Sure.

Counsel Inquiry: – ever so slightly shorter so that we can make sure we cover all of the key issues you’d like to today.

Dr Ruth Allen: Sure.

Counsel Inquiry: So moving on to another issue, and that’s end-of-life care and DNACPR notices. The Inquiry has heard a lot of evidence on this topic but you’ve explained how BASW produced professional practice guidance on end-of-life care in April 2020 in response to concerns about the reported blanket use of DNACPR notices.

So my question is this: did BASW received any reports of blanket use of DNACPR notices from its members that prompted it to produce that guidance when other guidance was already available?

Dr Ruth Allen: Yes, we did. Kind of personal, mainly sort of personal individuals contacting us to say that they were – they were seeing this, they were experiencing it. But it wasn’t – we didn’t do any studies to identify that systemically, but it was also – it was coming up in feed-in from others, as well. I mean, some doctors were raising issues, other professions were raising concerns about the use of that.

So yes, it came through in a number of different ways.

Counsel Inquiry: And to your knowledge did those concerns continue to arise after the professional guidance that you issued, but also the national statements and guidance that were issued in April 2020?

Dr Ruth Allen: Yeah, I think that was very – I remember that specifically was a very important – a very important statement and I think we were then just keen to make sure that our members knew what they could do to challenge, if they saw that happening, and that we would support them and guide them if they needed to raise the inappropriate use of DNR statements.

Counsel Inquiry: Moving on to a different topic, and this time around PPE and IPC. Another issue which you say was a significant theme in BASW’s activities, particularly at the start of the pandemic which culminated in a letter to the UK Prime Minister from BASW on 1 April 2020.

So starting with access to PPE, how widespread were those concerns amongst the social worker workforce at the start?

Dr Ruth Allen: At the start, it was probably the primary concern. Social workers were still working in the communities, they’d all – they were working from home, not in offices, mostly, but they were then still largely going out and work in communities. They were concerned for their own welfare and they were very much concerned for the welfare of the people they were trying to reach, and they didn’t have access to PPE or they had inconsistent access.

Counsel Inquiry: Would social workers wear or use PPE in non-pandemic times?

Dr Ruth Allen: Only if they were in – probably in quite specialist settings. So if they were working in a hospital and that was needed, and others were using that same sort of equipment, yeah.

Counsel Inquiry: And did access to PPE improve, in your experience?

Dr Ruth Allen: Yes, it did. It improved quicker for social workers who were in hospital contexts than it did in local authorities, and other social care contexts. It was later and more protracted and more unreliable in wider social care contexts. But yes, we, in our survey that we did at the end of 2020, there’s some evidence there that people were reporting that the access to PPE had by then improved. But it was quite a long, it was a long period. It was many, many months of – and it was a primary concern for many, yeah.

Counsel Inquiry: And touching on the topic of guidance in the context of IPC and PPE, it’s right, isn’t it, that BASW produced its own professional practice guidance in April 2020, which linked to different pieces of public health guidance. So you’ve already mentioned the fact that social workers weren’t necessarily recognised and the role that they played in guidance generally. Did this also apply to IPC and PPE?

Dr Ruth Allen: Yes, so we provided guidance on the use of PPE, actually, and how to adapt practice to the use of – if you’re using masks and gloves – it’s very practical – how do you continue to communicate well if you’re using that kind of PPE? So we provided that and other kinds of guidance, yes.

Counsel Inquiry: And did the national guidance take into account the fact that social workers would be moving from setting to setting or house to house, for example?

Dr Ruth Allen: We only had, from the – the governmental advice was blanket advice for if you were – effectively, if you were an institution or a peripatetic health or care worker, you can – these were the ways in which you should use PPE. The difficulty for some – for using PPE for social workers in particular contexts wasn’t particularly explored, so we filled some of that gap.

For instance, people undertaking Mental Health Act assessments, how do you deal with wearing masks when you’re working with somebody who’s very, very distressed? And just – those were – those sorts of things were key issues.

Counsel Inquiry: And were your members able to access alternatives to PPE? So, for example – and the transparent masks or visors? And did they help with those communication difficulties?

Dr Ruth Allen: Yes, I think using – I mean, where they were available. I think everybody knows that it was difficult to get the right kinds of PPE in certain contexts. But yes, I mean they would use what was available.

It was very variable in the first six months about what would be available and when it would be available. The social work sector generally, even in care homes, they – you know, they had very – we were being told about very unreliable supply lines, in the early days, within adult social care.

Counsel Inquiry: Were you aware of your members having experiences where they were unable to carry out a visit or an assessment in person due to a lack of access to suitable PPE?

Dr Ruth Allen: Yes, that is exactly the sort of thing that our members were telling us in the early days, yes.

Counsel Inquiry: You have explained in your statement that social workers in future should receive training on IPC and PPE in advance of any future pandemic. So was there enough training in advance of the coronavirus pandemic for social workers in the use of IPC and PPE to start with?

Dr Ruth Allen: It was completely – there was no training. If you worked in a hospital you would probably have had some training because you may need to use it on occasions, but if you weren’t working in a health or integrated setting like that, it was very alien to people, I would say.

Counsel Inquiry: And what impact did that have on your members?

Dr Ruth Allen: It prevented them from undertaking key tasks that they really wanted to do. They were looking for ways around that, so how could they visit people safely at home et cetera. And I think it undermined their confidence. And it also, I think, particularly left social workers feeling like they were – their professional needs weren’t being acknowledged or recognised or met in the rollout of this key provision.

Counsel Inquiry: And was there appropriate training provided during the pandemic, to your knowledge?

Dr Ruth Allen: So, within employers, I think that training in PPE and other aspects of changed practice started to happen as organisations became more knowledgeable about what to do. So, again in our survey, we found that from the start of the pandemic through to the end of that year there was some acknowledgement that managers and organisations had started to really improve, had improved their support and training for social workers.

Counsel Inquiry: So around the end of 2020 was when we really saw an improvement?

Dr Ruth Allen: Yes, it was still very difficult but things had improved, I think, by then.

Counsel Inquiry: I’d like to take you to some of the results of the BASW survey you’ve been referring to.

So if we can please have on screen INQ000509534_0003. Thank you.

I’d like to just pull out some of the key findings from that survey to ask you about. So the first one is number 9. Thank you.

So 30.7 of respondents felt pressured to work when unwell.

In your experience, what was leading to that level of pressure?

Dr Ruth Allen: I think that the … there was a few things. There were a lot of issues around availability of staff because quite a lot of people were off sick with coronavirus or they were isolating because they were at risk. So there was pressure on remaining staff, I think, to continue going in.

The – there’s a general trend in social work that we find from other surveys around presenteeism and people coming into work even when they’re not quite well. So there’s an underlying overwork ethic, to some degree.

And there was a sense of – such a sense of urgent – I wouldn’t call it panic but there was such a sense of urgent – you know, urgency and general concern, and having to work in different ways and support each other. Peer support was very important. So I think people did feel a strong sense of peer responsibility to their colleagues as well, to make sure they were continuing to work.

So I think there’s some underlying factors there about people feeling very motivated and just keeping on working anyway. There were – yeah, a number of factors.

Counsel Inquiry: And the next finding was at 71.5% agreed or strongly agreed that the coronavirus crisis had adversely impacted workplace morale in their place of employment.

In BASW’s experience, what factor had the biggest impact on morale?

Dr Ruth Allen: This will be somewhat subjective, but based on all of the feedback that you had and the surveys that we did, the – well, in the initial stages there was a lot of confusion about how do we keep doing our work in this context. And of course there was – people were asked to work from home, and so they were isolated from their colleagues. I think that had an impact.

Everybody was affected by the coronavirus like everybody else was, so people were – had family and friends ill or they lost – had lost loved ones.

I think that one of the key issues, though, that came through in a number of ways was that – people not being able to do what they knew was the right thing to do, because they couldn’t always carry out their duties.

Counsel Inquiry: Then finally, at number 12, 58.8% agreed or strongly agreed that their working during the crisis had negatively impacted upon their own mental health.

Now, you’ve told us in your statement that BASW produced a staff risk assessment flowchart to help employers to carry out risk assessments and also to support their employees. So was there adequate mental health support available for the social worker workforce?

Dr Ruth Allen: I think this was one area where employers realised they needed to do more over the time of the pandemic. And some employers certainly started to innovate in this area, to be much more open about the need to understand the mental health needs of their workforce and put in more support.

I don’t – but yes, certainly, similar features to the impact on morale would have played a part in that.

I would just add in for both of those actually, I would want to mention lack of recognition of the work that social workers were doing in comparison to the recognition that some other parts of the health and care sector were getting, but I think that – that lack of – that lack of appreciation of the work that – was also a factor for morale. I don’t know if it was a factor for mental health. But it was extremely – people would just talk about how it was extremely stressful.

Counsel Inquiry: And finally, Dr Allen, you’ve set out a number of recommendations in your statement and we’ve discussed a number of recommendations today. Are there any other recommendations for a future pandemic that you may wish to draw the Chair’s attention to this morning?

Dr Ruth Allen: Yes, the – I think the overarching – an overarching issue is to understand that social workers have key and distinctive statutory responsibilities that are placed on them by governments and by society, and they have therefore – and they also have particularly practices they need to fulfil, and they couldn’t fulfil them without better guidance. And they can’t fulfil those without the right context and conditions, being supported in that, whether that’s by resources or guidance, or recognition.

But also a recognition, particularly in adult social care, of their leadership, coordination, and risk management role, and protection role. And I think that was sidelined in the coronavirus period, and that left individuals vulnerable and it left families unsupported.

And I think the particular importance that we’ve already touched on around social workers being seen as key in emergencies and disaster situations and being part – that – the role of social workers being represented in the most senior governmental and regional level planning, as well as in the provision of guidance, which of course, as we’ve talked about, can be a collaboration between governments and professional bodies.

And really, that social work should be seen as an equivalent to health colleagues, and social care to be seen as equivalent to healthcare in the importance in protecting and supporting individuals and families.

Ms Hands: Thank you, Dr Allen. I am very grateful.

My Lady, those are all my questions.

Lady Hallett: Thank you very much, Ms Hands.

Mr Wilcock, I think it’s you.

Questions From Mr Wilcock KC

Mr Wilcock: Good morning, Dr Allen.

Dr Ruth Allen: Good morning.

Mr Wilcock KC: Thank you very much for coming to answer questions. I’ve been given permission to ask you on four topics but in fact you have already been taken through two of them in some detail so we’ll reduce to two.

The first topical, actually, follows on from what you just said. You’ve talked a lot in your evidence, particularly at the beginning, about the relationship between government and social workers in adult social care, and you just ended by talking about the lack of recognition that social workers had.

I just wondered, would it have helped, in theory, at least, having a minister with direct responsibility for adult social care, in terms of building that relationship?

Dr Ruth Allen: So there are ministerial roles across the UK with responsibility for adult social care. I think the – we’ve – for instance, we worked quite a lot with Helen Whately in England, and colleagues around the UK worked with equivalents. But social work is a small part of social care and it’s complex and it has a, you know, a very large workforce. All of those matters tend to overwhelm the priorities, and social work, as the regulator – and, indeed, the other regulated professionals in social care like occupational therapy and nursing don’t really get as much attention and yet it’s the regulated professions that are carrying a lot of the risk and coordination responsibilities, and the kind of practice leadership responsibilities.

Mr Wilcock KC: So I should have made clear – obviously I’m representing families from Northern Ireland –

Dr Ruth Allen: Yeah.

Mr Wilcock KC: – and they have an integrated system.

Dr Ruth Allen: Yes.

Mr Wilcock KC: Is there a similar Northern Ireland minister for adult social care?

Dr Ruth Allen: There is – yes, there is. There is a Social Care Minister and there was a Social Care Minister at the time, but the extent to which – the extent to which they were aware of, knowledgeable about, supportive of, social work, I don’t know. That role, the role of supporting social work, was with the chief social worker who is obviously not a ministerial appointment and who is also a, I think a Deputy Director General, if I’ve got that right as well, at the time, in Northern Ireland.

Mr Wilcock KC: Thank you very much.

Second topic, discharge from hospital. You told us, and you describe in your statement, how social workers often play a key role in the discharge from hospital of the most vulnerable and isolated in society and you go on to explain how, during the pandemic, the requirement to undertake continuous healthcare assessments of patients was reduced in order to relieve pressures on the health service. Now, I assume that statement was actually drafted with reference to England and Wales in particular?

Dr Ruth Allen: Yes, yes.

Mr Wilcock KC: Was there an equivalent in Northern Ireland?

Dr Ruth Allen: I don’t know, actually. I don’t know what – how the – I don’t know how – I don’t know how the legal provisions were changed –

Mr Wilcock KC: That’s fine.

Dr Ruth Allen: – I’m sorry.

Mr Wilcock KC: So now that we know that we’re dealing with England and Wales, can I just ask you, would you have expected the chief social worker to have been consulted in relation to that policy, and were they?

Dr Ruth Allen: Absolutely would have expected that. It was a very clear and very senior role that was – of chief social worker at that time. I would have – I would have expected them to be thoroughly involved in all decisions that would have an impact, for instance, in this case on something like discharge where social work assessment is so crucial.

Mr Wilcock KC: Was BASW consulted?

Dr Ruth Allen: No, not – no, nothing – no, there was no – BASW was not consulted on the changes to discharge processes. We would have been aware that there was – we weren’t consulted, we were then responding to the change that happened, and as it played out through the coronavirus period.

Mr Wilcock KC: If you had been consulted what would you have said?

Dr Ruth Allen: I know that members who work on this, our members who work particularly on this area have raised a whole number of issues about discharge to assess, which I’ve kind of broadly covered, that to ensure that people’s rights are protected and their wishes fulfilled there has to be enough assessment at the point of discharge.

Mr Wilcock KC: Which you’ve –

Dr Ruth Allen: And then it has to be really followed up, and that was overlaid with the clinical risk that was there, during – (overspeaking) –

Mr Wilcock KC: Which you explained to us earlier?

Dr Ruth Allen: Yes.

Mr Wilcock: Thank you very much. As much as I’d love to, I’ve got no further questions. Thank you very much.

Dr Ruth Allen: Thank you.

Lady Hallett: Thank you very much, Mr Wilcock.

Mr Stanton.

Mr Stanton is right over there.

Questions From Mr Stanton

Mr Stanton: Thank you, my Lady.

Good morning, Dr Allen.

Dr Ruth Allen: Good morning.

Mr Stanton: I ask questions on behalf of the Covid-19 Bereaved Families for Justice Cymru. I have a question for you in relation to the availability of testing in Wales, which you’ve already just touched upon in your evidence and, if there’s time, one in relation to inspections in Wales.

Dr Ruth Allen: Okay.

Mr Stanton: The first question concerns the content of your statement at paragraphs 73 and 74, and, as you have just explained earlier, about your concerns for the need for access of social care workers to care settings, including care homes, to ensure the rights of residents are upheld.

And you refer to particular concerns around mental capacity and some reports from your members that residents who had requested to go home were being refused on grounds of lack of mental capacity. And you told the Inquiry that you campaigned for testing to enable social care worker access?

Dr Ruth Allen: Yes.

Mr Stanton: And in Wales, that testing was announced to commence from 14 December twice weekly.

The question I have for you relates to when in practice that testing was actually made available to your members. I think Counsel to the Inquiry asked you a similar question in relation to England. I wonder whether you can recall any specific details about the situation in Wales?

Dr Ruth Allen: So the – certainly the response of Welsh Government was quicker in Wales than it was in England to this – to see the importance of this change. And so that happened, and I do recall that that was – that was recognised by our members as an improvement, and it started to happen.

How quickly and how widely that was available in practice, I couldn’t answer. But the policy change happened, and then, as a consequence of that, implementation started to happen.

Mr Stanton: Thank you. I think, then, I do have time to ask you about inspections, please.

At paragraphs 91-95 you indicate your concerns about the lack of scrutiny and oversight of care homes during the pandemic, including the suspension of inspections.

Dr Ruth Allen: Yeah.

Mr Stanton: Can I ask you, do you think enough was done in Wales over this period to monitor and support care homes during the pandemic?

Dr Ruth Allen: My understanding is that monitoring of what was happening in care homes throughout this whole period in all the countries of the UK was inadequate.

CQC in England suspended – suspended all of their inspections. My understanding is there were similar suspensions across the UK. And I remember clearly at the time thinking how just a suspension and no adjustment seemed inappropriate, given that these care homes were going to be at very significant risk, the people were going to be at significant risk, inevitably, by what was happening with the pandemic.

Mr Stanton: Dr Allen, were you aware that inspections of care homes in Wales in 2020 had reduced to just 20% of the level in the previous year?

Dr Ruth Allen: I wasn’t aware of that figure, but, given what I understood was happening across all of the nations, it doesn’t surprise me.

I think the issue was – the fact that – there were the consequences of inspections not happening, but I don’t think I ever fully understood the rationale for that, other than to say: well, you can’t go into care homes because of infection risk.

But care workers were having to go in every day.

So how could you – the need for monitoring and inspection was heightened rather than reduced. It was a question of trying to work out how possibly to do that. I didn’t hear any strong rationale for why it had been suspended completely.

Mr Stanton: Thank you very much.

Thank you, my Lady.

Lady Hallett: Thank you, Mr Stanton.

Ms Foubister.

Questions From Ms Foubister

Ms Foubister: Thank you, my Lady.

Dr Allen, good morning. I represent John’s Campaign, The Patients Association and Care Rights UK. You’ve given evidence this morning about problems with the exclusion of social work teams from hospital discharges, and at paragraph 40 of your witness statement you specifically raise concerns about the requirement to undertake continuing healthcare assessments being revoked for patients being sent home upon discharge in order to reduce pressure on the health service.

What was the impact of that is on people needing care and the quality and suitability of care and support that they received post-discharge?

Dr Ruth Allen: Well, I think we’ve covered some of this already in the sense that, clearly, rapid discharge without full assessment into care settings that were under tremendous pressure, was inevitably going to lead to people being in, at least some people being in very – being in unsuitable settings but also being at risk in those settings. So I think I would answer it in that way.

I think the – not – any delay – the fact that social workers couldn’t access care home residents who had been rapidly discharged in order to make holistic assessments meant that those individuals were not receiving a good service, and were potentially put at risk.

Ms Foubister: And what was the impact of the revocation of those assessments on the loved ones, familiar carers, or those providing care?

Dr Ruth Allen: Yes, I haven’t said very much about families and that’s not at all intentional, because I’m very, very exercised by the impact on families of everything that’s happened, and we did quite a lot of work with families during this time or with carers organisations and carers. So a huge impact of lack of access and fears for loved ones and not understanding the consequences perhaps of some of the rapidity of moving people out of hospitals. It may have been in people’s best interests but I’m sure for many families there was a sense that holistic and comprehensive assessments just weren’t happening. That’s what – that would be my understanding.

Ms Foubister: Thank you, Dr Allen.

Lady Hallett: Thank you very much, Ms Foubister.

Thank you very much indeed, Dr Allen. That completes the questions we have for you. We are very grateful for the help you have given to the Inquiry.

The Witness: Thank you.

Lady Hallett: And I’ve certainly got the message about the recognition of the role of social workers –

The Witness: Thank you.

Lady Hallett: – particularly during a pandemic.

Thank you, we shall break now and I shall return at 11.30.

(11.15 am)

(A short break)

(11.31 am)

Lady Hallett: Ms Jung.

Ms Jung: My Lady, the next witness is Professor Vic Rayner.

Professor Vic Rayner

PROFESSOR VIC RAYNER (affirmed).

Questions From Counsel to the Inquiry

Lady Hallett: Swapping roles now.

Ms Jung: Professor Rayner, your full name, please.

Professor Vic Rayner: Victoria Rayner.

Counsel Inquiry: Thank you. And you are the chief executive officer of the National Care Forum?

Professor Vic Rayner: Yes.

Counsel Inquiry: You’ve been in that role since 2016?

Professor Vic Rayner: I have, yeah.

Counsel Inquiry: And is it correct that the National Care Forum is a representative body for not-for-profit care and support organisations –

Professor Vic Rayner: Yes.

Counsel Inquiry: – primarily operating in England, although some of them do also operate in the devolved nations?

Professor Vic Rayner: Yes.

Counsel Inquiry: And is it right that therefore your focus is primarily in England and that’s what your statement and your evidence today will cover?

Professor Vic Rayner: Yes.

Counsel Inquiry: Does the National Care Forum currently represent 176 provider organisations?

Professor Vic Rayner: Yes.

Counsel Inquiry: And they collectively provide care and support to over 260,000 adults.

Professor Vic Rayner: Yes.

Counsel Inquiry: They operate over 8,000 services.

Professor Vic Rayner: Yes.

Counsel Inquiry: Provide more than 56,000 care home places.

Professor Vic Rayner: Mm-hm.

Counsel Inquiry: And employ over 145,000 staff.

Professor Vic Rayner: Yes.

Counsel Inquiry: During the pandemic, as at July 2020, is it right that your membership totalled 120 members?

Professor Vic Rayner: Yes.

Counsel Inquiry: So there’s been an increase of almost 50% since the pandemic?

Professor Vic Rayner: Mm-hm.

Counsel Inquiry: To what extent, if at all, do you think that that’s attributable to the raised profile and visibility of National Care Forum during the pandemic?

Professor Vic Rayner: Possibly, yes. I mean, we spent a lot of time in the pandemic supporting organisations and we were very clear that we wanted to extend that to the broadest possible scope of organisations, so many more people would have got our resources and support and got engaged with the work we did during the pandemic, yes.

Counsel Inquiry: Thank you. So currently what proportion of the not-for-profit sector do you represent?

Professor Vic Rayner: I think there’s about 20% of the overall care sector is not for profit, and in the context of something like care home places, the National Care Forum has about 15% of the overall places so – I mean, it will vary on a service-by-service basis but a significant number of those not-for-profit provisions will be within our membership.

Counsel Inquiry: Could I ask you just to slow down a little bit, please.

Professor Vic Rayner: Yes, of course.

Counsel Inquiry: Thank you.

Is it right that in terms of the types of adult social care services that are operated by your members, the majority of them operate nursing homes and/or residential care homes?

Professor Vic Rayner: I think our membership is very diverse, so lots of members. Interestingly, in the not-for-profit sector lots of organisations will operate multiple types of services, so that’s different often to the for-profit sector where they might just operate care homes or home care. So in the not-for-profit sector, because they have been part of communities often for centuries if they are charitable organisations they might do nursing homes, care homes, day services, community services, extra care housing, they might offer all those different types of services within one organisation.

Counsel Inquiry: I see. Thank you. And I think you have there just covered the range of services that your members provide.

In terms of the categories of people that are supported, does that cover older people, people with learning disabilities, physical disabilities, mental health needs, those with dementia and other needs –

Professor Vic Rayner: Yes.

Counsel Inquiry: – such as – (overspeaking) –

Professor Vic Rayner: All adult – all adult services.

Counsel Inquiry: Thank you.

Professor Vic Rayner: And some members will provide transition services between children’s and adult services as well.

Counsel Inquiry: Thank you.

Can you just give us an overview of the types of not-for-profit organisations in your membership, please.

Professor Vic Rayner: Yes. So we’ll have charities. We’ll have what are called LATCos, which is local authority trading companies, housing associations, non-shareholding community interest companies, you know, anything – and we have now within our membership some local authority direct provision as well.

Counsel Inquiry: When did that come in?

Professor Vic Rayner: Just very recently.

Counsel Inquiry: So before – that didn’t exist during the pandemic?

Professor Vic Rayner: No.

Counsel Inquiry: Can you tell us a bit more, please, about the funding and commissioning structures.

Professor Vic Rayner: Of the –

Counsel Inquiry: Of the not-for-profit organisations that are in your membership.

Professor Vic Rayner: I mean, they are – operate within the wider care sector, so the commissioning arrangements will be as they are for other care providers, so they’ll be commissioned directly by local authorities or people will pay for their own care if they’re self-funders, or they are commissioned by health organisations if they’re providing perhaps mental health services, drug and alcohol support services, those types of things.

So they have a variety of different funders and commissioners.

Counsel Inquiry: Are you able to help us as to what percentage of your members are publicly funded as opposed to –

Professor Vic Rayner: Probably – well, so if it’s working age adults, almost all working age adult services are publicly funded. If it’s older people services, then there will be a mix of provision. So, because of the way social care is means tested, if people are providing residential care, for example, they would generally have a mix of people within a home, some whom are directly funded by the state and some who are funded for a self-funding – so it would vary from a home-by-home basis.

Counsel Inquiry: Thank you. And could I just ask you once more to slow down a little bit –

Professor Vic Rayner: Apologies.

Counsel Inquiry: – because everything you say is being recorded, and it’s important it’s recorded accurately. Thank you.

Can you help us as to whether there are any structural or operational differences between not-for-profit and profit – for-profit providers that were particular significant in the context of pandemic response, for example in relation to resources or relationships with commissioners.

Professor Vic Rayner: So the main structural difference is not-for-profit organisations will reinvest any surplus back into the organisations they are running. So that will go back in either to invest in the care they are delivering, the building, perhaps, or the types of services they’re able to offer, or in the staff and the payments to staff.

So there’s no all – any surplus funding is redirected into the organisation.

Counsel Inquiry: Sorry to interrupt, how does that – how would that have impacted on pandemic response?

Professor Vic Rayner: So there have been a number of independent studies that have looked at what the model of – how the model of delivery might impact. So I think the Inquiry has heard about the Vivaldi Study?

Counsel Inquiry: Yes.

Professor Vic Rayner: And that highlighted some better outcomes in not-for-profit provision services. And there was a study called the FICCH study which looked at the financial impact of Covid in care homes, which reported on better return, better staff experiences during the pandemic in not-for-profit provision in terms of staff satisfaction and wellbeing.

Counsel Inquiry: And just briefly, why do you think that structure led to better outcomes?

Professor Vic Rayner: I think there are a number of things that are also different in a not-for-profit organisation. One of those is the governance. So often they are governed by local – if they’re a local organisation, they will be governed by a board who is made up of local representatives who will be invested in the long-term ongoing provision of that service to serve that community. And I think they also often come from a perspective of charitable purpose and their aims and objectives will make it absolutely clear their need to serve their community and ensure ongoing delivery.

Counsel Inquiry: Thank you. And as far as the workforce is concerned, are there any distinguishing features that we should be aware of, again, that would have impacted on the pandemic?

Professor Vic Rayner: Yes, I mean, we’ve carried out long-term surveys on pay terms and conditions across the workforce with our members, and generally, when we’ve compared those against statistics from organisations like Skills for Care, there have been better terms and conditions in some of the services. It’s very difficult to say that universally, but that’s one of the things that came out through some of those surveys in the past.

Some of that was pre-pandemic, obviously we weren’t in a position to look at the detail during the pandemic, but we continue to look at those operating environments, and we continue to offer extensive support to our members to encourage them to look at things like the sort of funding conditions that were available during the pandemic and encourage them to utilise those for staff in that way.

Counsel Inquiry: And to what extent does your workforce include, for example, people who were on zero-hour contracts?

Professor Vic Rayner: Some of the zero – some of the – when we’ve looked at that pre-pandemic, certainly it wasn’t a huge part of the workforce. It’s less common generally across the sector in residential than home care and within our membership there’s not huge numbers of home care deliveries.

But it’s one of the areas that’s driven often by commissioning behaviour, as well. It’s not necessarily a decision made by an employer based on a particular type of employment. It may be driven by the need to commission in that – to employ in that way because of the way they are commissioned to deliver services.

Counsel Inquiry: And can you help us as to what percentage or proportion of your members do deliver home care?

Professor Vic Rayner: I haven’t –

Counsel Inquiry: It doesn’t have to be exact. Just to give us an indication.

Professor Vic Rayner: They’ll deliver it as part of their services so there’s no – I don’t think there’s any of our members who are home care only, so they’ll be delivering it alongside other services.

If I look at … so 30% of our members have some home care.

Counsel Inquiry: Thank you. And I’ll be moving on later to your role during the pandemic but one of those was advocating on behalf of the sector?

Professor Vic Rayner: Yes.

Counsel Inquiry: So when you did that, was it on behalf of both the home care and the care home sector, which are the main areas we’re focusing on in this module, or were you focused primarily on care and on residential and nursing homes?

Professor Vic Rayner: So our advocacy was generally across all of member services but we worked very closely with colleagues like Homecare Association, who had a very specific and unique focus on home care. So where we could add value to that we did; where we could – where they could benefit from the things we were working on, we did that too. We worked very collaboratively.

Counsel Inquiry: Thank you. And we’ll be hearing from Homecare later on in this module, thank you.

Can I ask you briefly about pre-pandemic structure and capacity. The Inquiry has heard quite a bit about this, but just help us as to whether there were any pre-existing issues which were especially pronounced for not-for-profit providers and in what ways the pre-existing weaknesses affected the ability of those providers to respond to the pandemic on the ground, please.

Professor Vic Rayner: I mean, I think there are pre-existing – there were many pre-existing pressures that had been highlighted by multiple Green Papers and White Papers and a whole variety of commissions and they’ve looked at a number of core areas. One is about the lack of funding and investment in the sector; the other is about the lack of focus on the workforce, and the lack of workforce strategy and plan; and the other is about the lack of recognition and partnership. These were things that were evident for the not-for-profit sector as well as the wider social care sector.

I think in the context of not-for-profit organisations specifically, they were trying very hard, often, to operate a wide variety of services, as I’ve talked about.

What that means is that each, often they create an organisation model that requires some sort of central contribution from each element of services, and what was happening pre-pandemic was significant constriction in commissioning arrangements. So, for example, many of them would have offered what were described as preventative services, so non-regulated care services, alongside their services that were regulated by the CQC and there’s an interdependency between those services, so if you offer what’s called housing support, for example, and you’re –

Counsel Inquiry: Yes.

Professor Vic Rayner: – you know, if that commission –

Counsel Inquiry: Sorry to interrupt, but just focusing on the regulated sector because that’s –

Professor Vic Rayner: But I think – so I suppose I’m just trying to answer your question which was about was there anything specific for not-for-profit –

Counsel Inquiry: Yes.

Professor Vic Rayner: – and the specific bit was because it was operating both –

Counsel Inquiry: – (overspeaking) – yes.

Professor Vic Rayner: – if you constrict one or you cut the funding off for one set of services it has an impact on the regulated services.

Counsel Inquiry: I see. Thank you very much.

Professor Vic Rayner: Yes.

Counsel Inquiry: Can I move on then, to your role during the pandemic and as I’ve said, one of the key things that you did was to advocate on behalf of the sector. Is it right that the two other things that you did were A, navigating guidance on behalf of your members?

Professor Vic Rayner: Yes.

Counsel Inquiry: Supporting them to help them understand what the guidance was and know when the changes came in?

Professor Vic Rayner: Yes.

Counsel Inquiry: And the second thing you did was engage with the UK Government on their behalf.

Just briefly dealing with the navigating of guidance first, if I way. Is it right that the National Care Forum issued around 200 briefings during the course of the pandemic, and during the majority of the first wave, those were daily?

Professor Vic Rayner: Yes.

Counsel Inquiry: Just help us, please. Were those briefings delivered by email?

Professor Vic Rayner: Yes, they would be.

Counsel Inquiry: And it’s right, isn’t it, that at some point during the pandemic you opened up that service much more widely to the sector?

Professor Vic Rayner: Yes.

Counsel Inquiry: Did that include for-profit organisations?

Professor Vic Rayner: Yes. Yes.

Counsel Inquiry: So it was to the sector as a whole?

Professor Vic Rayner: Yes.

Counsel Inquiry: Just help us to understand, so how would those organisations have known and been party to that service? Would they have registered with you and then gone on to the email list? Or how would they know about it?

Professor Vic Rayner: Yes, or they – or it would be cascaded through other organisations they might be part of.

So, I mean, we work – we’re very, very enthusiastic about working together, so we work – we’re part of something called the Care Provider Alliance, that brings together all of the trade bodies that work in the care sector, and we work with lots of local care associations as well. So we shared all that information with whoever wanted it, really, and alongside those emails we had weekly briefing meetings, which again we included many other people in. We produced lots of resources and made as much as we could freely available to everybody.

Counsel Inquiry: Thank you.

So the Care Provider Alliance, is it right that that is an umbrella organisation?

Professor Vic Rayner: Yes.

Counsel Inquiry: And in fact one that you currently chair?

Professor Vic Rayner: Yes.

Counsel Inquiry: So how many organisations are there?

Professor Vic Rayner: So there’s ten trade bodies in that.

Counsel Inquiry: There’s ten? And is it right that each takes it in turn to chair it –

Professor Vic Rayner: They do.

Counsel Inquiry: – for a year at a time?

Professor Vic Rayner: Yes.

Counsel Inquiry: So you weren’t the chair –

Professor Vic Rayner: I wasn’t.

Counsel Inquiry: – during the pandemic.

And as far as the CPA is concerned, is it right that their reach is – covers about 95% –

Professor Vic Rayner: Yes.

Counsel Inquiry: – of the adult social care sector?

Professor Vic Rayner: Yes.

Counsel Inquiry: And so in terms of an organisation that the government, when it comes to future pandemics, may use as a source of distributing information, would you say that they are an appropriate body to work with in that sense?

Professor Vic Rayner: Yes. Absolutely.

Counsel Inquiry: In terms of advocacy, you issued over 150 press releases, is that right, during the pandemic?

Professor Vic Rayner: Yes.

Counsel Inquiry: On a wide range of topics. So covering, for example, death data, visiting restrictions and things like that; is that right? And that was often jointly with other representative groups; as you’ve told us, you liked working together.

Did you also undertake a range of surveys?

Professor Vic Rayner: Yes.

Counsel Inquiry: Do you know how many of those you undertook?

Professor Vic Rayner: I couldn’t tell you off the top of my head but I would think it would be around about 30 surveys on different topics, sometimes repeat surveys on the same topic. And we also engaged in lots of research where that was available, as well. We stimulated research happening, as well, and brought members together with academics and other experts to ensure that the best information was available.

Counsel Inquiry: Sorry, I don’t know if I misheard, did you say stimulated research?

Professor Vic Rayner: Yes. So, for example, the Less Covid research, we worked directly with Leeds University, supported by the Dunhill Medical Trust, to get early understanding of the impact of Covid on older people.

Counsel Inquiry: And could you just explain what “stimulated research” is? What does that mean?

Professor Vic Rayner: We talked to researchers and said: this is vital that somebody’s looking at this.

It wasn’t being looked at by the government. There was a massive gap in terms of understanding of how Covid impacted older people, what was happening in care homes, and so – we have good, strong relationships with universities and so we were able to work with them at pace to produce some research.

Counsel Inquiry: And just briefly, what were the findings of Less Covid?

Professor Vic Rayner: So Less Covid was really focused on what the experiences of – was within care homes, so that the key kind of learnings were that the way in which Covid manifested for older people was not the way the government was describing symptoms. We were telling the government this. And of course that created a problem when it wasn’t possible to access tests unless people were symptomatic in line with the government’s version of symptoms. But this Less Covid was showing and our work with members showed it was very different.

It showed that there was an – there had been siloed approaches to healthcare, and so people were not able to access healthcare within care settings, and that included the care that was needed for end-of-life care.

It sort of laid bare, I think, some of the kind of isolation that care homes had recipients during particularly during that first wave.

Counsel Inquiry: So very important research?

Professor Vic Rayner: Very important research.

Counsel Inquiry: The Inquiry heard earlier in the week that there were some big gaps in the data available.

Professor Vic Rayner: Yes.

Counsel Inquiry: And the infrastructure was quite lacking when it came to data. With regard to the research and the surveys that you were carrying out, were they covering the sector as a whole, or were they specific to the not-for-profit sector?

Professor Vic Rayner: So generally our surveys would have been with our members directly. Obviously, probably the one that we thought was most important to start with was one about the deaths within care homes. We were hearing directly from members of the very huge toll within care homes and we weren’t seeing any of that reflected in government data.

So yes, that survey particularly was carried out directly with members asking them, with a week apart, what their experience was and what was happening within their homes, and that – we published that, I think, on 19 April, ten days before the government produced any data on the deaths within care homes.

Counsel Inquiry: And we’ll go to that in a moment, but with the surveys, were they collecting quantitative data or qualitative data based on people’s experiences or was it a mix of the two?

Professor Vic Rayner: It was a mix. If you could ask a question with a number we did, because we know people love numbers, but we also wanted to capture some of the real-life experience of people, as well, so it was a mix. And later on we developed what were called pulse surveys. So we developed those on a monthly basis, which looked at core areas once it became clear what they were, so things like access to PPE, access to testing, visiting, you know, all of the sort of things that were part of the ongoing delivery of care within a pandemic, and we wanted to use those to kind of provide a benchmark to say how things were changing or how resources were or weren’t reaching the front line.

Counsel Inquiry: We heard that the Vivaldi surveys were carried out by telephone –

Professor Vic Rayner: Mm-hm.

Counsel Inquiry: – with the managers of care homes.

Professor Vic Rayner: Mm-hm.

Counsel Inquiry: How were yours carried out and –

Professor Vic Rayner: Usually by email.

Counsel Inquiry: By email. So was it a questionnaire –

Professor Vic Rayner: By online questionnaires – yes.

Counsel Inquiry: – that were distributed.

Professor Vic Rayner: Yes.

Counsel Inquiry: And generally what kind of response rates did you have?

Professor Vic Rayner: Again, without looking at individual surveys, but we had, you know, we always reflected it as a percentage of the membership and I think we were generally getting 60,70% of the membership.

Counsel Inquiry: And was the data that you were gathering through these surveys purely to assist you and to help you with your advocacy, or was the data sent directly to the government?

Professor Vic Rayner: It was always sent directly to the government as well as the advocacy. You know, as part of our advocacy, but also it was, you know – I mean, I think, I hope it’s reflected in the papers that you’ve seen. We felt it was very important to keep the government as up to date as possible in terms of both the questions and challenges that were happening but also to, you know, show them, you know, what the direct experience was of people on the front line.

Counsel Inquiry: And was the data that was gathered through the surveys collated in a structured and formalised way?

Professor Vic Rayner: I mean, it was – we used a tool probably something like SurveyMonkey, and it was utilised, you know, we pulled it together in that way. So, you know, there would be a variety – depending on the topic, sometimes it would be anonymised. Generally we asked a similar set of questions so we could stratify it, you know: what’s the size of your organisation? Because we were aware that different size organisations were impacted differently by different elements. What group of people are you working with? What types of settings are you talking about?

So yes, we definitely tried to represent it in that way.

And if it wasn’t anonymous because we wanted to follow up with people, then we would ask them if they would be happy to be followed up with directly, and for some – sometimes we would ask people if they were happy to be connected directly to government and sometimes we brought people directly to government as part of a round table, or because they had a particular issue or problem. So when we were the – particularly when we found an early issue that hadn’t been raised before, for example when it was – it became clear that, quite early on in the pandemic, when people were coming up for insurance renewal, for example, and were being told by insurance companies they would no longer provide any public liability insurance, you know, which is a fundamental problem because it’s part of a regulatory requirement, we would – we brought those members directly to government officials to say, “You need to take this issue seriously”.

Counsel Inquiry: And how receptive did you find government? When we say government, are we talking about the DHSC?

Professor Vic Rayner: We’re talking about the DHSC primarily. Sometimes we would have gone to other departments, but we sort of saw them as a route through, if there was a need to bring in other people.

Counsel Inquiry: Did you ever work with any of the scientific advisory groups, the modelling groups, for example, to assist in the response?

Professor Vic Rayner: I didn’t personally but my colleague Liz Jones was involved in the Social Care Working Group.

Counsel Inquiry: Yes, but in terms of the provision of data, I think she was a member of a group?

Professor Vic Rayner: Yes.

Counsel Inquiry: But in terms of the provision of data did the government or any of those groups come to the National Care Forum and say, “Look we’ve got these gaps, are you able to survey your members and collect this individual care home level data for us?”

Professor Vic Rayner: No, not to my recall.

Counsel Inquiry: Is that something that you were set up to do? To be able to do during the pandemic?

Professor Vic Rayner: We weren’t set up to do that, in that sense, but if there had been an opportunity to do that, I’m pretty sure we’d have grabbed on to it, if it was possible to do without significant burden.

And I think that is part of the balance, I guess, that we were always aware that if you were going to ask people to do things, then they needed to – you know, you needed to balance that appropriately with what else they were trying to cope with, and also you needed to give them information back, and that – so there was a corporate data collection vehicle, which was Capacity Tracker, and so whether those particular scientific questions were being fielded through that – we did sit on some of the groups that looked on the data that was being collected, and I think our big – you know, we’re very supportive of the need for a better data infrastructure, but what never came forward in a way that appeared helpful was feeding that data back to the sector itself.

So not recognising that actually, with that information, people could have made active choices to perhaps do things differently or …

Counsel Inquiry: We heard earlier in the week how, especially when it comes to the domiciliary care sector, there are real difficulties in gathering some of this baseline data. Are there any practical recommendations that you would invite the Inquiry to make to deal with some of those difficult issues?

Professor Vic Rayner: Yeah, I mean, I think that there are – there was a huge amount of data in the care sector, which can tell us lots of things about the kind of wellbeing of individuals, what supports them to work, you know, to deliver effective care, and so forth.

So I think in terms of the recommendations, we need to invest in that data infrastructure. We don’t have routinely, in care organisations, people who are – hold a role of data analysis, for example.

At the beginning of the pandemic we only had 20% of care providers who had electronic care records, and yet one of the early learnings from the Less Covid research was that actually having an electronic care record made it so much more straightforward to understand what was happening to people. So –

Counsel Inquiry: – and has that position improved now?

Professor Vic Rayner: That position has now improved. So the government did eventually invest in that, but not until April 2022, so after the pandemic.

So we’re – there was quite a shift in – in terms of take-up, but that was all care providers investing in that kind of data system themselves.

Counsel Inquiry: But perhaps – sorry to speak over you – perhaps focusing more on the domiciliary care sector, and it may be that we need to ask the Homecare Association about this too, but do you have any insights into how we might deal with that tricky issue of gathering data from not just regulated domiciliary care providers but also unpaid carers?

Professor Vic Rayner: I don’t have in relation to unpaid carers, but for domiciliary care it’s the same – there is the same opportunity in terms of electronic care records, and there is a good take-up of electronic care records now within domiciliary care.

I think that there are great opportunities going forward about supporting people to own their own data, so that would be an opportunity for unpaid carers to be able to contribute data that they observe, and that they identify in the delivery of their care. And you can see that in some of the initiatives that have happen with things like virtual wards, for example, where people who are looking after somebody in their own home are asked to carry out blood pressure monitoring and things, and gather that kind of data.

So I think there are ways like that. But I think probably the other side of it is social care data has not been recognised as important, because the professional skills and expertise of that sector are not recognised in that way. So we haven’t seen it as valuable in the past, and I think – I hope that’s one of the, sort of, opportunities from the pandemic: to recognise that, actually, that data could tell us – you know, if you wanted to understand how Covid impacted on somebody with dementia, the only people who could really tell you that were people who were working in social care, because they were the people who were looking after and supporting those individuals. And we were not routinely asking those people or enabling them to carry out that data collection in a meaningful way.

Counsel Inquiry: Thank you.

Do you have any – before we leave this topic, do you have any insights in relation to research in the adult social care sector?

Professor Vic Rayner: Yes, I mean there’s lots of work we do, ongoing work with academics in the context of research. I mean, I think one of the successes of something like Less Covid and other research that we’ve been involved in subsequently, is having the operational expertise involved at the development of that research. So not creating studies which won’t have a material day-to-day impact.

And I think the other element is about speed. So the changes, in terms of, you know, what we want to do with research, generally the priorities are things that need to change quickly. So we need to think about how we can utilise some of the speeding up of research, speeding up of approvals, for example, on things like that, that happened during Covid, and think about how they can be applied in real time now.

Counsel Inquiry: So could a solution be, for example, to have a number of sleeping contracts –

Professor Vic Rayner: Yes.

Counsel Inquiry: – for specific types of research –

Professor Vic Rayner: Yeah.

Counsel Inquiry: – that could be activated quickly – (overspeaking) –

Professor Vic Rayner: And to create and to sort of think about those sort of bits of the architecture we don’t have in social care, like a social care data observatory that would mean you could regularly feed this in. We have huge amounts of wonderful research of the voices of people in care which provide great insight and great recognition of the importance of the – of what people value, and yet, because we don’t capture that in a sort of central repository, we don’t – we can’t learn from them again and again. And I think we need to think about how we do that.

Counsel Inquiry: And who do you say should be responsible for maintaining that sort of repository?

Professor Vic Rayner: I mean, I think the – social – I mean, from my perspective, social care is a public service. If we want to improve the public service then the people who generally – who have overall responsibility for the public service, which is the government in the context of the Care Act, should make sure we’ve got the best available information, expertise, innovation available for those who are going to receive care. That’s our commitment, is to deliver the best care for people to enable them to live the most fulfilling lives.

That data, that richness of experience, would tell us what that is, and so yeah –

Counsel Inquiry: But in terms of the –

Professor Vic Rayner: – if we’re going to deliver public services, let’s invest in that.

Counsel Inquiry: Okay, but you wouldn’t specify a particular –

Professor Vic Rayner: Well, I would specific that, you know, the government already funds NIHR, the National Institute for Health and Care Research, it’s that kind of body that I think we should be looking at. The government is looking to fund very significant data platforms, for example. If we can get the social care data from that and draw that into ongoing plans for the development, we’re just about to, or just started a significant reform exercise through Baroness Casey’s commission.

Counsel Inquiry: Yes.

Professor Vic Rayner: That’s exactly – that sort of data should and could inform a commission.

Counsel Inquiry: Thank you. I said earlier that we would go to the deaths press release, but I hope we’ve covered it, and is it a fair summary to say that in April 2020 you carried out a survey which showed that the number of deaths in care homes was much greater than that had been reported, and you say that by the end of April, as a result of that advocacy, the data did start to be properly reported –

Professor Vic Rayner: Yes.

Counsel Inquiry: – in public.

Professor Vic Rayner: Yes.

Counsel Inquiry: Is that right?

Professor Vic Rayner: It is. I think what we also did at that time was make really clear the things that needed to happen to prevent – to prevent it further and support the sector, and those things didn’t happen in the way that we talked about. I mean, there are various things that came along as things – as time progressed, but key issues like the access to community healthcare, access to expertise and geriatricians coming into care homes or explicitly looking at the experience of care homes was not happening, nor was the sort of testing of everybody within care homes.

And I think, whether you’re going to focus on the discharge experience but, you know, we were relaying what members were telling us, we’re not sitting in – I’m not sitting in a position claiming clinical expertise in that sense, I’m just – we were telling them what was actually happening and what members said that they needed to have in order to ensure that the people they were looking after were as safe as possible.

Counsel Inquiry: And with that particular issue of geriatricians coming into care homes, did that improve as a result of your advocacy?

Professor Vic Rayner: It raised the issue. I don’t think we saw a direct response in terms of that.

Counsel Inquiry: Thank you. The next topic is, in fact, your engagement with the government.

Professor Vic Rayner: Mm-hm.

Counsel Inquiry: I’m just going to go back in time a bit to January.

Professor Vic Rayner: Mm-hm.

Counsel Inquiry: So if we could please look at our first document, it’s at tab 3 of your bundle if you want to turn it up, Professor.

It’s INQ000532335 and if we start, please, with page 6 of that document.

Can you see there’s an email from you on 24 January 2020 –

Professor Vic Rayner: Yeah.

Counsel Inquiry: – to various people at the DHSC. And is it right that you were in contact with the DHSC at this early stage –

Professor Vic Rayner: Yes.

Counsel Inquiry: – to raise concerns about the potential impact of the pandemic –

Professor Vic Rayner: Yes.

Counsel Inquiry: – on members? And do you remember what it was specifically that triggered you to take that action?

Professor Vic Rayner: Members getting in touch with us directly to say, “What should we be doing? How should we be protecting staff and people we’re working with?”

Counsel Inquiry: But at that early stage, what was it in particular that was concerning –

Professor Vic Rayner: I think people had seen the stories of what was happening in Wuhan and were thinking about how that might have an impact here.

Counsel Inquiry: So they were thinking ahead –

Professor Vic Rayner: Yes.

Counsel Inquiry: – to what preparations they could put in place –

Professor Vic Rayner: Yes.

Counsel Inquiry: – at that time –

Professor Vic Rayner: Yes.

Counsel Inquiry: – so that they would be better prepared for something if it did come along?

And in this email were you asking the DHSC whether the guidance that you had found online, which I think was available for healthcare services –

Professor Vic Rayner: Yes.

Counsel Inquiry: – was the one that you should be advising your members to apply, or whether there was any other guidance or advice that you should be –

Professor Vic Rayner: Well, I think I was thinking: if people were asking me, I’m kind of hoping that people are asking internally in government, and somebody is busy thinking about how social care should prepare.

Counsel Inquiry: Yes.

And if we look at page 5, we can see that you received a response that day, and in fact replied back saying:

“… I understand …”

Sorry, if we go to the top of the page.

So this is after you’ve had an initial response saying that they would look into it and get back to you. And then you say:

“… yes I understand that we have been connecting across a number of levels …”

What was that in reference to?

Professor Vic Rayner: That was because they were saying two other colleagues had been in touch with the same questions.

Counsel Inquiry: With the same questions.

You say in fact:

“… I suspect that is reflective of the growing concern amongst providers who have been contacting us individually wondering if there is [any] particular action they should be taking.”

And you go on to say that you’ll be able to ensure that the information received gets shared across the CPA and on the website. What was the purpose of you including that in your email?

Professor Vic Rayner: Why did I say that?

Counsel Inquiry: Yes.

Professor Vic Rayner: Just to be clear that they didn’t – because the other colleagues who had connected were from the CPA, so I wanted to make – I wanted to be clear that I was going to take that action and that they didn’t have to. So it was a sort of message to government and to my colleagues to say: we’ll do it once.

Counsel Inquiry: Was it to say, “You can use us as a vehicle to communicate with – across the sector”?

Professor Vic Rayner: Yes, I mean I – yes, partly that too, yeah.

Counsel Inquiry: And is it right that you were then told by the government that the guidance that you had sent a link to was indeed the one that you should be –

Professor Vic Rayner: Yes.

Counsel Inquiry: – directing your members to? And that was the healthcare-specific guidance?

Professor Vic Rayner: Yes.

Counsel Inquiry: Then if we go to page 3, please, we can see that on 13 February – it’s the page before, please, page 3 – you got in contact again on 13 February.

Professor Vic Rayner: Yeah.

Counsel Inquiry: And you say there that the reason that you were coming back is:

“… to provide some feedback on specific concerns that members [had been] raising [with you] … when trying to apply [that] guidance …”

Is that right?

Professor Vic Rayner: (No audible answer)

Counsel Inquiry: You then set out a number of key concerns of your members, which included problems with being able to self-isolate, problems with accessing people or knowing what PPE they should be accessing. You also highlight workforce issues.

And then you say in the penultimate paragraph that it’s “imperative” that you provide some “targeted guidance for the sector that picks up on these and other issues”, and you explain that:

“It is a very fractured sector, and [you] want to ensure that all those who receive care and support continue to be provided with safe and effective care.”

Professor Vic Rayner: Yeah.

Counsel Inquiry: So was this early warning of the issues that in fact ended up being accurate as to the key issues that eventuated in the pandemic?

Professor Vic Rayner: Yeah. I mean, it’s probably one of, you know, many, many emails that we sent through basically saying that the guidance that was being produced was not adequate. It didn’t demonstrate any operational understanding of how social care was delivered on the ground.

We may go on to look at it, but as – when further guidance was developed, which supposedly was accurate, or targeted at social care, it continued, I think, to not address the issues that had been raised.

Counsel Inquiry: Yes, and we will go on to that.

Professor Vic Rayner: Yes.

Counsel Inquiry: So just keeping to the chronology if we can.

Professor Vic Rayner: Yeah.

Counsel Inquiry: So you’ve got in contact end of January. Mid-February you’re saying, “We really need bespoke guidance”, and just for completeness with this chain, we can see that, on page 2, you’re told that there’s a small team coordinating central support at DHSC and that they’d get back to you?

Professor Vic Rayner: Mm.

Counsel Inquiry: Then, on page 1, is it right that you were saying that you – paraphrasing, it’s a very rapidly developing thing that’s happening, but you would appreciate, rather than waiting for central guidance, which might take some time, you would prefer to have small bits of advice quickly?

Professor Vic Rayner: Yeah. I mean, I think that I don’t – clearly this is written before we knew what some of the challenges of waiting for guidance would look like.

Counsel Inquiry: Yes.

Professor Vic Rayner: So, yes, I think that – I’m trying to give them some opportunities to get something out that’s clear what people should be doing, so that – so, you know, if you’ve got a sector of 18,500 organisations, in my mind getting 18,500 organisations to work it out for themselves does not seem a sensible or efficient way of responding to a crisis. So it was to try and say: if you can’t get it perfect, get something that will help people to know what to do right now.

Counsel Inquiry: And we –

Professor Vic Rayner: And plan. I mean, I think it’s all about – at this stage, it’s very much planning. So, you know, if it was going to be, as it then transpired, something that needed largest amounts of PPE or, you know, some of the things that it’s now clear that the government was talking about behind the scenes, in a sense, if providers had known some of that, then it would have been possible to be better prepared. It might have been, you know, in terms of doing things like thinking about what isolation might look like and how can you build that into your structure in a care home. But that’s what we were looking for, some sense of that.

Counsel Inquiry: So you were looking for as much advance notice as possible of –

Professor Vic Rayner: Yes, yes, I mean, that’s my job.

Counsel Inquiry: – the types of things that you might need to put in place?

Professor Vic Rayner: Yes.

Counsel Inquiry: And we can see in that email that you say in the third line from the bottom “happy to help”. Was that you again offering –

Professor Vic Rayner: Yeah.

Counsel Inquiry: – to help?

Professor Vic Rayner: Yes.

Counsel Inquiry: And what did you mean by that? Was that a reference to helping with co-production of guidance – (overspeaking) –

Professor Vic Rayner: Yeah, I mean, generally it would be about, you know, either looking at something and giving some feedback, or testing it on people, or, you know, asking people who’d got experience. It’s not – you know, it’s not that there wouldn’t be anybody who didn’t have some of the answers perhaps out in the sector that we could have drawn on.

Counsel Inquiry: Thank you. And just at the top of that page, we can see that DHSC in fact agree with you that getting out what they can to the sector quickly is more useful than “hanging around for a blockbuster edition”?

Professor Vic Rayner: Yes.

Counsel Inquiry: Then if we go to tab 18 in your bundle which is INQ000051203, please, and if we start at page 6.

And again working backwards, we can see that on 19 February 2020 that a draft, is it right this is a draft of the guidance that eventually came out on 25 February?

Professor Vic Rayner: Yes.

Counsel Inquiry: So a draft is sent to you and others in an email, and we can see that you received that at 1.54 hours on 19 February, and in the email itself, they’re saying that the deadline for reply is “lunchtime tomorrow”?

Professor Vic Rayner: Yes.

Counsel Inquiry: “… so it would be helpful to have returns by 12.00 at the latest.”

So you had less than a day –

Professor Vic Rayner: Yes.

Counsel Inquiry: – to respond. And was that sufficient for you to be able to meaningfully input and respond to that draft guidance, do you think?

Professor Vic Rayner: No. I mean, clearly, patently not, if I’m going to do something directly with providers. I mean, as we had already started to raise issues and discussions, I mean, we did respond and gave lots of detailed feedback around it. But I think it is – yeah. I mean, I think this – if this is about getting people prepared and in the right space, then we felt that something that absolutely talked to people in the settings and environments that they were working in was going to be crucial. If you get a bunch of stuff that doesn’t relate to your experience, then all you’ve got to do is reinterpret that and try and understand it, and fit it into the space that you’re in.

So yeah, I mean, more time would have been helpful. Clarity, you know, I think at this stage setting up, you know, working groups that could do this. This was sent to me. I’ve no doubt it was sent to a variety of other people, as well, to comment as well.

Counsel Inquiry: Yes.

Professor Vic Rayner: No inducement for us to work together or to … so where we’re trying to do some of that as much as we can, and I’d done that through a tried and tested mechanism of copying in multiple people to show them what our thoughts were so they could respond, rather than getting them to do it themselves.

Counsel Inquiry: The reason I asked is because I think you and also a number of other people in their evidence talk about the lack of time that they had –

Professor Vic Rayner: Yes.

Counsel Inquiry: – to respond to draft guidance, for example.

Professor Vic Rayner: Yes.

Counsel Inquiry: But is it a fair summary of what you said that you’ve got to balance things, and you appreciated that on the one hand there was a need to get things out quickly to the sector, so although ideally you would have had more time, actually you appreciate that this was a fast-moving situation and so –

Professor Vic Rayner: Yeah, I think it’s a fast-moving situation. It’s a situation where lots of people are just beginning to think about it, as well.

Counsel Inquiry: Yes.

Professor Vic Rayner: But I suppose the point would be that at this stage you could have set up something more meaningful to focus on guidance on an ongoing basis that would mean you didn’t get yourself in this mess time and time again.

Counsel Inquiry: Yes.

Professor Vic Rayner: Because this was a repeated pattern of less than 24 hours to respond to anything. A repeated pattern of asking multiple people without being clear who’s being asked, so then as a government, getting multiple responses which they were trying to balance. There wasn’t a weighting, I understood, that was attached to operational reality versus clinical guidance, for example.

Counsel Inquiry: So is it the case that you’re saying that groups that are co-producing guidance and policy should be set up right at the start of –

Professor Vic Rayner: Yes.

Counsel Inquiry: – an emergency?

Professor Vic Rayner: Yes.

Counsel Inquiry: Whereas what in fact happened was that you were being sent almost finalised versions of guidance –

Professor Vic Rayner: Yes.

Counsel Inquiry: – and not given an opportunity to shape that guidance –

Professor Vic Rayner: Yes.

Counsel Inquiry: – as it was written?

Professor Vic Rayner: Well, I think at this early stage we were getting guidance that had “and social care” added in behind health.

Counsel Inquiry: Thank you.

Professor Vic Rayner: That’s as bespoke as it felt.

Counsel Inquiry: Thank you. And if we look at page 4 of this chain, we can see that, just summarising, you say that the information is helpful, and then in the second paragraph you say:

“However, I think that the advice, whilst talking about the care sector, does not feel like bespoke guidance that will reflect the reality of someone in either a homecare or residential setting …”

And you go on to say that there are some really practical challenges that you think the guidance either needs to recognise or, better still, address.

Professor Vic Rayner: Yes.

Counsel Inquiry: And then you go on, don’t you, to set those out?

Professor Vic Rayner: Yes.

Counsel Inquiry: And again, just summarising, you talk about people, older people who were living with dementia or very profound learning disabilities, and the practical difficulties they would have, for example, with face masks or self-isolation?

Professor Vic Rayner: Yeah.

Counsel Inquiry: You talk about the storage of waste and how guidance that would be given to hospitals, where there would be special areas to store waste –

Professor Vic Rayner: Specialist areas, yes.

Counsel Inquiry: – would not apply to someone, for example, with incontinence pads building up in their own home where they’ve got no other space?

Professor Vic Rayner: In their own home, yeah.

Counsel Inquiry: You talk about laundry in the same context, and you go on to explain, quite importantly, that personal care in fact involves care workers being in very close contact –

Professor Vic Rayner: Closer than 2 metres, yes.

Counsel Inquiry: – and therefore the advice that was being given that people should avoid within being 2 metres didn’t really apply, and then you go on to talk about self-isolation again.

Then you say that you would recommend that before the guidance is published, that you’re given an opportunity to have a second review of that guidance.

Professor Vic Rayner: Mm.

Counsel Inquiry: Did that happen?

Professor Vic Rayner: I don’t know, to be honest with you. It came out a few days later, so quite possibly not.

Counsel Inquiry: Thank you.

Then on page 5 we can see in the last main paragraph that you say that there’s a wide range of other issues that you know have been discussed, and that relates to issues that you’d already raised in January and February in relation to things like workforce, PPE supplies, and additional costs; is that right –

Professor Vic Rayner: Yes.

Counsel Inquiry: – of the equipment that was being required?

Professor Vic Rayner: Equipment, working in different ways, trying to support people who were being isolated, you know.

Counsel Inquiry: Thank you. And just for completeness again, if we look at page 2, we can see that other people who were copied in, so at the bottom of the page, that’s the Care Quality Commission responding to your email saying that they have nothing to add beyond what you had raised. They agreed that it wasn’t particularly tailored to the adult social care context, and they encouraged taking up of the offer of working with the Care Provider Alliance to make sure that the guidance landed well and didn’t create a high volume of follow-up questions and feedback that they had no plan for addressing.

So the position is that they’re saying, actually, this is going to save you work –

Professor Vic Rayner: Yes.

Counsel Inquiry: – if you put the work in now.

And on page 1, we can see – sorry, in between there is also a response from the director of Association for Real Change and then on page 1, there’s also response from the government saying that you made some good points, but also raising the fact that social care is also provided a great deal by unpaid carers and personal assistants, and it would be helpful to have that reflected in the guidance. So that’s someone within the government raising that in February?

Professor Vic Rayner: Mm.

Counsel Inquiry: And did the guidance in February that was issued on the 25th include all of those points?

Professor Vic Rayner: I don’t think it did. But I haven’t got that, the detail of that.

Counsel Inquiry: If we look at, please, INQ000049574.

Professor Vic Rayner: Do you know what tab that is?

Counsel Inquiry: Yes, sorry, I didn’t make a note of that, I’m trying to look it up now. I think it’s tab 17.

I’m not going to go into the details of this but just to have a quick look, we can see that this is a meeting on 10 March. It’s a meeting between Liz Jones, who is your policy director, and 53 members?

Professor Vic Rayner: Yeah.

Counsel Inquiry: We can see that the purpose of that, if we look at the session names, is to support members, but also in the fourth paragraph we can see that it – what’s noted there, that it’s:

“Important to engage to try to ensure government does not make incorrect assumptions about how local areas are responding” –

Professor Vic Rayner: Yeah.

Counsel Inquiry: – “and the ability of providers to respond on their own, without coordination and support across [local authorities], local health systems and supply chains.”

And was the plan to feed back these concerns to the government, I think at this stage through the national steering group?

Professor Vic Rayner: Yes. So there were various iterations of early groups, and the national steering group may have been one iteration of that, but yeah.

Counsel Inquiry: Yes, thank you. Sorry to rush you, but I just want to deal with this quite quickly.

Professor Vic Rayner: Yes, of course.

Counsel Inquiry: Because we will be moving on to the various groups that were set up, but on 10 March, is it right that you were raising similar concerns again, but in addition at this point, you were also raising the concern that actually it wasn’t something that could be coordinated locally, and that there were concerns about the response that had been received so far locally –

Professor Vic Rayner: Yeah.

Counsel Inquiry: – from local resilience forums, the NHS, and community healthcare?

Professor Vic Rayner: Yes.

Counsel Inquiry: And so was this, on 10 March, the National Care Forum really saying to the government: We need central leadership and coordination?

Professor Vic Rayner: Yeah, I mean, I think there were – part of the challenge throughout the pandemic, to be honest, was the – was about the relationship between national, regional and local systems, and indeed between different parts of national government.

So, for example, in areas like guidance, we had a number of different bodies making guidance. So Public Health making guidance, NHS England making guidance, DHSC making guidance, which all interrelated. And then what happened was that went out to local systems and sometimes it said things like, you know, the local director of public health will make a decision in relation to this. So then there was another layer of decision making and direction that providers had to experience.

So I think that early on it was obvious that there did need to be some national steerage of it, but that the sort of – those inconsistencies between who held decision making powers that were evident from 10 March and earlier, to be honest, onwards, continued throughout the pandemic, actually.

Counsel Inquiry: Thank you. And I don’t think we need to go to them but is it right that one of the issues that you had to repeatedly raise similar concerns about was in relation to PPE?

Professor Vic Rayner: Yes.

Counsel Inquiry: And you have exhibited, for example, communications I think from Liz Jones on 1 April 2020, and again on 7 April 2020, raising concerns about guidance and, in particular, the sector-specific PPE guidance that was issued in April?

Professor Vic Rayner: Yes, so that guidance was issued with – that was the first – on 2 April, that was the first kind of bespoke PPE guidance, but it wasn’t – it didn’t feel bespoke. It referred – it tried to compare domiciliary care sessional – sessions with ward rounds. It talked about – it very clearly was based around a model where people who were receiving care, which really meant healthcare in that context, stayed in bed all the time, and didn’t move anywhere. It was just inappropriate.

And it talked about bits of PPE which really were not part of the common usage in the care sector. So particularly around eye visors and goggles which hadn’t been – are not a day-to-day part of the delivery of social care.

Counsel Inquiry: So that stemmed from, you say, a misunderstanding –

Professor Vic Rayner: Yeah, I mean, it just –

Counsel Inquiry: – an over-clinicalisation of –

Professor Vic Rayner: Well, I think if that was what people needed to wear and use, that’s – you know, we’re not – I don’t think anybody was disputing the kind of clinical expertise. It was more about, if this is a piece of guidance that’s supposed to give clarity to people who are delivering social care so that they are confident that they are supporting their staff appropriately and supporting people who deliver care and support, then it had to talk to the experience that they were living.

So it was so confusing. We had so many questions about it. And that was on 2 April.

Then on 12 April, they moved to a position of sustained transmission, which required people to shift gear again to another level of PPE. And that was so poorly communicated to the sector –

Counsel Inquiry: Is the example that you give in your statement where there’s a small print –

Professor Vic Rayner: There’s a small phrase that says we’re now in sustained transmission –

Counsel Inquiry: – (overspeaking) – communicated –

Professor Vic Rayner: – look at table 4.

Counsel Inquiry: – yes.

Professor Vic Rayner: You know, so that meant again, that people, you know, were trying desperately – I think that was one of the, you know, very difficult times, over an Easter weekend or something – you know, it was one of those periods where people were trying to get hold of PPE. We spent all of our time trying to support members to connect up with local resilience forums, access PPE in other ways, trying to – and raising those directly with the government centrally, but also working with colleagues in local government and the Association of Directors of Adult Social Services to ensure people understood what they needed to do, but also got the resources they needed.

Counsel Inquiry: Just to summarise, Professor, on 1 April, this is one of the emails, we don’t need to go to it, but it’s one of the emails that was sent to DHSC about PPE, and in that email, there’s a reference to what’s called “the cycle of doom”?

Professor Vic Rayner: Yes.

Counsel Inquiry: Is that right?

Professor Vic Rayner: Yes.

Counsel Inquiry: And that’s a reference to care providers feeding back that they were contacting the PPE helpline, the helpline then said, “No, either you’ve had a delivery or you need to talk to your usual suppliers”?

Professor Vic Rayner: Mm-hm.

Counsel Inquiry: The usual suppliers would then say, “Oh, no, the NHS have requisitioned all the supplies, you need to speak to them”, and then the NHS Supply Chain would say, “No, you need to go to the PPE helpline.”

Professor Vic Rayner: Yes.

Counsel Inquiry: And so that’s what was called –

Professor Vic Rayner: It was the PPE cycle of doom, yes.

Counsel Inquiry: – the cycle of doom?

Professor Vic Rayner: And it was –

Counsel Inquiry: In addition to raising issues about wrong people being delivered, poor quality PPE being delivered, the rising costs of PPE, and also inconsistent –

Professor Vic Rayner: Yes.

Counsel Inquiry: – advice about PPE being given by different people.

Professor Vic Rayner: Yeah, a huge – hugely escalating cost of PPE. I think that’s really important to understand.

Counsel Inquiry: Thank you.

Professor Vic Rayner: Things that people were, you know, routinely buying, you know, in small quantities, they were now having to buy in huge quantities and the price had gone up, you know, 100% or more and there was not funding or support for that.

Counsel Inquiry: Thank you. And is it right that the PPE guidance also made the incorrect assumption that care providers in fact had a stock of PPE, but you say in your statement that actually the use of PPE within the sector was pretty limited –

Professor Vic Rayner: Yes.

Counsel Inquiry: – before the pandemic?

Professor Vic Rayner: So people would have had PPE for instances where they needed to do sort of barrier nursing or, you know, if somebody – if there was an outbreak of something like norovirus or that, but it’s not routinely used, for many of the issues we’ve raised, so if you have a face mask on, for example, it’s very difficult to communicate with somebody with a hearing loss or with dementia who is reliant on, sort of, facial recognition, signals, et cetera, and it’s not part of the kind of clinical guidance in those settings.

Counsel Inquiry: And –

Lady Hallett: Forgive my interrupting. Did you hear Mr Hancock suggesting that care homes should have a month’s supply of PPE? Have you got a comment on that?

Professor Vic Rayner: Well, it’s – I mean, his sort of assumption that having that in preparation for a pandemic, and the volume of PPE that people were using did not seem to be particularly practical. And there are many other practical recommendations like, for example, allowing care providers to purchase through the NHS PPE procurement channels, or indeed providing free PPE right from the start at the beginning of the pandemic, so that people don’t have to rely on that.

Of course providers – you know, they will have some stock available because they need to be prepared for outbreaks of, you know, or a requirement to do that, but yeah, the idea that they have got a month’s worth of supply. If they want – you know, this is a broader – that’s a broader discussion about what we want providers to do, and actually, if on 24 January, there had been an engagement with the sector to say, “Okay, this is what we think is going to happen, let’s help you get the PPE you need, let’s help you think about what isolation might look like, let’s help you think about the fact you might not be able to move staff around”, that would be a very different situation.

Lady Hallett: Thank you.

Ms Jung: You talked about the National Steering Group earlier. And is it right that that did start meeting fairly early on in the pandemic?

Professor Vic Rayner: Mm.

Counsel Inquiry: But what you say about that in your statement is that the early meetings were ad hoc and uncoordinated.

Professor Vic Rayner: Mm.

Counsel Inquiry: And it wasn’t, I think, until the summer of 2020 that the processes became more structured.

Professor Vic Rayner: Yes. So there were lots of little groups that met about particular topics, and then that all got sort of brought together, but the very early groups were really, you know, a meeting with sort of a peer with very short notice and as far as I’m aware, I don’t think we got particular minutes from those meetings or anything. They were a more of a kind of, you know, “What’s the latest situation?”

Counsel Inquiry: Did you find them helpful forums for being able to input and pass on the concerns?

Professor Vic Rayner: I certainly passed on the concerns. I think it’s less obvious what happened as an immediate result of that.

Counsel Inquiry: And what access did you have through those early forums to decision makers?

Professor Vic Rayner: I mean, I think we had – one of the reflections, I think, in the email you’ve just shown is that it was a small team in DHSC, so there was a relatively small team focused on social care pre-pandemic. So we had, you know, we did have connection with the director at the time, and soon to be Director General, and others. So yes, it wasn’t – there wasn’t a barrier that was put in the way of that.

And similarly with the minister when Helen Whately came into the ministerial role that the Department encouraged connection with her.

Counsel Inquiry: And it is right, isn’t it, that you say that those small groups were constantly merging and changing?

Professor Vic Rayner: Yeah.

Counsel Inquiry: Did you think that that was a necessary response to the rapidly evolving situation, or did it lead to any overlap and duplication of work or groups working in silos?

Professor Vic Rayner: I think there was definitely some silo working. So often we as an organisation, you know, and we’re not a big organisation in any stretch of the imagination, and certainly we tried to go to as many of those meetings as possible and we often found that we were in those meetings pointing out what the other meetings were talking about, so, you know, trying to connect the workforce meeting, for example, with the discussion around PPE with the discussion around testing. So there was definitely a need for more coordination in that sense.

Counsel Inquiry: And did the same principle apply with guidance –

Professor Vic Rayner: Yes.

Counsel Inquiry: – writing, that there were various different teams doing the guidance. I think you alluded to that earlier. But –

Professor Vic Rayner: Yes.

Counsel Inquiry: – did that lead to a lack of coordination?

Professor Vic Rayner: Yeah, and I think the team that we might have had more opportunity to influence was DHSC when they were writing guidance. We had very little ability to influence PHE or NHS England where they were writing guidance that was relevant to the social care sector which lots of it was, but we didn’t – we relied on DHSC colleagues to do that, and I don’t know how straightforward that was for them to influence it.

Counsel Inquiry: I think in your statement you say that your engagement with PHE improved over time.

Professor Vic Rayner: Mm.

Counsel Inquiry: But they were involved in drafting some of the guidance in February, so quite early on. You say in your statement that DHSC had limited understanding of how adult social care was provided in practice and on the ground. Is that something that you also say applies to PHE or not?

Professor Vic Rayner: Yes, I would say that. So we had some good engagement with individuals in PHE and, you know, hugely grateful to them for the time that they gave to that but I think it’s only relatively recently in the reformation of UKHSA that there’s a specific social care team now within that body.

So, you know, that will have a better understanding of the environment in which PHE – public health advice has to operate within.

Counsel Inquiry: Thank you. And you said earlier that all of these small groups eventually came together and you were part of the taskforce, weren’t you, led by Mr Pearson?

Professor Vic Rayner: Yes, so –

Counsel Inquiry: And as far as thinking about the future is concerned, would you say that the membership and the structure of that body is the type of thing that should be replicated again in future or do you have any concerns, for example, about any voices that were missing from that group, or anything else?

Professor Vic Rayner: So the taskforce then split into a number of different subgroups. So I co-chaired the workforce taskforce side of it, and we came up with a range of short – immediate and short-term actions.

I mean, I think the problem with that is that they were not implemented. Largely, they were not implemented. They were very – they were based on the experience of trade unions, of other workforce representatives, of employers, including people who employ their own assistants.

You know, they were – they represented a broad cohort of stakeholder voices. I think the difficulty is that they – the recommendations didn’t manifest. So there is a real challenge about setting up that kind of body –

Counsel Inquiry: Yes.

Professor Vic Rayner: – and then not delivering on what it’s suggesting. I think –

Counsel Inquiry: There’s no point having a body recommending things if they’re not going to be implemented?

Professor Vic Rayner: No, and I mean – and some of those things I think, for example, in that context were about sort of the occupational health and wellbeing of staff, a crucial concern for employers, a crucial concern for people across the sector. And recommendations about occupational wellbeing schemes and things, you know, that could easily, relatively easily have been operationalised and weren’t.

Counsel Inquiry: Yes. And we have, in fact, your reports from that subgroup.

Professor Vic Rayner: Yes.

Counsel Inquiry: And the Inquiry has read those, but as far as the structure of those groups are concerned, would you say that they did allow you to meaningfully engage at that time?

Professor Vic Rayner: Well, depends whether engagement leads to something.

Counsel Inquiry: Yes.

Professor Vic Rayner: But they certainly allowed us to express a set of perspectives.

Counsel Inquiry: You talked about there now being an adult social care team. Just before we end this topic, are there any other specific recommendations that you would invite to help with improving the understanding of decision makers and people who are drafting guidance when it comes to the realities of adult social care operation on the ground?

Professor Vic Rayner: Yeah, I mean, I think that they shouldn’t – you know, those kind of decision-making groups shouldn’t exist without the experience of – the operational experience of both people delivering care and support and people receiving care and support.

I mean, I think you can see that in all sorts of decisions that were made, that they didn’t – they would have been much better able to be implemented if they had had that operational experience right from the start.

Counsel Inquiry: From the start.

Professor Vic Rayner: And I think that is an – there’s an underpinning message there about recognising the professionalism and expertise within the sector, that when there are – I mean, I was listening carefully to Mr Hancock’s evidence yesterday when he was talking about social care representation being him and his minister. You know, we are still in a position where the, sort of, leadership and expertise of social care is not properly recognised and built in, and I think that’s – having that as a legacy of the pandemic would be really valuable, to have that built in.

Counsel Inquiry: You say the voice should come from the sector?

Professor Vic Rayner: Yes.

Ms Jung: Yes. Thank you.

My Lady, would that be a convenient time?

Lady Hallett: I hope you were warned that we were going to go over lunch. I’m sorry, I usually try to finish a witness, but I’ve got to be considerate of the stenographer, who had quite a tough day yesterday.

The Witness: Yes.

Lady Hallett: So I shall return at 1.45 pm.

(12.49 pm)

(The Short Adjournment)

(1.46 pm)

Lady Hallett: Ms Jung.

Ms Jung: Thank you, my Lady.

Can I ask you, on a very brief topic, when did the National Care Forum first become aware of the possibility that patients being discharged from hospital would be discharged to care settings?

Professor Vic Rayner: I don’t know exactly when we were involved in some of the discussions about it. I obviously know the dates when the various bits of guidance came out. There may well have been discussions previously at the national group about it and about the implications of that and some of the things that we would have certainly been advocating needed to be put in place before that was possible.

Counsel Inquiry: But you think it was ahead of the guidance.

Professor Vic Rayner: I think it would have been part of a discussion, yes. But not, not in a kind of … yeah. I’m sure it would have – there would have been discussions because that was part of that, yeah.

Counsel Inquiry: Can you say whether it would have been as early as February or not?

Professor Vic Rayner: I don’t recall.

Counsel Inquiry: Okay. Do you think, if you had had early notice of that possibility, that there would have been any practical measures that your members could have –

Professor Vic Rayner: Absolutely.

Counsel Inquiry: – put in place?

Professor Vic Rayner: Yes.

Counsel Inquiry: What do you think those –

Professor Vic Rayner: I mean, I think that – I think when there were – I mean, some of the things, we produced something post the guidance and post the discharge which was something that was framed as, sort of, tips for providers about hospital discharge and that included the, sort of, things that they should be advocating for and were necessary about, you know, having sufficient PPE for somebody during the period of isolation; obviously testing prior to discharge; having access to the correct clinical and community health support that people might need, you know; and ensuring people’s ongoing health needs, because I think that’s a really important part of the whole discharge discussion, is that people were clinically fit in the sense they didn’t need hospital treatment but it didn’t mean they didn’t need ongoing health treatment.

In fact, most people within care settings have some generally fairly significant ongoing health requirements, sorry, in care settings have that.

Counsel Inquiry: Thank you.

Last main topic. It’s on ventilation, please.

Professor Vic Rayner: Okay.

Counsel Inquiry: Is it right that in April 2020 you had an expert called Eric Fewster come and do a report, I think, following which you produced some materials on ventilation.

If you want to turn it up, Professor, it’s tab 11, his report, in your bundle. I don’t think we need to put it up on screen. But just to summarise, is it right that he advised that it was important to understand that natural ventilation, for example opening doors and windows, may not provide the ventilation rate required to significantly reduce airborne transmission risk, even in the summer?

Professor Vic Rayner: Yes, that’s part of his report yeah.

Counsel Inquiry: He went on to say that when windows are closed in a shared communal airspace, the only reliable way of reducing the risk of airborne transmission is to install a mechanical system of some sort. This could be a ventilation system that brings in fresh air to the room and extracts stale air and/or a recirculating HEPA air filtration system.

Professor Vic Rayner: Yeah.

Counsel Inquiry: And he went on to say that if such a system wasn’t available, then even if it was winter you would still have to open the doors and the windows.

Professor Vic Rayner: Yes. I think – we engaged the – Eric Fewster because he was demonstrating some expertise in this area and members were concerned about what was happening. I think, I suppose the point that this talks to, as well, is that, you know, the care settings that people operate within care homes are very, very different across the country. There are some, you know, old stately home care homes; there’s very small purpose-built homes; there’s ones which allow for cohorting and zoning and all sorts of different things. They’re not a universal approach. And so what we thought by bringing Dr Fewster and his expertise in, he could talk to members to help them work through what to do.

I think – obviously, we are not going to get a chance to talk about all the different funding that came through the very kind of sporadic funding that came from government, but it is of note that it wasn’t until the very last Infection Control Fund that there was any funding that was – that providers could possibly use for this very area of CO² monitoring or HEPA filters, so any action that providers took prior to that – and that last tranche of funding I think was towards the end of 2021 – was done by themselves with their own intent. It wasn’t supported by government in any way to do that, so …

Counsel Inquiry: And he advises, in terms of long-term strategy, that there are whole-building improvements that could be made?

Professor Vic Rayner: Yeah.

Counsel Inquiry: He acknowledged during the pandemic that those weren’t realistic in the short term?

Professor Vic Rayner: Yeah.

Counsel Inquiry: And so he advised things like PPE and good infection control measures to be put in place?

Professor Vic Rayner: Yes.

Counsel Inquiry: Do you know what the position is now, Professor? Do you know if any changes have been made in, for example, any building regulations or anything like that in relation to ventilation, and are there any practical recommendations that you would invite the Inquiry to think about when it comes to ventilation of care home buildings?

Professor Vic Rayner: Yes, so I’m not aware of any changes that have been made in relation to ventilation or in the building regulations in relation to that. There have been some made in recent years in relation to fire but not particularly in relation to ventilation.

I think that there are, you know, definitely – action that could be taken in terms of thinking about how – you know, back to my sort of central tenet, I guess, that social care is a public service, and if you want service to be delivered in a safe way, you have to think about what the state’s role is in that.

So there are many other examples of other types of services where the state has made a significant investment in the built environment, like homelessness and housing services. So if we were to look towards a different model going forward in the future of a built environment, then I think there’s clearly an opportunity for the government to think about how it invests in that in a meaningful way.

Many – much of the stock, I think there’s sort of some recent survey by – Knight Frank talked about much of the stock being over 40 years old. So it isn’t that it’s a – there’s a lot of new purpose-built provision in the environment. So if you want to retrofit filtration or if you want to create an environment where future build has that in place, we need to have some clear direction and some support to deliver that.

Counsel Inquiry: Thank you.

Could we move on to something a bit more positive.

Professor Vic Rayner: Mm-hm.

Counsel Inquiry: So is it right that National Care Forum produced an e-book called Caring in COVID?

Professor Vic Rayner: Yes.

Counsel Inquiry: Can you just tell us briefly what that was, please?

Professor Vic Rayner: So we produced the Caring in COVID book. It’s a collection of stories primarily from the first wave of the pandemic, which is showcasing the kind of activities that members of ours did during the pandemic, and it’s across a variety of themes, so there’s a strong focus around visiting and how people supported people to stay connected with their relatives and loved ones.

There’s a focus on the kind of things that staff did in order to ensure people remained safe, some very heartrending stories of people who went and lived in greenhouses in their gardens so they didn’t come near their families, or stayed within care settings.

People who worked to support the broader community, so potentially they thought about how they could engage, and people who were supported by the community too.

And I think it’s really important that there’s a recognition that, you know, whilst maybe there wasn’t such – as much national attention from a perspective of – on what care was there to do, local communities really recognised some of that and were very supportive and helpful. So it’s a great collection of that.

And we wanted to have a record of that, because we knew that as time went on, it was going to – it’s an incredibly painful period to talk about, but people are amazing, and we wanted to celebrate some of that.

Counsel Inquiry: Thank you.

Just to take one example, the Inquiry heard in the impact film that there were some people, for example, with learning disabilities who couldn’t read or write and so they were very much reliant on human contact. And I think one of the stories in the e-book talks about one particular individual who was struggling with the lack of contact, and when they introduced the virtual contact, social contact, there’s a record of that particular individual kissing the iPad?

Professor Vic Rayner: Kissing the screen, yeah. And I think this – I suppose that was the other point, is to actually just – and you would expect me to do this from my position, but I was completely overwhelmed by how creative and positive and responsive people were to try to make things better for everybody. So again – but again, that level of – you know, you’re going from a scenario where only 20% of organisations had digital care records. There was low levels of digital literacy within the care sector. There was often poor wi-fi and challenges in that context. And people invested in all of those things. They brought in iPads, they brought new technology, they fashioned pods, they created garden environments to allow people to have as much interaction and connection as possible, and I think that’s really – that’s an important part of the story as well.

Counsel Inquiry: Thank you.

And finally, Professor, are there any other recommendations that you would like to discuss today?

Professor Vic Rayner: Yes. Yes, there are.

I mean, I think there’s an overall recommendation which is about the urgent need for reform of the sector. You know, we’ve had multiple papers, policy positions, et cetera, looking at this. We went into it in a very difficult position. Five years later we’re still in a very difficult position.

Counsel Inquiry: Yes.

Professor Vic Rayner: So I think there’s things about workforce, absolutely: a workforce strategy that properly recognises the skills and expertise, and the new skills and expertise we want those workers to deliver in the future; and obviously the funding that goes with that.

The – we’ve talked a lot about data, digital, and buildings. Those all need – we need to look at what that is to be fit for the future and to have a kind of strategic plan to develop that.

And finally, something about a kind of – you know, recognising the professional kind of expertise of the social care sector as equal partners when decisions are being made. And that’s at a local level a regional level, and a national level.

I suppose my ultimate message is that we need those decision makers to think about social care first. It’s not Cinderella. It’s not the handmaiden of the NHS. It’s a vital public service that’s the backbone of communities. And we forgot that then and we must never do that again.

Ms Jung: Thank you very much.

My Lady, those are all my questions.

Lady Hallett: Thank you, Ms Jung.

Mr Weatherby, just there.

Questions From Mr Weatherby KC

Mr Weatherby: Thank you very much and good afternoon, Professor. I ask questions on behalf of the Covid Bereaved Families for Justice UK. And I have just one topic and a few questions. It’s an important topic. It’s DNACPRs, which, as you’ll appreciate, is a very traumatic topic for quite a number of the families I represent.

On 26 March 2020, you emailed Ros Roughton, who was then the DHSC director of adult social care, following contact from one of your care providers. And I wonder if we can just put the email thread up: it’s INQ000466452 and I think it’s your tab 18.

Professor Vic Rayner: Thank you.

Mr Weatherby KC: And it’s up on screen now. Can we have page 3, please. So 26 March. And you’re sending this, as I say, to Rosamond Roughton?

Professor Vic Rayner: Mm-hm.

Mr Weatherby KC: And you say:

“Ros – we have been contacted by [a care home provider] in relation to a flurry of emails and letters from their local GPs essentially requesting that all residents in the home are put onto a DNAR. In one of the emails (which I know is not the scanned copy …) there is even a suggestion the GP is following government guidance stating that all over 70s in homes should be issued with a DNAR. This is a very urgent situation that could escalate very quickly and unhelpfully causing lots of fear and concern amongst residents and their families. Made worse by the fact that people are being asked to make decisions about their family members who they may not even be able to see for the last couple of weeks, nor do they have any prospect of seeing.”

“I would like clarification asap if this is in any way endorsed government policy …”

Then it goes on. I won’t read it all. Then finally:

“I would be grateful if you could also let me know the response … I think these things are probably happening all over the country …”

You then sent, later the same day in fact, going up to page 1 of that thread, please, the bottom half, to the same – well, to a CQC person but also copied to Rosamond Roughton – sorry, I’ve lost my reference. Just give me a moment.

Sorry, you sent another email in the afternoon, bottom of page 1.

Professor Vic Rayner: Yeah.

Mr Weatherby KC: “Further letter has come through on this issue” – it’s headed “Sample of GP letters”.

“The penultimate paragraph says this:

‘We will also be signing forms to say that if your heart or breathing stops, the carers will not resuscitate you, there will not be ambulances available to continue any resuscitation or take you to hospital so that will not work. You would be unconscious quickly and not be aware that this is happening to you and not be in any pain.’

“The homes are being asked to give this letter out to residents in the care home. Apart from this being an extraordinarily upsetting letter for people to deliver to already vulnerable and anxious residents and families, it is essentially telling people that they will be left to die. Where was the decision to ration resources in this way made?”

Then you continue, in terms of community health and the CQC.

Just two points arising from that. Your email suggests that there were multiple GP practices involved. Are you able to help us in how widespread you understand this issue was at the time?

Professor Vic Rayner: So on that day that we had received note that there was a flurry of emails, so that was the description that I haven’t – couldn’t quantify that any more, but I was aware from talking with other colleagues in other organisations like my own that they were also aware that other groups of people had received these messages –

Mr Weatherby KC: Yes, so not an outlier but a flurry.

Professor Vic Rayner: It was – I think it was an early – a bit like I was describing earlier: an early indication of something that we wanted to stop before it got more. But there’s definitely not the suggestion it was one letter alone.

Mr Weatherby KC: No, indeed. And you say as I’ve just read out:

“I think these things are probably happening all over the country.”

And is that because the accounts you were receiving were coming from different areas?

Professor Vic Rayner: So the provider I was talking about were a national provider so they were reporting it was from different parts of the country.

Mr Weatherby KC: Yes, thank you. To your knowledge, who was instructing, if anybody, who was instructing GP practices to put DNACPR notices such as this in place?

Professor Vic Rayner: I never had any answer to whether there was any instruction around that, and in fact, what happened as a result of this is we quickly did work with the Care Quality Commission and the BMA, and I can’t remember who else’s signatures, but we put together a statement to –

Mr Weatherby KC: That’s my last point –

Professor Vic Rayner: – (overspeaking) –

Mr Weatherby KC: So I’m going to take you to that if I may. I think it’s your tab 19. It’s INQ000398629 and it’s page 7.

So as you say, within a very short period of time, this is 31 March –

Professor Vic Rayner: Yes.

Mr Weatherby KC: – you and others, and you say the RCGP, the BMA, and the CQC –

Professor Vic Rayner: Yeah.

Mr Weatherby KC: – got together a joint statement.

Professor Vic Rayner: Yes.

Mr Weatherby KC: It’s set out there in your email.

Professor Vic Rayner: Yeah.

Mr Weatherby KC: I won’t read it all out but it sets out in very clear terms the importance of having personalised care plans in place, particularly for people who are elderly, frail, or have other serious conditions. And it sets out what we’ve heard over and over again in this Inquiry about the importance of the person themselves that they have capacity, and the family?

Professor Vic Rayner: Yes.

Mr Weatherby KC: And then being individually put forward. And it finishes:

“It is … unacceptable for advance care plans, with or without DNAR form completion to be applied to groups of patients of any description.”

I think, again, we won’t go through the thread but on that thread there was some discussion about whether it should be made even tougher –

Professor Vic Rayner: Yes.

Mr Weatherby KC: – in that joint statement.

Professor Vic Rayner: Yes.

Mr Weatherby KC: But that was point out in an attempt to bring an end to –

Professor Vic Rayner: Yes.

Mr Weatherby KC: – what was apparently a –

Professor Vic Rayner: In the end that was a – we were happy to go forward on the basis of expediency.

Mr Weatherby KC: Yeah. And knowing what you know, was the statement, in your view, strong enough?

Professor Vic Rayner: I think that was the last time I heard of that situation. So yes, I – and I think it’s a very good example of that, but it also, I think, is, you know, the mechanism from my memory was that the surgery had sent this to the care home and asked the staff to deliver that message.

Mr Weatherby KC: Yes.

Professor Vic Rayner: You know, based – bearing in mind this is potentially against people who have only just been discharged into the care of that home where they have no relationship with the relatives, so I think the impossibility of the task and the inappropriateness of it combined was our urgent act – need to act.

Mr Weatherby KC: So you as an organised identified the problem, brought it to government’s attention, got together a consortium of people –

Professor Vic Rayner: Yes.

Mr Weatherby KC: – to put forward a strong statement in an attempt to do something to stop it?

Professor Vic Rayner: Yes.

Mr Weatherby KC: Do you think there’s a risk of a similar practice happening in the future, and what needs to be done now, in terms of avoiding it if that’s the case?

Professor Vic Rayner: I mean, I think that the – I suppose I’ve mentioned about the need to have social care as part of decision making, so I think this is – I suppose we read this as a kind of clinical response to a situation, rather than a response that focused on people, and that’s, I think, where social care can add huge amounts of value. So I think having an integrated – I mean, we talk a lot about an integrated health and social care system but often that means an integrated health system delivering to care and I think, going forward and we’ve just got the 10-year plan launched today, and we’ll be looking at that very closely to see if it actually means meaningful integration.

Mr Weatherby KC: Yes.

Professor Vic Rayner: So that will be one bit of it. And I think the other potential – you know, the other way, going forward, is to have a much, you know, there’s an ambition for a shared care record. I think, very clearly, having a care record that moves when people move, goes with them, would mean that their sort of wants for themselves or their guardians’ wants for themselves are clearly articulated and cannot be overridden without permission.

Mr Weatherby KC: Yes. And finally, we heard yesterday the suggestion that there were various rumours during the pandemic about things which may or may not have happened in respect of this problem, DNACPR; you’re clear, I think certainly from this correspondence, that there were blanket decisions –

Professor Vic Rayner: Yes.

Mr Weatherby KC: – being made? At least at that point.

Professor Vic Rayner: Yes.

Mr Weatherby: Thank you very much, Professor.

Lady Hallett: Thank you, Mr Weatherby.

Ms Foubister. Who is over that way.

Questions From Ms Foubister

Ms Foubister: Thank you, my Lady.

Good afternoon, Professor Rayner. I represent John’s Campaign, The Patients Association, and Care Rights UK.

At paragraph 6 of your statement you explain changes to the CQC regulatory inspection regime during the pandemic, and you highlight some concerns, including: first, that the regulator was slow to act on serious concerns about clinical practice and decisions relating to social care; second, the suspension of onsite inspections; and third, the move to a risk-based model for inspection and regulation.

And you also explain that outdated ratings caused issues for providers accessing insurance cover and in securing public sector contracts at crucial points in the pandemic, and in many cases are still causing issues.

Do you agree that proper regulatory oversight should have continued during the pandemic, and if so, what more should the CQC have done?

Professor Vic Rayner: Yes, I think that we – the points that you’ve raised were absolutely the things that we were concerned about. I think, in the context of what proper regulatory oversight would look like, did need to change, probably because of the – you know, the prevalence of onsite inspections.

I think our experience of working nationally with the CQC was different to the local experience of providers. So some providers would talk positively about their relationship – their ongoing engagement with their local inspector, and that – you know, that was helpful for them. It wasn’t universal, it wasn’t across the board, but that was helpful for them.

I think nationally we saw that there was – there was probably more that could have been done to identify – you know, utilise their data, for example to identify trends and issues, and to be more public about some of those challenges that they were seeing.

There were lots of – you know, we knew there were lots of data coming through which talked about any breaches or anything like that, but more sort of oversight of that and bringing that forward would be helpful.

I think there’s a very large support from the provider sector about what good regulation is. I think you’re right to say that we believe that there’s challenges continuing and ongoing, and we certainly, in part of my role in the Care Provider Alliance, have been focused in on reviewing the CQC and the changes in regulatory regime that’s made subsequent to the pandemic.

Ms Foubister: And visitor restrictions removed other eyes and ears which played a role in ensuring good quality care and identifying inadequate care during the pandemic, including not just family members but also visiting professionals like GPs. How did that impact on the rights of people who live in care homes, including to access the healthcare they needed?

Professor Vic Rayner: So, I think that – I mean, we were very active working with colleagues in John’s Campaign and other organisations around visiting restrictions, to try to do as much as possible to bring more visitors back in to services, and, equally, trying to ensure there was better access for community health services and access to physios and others.

I believe that we need to do much more going forward to balance those risks that came, that were identified in the pandemic.

So we spent a lot of time kind of measuring those markers of infection but not looking as much at the, kind of, markers of isolation and loneliness, and getting that balance right from a human rights perspective.

So I think that the absence of visitors and the absence of visiting professionals changed the dynamic of the home, absolutely. And I think that would – that is things that – you know, I hope people feel that, once restrictions were lifted, there’s been a welcoming back in of both people and those professionals.

Ms Foubister: Do you agree that CQC should have a duty to monitor compliance with legal duties, including human rights and equality legislation and guidance, including on visiting and risk assessments?

Professor Vic Rayner: Well, the CQC – well, my understanding is the CQC framework is built around a human rights framework, so it does have a strong focus on human rights within it.

I think in the context of the regulations that have been introduced since the pandemic around visiting, I think that, you know, it’s an important – you know, it’s back to: what are we going to value?

And if – we need to make sure that if the regulator is looking at areas like visiting, we’re also at the same time capturing why that’s important. So that when or if another pandemic comes that puts at risk roles like essential caregivers, we’ve got the evidence there to demonstrate not just that people have complied with allowing visitors in, or whatever the – you know, the detailed regulation, but that actually we are really clear what difference that makes to the ongoing wellbeing of people.

We’ve got the data, we’ve got the information, we can evidence it and we can show how somebody’s wellbeing is impacted by not having visiting.

And so we don’t have to have – you know, we don’t lose that relationship as swiftly and rapidly and for as long as we did during the pandemic.

Ms Foubister: And final question. At paragraph 3.2(h) of your witness statement you refer to “Care Act ‘easements’”. What was the impact of these Care Act easements on people needing care?

Professor Vic Rayner: Sorry, 3.2?

Ms Foubister: (h).

Professor Vic Rayner: (h). Sorry, I’m struggling, can you –

Lady Hallett: 3.2(h).

It’s just – the question is: you refer to Care Act easements, what was the impact of the easements on people needing care? Can you deal with that in general terms?

Professor Vic Rayner: Yes, of course. Yes. So I think the impact – I think part of the – the easements were something that we, you know, obviously monitored where easements were happening in different parts of the country, but I think the part of the – part of the reality of the squeezes and the decades of kind of austerity prior to the pandemic meant that the Care – the overall implementation of the Care Act as a whole has not been fully achieved in lots of parts of the country. So the easements – the impact of bringing in easements at that point will have exacerbated for some groups of people the challenges that they were facing already.

I think, in terms of sort of lack of access to assessments and those other areas, you know, we’re in a scenario where currently we have long backlogs of people accessing assessments. I think, you know, it’s part and parcel of an overall lack of value of the importance of social care to people in terms of living the fulfilling lives that they need to have, and the willingness to, sort of, bring in sort of easements rather than perhaps some of the other changes that might have properly funded, for example, people’s ability to isolate or buy in HEPA filtration or whatever. I think it is – you know, there’s a story that needs to change about how people’s care is valued at both a national level and in the public’s perception.

Ms Foubister: Thank you.

Nothing further, my Lady.

Lady Hallett: Thank you.

Professor, that completes the questions we have for you. Please don’t worry if we haven’t covered everything in detail, I will obviously read your witness statement very carefully, and of course have an opportunity to make some closing submissions at some stage. I don’t know whether that will be you again, but wherever you are, be that in the witness box or over there, you’re an excellent advocate for an excellent cause. Thank you very much.

The Witness: Thank you very much.

Ms Jung: My Lady the next witness is being taken by Ms Shotunde.

Lady Hallett: Thank you.

Sorry we’ve kept you waiting for so long.

Reverend Hudd

REVEREND CHARLOTTE HUDD (sworn).

Lady Hallett: Ms Shotunde.

Questions From Counsel to the Inquiry

Ms Shotunde: Reverend Hudd, you may be seated.

Reverend Hudd: Thank you.

Counsel Inquiry: Reverend Hudd, thank you for coming today to give evidence. I understand that you’re happy for me to call you Reverend Charlotte today?

Reverend Hudd: That’s fine, thank you.

Counsel Inquiry: Thank you for coming to give your account of your experience nursing during the pandemic in care homes.

If I could just start briefly with your professional background. You qualified as a registered nurse in 2009. You spent some time on wards before gravitating towards care home nursing, and you had a particular interest and specialism in end-of-life care.

Reverend Hudd: Yes.

Counsel Inquiry: You were also made a Queen’s Nurse in 2015, and became a mentor for the Queen’s Nurse Aspiring Leaders course. You then went on to qualify as a registered healthcare chaplain.

Reverend Hudd: (Witness nodded).

Counsel Inquiry: And you stopped working in care home nursing. You then started working part-time as a receptionist/patient adviser in a GP practice alongside a parish curacy as a trainee vicar.

Reverend Hudd: That’s right.

Counsel Inquiry: But at the moment you’re not working currently, are you?

Reverend Hudd: No.

Counsel Inquiry: No. So during the pandemic you worked in a number of different roles. When it started in March 2020, you were working as a charge nurse in a nursing home. You then left that role in April 2020, undertook a role as ambulance control, but then missing patient-facing care you decided to go back into nursing?

Reverend Hudd: Yes.

Counsel Inquiry: Thank you. Now, you remained as a nurse in that nursing home until 2021, and then you left that role due to the impact that the pandemic had on you; is that correct?

Reverend Hudd: Yes.

Counsel Inquiry: We’re going to go on to that during this evidence. But before we do, I just want to start briefly to discuss government guidance.

Reverend Hudd: Okay.

Counsel Inquiry: Because of course during the pandemic, the government issued a number of different pieces of guidance on different areas.

How did you receive guidance from the government?

Reverend Hudd: So if I go to the first nursing home I was in during the start of the pandemic, we – I think most of us relied on the daily address. I think what was difficult is that the daily address would happen, and then we would get to work, and we’d be expected to have put into place things that may have come up on the address, which then, as a care home, we would then be catching up a bit on “Oh, this has been announced to the public that this is going to happen” and then if there are measures to be put in place we would feel like we would be a bit behind, sometimes.

Counsel Inquiry: And so you weren’t given any advance warning of guidance before it came out, were you?

Reverend Hudd: Not to my knowledge no.

Counsel Inquiry: What do you think may need to change if there was another pandemic in the communication of guidance to care homes?

Reverend Hudd: I think, so with social care, guidance to social care sector should be on par with acute NHS, acute NHS and community NHS. They should be seen as concurrent service providers.

Lady Hallett: In other words, guidance that’s targeted to the social care sector, as opposed to just handling the social care sector, the guidance that goes to NHS? Is that what you mean?

Reverend Hudd: Um –

Lady Hallett: And at the same time?

Reverend Hudd: Yes, so – yeah, so equity of communication to be paid to each.

Lady Hallett: I have it. Thank you.

Ms Shotunde: And just to talk about the types of homes, nursing homes that you were working in, were they both in respect of older people, people with complex needs, those sorts of conditions?

Reverend Hudd: So the first home I was in was mostly people living with dementia, and some with long-term neurological conditions, so Parkinson’s, strokes, that sort of thing. The second home I worked in unusually, but not uniquely, we had a person in there with complex needs, 24-hour needs, which needed one-to-one nursing care over the 24-hour period. So that isn’t a norm for a nursing home.

Counsel Inquiry: And with that second nursing home, I understand it could cater for up to 21 residents; is that correct?

Reverend Hudd: Yes.

Counsel Inquiry: Yes. So just generally, just in respect of guidance on infection prevention and control, such as visiting, testing, isolation, PPE, those sorts of things, did you find that they helped or hindered in your attempt to keep those residents safe in nursing homes?

Reverend Hudd: So if I go back to my first nursing home, so guidance came out quite quickly, and so for example, wearing masks, when to wear them, how often, and I remember in the first home we couldn’t keep up with – we couldn’t put our hands on materials, masks and things, as efficiently as we wanted to, because in that sector we weren’t used to – we had loads of aprons but masks were a main issue.

But our home were quite creative, we were all quite creative in trying to source products from other means, other businesses, even a local university. And even to the point of sheets being assembled and I remember seeing two seniors in the home making full aprons as a ‘just in case’ – yeah.

Counsel Inquiry: Were they making them with the sheets?

Reverend Hudd: Pardon?

Counsel Inquiry: Were they making the aprons with the sheets?

Reverend Hudd: Yeah, we made them so then they could at least be washed because then the next worry was okay, masks are an issue, what if gowns are going to be a supply problem as well? And obviously bin bags only go so far. So yeah, so we made things that could be washed, essentially, and that was probably more geared up to, again, with that patient group being quite vulnerable. People with neurological conditions often have swallowing deficits and cough a lot anyway, so we were prepared for a full ‘just in case’ for spraying.

Counsel Inquiry: And I understand you did not have plentiful supply of masks when wearing masks became mandatory?

Reverend Hudd: No.

Counsel Inquiry: In your statement you mention things that you and your colleagues used to do to try to preserve the masks during lunchtime. Could you just describe that, please, briefly?

Reverend Hudd: Yes, so when mask wearing was mandatory continuously, as it should, at that time, we didn’t have enough products so we were then suggested – we had little – those little self-sealed Tesco bags that you put your lunch in, so we’d have the same mask, and then we’d put that into our little bag, seal it, have our lunch, and then put it back on. But then the confusing thing was, was the minute you touch your mask, you can’t – you have to get another one. But, you know, we just had to make, you know, we had to make do with what we did, and so that’s what we did. Yeah.

Counsel Inquiry: I understand you had training on the donning and doffing of PPE; is that right?

Reverend Hudd: Yes. So donning and doffing, that’s something that’s not uncommon in care homes anyway. That’s actually a – that’s part of mandatory training, but obviously it was re-emphasised because of the frequency of donning and doffing and appropriate dressing.

Counsel Inquiry: You speak in your witness statement about there being a stark difference between the PPE that you would wear or care home staff would wear and the PPE that external professionals would wear coming into the home, and could you just describe that for me, perhaps maybe the funerals directors for an example?

Reverend Hudd: Okay. So that was in my second care home. So that was – so 20 – start again. January of 2021 was when the care home became a hot zone because of multiple infections. So during that time, we still wore the surgical masks and aprons, getting hold of FP3 was difficult. We did at one time have a small supply of the FP3 masks which was just for one particular patient, the intensive care patient we had.

But yes, so we had this, and at the beginning of that period of when I was living in, so any hospice or other clinicians visiting the home, which they didn’t do very often, they initially started off, they would come in and put aprons and everything on, then as time went on, as I was only living in, my window to the outside world became whoever came to the door. So as funeral directors came, the first lot would arrive in their suit and tails and then they’d put on their apron, gloves and things, and come and collect. And then that sort of progressed to suited and booted in their white hazmat, and I’d watch them dress outside, come in, and then get undressed outside.

And then further down the line when we had another hospice visit, which was a bit of an SOS from my point, then that staff were wearing full apparatus, that’s the only thing I can – you know, with the head mask and the respiratory – you know, with the visor. Something from like a CBRN, you know, a chemical nuclear – yeah.

And I think what was startling about that is not only were they – was I watching the progression of the PPE being worn, but I think for me personally, I then realised that they were suiting and booting to be protected from me because I was then living in the home, and that was quite stark, that they were being protected from me. Yeah.

Counsel Inquiry: So when those visiting professionals would come in in those forms of PPE, what were you wearing, and the other staff?

Reverend Hudd: A plastic apron and a surgical mask.

Counsel Inquiry: That’s it?

Reverend Hudd: Yeah.

Counsel Inquiry: How safe did you feel in that PPE?

Reverend Hudd: Not much. Yeah … it was a funny thing, because I was living there 24 hours a day, so the only time it really came off and stayed off for a bit was maybe at night, you know, when I put my nightie on, kind of thing. But otherwise I had, you know, PPE on my room, everywhere, and it didn’t feel great. There were times when I would double-mask, wore short sleeves. My uniform would be washed every day. But no, it wasn’t great. But then it got to a time where there were so many people infected, patients, so many staff were, and had left, that for all I knew, all of us could have been infected. Yeah.

So it was quite strange.

Counsel Inquiry: So you mentioned living in the home. That’s a period in January 2021 –

Reverend Hudd: Yeah.

Counsel Inquiry: – when you decided to stay in the home; is that correct?

Reverend Hudd: Yes.

Counsel Inquiry: I’m going to go on and talk about that experience that you had, that locked-in arrangement in a bit.

Reverend Hudd: Okay, yeah.

Counsel Inquiry: But if I could just start talking a bit about the residents.

Reverend Hudd: Sure.

Counsel Inquiry: We were just talking about PPE.

Reverend Hudd: Yeah.

Counsel Inquiry: You mentioned that you were in homes where there were older people, people with neurological conditions, people with dementia.

Reverend Hudd: Yeah.

Counsel Inquiry: What was the impact of you and other members of staff wearing PPE on those particular residents?

Reverend Hudd: The main barrier – because residents were used to others wearing aprons and gloves for personal care, but the masks was a real issue. Because people living with dementia or dementia process, they rely a lot more on your face to communicate, even if – when they have sensory impairments, sight and sound, they need to see something. And in fact a lot of us nurses wear bright lipstick so that even when their sight is impaired, they can see, you know, your mouth.

And then suddenly having that, your face blanked out, must have looked like – it was like a horror story, I think, for them, initially, because they couldn’t see you. And that created a lot of distress for them. We’d even try and draw lips sometimes on there but I don’t think that really worked.

So it would then mean that we would need more time and reassurance, which became more staff-intensive, to try to reassure and settle residents. And we’d use our eyes and eyebrows. We really trained ourselves to speak sort of above here [indicates] so that we could communicate.

But it made it really difficult for them and us, because when people living with dementia are further confused or isolated, they can become distressed, tearful, lonely, which then affects the staff, because they care for these people, but also more time was invested in settling, which is very difficult when staffing resources are already shrinking quickly.

Counsel Inquiry: So those residents were distressed by the PPE that was being worn?

Reverend Hudd: Yes, yeah.

Counsel Inquiry: You also mentioned isolation as well.

Reverend Hudd: Yes.

Counsel Inquiry: I’m going to come on to discussing visiting restrictions, for example.

Reverend Hudd: Okay.

Counsel Inquiry: At the beginning of the pandemic, I believe when you were in your first home –

Reverend Hudd: Yeah.

Counsel Inquiry: – you guys decided to put a stop to visits at the beginning?

Reverend Hudd: Yes.

Counsel Inquiry: And you stated that you could see an impact that it had on the residents. What kind of impact did it have on them?

Reverend Hudd: Confusion. And it would be things – even when it’s not clearly articulated, people who work in care homes with people with dementia become really skilled in picking up the cues of behaviour. So that sort of behaviour we could pick it up was that the residents couldn’t understand why they were in their own room and they were left there – they felt left there. Why is nobody coming to see me?

And frightened. Some thought: is it a punishment? Where is everybody? Why have you done this to me?

Lonely. And tears can happen.

And even frustration. You know, shouting. “Help!”

And one person shouted help so loudly that a policeman walking by stopped in to see what was happening. There wasn’t anything happening but, you know …

So as well as the distress of the home, it would – and us in it, and the residents, when you have a home that’s in a busy town, people do hear. And it does – it sounds horrendous. Can you imagine hearing “Help me! Help me! Waaa!”

So, you know, that was an added stress to the residents, the families, and us. Very much.

Counsel Inquiry: And there were communal areas in the home; is that right?

Reverend Hudd: Yes.

Counsel Inquiry: At some point they were closed down?

Reverend Hudd: Yes.

Counsel Inquiry: Did the residents have an opportunity to socialise with each other at all in any other way?

Reverend Hudd: So, again, depending on the guidance, and there was various, you know, 2 metres and things, so we would try and do, if you like, a communal rota, where some residents could come into – we had quite a long sitting room, fortunately, and we could put gaps between people. And that way, they could actually see another human for more than – and in and out in their room for something.

So yes, we would try to do, like, a rota of socialising, social distanced, as best we could. Yeah.

Counsel Inquiry: And then when it came to visits from family members, you’d mentioned in your statement about government guidance, and you mentioned it earlier, about it coming in quickly with no warning.

Reverend Hudd: Mm.

Counsel Inquiry: But in your statement you specifically mention guidance in respect of visiting, and how difficult it was to deal with that –

Reverend Hudd: Yes.

Counsel Inquiry: – without any advance warning. Could you just tell us a little bit about that.

Reverend Hudd: Sure. So in my second home – so by this time there had been a lot of guidance going on about no visiting, then some visiting, specific, so end – for, you know, end-of-life visiting. And lots of recommendations. And also lots of rumour because staff – people in groups hear rumour.

But the one particular thing that was very difficult was we – recall an address being made that, yes, families can go into the home – I mean, we were already doing guided visits anyway, but families can go into the home more regularly, with these things put in place, you know, the testing, putting the visitor into, like, an airlock or a specific place, you know, room, for visits to happen. So – “and this can happen on Monday”, I think it would be something like that.

So we then get lots of calls, naturally, from residents’ families, saying, “Oh, when can we come in? When can we come in?” We hadn’t had time to build an airlock. And a lot of these homes are old – big, old buildings and you might not have a particular room.

So luckily in this particular home we had such a massive, like, front door area that we built an airlock, with a door in and things, so that people could come in, have their testing, wait the time for the result to come through, dress up and come in.

But the distressing thing would be that as a registered nurse we often carry a mobile phone with us, so when we’re on call, on duty, doing drugs rounds and everything else, we were getting flooded with calls from, quite rightly, families “When can we come in? When can we come in?”

And, “Just not yet, because we haven’t built it yet.”

So that would be an enormous burden on them but also a lot of time taken up with us to explain that, “Yes, this can happen but we just haven’t done it yet.”

Counsel Inquiry: How did that affect the relationship between the care home staff and the families?

Reverend Hudd: It could put strain on it, because care home staff and families build up really good relationships over the years. And when they’re tough, there’s always a work-through. But then when families just want to be with their loved ones and they just hear this public address, “Oh, but it’s law now, we can do this”, then for staff it becomes a real – it then becomes a tension because we can’t deliver.

And we’re trying to keep relationships good, but we can’t do what you want when you want it because this address has gone out before we’ve had time. You know, we didn’t have an advance warning or anything. So it could become really strained. Really strained.

And in small places some families talked to each other, and “Well, they did, that’s not fair”, and … yeah.

Counsel Inquiry: You say in your statement that amongst families there were mixed feelings about how the home should respond in respect of visits. You said some wanted visits and others wanted a stricter lockdown?

Reverend Hudd: Yes.

Counsel Inquiry: And the tough work of mediation fell on you, as staff?

Reverend Hudd: Yes.

Counsel Inquiry: How did you approach the difficult task of balancing the competing interests of families and the concerns about infection prevention and control?

Reverend Hudd: So if I use an example from the second home with that. So factors taken into consideration are: how much staff do I have here? Because obviously when people come and visit, you need to have staff off the floor to do the testing and all that sort of stuff.

But equally, of course we want families to come in. And not only that, it’s really helpful having someone else in the room with their loved one, because it means that we know they’ve got eyes on, so we can respond elsewhere.

But every family, when it came to the time when the home was hot, it was infected, I would then risk assess every visit to each situation. So, for example, one person had a downstairs room with their own backdoor access. So their family could come round the side of the building, round the back, into the room, job done. Another family would – and if it was nice, we could do all the testing and stuff there.

Others would come through the main, into the airlock, and I would then, when it was just me as the only nurse, I would then risk assess their visit, who are they seeing, why are they seeing them, how can it be accommodated? And I took a lot of that on myself, as the registered practitioner and the senior person in the home at the time, to make sure that the family and the patient had the right care.

And sometimes it would be if staff got afraid, at this particular time, you know, two people coming in, I would, against that sort of animal, it’s that group behaviour thing of panic of explaining that: look, we’re letting funeral directors come in under guidance, and it’s the same way with allowing this particular family to come in, they’re being guided in, going through the same routine, for them to visit. So risk assessing each visit, and eventually some of the staff got really worried about infection coming into the home and so on, but we did the testing, we did all the right things.

But when I used that analogy of, well, we’re letting funeral directors in, we’re letting, you know, other community practitioners in, we’re doing the same thing, I think once that sort of got into mind, okay, then I had buy-in, and then they weren’t sort of disappearing and leaving me to facilitate. I think once they’d got that, then they were “can do” and then we could all work together.

But fear, fear is such a huge driver, and misinformation, especially people in groups.

Counsel Inquiry: Yes. You discuss an infection spike in January 2021 and still ensuring that end-of-life visits took place.

Reverend Hudd: Yeah.

Counsel Inquiry: In your statement you say that these end-of-life visits were the most sterile end-of-life visits you’ve done in your entire career?

Reverend Hudd: Yeah.

Counsel Inquiry: Now you recall a visit that took place where a resident died two hours later?

Reverend Hudd: Yes.

Counsel Inquiry: Could you just tell us a little bit about how including how you facilitated that visit?

Reverend Hudd: Sure. So that visit, very similar to the scenario I’ve given just now, actually. So the daughters, in this example, came in, did the testing and the waiting, and everything, and I took them up to see their loved one. And I’m an experienced nurse with death and dying. We can never give an exact, oh, you know, hours or days. We can usually give a, you know, like a spectrum of time, but with Covid, Covid could be really quite quick and malevolent sometimes. So when these people came in, and we went upstairs and they had their time, the patient dying two hours later, I didn’t think it would be that quick.

So it was just things like that, having to constantly update clinical thinking of visiting in good time, not too late. It was really difficult.

What was the original bit of the question? Have I just gone often on a tangent?

Counsel Inquiry: You’ve told us everything.

Reverend Hudd: Oh, sorry. I do that.

Counsel Inquiry: Thank you. We’re now going to move in to the locked-in arrangements which happen around the same time in any event. The home had managed to avoid an outbreak until January 2021, when there was a new variant. In your statement you state that 95% of the home staff were off work –

Reverend Hudd: Mm.

Counsel Inquiry: – because of Covid-related absences, and you state that you arrived on shift after the fourth long day you’d done in the past five days –

Reverend Hudd: (Witness nodded)

Counsel Inquiry: – and you were told, “You are the last nurse standing”.

Reverend Hudd: Yeah.

Counsel Inquiry: How did you feel at that moment?

Reverend Hudd: The days leading up to that day, I’d started to feel panic and fear rising, as people were dropping off, and those days leading up to that, every time I looked at the rota, it was like a Harry Potter thing where things just disintegrate in your hand. Every time I readjusted the rota, it just disintegrated, and there were less and less and less. So when I came in that morning and that night nurse was … just give me a minute.

Counsel Inquiry: It’s okay. There’s some water there if you some, and some tissues.

(Pause).

Okay, so –

Reverend Hudd: It’s all right, I can carry on.

Counsel Inquiry: Are you sure?

Reverend Hudd: Absolutely. I’ve come all this way.

So yeah, that was already building up and so when I came in and that night nurse gave me the night’s handover through an open window outside, the first thing was, I was absolutely furious that she had to be outside. She didn’t have to be outside. That was so undignified and ridiculous. Then came the realisation of there’s no more nurses left. It’s just me. And that was quite a, like an adrenaline kick.

Counsel Inquiry: And there was around 20 residents, weren’t there, at the time?

Reverend Hudd: There were –

Lady Hallett: Sorry, how many?

Ms Shotunde: Twenty.

Reverend Hudd: Around – around that. Yeah, that was boof. And I suppose in a way I knew that it was a thing that could happen, and then when it did, it was a cross between like oh, okay, a decision’s been made now, but also, fear and disbelief, a bit.

Counsel Inquiry: And it wasn’t just care staff and nurses that were not there; there was no management in the home. There was no housekeeping staff as well. There was one person to run the kitchen, and there was no cleaner or laundry service, was there?

Reverend Hudd: No.

Counsel Inquiry: So did some of those tasks fall on you?

Reverend Hudd: They – they did. And, you know, in nursing, the basics are always – they’re not basic, they’re fundamental, which is: clean, infection control, nutrition.

When the cleaning – when the housekeeping staff left, weren’t there any more, who’s going to wash the sheets? Who’s going to wash the clothes? Who’s going to keep the house clean all the time? And we were already sharing that bit, and that was just like, ooh, that’s gone, they’re gone. And no nurses except for me. Boom, that’s gone.

Kitchen. Thank goodness the guy stayed in the kitchen and came in every day. That was the only consistent thing. At least we all got fed. But every time a staff member tested positive and had to go home, I just remember, like, a little piece of me would be lost each time, of: oh my god, how are we going to – how are we going to look after these people?

Counsel Inquiry: So in those locked-in arrangements you stayed in the home for ten days straight; is that right?

Reverend Hudd: Yeah.

Counsel Inquiry: And you were providing 24-hour clinical care –

Reverend Hudd: Mm.

Counsel Inquiry: – during that period. Now, you mentioned earlier the residents who had complex care needs and required one-to-one care.

Reverend Hudd: Mm-hm.

Counsel Inquiry: And there was no one else, just you –

Reverend Hudd: Mm.

Counsel Inquiry: – wasn’t there –

Reverend Hudd: Mm.

Counsel Inquiry: – having to deal with all the other 19 other residents?

Reverend Hudd: Yeah.

Counsel Inquiry: You spoke to your husband?

Reverend Hudd: Yeah.

Counsel Inquiry: Called him and told him what was happening?

Reverend Hudd: Yeah.

Counsel Inquiry: He gathered some things for you and brought them.

You were there thinking about what’s going to happen, how you’re going to treat the patients, et cetera, et cetera.

Reverend Hudd: Mm.

Counsel Inquiry: How did you go about – with the treatment of the patients and their care needs?

Reverend Hudd: I think – so, leading up to me saying to my sick manager, who was at home at the time, leading up to the moment when I said to them, “I’ll live in, I’ll stay” – and the relief that I heard was quite sweet from them – on the run-up to that I remember just gathering as many resources as possible.

I knew I couldn’t have people physically with me, but the Royal College of Nursing and the Queen’s nurse institute comrades were – it was really important that I had that back-up, that background, psychological and professional back-up.

So when that decision had been made, to stay indefinitely, I called my husband, and I knew he would be upset and cross, and he was, like, “Well, why is it always you?”

I said, “Well, because I’m only the one left.”

But – so I had to just speak to him very calmly and succinctly. And my husband has experience in the armed services, and he likes a thing to do, so it was like, “Right, okay, this is the situation, I need you to do this, this, and this. Get active.”

So off he went. He did his thing, with my daughter, which was great. And then – yes, so there was that. And then he was going to care staff, telling them – and people just sort of sprung into action.

So after a few days of feeling like I was spiralling into an abyss, even though there were just a few, you know, two care staff went and cleared a patient’s room who’d recently died, made that room – “Oh, we’ll do that for you, Charlotte.”

And that –

Counsel Inquiry: That was a room for you to stay in, in fact?

Reverend Hudd: Yeah, the room that I stayed in.

And people – people are really good like that. I think, when something is, like, so – like, “Okay, we’re at the bottom of a pit here, how do we get through this together?” People just put out for you.

And it’s amazing what skill sets people have and don’t utilise until a situation. And I saw a lot of real gifts come from people, real ‘can do’ things, which was quite awesome.

Counsel Inquiry: So you were living in the home and the residents were in the home, as well. Were they were isolating in their rooms or were they out and about –

Reverend Hudd: Yeah.

Counsel Inquiry: They were isolating in their rooms?

Reverend Hudd: Yes.

Counsel Inquiry: What could you hear from them?

Reverend Hudd: Okay, so for the residents, we had one – one resident who was mobile. So they, sort of, resided in one particular space. The others were in their rooms.

And as the staff depleted, we had to sort of prioritise nutrition, continence – and so they were seeing even less of us. That was really hard. And I would hear at night sometimes, the person next door to my room crying at night, “Where is everybody?” That was quite distressing sometimes. But the fact that she was able to do that meant that she was actually okay. I know that sounds awful – as in she’s not – she doesn’t need end-of-life care or anything high maintenance.

And then I might hear a voice, someone – another resident swearing because they were on their own and that. And that was really, really hard. It was really hard knowing that because there weren’t enough of us and we were having to prioritise by activities of living, things to survive, it did sort of come to the forefront of moral distress. The staff were feeling that. They weren’t physically able to give the care and resources they wanted to.

And for me, knowing that I would have exhausted times, I was constantly afraid of making a mistake. And nursing home nurses, it’s – there’s a lot of drugs management to do. So what I would do when I had quite sane, clear moments of sparks of energy, I would just get really organised. I’d be looking after my future self the whole time, organised, organised, because some nights I didn’t get any catnapping at all because my intensive patient, who – I would carry, like, a monitor with me all the time, so if I wasn’t in the room with them, I could hear the breathing because breathing was quite a high maintenance matter already with their admission.

Counsel Inquiry: Yes. So from your statement you did say you were having to take little naps in 30-minute snatches –

Reverend Hudd: Yeah.

Counsel Inquiry: – to keep listening out for people?

Reverend Hudd: Yeah. I did think at one stage perhaps I should go and sleep in their room, but all the bleeps of their monitors and things would have kept me more awake, I think, than the breathing monitor, so I had to make that decision, yeah.

Counsel Inquiry: And you mentioned a moment ago about sort of planning in advance –

Reverend Hudd: Yes.

Counsel Inquiry: – for yourself, I’m assuming in respect of caring for the residents. But you also did do some advance sort of planning, as it were, for yourself, didn’t you?

Reverend Hudd: Yes, yes. I did.

Counsel Inquiry: You state in your statement that you were running through worst-case scenarios in your head?

Reverend Hudd: Yeah.

Counsel Inquiry: Questioning what would happen if you collapsed, and there was no one to take over from you, and you recall writing your final wishes on a card at 3 am?

Reverend Hudd: Yes.

Counsel Inquiry: You also wrote a DNACPR for yourself, didn’t you?

Reverend Hudd: Yes.

Counsel Inquiry: And you made sure that that card was placed in a prominent place.

Reverend Hudd: Yes.

Counsel Inquiry: Now there was a point where two carers were sent from a London agency to support, finally.

Reverend Hudd: Yes.

Counsel Inquiry: Despite at the beginning you trying and calling and calling and failing to get support.

Reverend Hudd: Yeah.

Counsel Inquiry: How did that feel?

Reverend Hudd: It was – yeah, it was awesome. So after having so many “nos”, because no one wants to – even if there were staff, no one wants to work in an infected – a hot zone, but yes, these two chaps arrive at the front door one morning, and I think I must have been going through one of my, sort of, high moments of like, “woooh”, and when they arrived at 7 am on a Sunday, just seeing them in there, coming, I just remember like, “Yay! Come in!”

And so I put them on to day shifts. They did 12-hour day shifts so they could sleep at night, and I was so made up. They didn’t have any care experience, so this was their first job looking after other humans. So I was delighted to see them, but then there was that, “Oh no, uhhh”, but they did really well, and what they did bring was their presence, the things that humans so need. Of course we need to have clean and food and stuff. They brought their presence and one particular person had quite intensive complex behavioural needs. She was a little monkey but we loved her. And one of the guys who came to stay, I don’t know how it happened, they just clicked.

You know, different cultures, different ages, different everything. And having them about was, yeah. It was like a hostel in the end. It became a real place of, you know, aside the fatigue and the fear and stuff, it became a real place of love, and the sort of mixed, mixed faiths, mixed cultures, all living in this house together, it was strangely an awesome privilege amongst all that. So yeah.

Counsel Inquiry: Yes, in your statement you do say that it was a mixed experience – (overspeaking) –

Reverend Hudd: Yes. Very much.

Counsel Inquiry: – (overspeaking) – experience, but also being a pleasant one.

Reverend Hudd: Yes.

Counsel Inquiry: I’m sorry, but I’m going to have to turn to a bit of a harrowing experience for one quick second.

Reverend Hudd: Absolutely.

Counsel Inquiry: You discuss living in the home and being alerted to a patient’s deteriorating condition at 3 am.

Reverend Hudd: Mm-hm.

Counsel Inquiry: You state you went to assess him in his (sic) nightie.

Reverend Hudd: Yes.

Counsel Inquiry: Because you were trying to get some sleep.

Reverend Hudd: Yes.

Counsel Inquiry: And you could see and hear Covid at work in the death rattle?

Reverend Hudd: Yes.

Counsel Inquiry: What’s the death rattle?

Reverend Hudd: So the death rattle can be … so when someone’s in their final hours or breaths, if there’s some fluid that hasn’t been removed or if they’ve got some fluid here [indicates], in the breathing you can hear the sound. It can be quite rasping, it can be quite loud, it can be quite distressing.

Lady Hallett: Can we just pause for a second, I am just wondering if we need this – it must be very distressing for some people, and I don’t think we need to go down here. It is obviously distressing for you and I’m not comprised. So I think we’ll leave that subject, please.

Reverend Hudd: Okay.

Ms Shotunde: Sure.

Whilst you were working in the home and, in particular, in the locked-in arrangements, did you have any access to any sort of medical support, for example a GP or anything like that?

Reverend Hudd: Yeah, fortunately our local GP, they were aware of the situation. I made them aware. And I had what I can only call a hotline. So I had a phone number which bypassed the main enquiries that you call when you call your GP, you go straight into this number. And then I could communicate what I needed, why, and when, and they would – and they would act on it which would be really good. There was a really good professional relationship and trust of clinical judgement to be able to – if I could see that perhaps someone is heading down a certain way, I would get medications and things in place in a timely way, and they trusted my judgement.

Counsel Inquiry: And I understand that there were difficulties in getting residents transferred to hospital. In your witness statement you mention a patient who was developing urosepsis.

Reverend Hudd: Yes.

Counsel Inquiry: And you made a category 2 999 call which would usually have an average response time of 18 minutes?

Reverend Hudd: Yes.

Counsel Inquiry: But that there were 14 other category 2 calls in the pipeline and only two or three ambulance staff available.

Reverend Hudd: Yeah.

Counsel Inquiry: Was that a sort of regular experience in respect of trying to transfer residents from the care home to hospitals during the pandemic?

Reverend Hudd: During the – yes, yeah. In pandemic time, yeah.

Counsel Inquiry: You mentioned earlier about short staffing and moral distress.

Reverend Hudd: Mm-hm.

Counsel Inquiry: Moral distress presumably being there’s not enough of you guys to be able to provide the care that you –

Reverend Hudd: Yeah, yeah.

Counsel Inquiry: – would want to. You were so concerned that you made a safeguarding alert, didn’t you?

Reverend Hudd: Yes, yeah.

Counsel Inquiry: What happened with that?

Reverend Hudd: So safeguards are raised by a person when there’s a risk of abuse or neglect. And in this situation it was by omission. So it’s – even when it’s unintentional, we have a duty of care to report a situation where people are at risk of harm, and in this case it was risk of harm by omission, because there weren’t enough of us to ensure timely continence care, repositioning, nutrition, all the, you know, medication; everything that goes around good quality care.

I called the local authority to raise a safeguard, but I did it on myself, because what I was angst about is that because I was one person with so many things to do, that I could make a medical – I could make a medication error, I could make any kind of error, but also the concern that not only myself but also the wider perspective of the team is that – I’m like a real quality care person, you know, auditing and – and – above and beyond, and to make this call on myself and that I’m now having to declare that, you know, neglect is in progress through – not wanting, you know, through circumstance, was really difficult.

And I’ve had a bit of a colourful relationship with safeguarding in the past, but what was really nice is that the safeguard – the officer who I spoke to was just awesome and really supportive and understanding, and said, “No, Charlotte, you can’t do that to yourself. But you can for the home, because of the situation.”

So that – it was good to have that clear. But also quite unpleasant.

Counsel Inquiry: I’ve just got some last questions, and it’s in respect of the sort of impact to of the pandemic on you and other staff.

But before I do that, sick pay. I understand that there was the announcement that you would have – that there was going to be some Infection Control Fund money that should be going into care homes to help tackle the pandemic –

Reverend Hudd: Mm.

Counsel Inquiry: – including providing PPE, but also ensuring that staff could get their normal pay if they had to be off sick with Covid or isolating?

Reverend Hudd: Yes.

Counsel Inquiry: Did you receive any when you had to be off?

Reverend Hudd: So the original address was when the Prime Minister said, rather than wait for day 5 to have sick pay, SSP, it will be from day 1. So that was a relief.

Then, when I found out about ringfenced money, infection control funding being sent from central to social – to the care sector, one of the top main things on there was giving – was for staff to have full sick pay – not indefinitely but for at least – for those who have, you know, gone off with Covid-19, for at least the ten days, which was the policy of isolating.

Counsel Inquiry: Did you receive it?

Reverend Hudd: I didn’t receive it, nor did anyone else in – where I worked. I questioned it. And it – enough to motivate me to have a conference call with my MP from the angle that: this is happening in your constituency, there are these people, minimum wage a lot of them, and the impact of them not having that full pay even for ten days makes a huge difference.

What was happening is that people were coming back to work as soon as that ten days was over. Even if they were really ill, they were coming back to work; (a) because they need to eat and (b) because they don’t want to let their comrades down, and they feel guilty. And that’s a huge, that’s a massive thing.

Also with the sick pay, where did that money go? So part of this conversation with him was – I know it came to local authority, and then local authority deal it out to the care homes, so my angle for him was: well, where is it then? Is it local authority? Is it care homes? Where is this recommended money for these people?

Because then it became such an issue between even management and staff, staff and staff, that after day 10, day 11, “Magic, you’re really well and you can go back to work”, and people who were still very ill – and again, this is where misunderstanding comes – felt well – you know, “Well, that they’ve been off for ten days, so they’ll be back tomorrow”, but they were still ill. These people were ill. Some people for a long time. Some staff died.

Counsel Inquiry: They did.

Reverend Hudd: They died in service.

Counsel Inquiry: They did. And you gave up your nursing pin in October 2024, didn’t you?

Reverend Hudd: Yeah.

Counsel Inquiry: You unfortunately had contracted Long Covid and you’ve suffered from post-traumatic stress disorder as a result of your experience working during the pandemic?

Reverend Hudd: Yes.

Ms Shotunde: Thank you for answering my questions.

My Lady, I have no further questions.

Lady Hallett: Thank you very much indeed, Reverend Hudd. It is an extraordinary story and a terrible thing to say but I’m not surprised you got post-traumatic stress disorder, to be honest, after you went through what you went through.

The Witness: Yes.

Lady Hallett: You looked towards the public gallery when you mentioned your husband. Has he come along with you?

The Witness: He’s here.

Lady Hallett: Well, I’m delighted that –

The Witness: There he is!

Lady Hallett: – you’ve got somebody here to make sure you get back, because it sounds as if you’ve come some distance, you said earlier.

The Witness: We have.

Lady Hallett: Well, thank you very much indeed for taking the time and, as I say, it was an extraordinary story and we needed to hear it.

The Witness: Thank you for the opportunity. Thank you.

Lady Hallett: Safe journey home.

The Witness: Thank you.

Lady Hallett: Very well. I shall return for a 10.30 start on Monday, 7 July. Thank you.

(3.14 pm)

(The hearing adjourned until 10.30 am on Monday, 7 July 2025)