21-07-2025

(10.30 am)

(Proceedings delayed)

(10.45 am)

Lady Hallett: Apologies for the delay. Transport problems.

Ms Carey: My Lady, good morning. May I call, please,

Mr Sean Holland.

Professor Sean Holland

PROFESSOR SEAN HOLLAND (sworn).

Lady Hallett: Sorry for keeping you waiting,

Professor Holland. You’ve probably travelled much

further and got here quicker.

The Witness: Delays, I think, are inevitable at this time

of the year, my Lady.

Questions From Lead Counsel to the Inquiry for Module 6

Ms Carey: Mr Holland, your full name, please.

Professor Sean Holland: Sean William Holland .

Lead 6: You were, during the pandemic, the Chief Social Work Officer in the Department of Health in Northern Ireland,

is that correct, taking up that role, I think, in

July 2010?

Professor Sean Holland: That’s correct.

Lead 6: And moving on to pastures new in October 2022?

Professor Sean Holland: Yes.

Lead 6: Just so that we can orientate ourselves in Northern

Ireland and the position there, we know that it’s the health and social care trusts who contract with the care home providers and, indeed, the domiciliary care agencies; is that correct?

Professor Sean Holland: That is correct.

Lead 6: But as at the start and during the pandemic, I think there were 482 or 483 care homes in Northern Ireland –

Professor Sean Holland: (Witness nodded).

Lead 6: – numbers vary slightly. 16,000 beds, 93% occupancy rate within care homes in Northern Ireland, which I think is one of the highest across the UK.

Would you mind just saying “yes” or “no” for the stenographer.

Professor Sean Holland: Oh sorry, yes, yes, yes.

Lead 6: Thank you.

And I think there were something like nearly 21,500 individuals in receipt of domiciliary care and 300 domiciliary care agencies registered with the RQIA?

Professor Sean Holland: Yes, all of that’s correct.

Lead 6: And I think in terms of workforce, as at March 2020, there were 36,855 social care workers who were registered.

Professor Sean Holland: Yes.

Lead 6: Can I ask you about the workforce though, please, in the run-up to the pandemic. In your statement, which is INQ000613603, you make reference there, Mr Holland, to

a 2018 Department of Health report called the Health and

Social Care Workforce Strategy, and that 2018 report

outlined that there was an estimated 1,400 care workers

needed every year to meet the growing demand on the

adult social care sector. And the report noted that

domiciliary care workforce needs and should be an early

priority in recognition of the particular

vulnerabilities we faced in social care.

Can you help us, Mr Holland, with what was done to

try and increase the numbers of workers in the

domiciliary care workforce as a result of that 2018

report?

Professor Sean Holland: I think the demand for domiciliary care workers, it’s

helpful to understand, there are a couple of different

components to it. One is demographics, and I’m sure

a lot of people will be aware that the demographic

profile of the population is changing, and it’s changing

in that we have a growing population of older people.

Within the population of older people we have a growing

number of people who are older old people, that would be

people over the age of 85, and they particularly drive

demand because they’re much more likely to have health

and social care needs.

The other aspect of the demographic challenges is

that we have fewer young people and so that’s restricting workforce supply. There are fewer people in the labour market available for supply.

And then the other side to the workforce challenge is that social care, particularly at the point of being a social care worker, a care assistant, or a domiciliary care worker, is a service that’s largely delivered by the private sector subject to market forces, and the market has settled at a place where those are often low-wage, indeed minimum wage, jobs, and zero-contract-hour jobs, which then leads to a churn within that workforce.

So there are a few different elements all of which combined to give a fragility to the social care workforce.

In terms of what was done, each year the contracting of services would have tried to respond to the demand increase, and so that would be a case of we would find ourselves spending – trying to allocate more money and sometimes that would be in-year monitoring money, other times it would be more planned, but you were trying to expand the capacity to contracting services, but then we also took other actions to try and make the sector more appealing.

So for example, the department would have funded the Northern Ireland Social Care Council to promote the career and the sector as a rewarding place to work in. They also, again funded by the department, would have created employment frameworks which would outline how your career could develop within social care, and they also outlined practice learning requirements, ie, a qualification framework. But all of those efforts are fundamentally challenged by the fact it still remained largely a very low-wage sector.

That said, I’d have to say that that’s a variable picture. There are some employers who do much better than others in terms of both being able to recruit and retain staff, and that’s reflected, they tend to make decisions about taking a smaller profit margin, investigating more in staff, that sort of thing.

Lead 6: And from the department’s perspective, do you know whether there – the 1,400 estimate was actually met? Were you increasing by 1,000 care work – or only 500? Do you have any idea about how, if at all, the workforce was expanded to the estimated 1,400 care workers needed every year?

Professor Sean Holland: I don’t have that information available to me at the moment but we would have information about the registered numbers of social care workers which, broadly speaking, has shown a trajectory of increase, and had increased dramatically during the later parts of – well, from the beginning of Covid it was a very volatile figure but it did increase.

But there are limitations to that number because that is a record of people who have joined the register.

Lead 6: Yes.

Professor Sean Holland: People may join the register, and you’re registered for a period of three years, but then you may leave the job after three months.

Lead 6: Yes, understood. All right.

Do we take it, though, that as a general proposition there was the fragility in the workforce entering the pandemic in sort of January, February and into March 2020?

Professor Sean Holland: There would have been a fragility in the workforce and there would have been pressure on budgets, because – the relationship is: the budget buys the service, which drives the workforce. And there were pressures that were evident through a mixture of waiting times and thresholding of those services.

Lead 6: Can I ask you about one particular trust and can I have up on screen, please, INQ000582513_11.

Mr Holland, this is an extract from, I think, the Belfast – sorry, the Northern Health and Social Care Trust, and can we see there:

“[In] January … the Trust’s Corporate Risk relating to the lack of capacity for Domiciliary Care was recorded as follows:

“The capacity of Domiciliary Care Services, both Trust and Independent Sector services are unable to meet increasing demand.”

It sets out there the implications of that.

And at the bottom of that italicised section:

“The risk has recently been exacerbated by Independent Sector providers handing back cases to the Trust to source alternative care provision.”

Two things about that, please. Was the department made aware of the fact that there were trusts out there that were struggling to meet increasing demand?

Professor Sean Holland: Yes.

Lead 6: And do you know, was this a position common across the other trusts, or was it particular to the Northern HSC Trust?

Professor Sean Holland: The position would vary in trusts, and indeed in some cases it would vary within different geographical sectors of trusts.

So, for example, in the Western Trust, the area of – what we would call Fermanagh and Lakelands, which is a very low population density, very rural area, would have had particular difficulties delivering domiciliary care services. Other areas wouldn’t have had the same difficulty. So it was a problem across the sector. This quote specifically is looking at the capacity of domiciliary care and it’s important to draw a slight distinction here between different parts of the adult social care sector.

So, care home provision nearly exclusively, but not completely exclusively, has ended up – and it was never the policy intention explicitly for this to happen, but it has ended up nearly exclusively being delivered by independent providers.

Lead 6: Yes.

Professor Sean Holland: Domiciliary care, about 70% of the services are provided by independent service providers, but there would be a capacity retained within all of the trusts for in-house domiciliary care. And so one of the actions that we were talking to the trusts about in relation to the issue of handbacks was expanding their in-house capacity.

Lead 6: Right. And does that then relate to the final paragraph on this italicised section:

“The risk has … been exacerbated by [the] Independent Sector providers handing back cases”, ie, we can’t look after them in the independent sector so the trust is going to have to meet their needs? Is that what it means, in short?

Professor Sean Holland: Yes, although it’s slightly more nuanced in that you could have a provider saying “We can’t meet this need” and you might find another independent sector provider who could. But you would also be looking to your in-house provision. The net effect was that trusts were reporting a drift of complex high-need cases coming to their in-service provision. So independent sector providers – I mean, it’s a pejorative phrase and it’s one I wouldn’t necessarily choose to use, but I would have trusts saying “The independent sector are cherry-picking the cases that they want to deal with.”

Lead 6: Yes.

I ask because obviously we’re going to look in a moment at the discharge policy in March 2020, but does the department know how many or the proportion of patients that were discharged to care homes and those discharged to domiciliary care? We’ve heard in other countries it’s a much higher proportion are discharged to domiciliary care. Was that the same in Northern Ireland?

Professor Sean Holland: I don’t have the figure with me but we would be able to access that.

Lead 6: Because the reason for asking about the lack of workforce in domiciliary care is if you’re discharging many patients from hospitals into the domiciliary care sector, what steps were taken by the department to increase the capacity, given that there was going to the expedited discharges?

Professor Sean Holland: A few things – and this is increasing the capacity, specifically in the domiciliary care?

Lead 6: Yes.

Professor Sean Holland: Some of the measures apply to both the care sector and the domiciliary care sector. We sought to make it easier to recruit people so, so we entered into a new arrangement in relation to police checks, pre-employment checks for care workers. Ordinarily for care workers, you would have a check that encompassed two components: one would have been to check a barred list because there are people who would be barred because of previous conduct from ever working in that sector. The other would be an enhanced disclosure check, which would be a more general check of police records. And for some posts you could also consider non-adjudicated intelligence the police may have held on someone.

Now, what we said was that to speed up the process, we’ll check the barred list, you can employ someone on the basis of them not being on the barred list, but there are conditions associated with what they can do. They have to be closely supervised. You will pursue the enhanced disclosure check and you will obtain that as soon as possible, but the safeguard being that you knew they weren’t barred.

So that was one step we took.

Another step we took was, unlike the situation, say, for example in England, our social care workers are registered. So that’s a statutory registration, it’s not a voluntary scheme, there’s legislation requiring it to be the case, and we have a regulatory, a workforce regulatory body, the Northern Ireland Social Care Council, who register. As is common practice with registered professions, there’s a fee associated with registration. Now, the Northern Ireland Social Care Council registers both social workers and social care workers. The fee is low for social care workers, it’s £30, but recognising that people might join the workforce for a short period of time and then leave again, we suspended the collection of fees –

Lead 6: The waiver fee?

Professor Sean Holland: – so that people weren’t going to be put off by having to pay a fee.

And then thirdly, we funded the NISCC to increase their efforts to promote people coming into the sector to work.

Lead 6: You mentioned there the register, and I’ll deal with it now, perhaps, if I may. We know that the Northern Ireland Social Care Council maintains the register and it includes adult residential care workers, daycare workers, domiciliary care workers, supported living care workers. And you have rightly drawn our attention to the fact that there is no such register in England. From your perspective, Mr Holland, what were the benefits of having this register in Northern Ireland during the pandemic?

Professor Sean Holland: I think there are a few different benefits. Firstly, it gives you some, albeit slightly flawed intelligence about the workforce. You know how many people at least are registered to work in social care. So that gives you that information. The other benefit, I think, is that it gives you some assurance, and it’s probably particularly important if you’re doing things like expanding the workforce rapidly under less than ideal conditions. It gives you some quality assurances because the registrants have some requirements placed on them. So they are expected to complete what we call PRTL, which is post-registration learning and training (sic). They’re meant to do 90 hours per registration period, which they’re meant to document, or be able to document that they’ve done 90 hours of training.

It also means that they are subject to fitness to practise regulations. So if someone, someone’s conduct is such that it’s deemed necessary or it reaches a threshold for a fitness to practise, that takes you beyond the situation in England where –

Lead 6: Can I pause you there, because I understand that that’s a general benefit of the register but what I was trying to ascertain was, was there any particular pandemic-related benefit?

Professor Sean Holland: We could communicate with the workforce. So on a number of occasions we both issued email messages and we also directed people through their accounts to social media messages that we were issuing in relation to the pandemic.

And NISCC also produced some very targeted learning resources for the workforce which people would be able to access, the registrants would be alerted to, and they could access those. I think it was a suite of four learning packages. One related to infection prevention and control; one was advice actually targeted to the general public about shielding and isolation; there was another package on resilience and emotional wellbeing. And I’m sorry, I’ve forgotten what the fourth package was.

Lead 6: Don’t worry.

Professor Sean Holland: But they were, I have to give credit to the Northern Ireland Social Care Council, they actually won a European social services award for that suite of – and it was specifically for those Covid resources that they won the award for. But we were able to communicate and direct the workforce towards resources.

Lead 6: Thank you.

Can I just take a step back, then, and ask you some questions, please, about surge planning. And in your statement you say that the Chief Medical Officer commissioned work on – to quality assure and address gaps in the initial surge plans, recognising obviously that there were going to be pressures coming to both health and social care. And I think in your statement you set out that there were gaps in the plans as far as adult social care was concerned. Obviously the plans were predicated on staff absence being the most significant risk factor. Were there any other gaps identified in the plans as far as you were aware, Mr Holland?

Professor Sean Holland: I think that the workforce was probably the main gap that we saw, but also there was a lack of account taken for the impact of mitigating measures. So the surge plans were initially developed on information that indicated that up to 80% of the population could fall ill, a proportion of those would require hospital accommodation. That would have an impact on the workforce. But the – now, and I think I’m right in this, that one of the things that we were concerned with was that the surge plans didn’t take into account the potential impact of any measures that might have impacted on those figures.

Lead 6: Yes. Right. Can I just ask, ordinarily, surge planning, is that something that should be done at trust level? Does the department ordinarily have oversight of the quality and content of the surge plans? Can you help us?

Professor Sean Holland: Normally, the equivalent, I would say to surge planning would be winter pressure planning where – and not unlike the pandemic, you have pressures arising from communicable illnesses circulating in the community. The trusts will produce their own individual winter pressures plans. The quality assurance and coordination of those would be done by the Health and Social Care Board although they would then be shared with the department, but ordinarily most of the activity would have been between board and trust in relation to that kind of planning activity.

The responsibility in legislation for the board would have related to planning and commissioning services, whereas the primary responsibility of the department is about policy and legislation.

Lead 6: Right. So it sits at sort of one level down from you, if I can put it like that, but can I ask you about, please, the mid-March plan, and can I have up on screen, please, INQ000103714,_10. This was the initial, I think, it was mid-March to mid-April plan dated 19 March, Mr Holland. It was a 12-page document and in it the plan predicted a 21% absence from the health and social care workforce.

I appreciate, obviously, then there may be mitigations that might mean there are fewer absences than had been predicted.

Professor Sean Holland: That would have been the case.

Lead 6: I understanding that. But the planned discharge planning for patients in hospital is set out on screen. Clearly they’re talking about there the importance of discharge arrangements; the trust to activate their emergency discharge plans; reference there to expediting discharges; trusts working to maximise all spare capacity in residential nursing and domiciliary home care; and then potentially, as a contingency plan, needing to redistribute domiciliary care hours as is set out.

And pages 10 to 11, if you’ll forgive me for making the comment, don’t actually mention very much the adult social care sector at all in this plan. Can you help with how practical or otherwise this plan was meant to be, knowing that there was likely to be a large number of people discharged from hospital at a relatively quick pace?

Professor Sean Holland: This set of actions, although you’re looking at them in the context of a surge plan created during the pandemic, aren’t that different from actions that would be undertaken each year in relation to winter pressures. I suppose the question was, the degree of focus and energy placed into these different areas, but each year, part of the contingencies that you would adopt facing into winter pressures would include most of these. Some I don’t think we’d activated before, so the choice protocols, although each year we talked about it, this was the first time we actively said no, people would be discharged regardless of first preference choice.

But things like prioritising resources, maximising capacity, and speeding up discharge, all were measures that would have been in previous plans.

I think the important thing is that there was no change to the issue about medically fit for discharge. So that wasn’t compromised. It was more about the process that’s associated.

Discharge is always a point of pressure when the system is under pressure, and there’s a tension between social care and the acute hospitals with – and apologies for characterising it in this way – you’ll have the acute sector saying: beds are being blocked because social care can’t deliver, and you’ll have social care saying patients are being delayed because the acute hospitals aren’t operating effectively with their processes for discharge.

And actually, research has indicated that I think when people say “Oh, it’s a delayed discharge, it’s a social care problem”, normally 60% of the time it’s actually relating to the processes in the hospital as opposed to in the social care sector.

But what this plan is saying, make sure everyone’s focused, everyone’s working together, and that delays are minimised. It wasn’t saying people should be discharged at a lower threshold.

Lead 6: No, and I understand that and forgive me, looking at this plan, one might say it’s rather generic and not hugely helpful to the trusts who are then having to try to find the spare capacity or – can you help with – it’s relatively high level, isn’t it, Mr Holland?

Professor Sean Holland: Mm.

Lead 6: I just wonder how practically useful it was thought to be.

Professor Sean Holland: I think that there were processes happening at different parts of the system that would have different levels of granularity. So this is a high-level statement of what people should be doing. The how they’re doing it would appear in processes at a lower level.

I think it is also probably important to note that the capacity challenge that this anticipated was never realised. And the first quarter of 2020, although we were slightly up in the number of discharges into social care, it wasn’t particularly high. And if you took as an average between the first and second quarter, we were quite significantly down in terms of the numbers of people being discharged into social care. There are a lot of reasons I could go into if you want for that, but maybe that’s a later point.

Lead 6: Not right now, but – I mean, I’m taking that as your point, but of course you didn’t know that as of 19 March when this discharge – sorry, this guidance came out.

Professor Sean Holland: No, we didn’t. This was in anticipation of pressures that never realised to the extent that we were preparing for.

Lead 6: All right. Now, in, I think, early August, the department established the Adult Social Care Surge Working Group, and I just would like to understand why it was established then, and what practical benefits, if any, did it bring when we came into winter 2020 into 2021?

Professor Sean Holland: There was an evolution of various working arrangements from the very early days, when the Chief Medical Officer initiated the gold, silver, bronze strategic command response, where there were then a number of strategic cells incorporated within that, particularly focusing on things like infection prevention and control, testing, at one point in vaccinations.

But as we moved on, we recognised that while those had been an appropriate immediate response, we needed slightly different structures and we decided that there should be a broader coming together of focus on social care. It’s not that social care wasn’t being considered; it was the framework that we were using to do it we felt evolved once we got through that first wave, and that’s the structure that you’re referring to.

In terms of the benefit of it, it became where a number of different threads that might have been going through different cells were brought together and considered in relation to social care. It also was used to monitor progress against different initiatives or reports that were generated as we went through the pandemic.

So, for example, there were two rapid learning initiatives, one in relation to nursing homes, the other in relation to domiciliary care. They made recommendations. That structure would have tracked progress against those recommendations. It also would have tracked other pieces of work in progress that were happening.

Lead 6: Can I come on to the discharge policy, then, and we’re familiar with the arguments for and against it and the pressures that were certainly predicted to exist at the time.

Professor Sean Holland: Yeah.

Lead 6: And in due course I think there were various changes to the testing regimes pre-discharge. We may look at some of those in a moment. But in terms of isolation and the ability of care homes to isolate, I think certainly that there was – care homes were not expected to have dedicated isolation facilities but isolation precautions were to be taken when someone was being discharged from hospital into a care home.

And certainly isolation requirements were approved by the minister on 24 April – I’m at your paragraph 598 if it helps you, Mr Holland – and communicated to the sector at the end of April.

Can I ask you this, firstly: do you know why there wasn’t a requirement put in place for isolation prior to the end of April 2020?

Professor Sean Holland: I think this was a developing scenario, and there were a number of points at which we adopted positions which were changes from previous positions, and I think in almost every instance, and again, I’m probably echoing the comments of my counterpart in Wales, it would have been better if these were done at an earlier stage than they were, but it was the progress under pressure with resources that there was always a lag to some of these things.

Sorry, I’m not sure – did you ask me something else in that question?

Lead 6: No, no, no, it was why it hadn’t come in before, and effectively you said, well, with hindsight now – I think in short you’re saying you wish it had. But – (overspeaking) –

Professor Sean Holland: Yeah, and I’d also need to reference it against the infection prevention and control advice that was coming from the Public Health Agency, because that changed a number of times as we went through.

Lead 6: You do say, however, in your statement, though, that:

“The Department worked closely with the RQIA … to assess the different care homes to implement isolation policies …”

And indeed, it was noted that:

“… (… a small number of homes still used some double occupancy rooms).”

Does the department know how many care homes there were that still had a double occupancy room?

Professor Sean Holland: We may have that information but I don’t have it to call to memory.

Lead 6: And I think certainly the – some care homes were assessed by the RQIA as not being able to appropriately isolate individuals because of the configuration of the care home itself. It was considered to be a very small number of homes that wouldn’t be able to isolate.

Discharges to those homes, said the RQIA, should not take place from hospital. But was there a band, do you know, as far as the department was concerned, in saying “Well, if you can’t isolate, you must not accept them”? Or did it not work like that, Mr Holland?

Professor Sean Holland: No, the guidance issued was quite clear to say that if a care home couldn’t appropriately accommodate someone or isolate someone on discharge, alternative arrangements would be made. And that was also the case when it came to the point when people were being tested. If a test result wasn’t known, alternative accommodation could be arranged.

So – and that would have been in a step-down facility. There were a number of step-down arrangements. And there would have been some step-down facilities that preceded the pandemic and they would have been used under those circumstances.

But at no time were we seeking people to accommodate people that they couldn’t accept within the extant guidance.

Lead 6: Right.

Professor Sean Holland: And that – that is relevant to the previous point about the fact that we never faced the capacity pressures that we had anticipated as well.

Lead 6: I ask you that because I think there was a Northern Ireland Assembly committee for the Health Inquiry report from April 2021, and in the findings of that report the committee noted that many homes struggled to isolate individuals, either for reasons of facilities or adequate staff resources, or, equally importantly, residents’ wellbeing and issues of understanding amongst the significant numbers of residents with cognitive decline who presumably weren’t able to isolate themselves, and the department noted this was an area of policy the department continued to keep under active consideration.

In what way did the department keep under active consideration the ability or otherwise for a care home to isolate individuals?

Professor Sean Holland: Well, one of the things we did do is when we heard suggestions that people maybe had had to do something that they felt was outwith the arrangements, was we tried to pursue actual cases to find evidence of them, and this was true in relation to a number of things. It would have included, for example, PPE at one stage. The independent healthcare providers association were saying to us, you know, a number of homes aren’t receiving PPE. We asked for a list of those homes and followed them up. And when we did, we found that they actually were reporting that they received PPE. So that would have been one response.

The other response would have been developing guidance to support care homes on an ongoing basis around the requirements for isolation and compliance with it.

Lead 6: And are you able to give us a practical example of the guidance that supported the care homes around requirements for isolation?

Professor Sean Holland: I’m trying to recall, did … no, I think the PHA probably issued guidance at some point. We included it in the departmental guidance. We also would have been providing advice and support to care homes on an individual basis about how they could meet those requirements through the service support team that we established, and I’m assuming you might want to talk about that at a later point. That was the repurposing of the RQIA staff.

And we also gave them links with the PHA who would have provided direct advice to them on infection prevention and control including isolation.

Lead 6: Can I ask you to turn up, perhaps in your statement, paragraph 624 onwards, just sticking with the issue of isolation, because the RQIA did an assessment of care homes’ ability to provide isolation facilities, and I think the result was that there was about 80 care homes that were available and able to isolate, and I don’t want us to misunderstand the figures, and there were various ways that the RQIA worked it out, but if there’s 480-odd care homes across Northern Ireland but only 80 of which could isolate, I want – there’s potentially quite a large disconnect there and a large number of homes that were physically unable to isolate notwithstanding the importance of it by the end of April when it was written into the guidance.

Do you know why that number is so low, and does it cause you any concern on behalf of the department, Mr Holland?

Professor Sean Holland: I think this exercise needs to be put into context. This wasn’t the RQIA going out and inspecting homes and looking at them and saying “Oh, this home could only isolate three people” or “This home couldn’t isolate anyone at all.”

This was a desktop exercise that was only ever meant to be used at a system level. So they were simply reviewing things like what was the home registered for? How many single-use bedrooms did they have? How many of them were en suite? And they were coming up with an estimate.

This wouldn’t be a document that would have been used to guide individual decisions to discharge a person into a care home. They would have been done on a case-by-case basis and the two sides of the equation would have been the medical side, fitness to discharge, and on the care home side, ability to accommodate in line with the guidance.

And there would have been a fluidity to that that wouldn’t be reflected in this exercise. So, for example, you might have had a much lower level of occupancy in the care home for a variety of reasons, and there was a decline in occupancy in care homes through this period, which would have enabled them to enact isolation that wouldn’t have been obvious from the desktop exercise that the RQIA had done.

Lead 6: Right. So if I understand you correctly, the desktop exercise may in fact be an underestimate of the number of homes –

Professor Sean Holland: I would imagine it is.

Lead 6: Right. Put that figure to one side, one can foresee that in a future pandemic the need for isolation may be particularly uppermost now in people’s minds if there’s delays to testing capacity and the like. Does the department know now or has it asked for there to be any work done to actually ascertain which care homes could isolate an individual in their own home with en suite facilities for 14 days, as was envisaged by the guidance?

Professor Sean Holland: I would have to note that I’m coming up on three years from having left the department –

Lead 6: Yes.

Professor Sean Holland: – so I can’t really give an up-to-date position on the department. A few points I would make, and you may come on to data at a later point. I think that while we did hold information on social care at the point at the beginning of the pandemic, we very rapidly evolved a far more detailed level of data collection, both in terms of what we were getting information on, and the timeframe within which we were getting it. I think that’s a point for future learning, that we should make sure we have that data, or better data available on the sector.

The second point is, I think, that isolation is something that probably should be thought about in a much more anticipatory way in terms of pre-pandemic planning for a future pandemic and that then takes you to looking at the actual configuration of care homes.

I think that building of care homes over the years has always been subject to standards, but those may benefit from being revisited to consider how the infrastructure would support a positive response to a future pandemic. And I mean, an example of this – and it’s a tension that’s been there before – would be there’s been a movement over the past 20, 30 years, to try and make care homes as homely an environment as possible, and sometimes that creates a tension with IPC requirements. So I remember at the beginning of my career, if I went into a facility, a home, like a care home, they all would have had lino floors, and over the years there’s been a dynamic between trying to create a more caring, homely environment, and one that’s suitable for IPC.

Now, isolation is probably one of the areas where the two coincide because I think increase in single-occupancy rooms is something that both sides of that argument would have agreed to. But there are other elements, like considering air flow and ventilation, I don’t think that that –

Lead 6: Can I ask you about that?

Professor Sean Holland: Yes.

Lead 6: You argue there quite strongly for more work to be done and to think about this pre-pandemic. Is that something that sits at the department’s level? With the RQIA? With the PHA? Who is it that would be responsible for trying to ensure that some thought – more thought had been given to the need to isolate?

Professor Sean Holland: I think giving more thought to it probably rests across a number of bodies. So the PHA would be the experts in disease transmission and infection prevention and control. The department would be the source of the standards and regulations that would determine eligibility for registration. So those two would need to come together.

I also think that you need to engage the actual sector in that discussion as well, and recognise that “care homes” is a very generic term, and it’s probably not doing a service to the diversity of needs which are met by care homes.

There are care homes which are homes for life for people for a long period of time. There are places where people with physical disabilities and learning disabilities may live for decades, and I think that the consideration as to how you would build and configure something like that are different to the types of homes that are receiving very frail, elderly people, whose expectancy of residency is much shorter because they’re at a different life stage. And I think that you would need to have very close engagement with the sector to make sure that you had differentiated standards reflecting the different needs and requirements.

But certainly for those people who, I think on the back of the experience of this pandemic, we really know will be particularly vulnerable, there are things about building control regulations, and maybe even size of facility, that are going to be relevant. I mean, size of facility is probably one of the most significant –

Lead 6: I’m going to come on to size. All right.

Can I just, finally, dealing with isolation, you, say in your statement that:

“The 14-day isolation did have an impact on discharge and patient flow; however, the Department does not hold specific information regarding acute discharge delays …”

Can you just help us, are we there saying that actually it did inhibit and delay the output of patients by the need to isolate them for 14 days?

Professor Sean Holland: Yes, I’m sure it did because inevitably you will have had occasions where people were medically fit for discharge and sourcing a bed that could accommodate them appropriately would take – it wouldn’t instantly be available. I’d have to say that is not an uncommon problem. I mean, that is one of the challenges in normal times for discharge. You’re relying on a turnover and a churn in beds. So there’s sometimes a delay while you have to wait for the suitable placement for the needs of an individual.

Lead 6: Can I ask you about a different aspect of the discharge policy and I think the position in relation to residents with dementia. I think prior to the pandemic, residents with dementia could only be placed in a dementia-registered bed but that on 18 March in 2020, the Health and Social Care Board confirmed they were content, if necessary, dementia patients could be placed in beds registered for other purposes. And there were various conditions put on that, if a dementia patient was going into a non-dementia-registered based.

Professor Sean Holland: Yes.

Lead 6: Does the department know how many individuals with dementia were affected by this decision and sent to non-dementia-registered beds?

Professor Sean Holland: I don’t have that information, but I would refer you to the statements that have been submitted to the Inquiry from the trusts, who have indicated that this wasn’t a facility that was significantly used. I could elaborate a little bit about this if it’s helpful –

Lead 6: Well, I can help you to this extent: certainly we have a statement from the Belfast Health and Social Care Trust who said that that change in policy had a limited impact on discharges because it was dependent on the care home being agreeable to take –

Professor Sean Holland: Yes.

Lead 6: – the dementia patient and, indeed, it was met with resistance from the care home.

Professor Sean Holland: Yes, and I think a similar point was made by the Southern Trust or the South Eastern Trust and the informal feedback I was receiving was that this wasn’t having any impact on increasing supply because it was dependent on, and quite rightly, dependent on the care home agreeing. Because we were setting out conditions that had to be met if you were to do this, and if a care home was saying “Well, we can’t meet these conditions”, they were absolutely right to then refuse that discharge.

Lead 6: I think that change in the policy was not rescinded until 10 September 2021. Do you know why the policy was in place for such a long time, particularly if it wasn’t in fact being really taken up?

Professor Sean Holland: I think pressures on the system were an issue through that period which is why it wouldn’t have been rescinded, although it wasn’t having a significant impact. And when it was rescinded, I have to be frank about this, I think it was based about the fact that there had been a change in the – well, rescinded is the wrong way of putting it and I think we used that language so I apologise for that –

Lead 6: You did. It’s all right.

Professor Sean Holland: – but the RQIA, there had been a change in personnel at the RQIA and when we were seeking to renew this provision, they said, “Actually, we think that in terms of our standards, you don’t have that flexibility.”

Previously they’d been happy to accommodate that flexibility, I think they were saying “Now we’re not so sure we have that flexibility”, so although we describe it as being rescinded, what we actually said was if we are going to do this you need to get a temporary variation in your registration from the RQIA, but I don’t think that was ever sought then subsequently.

Lead 6: Right. Can I just stand back a little and ask you, please, about the Herity report that was conducted, and it might be easier if I call up on screen an actual paragraph in your statement, Mr Holland.

Could I have on screen INQ000613603_194, and paragraph 655.

Now, the Herity report I think came out in November 2020, and the links or otherwise between discharges and outbreaks in care homes was one of the matters that Dr Herity, I think, looked at and we can see there that the study examined two specific weeks in 2020, week 11, which started 8 March, and week 13, which started 22 March, where the number of people discharged to care homes after an unscheduled hospital admission was slightly higher than the typical week. 465 patients were discharged to care homes in those two weeks; five people tested positive within two weeks of discharge and 460 did not. It did not support the hypothesis that this group of people was a substantial cause of Covid-19 outbreaks in care homes.

Now, I think it’s right that certainly there was no discharge in – testing in week 11, but the first interim protocol on testing came out just before the week 13 testing. So clearly we need to bear in mind there was limited testing capacity at this time.

Do you know whether the department did any other work to try to establish whether there was a link between discharges and the seeding of infection in care homes once testing was up and running?

Professor Sean Holland: I’m not aware specifically of additional work that the department did. I mean, the decision to discharge people at a point before testing would have been informed by the existing advice from the PHA and other experts at the time, and that’s not part of my professional competence.

Lead 6: No.

Professor Sean Holland: This report – I suppose it’s a point I would make about a few different sources. A number of reports have looked at this.

Lead 6: Yes.

Professor Sean Holland: I think there has been the Vivaldi Study, there’s also been studies in Scotland and Wales, and they’ve all concluded more or less the same thing.

Now, I’m not a scientist and I’m not qualified to adjudicate the merits of each of those reports, but in a sense, these are all post hoc. They’re useful in terms of contributing to our knowledge for how we might respond to a future pandemic. And actually, I think that’s – if I was to ask you to do something, I think one of the things that would be – that we would invest a lot more in researching, understanding about the differences that occurred between countries and regions and services.

I mean, currently we know – and, please, when I say this, this is not in any way to minimise the experience of people who died in care homes in Northern Ireland, and it’s not to suggest anything positive about the system – we know that you were least likely to die in a care home in Northern Ireland compared to England, Scotland and Wales. Compared to England by quite a margin. Many European countries did much better than Northern Ireland so it’s not a point – but one thing, I think, for future learning is we need to understand that better because, currently, we don’t really know why. I mean, there are hypotheses about it, but we don’t really understand that.

Was it just purely about community transmission levels being different in countries? Or was it that the infrastructure of the systems was different in countries? Or was it individual Covid-specific interventions had an impact?

And I think that’s something that’s really important.

And this falls into that – it’s after the fact. The point at which the people were being discharged, we didn’t have this information.

Lead 6: Just picking up on that point, then, you are not the first, and I dare say you may not be the last, witness to suggest there should be more work done in this area. Do you know whether any work is being undertaken in Northern Ireland to understand how the infections get into the care homes, whether it’s the community transmission. And if you don’t know, who, in your opinion, would be the right body, organisation, department, to further that research?

Professor Sean Holland: I don’t know, currently. I think that there are a range of bodies ranging from academic institutions through to government ALBs who have a role in commissioning, conducting and funding research.

I think at a governmental level you can set a priority, particularly with funding bodies, to direct future research. And I really think that this is an area that merits that focus, because there were quite significant differences, and we don’t properly understand why.

Lead 6: Well, perhaps can we have a look at some work that was done in relation to characteristics of a home that was affected by an outbreak.

And could I have up on screen, please, INQ000103683_7.

This is an RQIA document, Mr Holland, I think dated May 2020, and they looked at some of the care homes that had outbreaks and then came up with these six characteristics, but it might require a little bit of elucidation through you, if you’re able to.

Clearly, I think the suggestion is that homes run by a larger provider had more outbreaks. That’s how I read it. Am I right in that?

Professor Sean Holland: Yes.

Lead 6: With 50% plus homes affected by Covid-19 outbreaks.

A “larger provider” – can you give us an idea, what is a larger provider? 10 beds, 20 beds, 100 beds?

Professor Sean Holland: 50 beds I think is what was being used. I mean, this piece of work was as a result of a conversation I had with the then interim chief executive of the RQIA, Dermot Parsons. And, I mean, the – at an early point, we were looking for any source of information that might be of assistance, and so I just contacted Dermot and said “Listen, maybe you’re already doing this or maybe it’s not valid” – because I’ve no scientific expertise – “but”, I said, you know, “might there be benefit in looking at the intelligence that you hold on care homes and seeing if you can find any correlation with either outbreaks or how well or otherwise they cope with outbreaks?”

And so they did this piece of work.

It’s not research standard. I mean, it was really that. And I think the RQIA produced a leaflet and they make the point, you know, correlation isn’t the same thing and, I mean, you shouldn’t use correlation purely as a way to target individual intervention.

But it was just a thought to say: well, you know, from what you know, can you link anything? Can you learn anything?

And so that’s what they came up with.

Lead 6: So if the home was run by a larger provider, then they were potentially more likely to have had an outbreak.

If the service had two manager changes. Is this, presumably, care homes again?

Professor Sean Holland: Yes, it was –

Lead 6: So if the manager changed twice, they were more likely to have an outbreak. And does the department have any observations on why the managerial changes has maybe led to a link in increased outbreaks?

Professor Sean Holland: This would echo with some work I was aware of pre-pandemic. I think John Kennedy did some work for the residential care forum in England, which was looking – and obviously he wasn’t looking at Covid at that stage; he was looking at regulatory failure and trying to identify factors that were indicators of an increased likelihood of regulatory failure, and I think he pointed to frequent changes of manager.

I think the understanding is that leadership is very, very important, and that if you have frequent changes in leadership, (a) it’s a discontinuity in leadership, but it may also reflect good leaders not wanting to stay and work in a particular place.

Lead 6: And just briefly, then, characteristics 3, 4 5 and 6: larger homes with 40 plus registered beds were more –

Professor Sean Holland: Sorry, I said 50 plus –

Lead 6: You did, it’s all right, don’t worry.

40 plus were more likely to have in outbreak. We’ve heard other evidence that’s – I think from Scotland, where a similar finding was.

“Less than 10 year[s] since [the] 1st Registration.”

What was the thinking as to why if they had not been – sorry, if they’d been registered in the last 10 years, they were more likely to have had an outbreak? Am I reading that the right way round?

Professor Sean Holland: Yes, I think you are, and I never really understood why there would be a correlation there –

Lead 6: No.

Professor Sean Holland: – but that’s what Dermot came up with.

Lead 6: All right. And are you able to help us with characteristic 5:

“More than 10 requirements and recommendations …”

Is that that they were required to improve by the RQIA?

Professor Sean Holland: Yes, that would reflect the level of previous regulatory direction they’d received. Now, it’s important to say that doesn’t mean that they necessarily have been subject to enforcement notices, but they may have been noted having areas of improvement. And I suppose that isn’t surprising.

Lead 6: And characteristic 6:

“High risk Local Government District … defined as over 60% of Nursing Homes affected.”

Can you help?

Professor Sean Holland: That’s community transmission.

Lead 6: Right, thank you.

So they’re potentially some ways which might explain why there were outbreaks in some care homes and not others.

You mentioned a moment ago Vivaldi, and we know that Vivaldi found that the use of bank staff in particular was a risk factor. And Vivaldi came out in July 2020, I believe. Do you know what was done to restrict staff movement or the use of bank or agency staff prior to Vivaldi? And then, again, what was done post-Vivaldi?

Professor Sean Holland: I think we had identified the use of bank staff and agency staff at an early stage in the guidance that we issued that predated Vivaldi.

Lead 6: Yes.

Professor Sean Holland: So we – from very early on, we were saying that you should minimise staff movement, because we’ve – I mean, it’s a logic that footfall of any description – I mean, we’d already modified the RQIA inspection methodology to reduce footfall. So recognising that having large numbers of people going into a home who may work in other places, it was something that we recognised.

So, from early on, we’d recommended minimising the use of bank and agency staff. I think we also gave, within the financial packages, the flexibility and suggested that care homes use some of the financial support that we were providing to block book agency staff, so that agency staff were being paid to go to them and they knew they could rely – that they’d been – would be paid to go to them rather than going to multiple providers.

Post-Vivaldi, I think it was a case of really just – it was a continued area of emphasis. So, subsequently, the PHA, at a later point after, it was after Vivaldi – I think it was quite a bit after Vivaldi – issued a leaflet which was specifically about highlighting the risks of bank and agency staff.

But that was, I think, from the very beginning, something that we were emphasising in our guidance to care homes.

Lead 6: Yes, you’re right, the March guidance said that homes should seek to limit turnover in staff they use and seek to limit the number of staff moving between different homes. A relatively uncontroversial but high-level statement.

But given that there was the workforce shortages that we discussed, how realistic was it, in the department’s view, to have fewer staff available because of (a) you’re going in without a strong workforce, (b) you’ve now got ill staff and or those who are isolating, and now you’re telling care homes to restrict staff movement. One might be forgiven for thinking that those things don’t sit very comfortably together. And so how was the care homes going to limit the number of staff if they didn’t have enough staff in the first place?

Professor Sean Holland: That’s why we didn’t issue a direction saying “Don’t do it.”

Lead 6: Right.

Professor Sean Holland: What we did was say “You should strive to avoid doing this”, and I think, as we went through, guidance became more granular and it was saying, you know: go through these steps before you look to engage agency or bank staff. So look at how you can manage your rotas, look at how you can cohort staff to particular units.

But we recognised the tension that you’re highlighting.

Lead 6: Yes.

Professor Sean Holland: So I suppose the balance was that you have the potential risk materialising from bringing someone from one setting in to another setting, versus the immediate risk materialising of not being able to provide the care someone needs at that point in time and that’s why it was about saying “Try very hard, make this your last resort”, but we never said “You can’t do it”.

Lead 6: Right. You’ve mentioned there a one-page document.

Can I have up on screen, please, INQ000508442. This was the document which we think was published in January, according to your statement, although it may have been actually written in November 2020.

Professor Sean Holland: Over the weekend I’ve been trying to track down the exact date and I’ve come up with both of those dates and I can’t stand over which one was the actual date it was published.

Lead 6: Well, it’s not going to stop me asking this question: if Vivaldi came out in July 2020, whether it’s November or January 2021, certainly a number of Core Participants think that this guidance came out too late, given the importance of the Vivaldi findings from the summer of 2020. Do you know why there wasn’t guidance put out before either November 2020 or January 2021?

Professor Sean Holland: Well, there was guidance put out, but this is the PHA guidance. So I mean, in every iteration of our guidance we, I think, were emphasising the importance of minimising movement of staff, so there was guidance put out.

Lead 6: Right.

Professor Sean Holland: I can’t answer for the PHA as to why they put this out at that point in time.

Lead 6: We can see there from the PHA document that:

“Agency staff must not work in more than one setting on the same day.

“Agency staff should choose to work in either a hospital setting or a community setting and not both.”

But do I understand it from you that this is not mandatory?

Professor Sean Holland: Well, there’s no –

Lead 6: Or there’s no sanction if you don’t do it –

Professor Sean Holland: No.

Lead 6: – may be a better way of putting it?

Professor Sean Holland: Yes.

Lead 6: Right. And just more generally on the topic of limiting staff movement, did the department put in place any funds or measures to try to recompense staff who could only now work in one setting or now had to do limited hours? We’re aware of the Infection Control Fund in England but was there any similar funding put in place in Northern Ireland that was ring-fenced for this?

Professor Sean Holland: The block booking, we specifically said that you can block book staff.

Lead 6: One other matter in relation to limiting staff movement, was any thought given in Northern Ireland to bringing in legislation to mandate staff not being able to move between care home settings?

Professor Sean Holland: I don’t recall it being an issue. I think before we got to the point where we might have thought about legislation, we were recognising this is a system that is fragile and, as with a number of things with the care home sectors, we thought encouragement, education, support, advice, was better than direction and legislation.

Lead 6: And do you know if there’s any thought being given to whether there should be legislation in the event of a future pandemic?

Professor Sean Holland: I don’t have that information.

Lead 6: All right. The – you mentioned there perhaps potentially some cohorting of staff and I think trusts were asked in October 2020 to consider how to cohort staff to limit the risks of infections, and there was a meeting, I think you say in your statement at paragraph 369, that on 16 October, there was a meeting.

“During that meeting it was confirmed that working in one care home was not always an option for agency staff as they were trying to assist shortages throughout all homes and Trusts.”

Did the department do anything to try to encourage cohorting, either by way of funding, additional guidance or anything of that nature?

Professor Sean Holland: I keep coming back to the block booking. That is a form of cohorting and so that’s what we were doing. And then the advice that I’ve referred to previously. But nothing in addition to those things.

Lead 6: And in relation to funding, I think financial support was provided in April 2020, June 2020 and October 2020. And there was various different funds then in ‘21 and into ‘22.

The department became aware of some instances where care home staff refused to take a Covid test. Can you help us about that, Mr Holland? Do you have any idea about the scale of that problem, the numbers, where this was happening, when it was happening?

Professor Sean Holland: I think we do have numbers on the uptake of vaccines by different occupational group and setting. I can’t recall –

Lead 6: Oh, that’s vaccines, but I was talking about – (overspeaking) –

Professor Sean Holland: Testing?

Lead 6: Yes.

Professor Sean Holland: I don’t think we’ve got the information on testing, I don’t think that was collected. Sorry, your original question?

Lead 6: That’s all right, let me help you. You were aware of the problem of some instances where care home staff were refusing to take a test?

Professor Sean Holland: Yes.

Lead 6: You’ve not been able to give us any detail about the scale of that but I think the department understood that part of the reason for refusing to take a test was because staff would have to rely on Statutory Sick Pay. Does that ring –

Professor Sean Holland: Oh yes, no, that’s absolutely the case. We were – I mean, it wasn’t simply the issue of taking a test; it was that people might turn up, even before, I think, the testing would have been available, that they might turn up for work when they were feeling unwell. So very early on, we said that we would fund an increase of people’s salary from Statutory Sick Pay up to 60% of their salary.

Lead 6: Yes.

Professor Sean Holland: And that – we just didn’t want people – testing probably became relevant to that later but it was before then, before the testing issue, it was just we didn’t want people who were symptomatic coming in to work because they were worried about losing their pay.

Lead 6: And so the department put in place some measures, I think, to fund independent sector employees up to 80% of the salary –

Professor Sean Holland: Yes.

Lead 6: – including those on zero hours.

Professor Sean Holland: Yes.

Lead 6: So there was some financial recompense –

Professor Sean Holland: Yes.

Lead 6: – if the staff member had to stay at home.

Professor Sean Holland: And that was also, I think, extended to staff who were shielding and I think to staff who might have been pregnant, because there was early advice, I think, about members of the workforce who were pregnant being kept away from face-to-face practice, I think.

Lead 6: Right. Can I turn to IPC as one of the other measures and ways in which to try and keep residents and, indeed, people living in domiciliary care safe. And I think – I know that the guidance was primarily led by Public Health Agency. Understood. But one of the things that the department did explore was what was called the Safe at Home model and can I ask you about that, please.

I think the department explored the possibility of staff living in care homes for seven days on, seven days off, with an isolation period of 48 hours before they started the seven-day shift.

Can you help with what was the rationale and the thinking between exploring this model?

Professor Sean Holland: There were two sources of rationale, I suppose. One was there were people talking about putting a ring of steel or a protective ring around care homes, and they weren’t defining what that meant. And then I was also aware – a lot of people were aware – but there were reports in the media where some homes where, on a voluntary basis, staff had chosen to move in and they seemed to be doing better at avoiding outbreaks. Particularly there was a home, I think it was called White House or the White House –

Lead 6: It doesn’t matter but –

Professor Sean Holland: – in Devon.

Lead 6: Anyway –

Professor Sean Holland: – I mention it because –

Lead 6: Thank you –

Professor Sean Holland: – we were able to look at that as being a starting point. And so we just thought: well, would this work? And so we did some work to develop a proposal. We did a very quick high-level outline about how you might do this, having staff living in, enhanced testing, and what have you. We circulated it and got the views of Chief Medical Officer, Chief Nursing Officer. I’m not sure if the Chief Scientific Officer was there at that stage, but we circulated it round. And I think the view back was it was worth a look at. So we then moved into trying to develop it in a more practical basis.

Conversations were opened up with Four Seasons, as was, Carol Cousins would have been the regional director. We had a very good relationship with Carol, we would have consulted with her a lot.

Lead 6: I think, though, that in due course, notwithstanding the conversations that were going on with Four Seasons to potentially pilot the Safe at Home model, there was concerns raised by the unions about the supply of and guidance on PPE, particularly whether staff might feel compelled to live in –

Professor Sean Holland: Yes.

Lead 6: – and the unions were not supportive of the Safe at Home model?

Professor Sean Holland: No. We got to the stage with Four Seasons of identifying two potential pilot sites. Then they received communication from the trade unions and the RCN where those points that you’ve just referenced were raised. There was a meeting held with the unions. The department tried to address their concerns. They were concerned, I think, about recompense, they were concerned about being pressured, as you say. And we made it absolutely clear: no, this would be an entirely voluntary scheme; no one would lose out financially if they chose not to participate. We went through testing and PPE and tried to address their concerns.

But subsequent to that meeting, Four Seasons came back to us and said: the unions still are not convinced, we can’t proceed with that.

Lead 6: All right. And I think in due course you and the Chief Nursing Officer issued a letter inviting expressions of interest wider than Four Seasons but received no positive response?

Professor Sean Holland: Yes. Well, basically we just went out to the sector and said: listen, if anyone is interested, we will work with you to try to implement this model.

Lead 6: Yes.

Professor Sean Holland: And no one came forward.

Lead 6: No.

Professor Sean Holland: I’d have to say, looking back, it was not something that we ever could have ramped up to scale.

Lead 6: No.

Professor Sean Holland: But it was –

Lead 6: Presumably because there wouldn’t be enough staff who would want to sleep in for seven days on –

Professor Sean Holland: A whole range of factors. I mean, you know, the layout of care homes where – you know, I mean, it just wouldn’t have been some – but we did think it might have been worth to run a pilot just to see if there were elements of it that could have been transferred to the wider sector.

Lead 6: Do I take it then that – do you know if there is any future plan to try to do a pilot like this, perhaps in peacetime, or to see if there’s any merit in the Safe at Home model being rolled out if needed in future?

Professor Sean Holland: I’m not aware of any plans in relation to that.

Ms Carey: My Lady, I’m moving on to a slightly different topic. Would that be a convenient moment for a mid-morning break?

Lady Hallett: Certainly. I shall return – I’m going to go by the Internet time rather than by the clocks. I shall return at quarter past.

Ms Carey: Thank you.

(11.57 am)

(A short break)

(12.15 pm)

Lady Hallett: Ms Carey.

Ms Carey: Thank you, my Lady.

Mr Holland, can I ask you, please, about PPE. And when looking at all the documents and reading your statement, would you agree with this general proposition, that the problems with access to PPE were most acute in March into April 2020 but thereafter, thankfully, access to PPE supplies generally began to resolve?

Professor Sean Holland: Yes, I think that’s a fair comment.

Lead 6: I just want to ask you about one example, please.

Can I have up on screen, please, INQ000397065.

At the time – this is an email from 18 March, and just to help you, IPC guidance for domiciliary care was issued the day before, the 17th, and it said that the trusts should help support independent providers if the independent provider could not get PPE from their usual sources.

So that’s where we were at and that was the guidance that came from the department, and here is an email from the chief exec of the IHCP to the department, that says:

“… I have been taking calls this evening from a distressed domiciliary care provider who has had no support from the Trust – they have a client presenting with coronavirus symptoms and have been told by the Trust they must provide the care even without the required PPE and that no test will be carried out to determine if it is [in fact] coronavirus – this is wholly unacceptable! They have doubled up on their normal protective equipment and provided the care rather than leave the client with nothing – the risks associated with this are totally negligent.”

Then Ms Shepherd goes on to say – she was asking for a number of questions: she would like a 24/7 response as “Coronavirus does not work on an office hours basis”, and clearly she has been taking a number of calls, she says, “for 10 days now with the communication not aligned through Trusts …”

And you can sense her frustration at being told things that are not been delivered.

“In the time of doing this email I have taken 2 more calls from Care Home providers – Southern Trust – having been advised that there is no PPE for care homes.”

It’s not a council of perfection, Mr Holland, I hope we can acknowledge that sensibly, but here you have, the day before, guidance going out to domiciliary care sector saying the trusts will help support independent providers and 24 hours later clearly still issues with providers getting the support they needed.

Do you have any sense of the scale of the problem – here we are in mid-March – where domiciliary care providers were not being supported by the trusts? And if so, what did the department do about it?

Professor Sean Holland: The first thing I’d say – I obviously can’t comment in any detail about an individual example that’s been presented.

Lead 6: No.

Professor Sean Holland: The first thing I would say is that I think it was actually from 12 March we first said that trusts needed to support the independent sector with PPE. And in addition to the guidance statements, I phoned each trust executive and made it very clear that there should be no organisational boundary in terms of the use of PPE between trusts and the independent sector. And I remember someone saying “Are you saying we have to share our PPE?” And I said “It’s not your PPE, this is a resource for Northern Ireland.”

So that was the advice. And that message was repeated several times.

Now, I think, inevitably – this was new. Previously, independent providers were responsible for sourcing their own PPE. So you’re introducing a new logistics arrangement. So it wasn’t going to be smooth, from the get-go. And, I mean, I know – I have a relative who was working as a care assistant in a care home and she told me of, you know, a car pulling up outside the care home, ringing the bell, and then throwing a box of PPE to the door. And it wasn’t a smooth, you know, “We need, you know, 100 gowns and 30 masks”, or whatever. You know, they got a box from the trust. But it did rapidly improve.

Lead 6: And what did the department do to try to aid its improvement?

Professor Sean Holland: We reinforced the messaging. We also clarified things like the single point of contact in trusts. I mean, I know Pauline was looking for a point of contact in the department 24/7. We weren’t suppliers of PPE. We didn’t hold stocks. So the place for them to have a point of contact was within trusts.

Lead 6: Yes.

Professor Sean Holland: And that was the way the supply chain worked. We instructed trusts to modify their ordering through BSO PaLS to include the care home needs that would be presented to them. So it was BSO PaLS to trusts, to care homes. That was the chain.

So, I mean, a single point of contact for – in the department would have added an extra link in that chain. And –

Lead 6: Although I think – sorry, go on.

Professor Sean Holland: And the other thing I would say is that – I mean, the IHCP had the direct phone number of me, my director, and actually the minister. You know, she was able to and did directly phone the minister.

What we did, as well, was we – in the early days, we were getting reports that were saying, you know, “Well, trusts aren’t giving us what we need”, or whatever. I think I mentioned before we took the break, we did ask the IHCP “Tell us who’s having trouble and we’ll pursue this.”

Now, I’m not saying that the list they gave us, those weren’t people who didn’t have trouble, but when she gave us the list and we started contacting them, they’d say “No, we’re getting supplies now. It’s working.”

Lead 6: Okay.

Professor Sean Holland: I think one other thing I’d mention, because I think it’s referenced in one of the statements I’ve seen from the IHCP, was that she referenced “We couldn’t get FFP3 masks anywhere”, and there wasn’t any guidance –

Lead 6: No.

Professor Sean Holland: – that would have required them to have used –

Lead 6: We understand.

Professor Sean Holland: Now, I am not saying the guidance was right or wrong, but we were only supplying to the guidance. And, I mean, people were scared and they were very, very anxious, so I understand that, but the fact that they couldn’t source FFP3 masks isn’t an indication that the arrangements weren’t working.

Lead 6: Right. Let me pause you there, because the Chief Medical Officer in his witness statement suggests three things that might assist with PPE supply. He says: greater resilience of supply lines, including scale-up for local manufacture.

What, if anything, has the department done to increase the resilience and maybe even do some work in relation to local manufacture?

Professor Sean Holland: I’m afraid I couldn’t answer that.

Lead 6: He also suggested there should be a greater supply of stock to be held by health and social care trusts.

Do you know, as at the time certainly when you left the department, was there a greater stock being held and was there any plan in place for the amount of stock that should be held? How long it should be held for?

Professor Sean Holland: I know that the – I think it’s called the PIPP, the pre – the pandemic influenza planning whatever, did allow for a strategic supply of stock, and at one point I know that – I think the minister announced that he’d released 30% of that –

Lead 6: Yes.

Professor Sean Holland: – pending more ordering.

I don’t know and nor would I have been involved in those discussions. It wouldn’t have been part of my responsibility. But just specifically on stock, I do know, quite quickly, because there was anxiety in the care homes. They were getting PPE but they were anxious they were going to run out. And I could understand that because at the early stages of us telling the trusts to supply them, it was a challenge in terms of supply and there were a lot of fears about supply.

So they wouldn’t have been being over-supplied, but at a fairly early opportunity the minister directed that a buffer stock, a two weeks’ buffer stock, should be issued to care homes, and that happened.

Lead 6: Yeah, I think that came out sometime in mid to late April of 2020?

Professor Sean Holland: Yeah, I mean, that was – take it – I mean, I’m sure you remember the stories of planes arriving from China and stuff being useless and all the rest of it. A lot of anxiety in the early days. But by – we were getting into April, the position hadn’t eased but there was more confidence, and so a buffer stock could be released, and so care homes were – well, trusts were instructed to give care homes two weeks.

Lead 6: Can I ask you about one other aspect of the department’s work which is the Department of Health’s PPE mailbox which was set up, I think, in late March when the Chief Nursing Officer and the Top Management Group, as I think it was then called, became aware of reports of concerns about lack of PPE and the mailbox was set up not as an advisory service but to forward the queries to the most other appropriate, either person, sector, department, organisation, to respond to them?

And it only received 95 queries as at the end of December 2020 across health and social care. Do you know, Mr Holland, why, on any view, that seems to be quite a low number of queries into the department’s PPE mailbox?

Professor Sean Holland: I would hope that it was a reflection on the fact that the other arrangements that were in place were working well. So we had reconfigured or repurposed the RQIA to provide service support teams.

Lead 6: Yes.

Professor Sean Holland: And they were providing advice and support to care homes. And I think it’s important, because I think most of the countries did something around repurposing regulators to provide an advice service, but there are differences. I mean, in England, for example, the CQC had the policy for years of having, I think they call them generalist inspectors and specialist inspectors, and the generalist inspectors weren’t health and social care professionals. The RQIA was never like that. All of its regulatory staff were either social workers, doctors, nurses, physiotherapists, what have you.

So the service support team providing that service were people who could give a high quality of advice and they would have been providing advice in relation to queries about PPE.

In addition, there was the point of contact within trusts and the PHA were also providing support to the independent sector on PPE.

So the helpline was, kind of, like, just to be sure to be sure to be sure, make sure that we’ve as many arrangements in place as possible that could address the –

Lead 6: You’ve just mentioned there the SST that was set up, services support team, and I’m going to deal with that topic mainly with the Chief Medical Officer, Mr Holland, but just from the department’s perspective do you think there’s a role in the future for the services support team in the event of a future pandemic?

Professor Sean Holland: I’d have to say I think it was – and again, I’m cautious about saying things worked well, because – well, anyway. I think it was a positive experience. The service support team became operational very quickly, it provided ongoing support from qualified and experienced people who knew that – these were people who would have inspected and regulated this sector and they were all health and social care professionals. Social workers, nurses, physiotherapists, and that was a source of advice directly to providers.

And it was – I was pleased to see, I think in the UK Homecare Association’s evidence, they noted the experience of the service support team positively in contrast to other arrangements in other countries … so yes, I do think it’s something – I mean, in terms of planning for a future pandemic there has to be a degree of realism. You can’t have a mirror system sitting for decades waiting potentially to be used. You know, but you can have plans in place to how you can quickly work up supports, and I think something like the service support team should be incorporated into future planning arrangements.

Lead 6: New topic, please, and visiting, and in particular I’d like to ask you some questions about the Care Partner scheme. But just to put it in some context, the guidance for care homes on 17 March 2020 did not impose a blanket ban but we are aware that, I think, certainly about 82% of care homes were restricting visits prior to that date anyway.

Come forward to September 2020, and I think there was a move for one face-to-face visit per week by one person, and there was the Care Partner scheme. I just want to be clear, was the care partner in addition to the one-to-one face visit?

Professor Sean Holland: The Care Partner scheme was intended to be something quite different from the regular visiting arrangements, and we were getting a lot of correspondence and we also would have had engagement with people. As restrictions were lifted for wider society, there was growing frustration, absolutely understandable frustration, from families, although it wasn’t always straightforward, there were families who didn’t want visitors coming in, but there were a growing number of people who did want to visit, and I can’t remember exactly the genesis of it but the proposal for care partners was slightly different to increasing regular visiting in that it was recognising – and I would have had experience of this from my own family with relatives in care homes, that sometimes you’ll have a member of your family who plays a particular role, and actually, the idea was you could – you’d be able to treat that person more like a member of staff, because I mean, I can think back to relatives who were in care homes pre-pandemic, and I can think of a relative of mine, and another relative, and the relative would have gone in and fed them every day, would have done sort of some physio with them and stuff like that.

So the Care Partner scheme was trying to say that where you have needs that pre-pandemic were being met in that way, can we start to bring that back in and treat the person as if they were a member of staff? Because it wouldn’t have been a significant additional risk if you put the right arrangements around it. If you’re letting staff in, why not let a designated person in who actually would be a support to the care home because they would be undertaking some of the burden that the staff would normally have to meet.

Lead 6: Let me just pause you there, because we’re going to look at a little bit of the guidance in a moment, but the guidance came out on 23 September and it was to be implemented by 5 November to give care homes time to make the arrangements, identify the care partner, and the like. But prior to 23 September had there been any engagement with the sector about the practicalities surrounding the Care Partner scheme? Or did that come after the guidance had come out, but before it was due to be implemented?

Professor Sean Holland: My understanding, and this work was led by the Chief Nursing Officer’s group, was both. There was engagement. I know that the IHCP said that they hadn’t been engaged –

Lead 6: Yes.

Professor Sean Holland: – prior to the announcement but there had been engagement with people in the sector and I suppose that reflects the fact that while conversations with the IHCP were important, they were an organisation who represented the business interests of care homes, whereas we had a lot of relationships directly with care homes where, if you were looking to discuss practice and develop practice, if we went through the IHCP they would simply have had to have gone to their members to get feedback whereas we would have just gone directly, and we had very good relationships with certain providers.

Lead 6: Let’s just look at the definition of a care partner, please, and have up on screen INQ000256450_30.

This is taken, Mr Holland, from the actual 23 September guidance. It says there at paragraph 4.1:

“Care partners are more than visitors. [They] will have previously played a role in supporting and attending to their relative’s physical and mental health, and/or provided specific support and assistance to ensure that communication or other health and social care needs are met due to a pre-existing condition. Without this input, a resident is likely to experience significant and/or continued distress.”

It’s a fairly broad definition there, if I may say, but how was it actually going to help the care homes decide who was or was not a care partner?

Professor Sean Holland: I don’t know the detail of the discussions as they developed, but I don’t think that would be necessarily that difficult, because as I said, this was building on arrangements normally that had been in place prior to the pandemic. Before the pandemic, we didn’t call them care partners, but it wasn’t uncommon for there to be visitors who played a much more active role in the care of someone in a care home beyond a wider range of visitors.

Lead 6: Let me put it another way, then. From the perspective of the loved one or the relative, how did they prove to the care home that they were a care partner and not just someone who was coming in once a week to see their loved one?

Professor Sean Holland: I think that the notion that they would just be coming in once a week, well … people want to provide care for people they love. I don’t – I wasn’t aware of a challenge with people putting themselves forward unsuitably for the role, and I’m not sure I understand why anyone would unsuitably put themselves forward for that role.

Lead 6: The care home guidance – sorry, the guidance that came out on 23 September said nothing at all about testing arrangements for care partners. Do you know why the guidance didn’t say either they’re not going to bring in testing or they’re going to bring in it in due course when there’s more capacity? Why is the guidance totally silent on whether care partners should or should not be tested before coming into the care home?

Professor Sean Holland: I have to be honest, the detail of this was dealt with by the Chief Nursing Officer. I think that the initial – there was some preparatory work before the September announcement. I mean, these weren’t just ideas that came out of the blue, but they were announced in a draft state, it was acknowledged there was going to be ongoing work to refine and develop them as implementation moved forward.

Lead 6: Okay. And as I understand it, it was not underpinned by legislation, the Care Partner regime, but the expectation was that it would be followed.

Professor Sean Holland: Yes.

Lead 6: And Minister Swann states that it should be put on a statutory footing. Do you know what the department’s view is on whether care partners should be made subject to statutory legislation?

Professor Sean Holland: I wouldn’t have current awareness of what the department’s position on it is, so this is a slightly speculative answer but I’d offer a few views.

I think both the RQIA standards and the fact that these are contracted services provide some levers that can be used to shape the nature of a service, and that could include care partners.

I think that there has been a reluctance on the part of trusts to use the contract with a care home to influence practice, and I think that’s been a failing. And if that was something that were more developed, I don’t know if you would need to think about a statutory footing for care partners.

I mean, I was struck very much in talking to trusts that I couldn’t find any instance where there had been deficits in service provided by a provider. And I’m not talking about minor deficits, I’m talking about where there had been significant problems that had resulted in a withholding of a payment for a service.

Now, that always struck me as strange, because – in most areas of life if you pay for something and you don’t get what you pay for, you know, sort of withholding future payments is an accepted practice. But there seemed to be a very strong reluctance. Maybe if that was explored.

Although, if you take care partners as being part of an expression of Article 8 rights, then maybe it is appropriate for it to go on a statutory footing. I mean …

Lead 6: Can I just move on a few weeks in time to 12 November, and, in theory, this Care Partner guidance should have been implemented by the week before.

Can I have up on screen, please, INQ000256455_3.

This is a letter co-written by you and the Chief Nursing Officer, and we can see at the top of the page there that you’ve annexed a copy of the guidance that had gone out. You said:

“Since that time we have been engaging with … stakeholders, including representatives of families and of care homes, [ICHP], Trust staff, including those providing support to care homes [et cetera], to listen to concerns regarding the implementation of the care partner and to provide a supplementary description around the concept.”

What was the supplementary description that you provided?

Professor Sean Holland: I think it was just more information and more granularity as to how it would work. But I’m not – I can’t recollect exactly. I mean, we were trying – we were getting a lot of feedback from families about visiting in general and the care partner concept. Once people became aware of it, they were very interested and wanted to engage in that. And myself and the Chief Nursing Officer held a few virtual meetings with relatives, and they were very emotional and fraught meetings for very obvious reasons, but they were very keen on relaxing and increasing access to visiting generally and the Care Partner scheme.

On the other hand, we had care homes who, understandably, were nervous, because of their experiences earlier on in the pandemic, and particularly if they hadn’t experienced it themselves, they will have seen other homes where there had been a significant number of deaths. So I think they were scared.

And, you know, in other contexts we’ve given a message out about absolutely minimising the number of people going into a care home, as a preventative measure, and now we’re trying to relax that arrangement specifically in relation to visiting and the care partner.

Lead 6: Should we take it, though, that if there was need for a supplementary description and work, perhaps that the original guidance wasn’t as helpful as it might otherwise have been had there been that stakeholder engagement? Do you think that’s a fair criticism Mr Holland?

Professor Sean Holland: No, I don’t. I think that it was always recognised – I mean, this occurred with some other issues where people – I mean, I can think – going back all the way to the March 17th guidance, where the IHCP were critical of the fact that we’d issued guidance without what they would have considered full consultation. Full consultation normally for a department could stretch anything from 6 to 12 weeks, involve very extensive engagement with a range of stakeholders.

I think there were points where it would have been negligent to have withheld what was available at a point in time to wait for full consultation. I think in the case of the Care Partner scheme, we wanted to give hope to relatives as early as we could to say: look, we’re looking at your concerns, we’ve got some plans, you know, that we are bringing forward. This is what they look like.

But those plans weren’t fully developed, and I think that’s okay. And then you then work through the issues with providers as you go.

Lead 6: I think in due course there was clearly always that tension between reducing footfall, particularly in the autumn of 2020 as numbers began to rise into that winter?

Professor Sean Holland: Yes.

Lead 6: And here you are, potentially – I think it was two – potentially two people could be named as care partners, plus the face-to-face visitor, so you’ve got three people potentially going into a care home without the professionals that are going in, without the staff going in.

Was any thought being given to increasing the amount of testing available to the care partners? We know it came in over the Christmas period, where there was one test a week for one visitor over, I think, about a three or four-week span, but do you know why that wasn’t done back in November when the Care Partner scheme should have been implemented?

Professor Sean Holland: I’m assuming, and it is an assumption because I wasn’t involved in the detail of the discussion, that as testing capacity became available, it was used for extensively. But that’s an assumption on my part.

Lead 6: And just finally on this topic, you say in your statement that by mid-December, 182 care homes had implemented the scheme, and by September 2021, 289 had, which rather begs the question what about the other 200-odd care homes that hadn’t implemented the scheme? What, if anything, did the department do to find out why they hadn’t and maybe to encourage compliance with the scheme?

Professor Sean Holland: There were steps taken to encourage compliance with the scheme from it being first announced in the September on a continuous basis. I think that the steps that were taken to encourage compliance started in a very supportive way. It was about trying to explain, reassure, provide more information, answer questions. As more time went by, if you had people who wanted to be care partners and there was still resistance from a care home, we started – and I think it might have been referenced in the letter you had up a few moments ago – reference to if you’re receiving funding, you know, we’ll need to consider whether, if you’re not complying – and we also, I think, referenced the fact that compliance with visiting guidance and – I can’t remember if it was also the Care Partner – certainly with the visiting guidance – might be considered by the regulator when inspecting against the relevant standards about maintaining contact with families.

So it was, as far as possible, a softly, softly encouragement, sort of, nurturing approach but there was a little bit of an edge as you went on.

As to the answer to the second part of your question, it was always recognised that not all families and maybe not all care homes would require a Care Partner scheme. The profile of people living in some care homes is very, very different. You know, we have homes and supported living arrangements and non-nursing homes, for example, where people are there on a respite basis, so it’s short-term, and indeed, normally that’s to give a break from the people who are primary carers so you wouldn’t have them there. You also have mental health facilities which would have a different – I mean, while I’m not saying visiting and relationships aren’t important, you wouldn’t have the need for support and assistance with direct personal care tasks. So there could be a lot of reasons as to why you would never reach the full 482 number.

Lead 6: Understood. Right.

Can I just ask you one other topic on visiting, please. Certainly the department’s position was that necessary healthcare visits should always continue throughout the pandemic, and I think you have seen reference in the Care Homes 10,000 Voices report from September 2020 where 58% of respondents said that their healthcare professionals did meet their needs but 22% stated healthcare professionals met their needs some of the time and 20% said they were never met. So 42-ish% are either not met at all or only met some of the time?

Was the department aware that there were problems with getting healthcare professionals to pay the necessary visits into care homes and if so, what did the department do about it?

Professor Sean Holland: That would have been a relationship between the trusts and the care homes. The trusts were contractors with the care homes. They were employees of the staff who needed to get access to care homes. We would have been aware, because trust would have flagged up that there were sometimes issues about getting access. We may have intervened directly in cases although I don’t recall it. I think that it was a case of the trusts working with the care homes to ensure that there was access.

What we did do was probably increase the capacity to provide in-reach support to care homes to meet healthcare needs. So there would have been, in trusts, acute care at home services, a hospital at home services, enhanced care in the community services. Different names, all of which related to the drive over the previous decade, probably, of trying to shift services that traditionally were provided in hospital into the community. The Chief Nursing Officer’s group and the Chief Medical Officer’s group had worked basically directing to say there should be a focus from these services during this pandemic on where we know there are concentrations of people with high vulnerability, so they would have been increasing the amount of service of that nature going into care homes, and I think, again, the statements you have from trusts reference the role of trust staff going in to deliver those kinds of services.

Lead 6: New topic, please. And just briefly some observations from you, please, Mr Holland on data.

In your statement, you say that prior to the pandemic, the Department did not collect data on care homes. You make reference – it’s at your paragraphs 831 and 832, you said:

“… NHS England were recording some social care data in respect of care homes …”

Including number of beds registered; number of beds that were available, vacant beds, the percentage of residents tested for Covid, and the like.

And we know that data collection improved over the course of the pandemic. But didn’t Northern Ireland have none of that data as at January or February of 2020? And if not, do you know who did?

Professor Sean Holland: Sorry, I’m just looking for –

Lead 6: 831 onwards in your witness statement.

Professor Sean Holland: Yeah. It’s maybe a definitional thing but I apologise if the statement is misleading by saying we didn’t have data. We had information about the sector but the type of information and the time frames within which it were supplied were not what we needed in the pandemic. And you could make a case and a criticism to say we needed it before the pandemic and I wouldn’t argue with that criticism. But we did have information.

So we had a lot of market information but not in real time. So the market information, we did an annual survey. There was a survey week in relation to domiciliary care where we took all the information that was available about who was receiving domiciliary care, what for, how many packages, who were providing. And that was the survey week. And that provided information. But it was an annual survey. That’s not the same as live-time data.

We also had market information from the analysis provided by commercial consultancies, and that’s a source I know NHS England also use. There’s – I mean, I can think of two consultancies, I think it’s Knight Frank or Frank Knight, I can’t remember which, and LaingBuisson, who were noted providers of market information. So they’ll tell you how many providers there are, profitability, how many business failures there have been, types of bed. But again, it’s not real-time information.

Lead 6: Can I just pause you there?

Professor Sean Holland: Yes.

Lead 6: I think you said in your statement there was, at your behest, a design of a template for there was one single return being made. I just want to have a look at it.

It’s INQ000560995.

Because clearly there were demands being placed on care providers and domiciliary care agencies to provide data to lots of people, PHA, RQIA, trusts and potentially the department, and I think your plan was to have it all in one place.

And is this is a mock-up of the template that you devised or that was devised?

Professor Sean Holland: It was – well, firstly, I can’t take credit for this solely. I think there were a number of people who would have been expressing the view: can we streamline this?

Lead 6: Yes.

Professor Sean Holland: And the idea was, as you say, to try to ease the burden on care homes, because a lot of people were asking them for information. And so we did two things. One, we made – I mean, we made a lot of financial provision to care homes. We guaranteed their income at one stage, very early in the pandemic, when – I mean, I know a lot of the talk has been about the sector being flooded, we were concerned about vacancies, so we guaranteed income.

But we also at a point said we recognised there are administrative burdens associated with data, so we paid a management premium to help people be able to make the returns. But the other thing was trying to simplify the process.

Lead 6: Yes.

Professor Sean Holland: And this was our attempt. And I think we were nearly successful entirely, but not entirely, in that the PHA wanted to retain some of their own data collection. But everyone else accepted the single point.

And in defence of the PHA, I’m not sure but I think that might have been in relation to statutory duties, because Covid is a registered disease.

Lead 6: Understood.

Professor Sean Holland: But we wanted to simplify it, so – and it did change. I think the big leap was being able to move to it being submitted by app.

Lead 6: Yes.

Professor Sean Holland: So we got to the point where your returns could be made by an app. There were some additions made to it over time as to information that was being sought, but the idea was that we would start getting real-time data, not the sort of data that you get from a survey once a year –

Lead 6: No, I understand that –

Professor Sean Holland: – but you will get a daily return, I think before 10.15 in the morning or 10.30.

Lead 6: I think you said in your statement, though, it was supposed to be mandatory but not everyone completed the form due to either staff absence or they were off caring for sick residents and the like.

Do you know if there’s any position now where data returns like this are mandatory and, indeed, monitored for non-compliance?

Professor Sean Holland: I don’t know what the current position is. I think we did get up to 99% return at one stage, but that was very late on, and there was a law of diminishing returns where, you know, you got big gains, big gains, large gains, less gains, and there’s a sort of small bit at the end. And we got to 99%.

I don’t know what the current position is, but I think, again, it’s one of the lessons for the system about the care sector. I would say one of the biggest failings pre-pandemic, and I would like to say it’s not a failing now, but quite often the health sector views the care sector as being something that’s there to support its effective functioning. And that’s wrong.

Certainly, without a – if you have a dysfunctional care sector, it’s going to add to burdens on the health sector and potentially collapse, theoretically, the health sector, but it should be seen as something that is important in its own right. People live there. Many people spend their last days there. So it shouldn’t just be viewed in terms of how it supports discharge or whatever. It needs to be something in its own right.

Now, in the healthcare sector, on any given morning in the department, with a few phone calls, I suspect that you could find out how many ICU beds were available, how many were occupied, you might know something about them. You would maybe know about what the staffing pressures were.

Now, certainly going into the pandemic we had nothing like that.

Lead 6: No.

Professor Sean Holland: Now, partly – it’s the private sector, there were, you know, 482 homes, 300 domiciliary care providers. You know, we’re not talking about a single unified system. This had been outsourced, in effect, and that made it complex. But certainly in the pandemic, it became really important that we knew, day-to-day, how the system was doing. And we didn’t know that before and I don’t know what the current position is.

Lead 6: There’s other people, I suspect, I can ask about that.

Just finally from me, please, Mr Holland, I’m not going to ask you about the RLIs and all of the other work done by the department, but there is one aspect of Minister Swann’s evidence that I’d like the department’s views on. He recommended a central registry of unpaid carers to be maintained either centrally by the department or at trust level, he wasn’t sure which might be more practical, but what’s the department’s view on is that necessary, and if so, how would it help in the event of a future pandemic?

Professor Sean Holland: I can’t give you a current answer to whether the department feels it is necessary or not, but what I would say is that it is challenging to have a statutory register, but there were deficits in the fact that we didn’t have a comprehensive register. We were able to identify people who were in receipt of a service but not all unpaid carers are. We were able to identify people who were in receipt of direct payments, but not all unpaid carers are. And we were also able to identify people who were in receipt of independent living fund payments and thalidomide grant payments.

But that’s a much smaller number than people who are – who were carers and not necessarily in receipt of a service, but who you might want to communicate with or you might want to reach out to at a time like this.

Lead 6: Yes.

Professor Sean Holland: So I can see where Robin is coming from and I can understand why he’s asking it.

Now, I don’t think you could force carers to put their names on a register they don’t want – when they don’t want to. But I suspect that it is an area where, with focus, we could improve our knowledge and ability to communicate with the sector. I mean –

Lead 6: Can I ask you this, then, because clearly you’re no longer in the department, but would it have helped you in your role as Chief Social Worker had there been such an unpaid carers register during the pandemic?

Professor Sean Holland: There are some things it would have helped with but I wouldn’t overstate it.

Lead 6: Okay.

Professor Sean Holland: So resources and services were already significantly under pressure and we were already thresholding services. So simply having the identification of unpaid carers wouldn’t necessarily have added to us being able to provide them with lots of services. We wouldn’t have been able to. But it would have meant we would have had a channel of communication with them and that would have meant things ranging from providing them with – directly, when we published advice, but directly providing them, maybe through an email link or whatever, advice on shielding, isolation, maintaining your own wellbeing, access to other supports. I mean, one example – I mean, and I know that you’re aware of this – we made available a carer’s recognition card.

Lead 6: Yes.

Professor Sean Holland: So people could access protected shopping time. If the police stopped them during lockdown, they could say, you know, they could produce this card and the police would accept it. Now, I don’t think we were very strict on issuing those, to be honest. I think more or less anyone who asked for one got one, but it still, at its height, reached 42,000. The estimate is there are 220,000 people.

Another area, I think, would have been advice on IPC, infection prevention and control.

Lead 6: Quite.

Professor Sean Holland: Now, we did promote that advice very strongly. There was a web-based – the one, I mentioned earlier, provided by NISCC which was deemed suitable for family carers to use to improve their practice in relation to infection prevention and control, but you’re sticking things out through social media and we did put a leaflet drop to everyone, but that’s not the same as maybe people knowing there was a portal they could go to for updated advice, where you could directly email them if you wanted to with information.

So yeah, there would be benefits but I wouldn’t overstate them.

Lead 6: Understood.

Professor Sean Holland: It wouldn’t lead to loads of new services being available.

Ms Carey: Understood. Thank you very much.

Mr Holland, that’s all the questions I have for you.

My Lady, I think there are some Core Participant questions.

Lady Hallett: There are.

Thank you, Ms Carey.

Ms Campbell, who is just over there.

Questions From Ms Campbell KC

Ms Campbell: Thank you, my Lady.

Mr Holland, you may know I represent the Northern Ireland Covid Bereaved Families for Justice, and we have questions across three topics, revisiting in fact some of the evidence that you leave already given this morning with the assistance of Ms Carey.

I want to focus, please, first on a correspondence that came to you and the Chief Nursing Officer from the IHCP on 16 November 2020.

I won’t put it on screen, but you’ll immediately notice it’s just a number of days after the letter that we’ve looked at recently from you and the Chief Nursing Officer in relation to Care Partner guidance, and the implementation of Care Partner guidance.

And the IHCP write are you that they had provided constructive feedback at the end of October 2020 on the documents issued regarding the care partner role and has offered to engage fully on, and I emphasise, shaping the concept of that care partner role, and they observe that they have yet received no response or feedback to their questions and, instead, there appears to be a delay in meeting to discuss the matter or to develop a supplementary description of the care partner role, with a shift from the Department of Health to the Public Health Agency to take the lead.

So we’re 16 November 2020 and this is from the IHCP.

And you have observed in your evidence that, of course, the IHCP represent the business interests of the independent care sector, and that’s correct, but it’s the business interests of some 50% of the independent care sector, and well in excess of 200 care homes, both nursing and residential; you’ll acknowledge that, is that right?

Professor Sean Holland: Mm-hm.

Ms Campbell KC: And I’m afraid I’ll have to ask for a –

Professor Sean Holland: Yes.

Ms Campbell KC: Thank you. It’s just for the purposes of the transcript.

And you’ll also recognise that behind those figures are many hundreds of residents and many thousands of family members being impacted by potential failures to implement Care Partner guidance.

Professor Sean Holland: Yes.

Ms Campbell KC: You understand that?

Professor Sean Holland: Yes.

Ms Campbell KC: And the question, really, on behalf of the Northern Ireland Covid Bereaved is this: here we are on 16 November 2020, almost two months after the guidance was issued, why is it that the representatives of 50% of the independent care sector appear to believe that the care partner role was, as yet, a concept and one that could be shaped or given a supplementary description?

Professor Sean Holland: Again, I have to caveat this by saying that the lead role in developing this work was done by the Chief Nursing Officer in our group. But I do know that both prior to the announcement in September, and certainly on an ongoing basis from September, there was ongoing engagement with actual providers in developing the concept.

I mean, the IHCP is one person and maybe some administrative staff, and the one person is not someone who has experience of running care services. And that doesn’t mean they’re not an important voice and on some instances they are absolutely the right voice, but if you’re looking to engage – and we found this around a number of areas – if we were looking to engage on a practice issue that – sometimes if you went to the IHCP, you were adding a layer into the chain that caused delay, because they in themselves were not experts in this. So they were going to members and then coming back to you.

We had a lot of links with a number of organisations, both in the IHCP and not in the IHCP. And those contacts would have been used particularly around some practically issues. So it would have been more appropriate for the nursing team to engage directly with care homes than with a representative organisation which in itself was not – and had limited capacity. I mean, at one stage I’m fairly certain to say the IHCP approached us for funding to increase their capacity because they said they had limited capacity to engage with us. And that was something we considered and we didn’t provide funding to them at that point. But we would have engaged directly with providers.

Ms Campbell KC: You see, because there are concerns, and there remain concerns on the part of the bereaved, many of whom you know either engaged with the development of the guidance or were desperate to see it implemented at this point in November 2020, that the department was insufficiently clear or robust with the sector, and that might well include the sector representatives, as to the expectations that had existed since, we know, 23 September 2020, that every effort should be made to implement the guidance. Do you recognise the legitimacy of those concerns?

Professor Sean Holland: I recognise that there was a tension between encouraging and supporting, and providing advice and information to care homes to enable them to be confident enough to engage with the Care Partner scheme, and reluctance on the part of some providers which, as time went on, became less reasonable, given the understandable fears that were there.

I think I indicated earlier that we had a graduated approach in that as we rolled out and there was still some resistance, from a diminishing number of providers, we started to reference that we would use regulatory standards and potentially contracting to encourage more firmly participation.

Whether we got that balance right or not, I can’t judge, but I do know that it was a risk if we were to alienate people, and our preferred choice was try, I mean, mainly carrot, a little bit of stick, but mainly carrot. If that was a misjudgment, it was one, but I don’t know if it was.

Ms Campbell KC: Well, you in your evidence, with the assistance of Ms Carey, talked about an approach of a softly, softly nurturing approach –

Professor Sean Holland: Yeah.

Ms Campbell KC: – in the first instance. But ultimately you had to address this impasse in part at a business level because in your statement you indicate that on 16 December 2020, recognising the concerns felt by many care homes about visiting and Care Partner arrangements, the department announced further support, and I think that included financial support to be available to all care home providers in Northern Ireland to facilitate visiting, in line with the guidance, particularly over the festive season.

Now, you talked about getting the balance right. Really, if we might focus on how quickly measures were taken at this particularly stressful time for families. Why did it take until 16 December, bearing in mind the 23 September announcement of the Care Partner guidance in particular, to announce a package that might be capable of achieving some resolution?

Professor Sean Holland: I’m fairly certain financial assistance to support visiting predated that by quite a significant time.

Ms Campbell KC: Well, we can look at that through your evidence and the evidence of others.

Moving on, then, to reporting of Covid outbreaks. And it’s a fairly discrete question. You’ve been asked a number of questions in relation to domiciliary care because we know how many people in Northern Ireland rely on it and how many families value it. In your statement, you indicate that there are over 21,000 individuals in Northern Ireland in receipt of domiciliary care, of which nearly 9,000 required six or more visits and ten or more contact hours per week. So that’s a lot of people going in and out of people’s homes on a very regular basis, and yet we know that there’s no statutory requirement for domiciliary care agencies to report Covid outbreaks to the RQIA or, indeed, anywhere else, and no legislative or regulatory amendments were made at any point to impose such a duty.

Do you accept the concerns of the bereaved that relying on domiciliary care agencies to self-report – and we know it came through a voluntary app – particularly when those individuals and agencies were operating under significant time and financial constraints, and you’ve told us some of that this morning? Do you accept that that was neither an adequate nor a robust mechanism to ensure proper monitoring and oversight of Covid outbreaks in domiciliary care?

Professor Sean Holland: I’m not absolutely sure, but the – I mean, the emergency legislation made Covid a notifiable disease.

Ms Campbell KC: Yes.

Professor Sean Holland: And I’m not sure the extent of which, I mean, that wouldn’t have discriminated against – I mean, it was a notifiable disease. The app was separate to that and that’s probably why the PHA didn’t – wanted to maintain the separate reporting on Covid from the app. I don’t think that the app was intended to be the main route by which public health surveillance would be notified through for outbreaks of Covid.

Ms Campbell KC: Particularly in relation to domiciliary care, is –

Professor Sean Holland: No – (overspeaking) – I’m just saying I don’t think that would be the case. I mean, there are public health requirements about notifying a notifiable disease. The app wasn’t replacing those. The app was about us collecting information about circumstances. I mean, I stand to be corrected on this, it’s not an area of expertise, but I don’t think that you can conflate the request for returns through an app with statutory requirements in relation to a notifiable disease and it’s not an area of my expertise.

Ms Campbell KC: That’s fair and, in fact, we’ve already touched on it through the RQIA, as well, so I should perhaps leave it at that.

Finally, testing in care homes, and particularly focusing on the period from August 2020. You indicate at paragraph 505 of your statement that a regular programme of PCR testing commenced on 3 August, so almost five years ago, 2020, with asymptomatic staff to be tested every two weeks and residents were to be tested every four weeks. And again to revisit some of the concerns that the IHCP raised with you, when they brought the views of care homes about the practical impact of that decision, which they again complained was made without consultation with them. I don’t expect you to remember the specific examples, Mr Holland, but I imagine you’ll remember some of the sentiment.

One care home provider wrote:

[As read] “I’d be keen to hear other providers’ thoughts on the Department passing over complete responsibility for administering, ordering, testing, data collection, regular Covid-19 testing for staff and residents to the care providers. I’m also keen to hear opinions about the timescale from implementation of 3 August. My opinion [writes the author] is unprintable.”

And within the same correspondence there were further, similar concerns being raised.

Is this is an example of the Department again failing to sufficiently engage with the sector when, in August 2020, it made significant changes to the testing regime?

Professor Sean Holland: No, I don’t believe it is. And indeed, the statement that you’ve just quoted doesn’t reflect the reality of the situation. There was significant support being provided in relation to testing, both direct support and financial support to facilitate testing. And it was a very, very significant level of support.

Now, I understand that peoples’ individual experience at a time of pressure, when they’re scared, when things are very difficult, can lead them to represent things in a certain way, but that statement wouldn’t be an accurate description of the situation.

Ms Campbell: Thank you. Those are all my questions.

Lady Hallett: Thank you very much indeed, Ms Campbell.

That completes the questions that we have for you, Mr Holland. I do understand how distressing it can be to have to relive those very difficult times. So thank you very much for the help that you’ve given to the Inquiry. I don’t know how many people were involved in preparing your statement, but thank you to everybody who helped with that and thank you for coming here today.

The Witness: Thank you very much, my Lady.

Lady Hallett: Thank you.

Very well, I shall return at 2.15.

(1.13 pm)

(The Short Adjournment)

(2.16 pm)

Lady Hallett: Yes, Ms Shotunde.

Ms Shotunde: My Lady, please may I call Nicola Dickie.

Ms Nicola Dickie

MS NICOLA DICKIE (affirmed).

Questions From Counsel to the Inquiry

Lady Hallett: Good afternoon.

Ms Shotunde: Please provide us with your full name.

Ms Nicola Dickie: Nicola Dickie.

Counsel Inquiry: Thank you for coming back to provide evidence for this Inquiry. And thank you for your witness statement dated 14 April 2025.

If I can just start with your role during the pandemic, you were the health and social care chief officer for the Convention of Scottish Local Authorities from February 2020 until September 2021; is that correct?

Ms Nicola Dickie: That’s correct.

Counsel Inquiry: And I’m going to refer to the convention as COSLA throughout.

Ms Nicola Dickie: (Witness nodded).

Counsel Inquiry: What was your responsibility in that role?

Ms Nicola Dickie: So I delivered policy as it related to health and social care, so that included adult social care, mental health policy, National Care Home Contract, all of the stuff as it related to health and social care for the organisation on behalf of our 32 member councils.

Counsel Inquiry: And in October 2021 you became Director of People Policy in COSLA. What was your responsibility in respect of the adult social care sector in that role?

Ms Nicola Dickie: So the chief officer role that, I had someone else took on that role and then they reported to me as a director alongside chief officer who was dealing with children and young people, and COSLA’s strategic migration partnership which is asylum and migration.

Lady Hallett: I’m terribly sorry to interrupt, can you slow down.

The Witness: Yes.

Lady Hallett: Otherwise, I’m going to have a stenographer –

The Witness: I will try my very best.

Lady Hallett: – complaining. Thank you.

Ms Shotunde: What is your role currently?

Ms Nicola Dickie: I’m the Director of People Policy now.

Counsel Inquiry: Thank you. I’m going to ask you some brief questions about COSLA. My understanding is that it’s a councillor-led cross-party organisation with all 32 unitary authorities as members; is that correct?

Ms Nicola Dickie: That’s correct.

Counsel Inquiry: It also has a Health and Social Care Board which leads on all aspects of policy development and political lobbying in relation to health and adult social care for COSLA; is that right?

Ms Nicola Dickie: Correct.

Counsel Inquiry: What was the role of COSLA in the context of the adult social care sector during the pandemic?

Ms Nicola Dickie: So during the pandemic we provided leadership from our sector. As an organisation we fed into national discussions. We provided political representation at all of the various meetings that were set up to guide us through the period of the pandemic. We were also responsible for agreeing and delivering the sustainability payments for the adult social care sector.

Counsel Inquiry: In terms of the adult social care sector in Scotland, it’s my understanding that local authorities have statutory responsibility to provide adult social care services, and local authorities and NHS boards are integrated or work together in order to achieve that; is that correct?

Ms Nicola Dickie: That’s correct.

Counsel Inquiry: How is this done? Through what organisations?

Ms Nicola Dickie: So local authorities will agree what services they wish to delegate to their IJB, which then governs those services. So all of the local authorities in Scotland have delegated in some way their adult social care, so we’ve got 31 health and social care partnerships. The services are delegated and therefore it’s up to the health and social care partnerships to agree and plan for the types of services that should be provided.

That includes health services but it also, importantly, includes adult social care services, and in some instances children’s services and justice.

Counsel Inquiry: And you mentioned IJB. Could you just tell us the full –

Ms Nicola Dickie: So, integrated joint boards are the governance mechanisms, so that’s the decision-making body, and the health and social care partnership is, if you like, the delivery arm. So that’s where you’ve got your paid officials who will take forward the work.

Counsel Inquiry: And were there any advantages or disadvantages to this model during the pandemic?

Ms Nicola Dickie: So I think the advantages were that we were already used to working in partnership to deliver services at a local level across Scotland.

It meant that there was a degree of integration already there in kind of peacetime, if you were, and many of our services and service users were used to getting services from both health services and social care services as we went into the pandemic.

Counsel Inquiry: So in Scotland would you say that, for example, the NHS, the health side, had a good understanding of the adult social care sector because of these integrated models?

Ms Nicola Dickie: I think the NHS had a good understanding of community services as they are provided in Scotland. I think the acute services that set outwith our community provision were perhaps not as integrated as they could have been just by nature of the very fact that they’re taking place inside hospitals as opposed to community provision that’s provided across communities in Scotland.

Counsel Inquiry: I’m going to ask you some questions about the pre-pandemic capacity of the adult social care sector.

And if I could pull up INQ000147362, page 5.

Now, this is the adult social care winter preparedness plan which was dated 6 November 2020, but it kind of gives an overview of the adult social care sector in Scotland.

“Around 245,000 … people receive social care and support in Scotland.

“Around 60,000 people in Scotland are receiving home care at any one point.

“The majority (77%) of people requiring social care services or support are aged 65 or over.

“People residing in a care home tend to be older, with around 90% of residents aged 65 and over, and 1 in 2 aged 85 plus.”

However it acknowledges that not everybody receiving adult social care is older, there are younger adults as well.

And if you go down – thank you – and have a look at the numbers employed. As at December 2019 there were 206,400 people employed in the social service sector.

There is a COSLA survey that was undertaken for this Inquiry, and in it, some of the local authorities answered the questions on preparedness.

And if I can pull that up, please, it’s INQ000587789, slide 6. Sorry, slide 5.

As you can see, on preparedness, of the 29 local authorities which responded to this question, 52% said that the preparedness of the sector was not very good, and 3% said not good at all. So that’s a total of 55%.

And capacity of the care sector, 41% said not very good. Ability to increase capacity, 55% said not very good.

However, when it comes to the resilience of the care sector, 72% of the local authorities that answered said it was very good or fairly good.

And if we can turn to slide 6, of the 14 local authorities that reported that capacity or resilience were not good, many of the reasons why are listed there. All 14 mentioned workforce recruitment difficulties, rising demand for adult social care services, funding pressures, et cetera, going down in a sliding scale in terms of the numbers.

You’d stated in your witness statement at paragraph 2.25 that:

“Issues relating to the sustainability of the care sector in Scotland, specifically in relation to capacity, were largely as a result of funding and workforce issues that COSLA has raised consistently with the Scottish Government.”

How did these capacity-funding workforce issues affect preparedness of the social care sector in Scotland when the Covid-19 pandemic hit?

Ms Nicola Dickie: The capacity issues meant that, already, most areas of Scotland were only providing support through adult social care to those with high or severe support needs. Those on low to medium support needs were probably not featuring in terms of access to support.

Counsel Inquiry: And in terms of pre-pandemic planning, who or which organisation was responsible for pre-pandemic planning?

Ms Nicola Dickie: So health and social care partnerships were responsible for the day-to-day planning. If we got into a situation where we needed to step into a resilience situation, then local authorities and health boards would step in as category 1 responders at that point. But the day-to-day planning and therefore annual winter planning was the auspices of the health and social care partnerships.

Counsel Inquiry: And were there any requirements for care providers themselves to have plans in respect of emergencies?

Ms Nicola Dickie: So there would be contractual obligements on recipients of the care home contract so there would be expectations in terms of, you know, access to PPE should there be an infection or an outbreak, et cetera. So there were that type of expectation on individual care homes to make sure that they had access to that. And then they would all be feeding up in to the overall planning that was being done through the – through the local area plans.

Counsel Inquiry: And then to zoom out and look at it on a more macro level, in terms of the Scottish Government’s, et cetera, more national planning, I understand that there was the Scottish Government Resilience Room, and under it the national incident management group and the National Contingency Planning Group, which, in your statement, you state:

“Both groups were established prior to the relevant period and were constituted in such a way as to ensure that there was a coordinated public sector response to emergency or critical incident situations in Scotland.”

Were either of those organisations responsible for pre-pandemic planning on a national level for the adult social care sector?

Ms Nicola Dickie: So the SCOR arrangements are normally stood up in response to an emergency. So they’re not standing arrangements that sit all of the time, so if we’d perhaps had a cluster of outbreaks of some infection we might have been in a situation where SCOR would have been stood up. The National Contingency Planning Group is group that COSLA would bring together in normal times, if, for example, we had a large care home that was faced with closure and a lot of residents that we needed to move out, or a string of care homes across Scotland that were needing coordinated arrangements to make sure that residents were being moved into alternative provision, so the National Contingency Planning Group was one that we would bring together as and when required. So whilst it was a standing group, it didn’t meet all of the time.

We started off with the National Contingency Planning Group but as the scale, and it was clear just how much of a difference Covid-19 was going to make, that was where we transitioned from almost kind of one issue, National Contingency Planning Group, or one site, into the arrangements that we had that took us through the period of the pandemic.

Counsel Inquiry: Is there any national pre-pandemic planning sort of organisation that exists now or before the pandemic that COSLA was involved in?

Ms Nicola Dickie: So what we do have is each of the health and social care partnerships will provide an annual plan where they will plan for peaks and troughs throughout the year, given that winter is always a particularly pressurised time in the health and social care partnerships. Those plans are written at a local level, and then they are fed into colleagues in government, and colleagues in government will check those plans and make sure that they after sitting in and against any national planning that they have done for the NHS or the social care system. So I suppose it’s a kind of averaging up, if you like, in terms of the 31 plans come in, colleagues in government will look at them, and then they’ll provide feedback to a particular area to say, “That doesn’t look strong enough in terms of planning”, or “Can we support you with that?” That type of thing.

So I don’t know that it’s pandemic planning in that respect, in terms of its – it’s the day-to-day way in which we deliver services in Scotland.

Counsel Inquiry: Do you think, let’s say there was a future pandemic that is coming into the fore in the horizon, do you think the current set-up for pre-pandemic planning which sounds like it’s more on a local level and then fed up nationally, do you think that is an adequate way for Scotland to prepare the adult social care sector for future pandemics?

Ms Nicola Dickie: I think, given the differences in areas across Scotland, you do need to start local. I think there are a number of things that it would be useful to almost have sitting to the side that you would consider as things that could be taken over nationally very quickly in the event of a pandemic, and I’m sure we’re going to come on and talk about PPE and provider sustainability payments, you know, who is classified as a key worker, for example. These are things that a local level it would be very difficult during a pandemic or in the run-up to a pandemic, for an individual local level to do.

So I think the local planning and the pushing it up the way is right, but it feels to me that we need a suite of things that we can kind of regularly go back and review in terms of that, nationally.

Counsel Inquiry: Thank you.

I’m going to ask you some questions now about your liaison with the Scottish Government and other stakeholders during the pandemic. We briefly touched upon the National Contingency Planning Group a moment ago. There were some other groups or subgroups that COSLA was involved in, one of which was the Workforce Issues Group, which I understand was constituted in May 2020; is that correct?

Ms Nicola Dickie: Yes.

Counsel Inquiry: What was the purpose of the group?

Ms Nicola Dickie: So that group’s purpose was an area where we could consider workforce issues as they applied to the local government workforce, so not specific to just adult social care. So it was everyone who worked for local government, and that was across, as you can imagine, you know, waste operatives, teachers, adult social care. So that was where we discussed all of the workforce issues as they were arranging – arising from the local government workforce. Obviously there are some staff in Scotland who provide adult social care that are employed by local government, but we had the separate forums where we were having conversations about the adult social care workforce that didn’t work in local government.

There were times when some of the issues were the same and there were times when some of the issues were very different. For example, access to sick pay between local government, adult social care staff, and those who don’t work in local government.

Counsel Inquiry: Okay. So the Workforce Issues Group, as you just said, was in respect of people who were employed by the local government.

Ms Nicola Dickie: Right.

Counsel Inquiry: So would that group have dealt with adult social care staff that were not directly employed by the local government, but were employed by private providers?

Ms Nicola Dickie: No. That stuff would have come up with the pandemic response, because that’s where we had representatives from the third and independent sectors.

Counsel Inquiry: So that’s the Pandemic Response in Adult Social Care Group which was set up in September 2020; is that right?

Ms Nicola Dickie: Yes, and it was a follow-on to some of the work that was being done through the Care Home Rapid Action Group and the regular meetings that we had stood up.

Counsel Inquiry: So was it that group, that Pandemic Response in Adult Social Care Group that just started to deal with the specific issues that members of staff in the adult social care sector were facing?

Ms Nicola Dickie: So I think that the Pandemic Response in Adult Social Care was when it became formally constituted. There were regular meetings before that. They were titled “gold” sometimes, they were “silver” commands other times, but there was regular dialogue and I think you can see that with some of the exhibits that we’ve provided. There was regular dialogue with those providing adult social care.

Counsel Inquiry: Prior to September 2020?

Ms Nicola Dickie: Yes.

Counsel Inquiry: Okay. And you mentioned the Care Home Rapid Action Group, that was established in April 2020 to address the urgent needs and challenges faced by care homes during the pandemic; is that right?

Ms Nicola Dickie: Yes.

Counsel Inquiry: How effective was that group, in your view?

Ms Nicola Dickie: So I think the group was effective in that it looked at issues of infection prevention and control. I think that the fact that the group was set up around about infection and prevention control meant that we were bringing, if you like, the existing doctorate that had come from how things worked in our hospitals and I think we took a while to get our heads around about the fact that care homes are not hospitals, they’re not – the physical location is not like a hospital and, indeed, the way they are actually used by people who are living in care homes.

So we were relying very much on the infection prevention control specialists to bring that type of expertise but we were working hard from a COSLA perspective to make sure we were bringing in the expertise of our chief social work officers, of our own health and social care chief officers who were used to providing services in these areas. So we were trying to, kind of, match up the health elements with the social care elements to make sure that what was there worked for the infection prevention and control measures that were required, but also that didn’t turn care homes into hospitals.

Counsel Inquiry: So you mentioned time needed to understand that care homes weren’t like hospitals and therefore IPC measures needed to be different for them. Do you have any examples of the differences and why IPC measures needed to be different for care homes?

Ms Nicola Dickie: So I suppose we’ve referenced one example in the statement around about Christmas decorations, and, do you know, recognising that these are people’s homes and the concept of saying to someone they can’t put up a Christmas decoration is probably not going to land that well.

I think another example is, do you know, in many cases, residents in care homes are free to move around the care home. So when you were starting to say, do you know, infection prevention measures mean you’ve got to be confined to the one area, we had to make sure – I suppose it’s different in a hospital because to an extent doctors and nurses and other professionals are controlling the flow of movements but in modern care homes, people don’t necessarily have their movements restricted.

So there was a lot of time having to be spent to make sure that what was coming through in the guidance, that absolutely, the infection prevention control guidance was there but it needed to come with a degree of additional explanation because people were going to have to explain to residents and their families why, do you know, a relative, potentially, was going to be kept in their own room when they had been used to moving out, for example, do you know, into communal day rooms where they could sit and be with other residents.

Counsel Inquiry: Before I move on from this point, you’ve mentioned staff, you’ve also mentioned care homes in respect of groups that were set up. What about domiciliary care?

Ms Nicola Dickie: So both Scottish Care and CCPS, who we were engaging with, represented those who were providing home care, not just care homes, although they mixed across the two organisations, and we also had our own workforce who were providing domiciliary care. So there was still the same ability to have that conversation with those representing the workforce that were providing domiciliary care.

Counsel Inquiry: Was that happening early in the pandemic or do you think it took some time before?

Ms Nicola Dickie: So I think it was happening early in the pandemic to an extent. I think the issues that we were starting to see in care homes meant that there was a lot of focus went on to that. But I can remember conversations early in the pandemic about what was the guidance for domiciliary staff when they were, as we were talking about donning and doffing their PPE and how did you do that, do you know, potentially in a rural location in the dark and in the wet?

So there were certainly conversations going on at that point, again, to make sure that people could be clear what was the guidance that they were being asked to follow, and importantly, how could they implement that?

Counsel Inquiry: I’m going to move on to discuss isolation. When it comes to hospital discharge, I will leave those questions for Core Participants once I’ve finished, but I do have a question in respect of designated settings in England and Wales – sorry, in England, and also the step-down facilities in Wales.

In England the UK Government created designated settings which were specific care homes that had isolation facilities to house Covid-19-positive people, and in Wales they implemented a step-down and step-up policy where people who were Covid-19 positive, still displaying symptoms, and/or still within the 14-day isolation facility would be transferred to an NHS facility to recover before then being returned to, let’s say, their care home or their own home.

Was a similar policy adopted in Scotland?

Ms Nicola Dickie: So I can’t recall COSLA being engaged in conversations around about anything that would have worked in that way at a Scotland level, and it’s certainly not referenced in any of the submissions that have come in from the member authorities.

Counsel Inquiry: Do you think something like that would have been useful or needed in Scotland?

Ms Nicola Dickie: I think it might have worked in areas that there was a lot of access to care homes. I suspect that might have been more problematic in more remote and rural areas, where you’re already travelling large distances, potentially, to access a care home. And we certainly had quite a bit of upset from residents and indeed relatives where they were not potentially getting their first choice, as it were, for care homes because we had care homes that were closed to admissions.

So it might have worked on a more highly populated areas where you had three or four care homes in a maybe five-mile radius. I’m not so sure it would have worked in big, remote areas of Scotland where, do you know, the distance between care homes, and therefore the distance that relatives might have been asked to be moved – to visit, would have been miles. But I would need to understand exactly how they worked in England to give a more definitive answer on that, but the geography would certainly have been a consideration, I suspect, for us.

Counsel Inquiry: Speaking of visiting, I’m not going to ask you any questions about visiting restrictions, because, again, I’m going to leave that to the other Core Participants, but I am going to ask you a question about Anne’s Law.

At paragraph 3.9 of your witness statement you mention the “distress and upset caused by restrictions placed on care home visiting”. You also state that the – then:

“The Care Reform (Scotland) Bill [had] been introduced [in] Scottish Parliament. … [which] introduces ‘Anne’s Law’ which would give visitation rights in the event of another such [pandemic]. [And that] COSLA fully supports [that] legislation.”

To help the UK Covid Inquiry understand Anne’s Law, could you please inform us what stage the piece of proposed legislation is at in Scotland?

Ms Nicola Dickie: So as far as I’m aware, the concept of Anne’s Law is in the amended Bill that the Scottish Parliament still currently has on its statute books, which should hopefully be seeing its passage before the end of this Parliamentary term in Scotland.

Counsel Inquiry: In respect of Anne’s Law, my understanding is that it would provide rights for a visitor to see a loved one in a care home.

May I just confirm from you whether that would be during a pandemic as well?

Ms Nicola Dickie: As far as I’m aware, it would be in only the most extreme cases that you wouldn’t be permitted to have a relative access you in a care home. So I would assume that that would mean for the period of any future pandemic, and indeed where we’ve got outbreaks of infection prevention control over the winter period.

Counsel Inquiry: Thank you.

I’m going to move on and ask some questions about the management of the pandemic generally, and in particular the enhanced professional clinical and care oversight of care homes.

Now, as previously stated, in Scotland, the delivery of adult social care is more integrated than some of the other nations in the UK, with this enhanced professional clinical and care oversight of care homes. Could you please just explain to us what that was.

Ms Nicola Dickie: So that entailed clinicians and, more often than not, nurses, taking a more hands-on approach, as it were, to how things were being run in care homes.

So, from a COSLA perspective, we obviously didn’t have the expertise to go in and do that, but we were in a situation where we were able to make sure that the balance of that clinical oversight we were still feeding through what were potentially implementation issues with whatever might be being suggested, because we were picking that up from our member councils and indeed professional associations that are associated with adult social care.

Counsel Inquiry: So my understanding is that it included multidisciplinary teams comprising of the NHS director of public health, an executive nurse lead, medical director, chief social work officer, and others, who would have assisted the oversight of care homes and, I would presume, also providing advice in respect of, like, IPC measures and things like that?

Sorry, that was a nod?

Ms Nicola Dickie: That’s my understanding, yes.

Counsel Inquiry: Thank you.

And my understanding is that they would also undertake visits to the care homes if, for example, the patients had tested positive and things like that?

Ms Nicola Dickie: Yes.

Counsel Inquiry: Would you say that this was beneficial during the pandemic for care homes?

Ms Nicola Dickie: I think it was beneficial for care homes during the pandemic, even if that was just to have a bit of reassurance that someone else was coming in and was kind of looking at what you were doing and checking you were complying.

Counsel Inquiry: Would you recommend the same system in a future pandemic?

Ms Nicola Dickie: Yes.

Counsel Inquiry: I’m going to ask some questions on data. What were the issues regarding data in Scotland at the start of the pandemic for the adult social care sector?

Ms Nicola Dickie: So, as I’ve said in the witness statement, we had no national oversight of what occupancy rates were like, what workforce statistics were like. So local systems, so health and social care partnerships and those tasked with delivering it at a local level, had that oversight. They could tell you where they had vacancies, where they potentially had outbreaks of other issues and, indeed, where they had any pinch points in the workforce.

But we didn’t have access to that at a national level, which goes back to the point I was making earlier about you have to deliver it – design it and deliver it locally, but you need the ability to push things up if we need more support than what the local system can provide.

Counsel Inquiry: And from your statement I’ve noted two potential data gathering tools or mechanisms. One is the Safety Huddle Tool.

Ms Nicola Dickie: Mm.

Counsel Inquiry: And the other is the data dashboard. Am I right in understanding that they’re both two separate systems, as it were?

Ms Nicola Dickie: Yes.

Counsel Inquiry: And in respect of the Safety Huddle Tool, my understanding was that this was in force from 14 August 2020; is that right?

Ms Nicola Dickie: Yes.

Counsel Inquiry: Do you know when the data dashboard came into force? Was that earlier or after?

Ms Nicola Dickie: So the data dashboard was somewhat iterative in terms of as we were going through, so the data dashboard was a kind of melting pot, if you like, of – as we started to see, you know, testing coming on board, we were adding that information into it. So – so you got to the national level where you could look and see, do you know, how many tests had been done, how many had been undertaken, et cetera, et cetera.

But it kind of started off with a few things on the dashboard, and as we went forward and we got more information from the Safety Huddle Tool, we kind of grossed that up.

Counsel Inquiry: Have the improvements in collecting national data continued to date?

Ms Nicola Dickie: Yes.

Counsel Inquiry: If there was a future pandemic, do you think that the data currently collected would be sufficient for – on a national level to support care homes and home care?

Ms Nicola Dickie: Yes, I would. And we use it for winter planning purposes as we move forward.

Counsel Inquiry: Do those mechanisms include data in respect of unpaid carers?

Ms Nicola Dickie: No.

Counsel Inquiry: No. Is that data being collected by local authorities or at a national level?

Ms Nicola Dickie: So one of the, kind of, lessons learned or recommendations I think is about data sharing, and unpaid carers is a really good example.

So there would be three or four different systems in local government where somebody might be classified as an unpaid carer because of things they’re accessing. That may well be on their GP record. That may well be somewhere else. But it’s quite difficult to get a collective list of our unpaid carers. So I think that’s an area where we need to work to join up the various bits of information that would be useful.

Counsel Inquiry: Thank you.

If I could just pull up a statement from the Care Inspectorate Wales on screen. It’s INQ000475130. And we’re looking at paragraph 92.

In this paragraph, the Care Inspectorate state that the new Safety Huddle Tool which captured daily data for care homes existed. But then if you go to the second page, the first sentence, it says:

“However, I understand we did raise strong concerns from the outset that this [the Safety Huddle Tool] involved duplication of data provision which would impact on care service providers who would experience it as a duplication of effort on their part.”

Did you hear similar concerns regarding data collection from care providers?

Ms Nicola Dickie: I don’t recall, but, to be honest, there were – there was a lot going on.

I wonder if the reason why we went for the Safety Huddle Tool is that it was a continual record as opposed to a snapshot in time, but I don’t recollect the exact issue that’s being raised there.

Counsel Inquiry: Do you think perhaps, in the context of considering a future pandemic, trying to find ways in which the data can be collected which aren’t too much of a burden for care providers is something to be looked at in Scotland?

Ms Nicola Dickie: Yes.

Counsel Inquiry: Thank you.

I’m going to move on to workforce issues.

And if I can ask for the COSLA survey to come back up on screen. That’s INQ000587789, slide 7.

This is a bit similar to the previous that we looked at but it’s about the care sector during the pandemic. As you can see, of the 29 local authorities who responded to this question, of capacity, 31% said that it was not very good and 3% said it was not good at all.

And on the ability of the care sector to increase capacity during the pandemic, 45% of local authorities said not very good, and 7% said not good at all.

And if we can turn to slide 8 quickly, please.

Again, it’s similar issues that were raised previously in terms of pre-pandemic preparedness workforce recruitment issues, retention difficulties, et cetera.

Since the pandemic, has capacity in the care sector, adult social care sector, improved in Scotland?

Ms Nicola Dickie: I would say it’s probably about the same.

Counsel Inquiry: About the same?

Ms Nicola Dickie: I think we still have workforce challenges in terms of recruiting and retaining staff in the social care system.

Counsel Inquiry: And in terms of attempts to increase capacity during the pandemic, the national recruitment portal was established in April 2020; is that right?

Ms Nicola Dickie: Yes.

Counsel Inquiry: How useful was it?

Ms Nicola Dickie: I think it was useful to an extent. I think it allowed us to bring people, who had perhaps not long left the adult social care system, back. We did something similar across the NHS workforce, of course.

I don’t know that it necessarily got us any new recruits who maybe hadn’t considered social care as a career up until that point. What I would say is COSLA is an organisation that also runs myjobscotland, which is where we put all of the vacancies for local government, and we’ve extended that so we now put vacancies for independent and third sector providers for adult social care on that website.

So there was an opportunity there.

The other thing I would say about it is that we maybe didn’t get, do you know, hundreds and hundreds of applications, but there was a really strong signal that colleagues in the NHS board, through NES, were willing to work through the adult social care sector to try to support us with our recruitment challenges. So I think that was – that shows and demonstrates the collaboration and partnership that we’ve alluded to throughout the statement.

Counsel Inquiry: And just on that, if you could just give us a little bit more information. How did the – sort of NHS assist with this – this increasing of capacity?

Ms Nicola Dickie: So I think the Cabinet Secretary asking an NHS board in the time of a pandemic to help us deliver on recruitment challenges in social care was a pretty strong signal that it wasn’t over at the social care system of – of – on its own to fix the recruitment challenges, so I think that’s – it was a pretty strong – they could have been off doing something else, I’m sure, but there was a recognition there that the social care workforce needed to be augmented in the same way that the NHS did.

Counsel Inquiry: Thank you.

I’m going to ask you some questions in respect of PPE, personal protective equipment.

If I could just pull up the Scottish Trades Union Congress statement, INQ000569884, and paragraph 75.

This a quote, I believe, from the GMB union where it states that:

“There was a shortage of PPE in private care homes, and there wasn’t enough PPE for everyone who was providing direct care. Generally speaking, there was an overall shortage of PPE in the country, so initially the PPE was so scarce that it was being directed towards the NHS, where people who were contracting COVID-19 were being taken. People working in care homes or in community care therefore weren’t getting access to PPE, or the equipment that was coming in wasn’t the proper equipment that [it should have been].”

They also go on to talk about concerns about the quality of PPE, stating that:

“… [they] felt our members, overwhelmingly low-paid, working class, women, were being provided with the cheapest possible masks or really low-quality plastic gowns.”

Was COSLA aware of the concerns regarding access to PPE at the beginning of the pandemic?

Ms Nicola Dickie: So I think we provided the Inquiry with our risks and issues log and PPE was raised very early on in the pandemic. So COSLA were aware from both conversations on our own workforce, those that were employed by local government and indeed those that were commissioned to provide services.

Counsel Inquiry: And I understand from your statement that there were near daily calls with trade unions and COSLA, and PPE was also raised in some of those calls.

Now, in respect of PPE provision, what was the role of local authorities in Scotland in providing PPE, distributing it to the adult social care sector?

Ms Nicola Dickie: Before the pandemic or during the pandemic?

Counsel Inquiry: During the pandemic.

Ms Nicola Dickie: During the pandemic. So as I said earlier on, the National Care Home Contract provides that providers supply their own PPE for their day-to-day running. It became clear that the scale of the PPE that was required was not going to be useful for individual providers to be trying to source that. I’m sure you’ve heard elsewhere about, do you know, the market all – there’s no point everybody bidding in the same market. So using our existing procurement systems in Scotland through both the National Health Service and, indeed, Scotland Excel who procure on behalf of local government, we were able to source PPE and then local government signed up to a memorandum of understanding with Scottish Government and colleagues elsewhere and we then provided hubs for access to PPE. So individual care homes and domiciliary care could come forward and draw down some of that PPE.

We also opened access to unpaid carers, and they were either coming in, individually through local government routes, or they were coming in through carer centres to access PPE.

Counsel Inquiry: And that memorandum of understanding, the MoU, commenced on 27 April 2020; is that right?

Ms Nicola Dickie: Yeah.

Counsel Inquiry: I understand there were 50 PPE hubs that were put up into existence?

Ms Nicola Dickie: Yes.

Counsel Inquiry: And they were managed and operated by the 31 health and social care partnerships.

Ms Nicola Dickie: Yes.

Counsel Inquiry: How successful would you say the distribution of PPE was through the PPE hubs?

Ms Nicola Dickie: I think the distribution was successful. I think there were always pockets of best practice that could have been better. I suspect the fact that you’re dealing with 1,200 disparate social care providers across 50 hubs in a time of a pandemic meant that there were some confused messages but for the most part, we heard a lot less, in terms of access to PPE, once the hubs were up and running. And I suppose those weekly calls that we were having with social care providers was an opportunity for people to say, do you know, it’s working really well in that area but there’s something not quite right in that area, and that would allow us as a membership organisation to reach out to that individual local authority and say, “Is there something we can help you with? Is there something that’s – you’re confused about?” Or whatever.

Counsel Inquiry: If we could pull up the COSLA survey again, INQ000587789, slide 12, please.

This is about accessibility of PPE in the first six months of the pandemic:

“Overall, in the first six months … how easy or difficult was it for care providers within your local authority area finding it to access PPE?”

Of the 29 local authorities that responded, 45% said providers found it either very or fairly difficult in the first six months of the pandemic, and 38% said they found it very or fairly easy.

If we could pull up the Local Government Association survey, that is INQ000400522, page 45, table 25. As you can see here, the local authority counterparts in England and in Wales have also answered that question. 87% of local authorities in England said that they found it very difficult or fairly difficult to obtain PPE in the first six months of the pandemic. And in Wales, 55% said that they found it very difficult or fairly difficult, both of which are higher than the 45% of providers that was mentioned by the local authorities in Scotland.

Do you think there was anything in particular that was particularly going well, in terms of PPE distribution?

Ms Nicola Dickie: I suspect the fact that we utilised the existing procurement routes, so we already had contracts that were up and running and we didn’t have to step outside those. So Scotland Excel always had and always continued to be able to procure on behalf of all 32 and, similarly, our NHS procurement arm were in a similar situation. So I suspect that in itself meant that because we had those tried and tested routes, it was a bit simpler. But again, I don’t know why our colleagues in LGA and Welsh LGA, I don’t necessarily know their systems as well as I know the Scottish system.

Counsel Inquiry: I’m going to move on to ask questions about testing for Covid-19. Some other local authorities in other nations were involved in some way in respect of providing tests to either staff and/or residents during the pandemic. What role did local authorities in Scotland play in respect of testing?

Ms Nicola Dickie: So we had no formal role in the testing regime, in terms of actually performing the tests. Where local government did support our colleagues in the NHS was in access to infrastructure. So knowing where was the right place to put a local testing system, knowing what the transport links were like, accessing some of our buildings that were closed, et cetera, et cetera, and then the other support that we provided in response to testing was support for shielding individuals and, indeed, access to support for people who were having to isolate and needed access to some income.

Counsel Inquiry: And my understanding is that when it came to lateral flow tests, those were made available through the PPE hubs; is that right?

Ms Nicola Dickie: Yes, and importantly that included for unpaid carers.

Counsel Inquiry: For unpaid carers, as well. Do you remember when that started?

Ms Nicola Dickie: As far as I’m aware, the lateral flow tests were available from the get-go, as it were, in terms of once we had the hubs up and running, they were there as soon as we had them in any scale.

Counsel Inquiry: I won’t take us to the surveys again but I will read the responses. In respect of COSLA’s survey, of the 29 local authorities that responded to the question in respect of access and testing for care providers in the first six months of the pandemic, 45% found it very or fairly difficult. In respect of England, local authorities in England, 84% of local authorities said that care providers found it very or fairly difficult to access testing in the first six months; and in Wales, 73%.

Obviously, you do not work in the other nations and I’m not going to be asking you what went badly there versus what went well in Scotland. However, I would just like to know, from your perspective, what went well in respect of testing in Scotland? Was there anything that needed to have been improved going forward or do you think it just – it went swimmingly?

Ms Nicola Dickie: I think it went as well as it could have done, given that we were waiting on tests being developed and other bits and pieces. But I think the integrated nature of the system in Scotland meant that we never had a situation where we were potentially having to prioritise one part of the system against the other because there was a recognition that, do you know, that the integrated system means that we need to know across all of the workforce, where we needed access to testing. And I think the fact that we did put that into the PPE hubs meant that there was a tried and tested method of getting that out.

Counsel Inquiry: Thank you. I’m going to move on to ask you some questions about funding and I’m actually going to start with the provider sustainability payments. Similarly to the other nations, there were concerns in Scotland about the sustainability of social care providers which existed during the pandemic. And this was due to the impact of additional costs, because of the pandemic, such as staffing, sickness, PPE and also a decline in care home occupancy; is that right?

Ms Nicola Dickie: Yes.

Counsel Inquiry: And the Scottish Government introduced provider sustainability payments to cover the additional costs in May 2020; is that right?

Ms Nicola Dickie: Yes.

Counsel Inquiry: My understanding is that the provider sustainability payments were distributed by local authorities; is that right?

Ms Nicola Dickie: That’s correct, yes.

Counsel Inquiry: If I could pull up the Scottish Care witness statement, that’s INQ000509530, paragraphs 113 to 114.

Here they talk about issues in respect of provider sustainability payments. And they state that:

“There were inconsistencies in the approach being taken to applications for under-occupancy and sustainability payments by local authorities. Local authorities did not have sufficient resources to process the applications and at times did not explain why applications were refused or partially granted.”

Scottish Care also say that they:

“… liaised with COSLA to highlight the pressures that the sector was under and the challenges that applicants were having when attempting to access sustainability funds.”

And if we could stick on the statement but go to page 33, paragraph 125 and 126. They also state that:

“… social care providers had to apply retroactively for sustainability payments and accordingly had to incur increased costs or providing services without any certainty as to whether such costs would be reimbursed.”

They also mentioned substantial delays between applications being submitted, being granted, and payments being received, which compounded this uncertainty.

Now, in respect of the first point that was mentioned, which was inconsistencies in approach being undertaken to applications for under-occupancy and sustainability payments by local authorities, was COSLA aware of those issues at the time?

Ms Nicola Dickie: Yes.

Counsel Inquiry: What, if anything, was undertaken to try to make things easier or to try to alleviate those inconsistencies?

Ms Nicola Dickie: So what we did was we looked to see if there was a fundamental issue with the process, so was it something that was wrong in the guidance or something that was unclear in the guidance? And we made that as clear as we possibly could and made sure that that was then reissued to individual local authorities. We then worked with Scottish Care, I think twice weekly, if there were particular issues in a particular area, that could be to do with the fact that there was a lot of staff who were off sick with Covid themselves in a particular team. It could be to do with the fact that there was – perhaps people were approaching the way in which they were looking through applications as if we were in non-Covid times and, do you know, at the end of the day, our finance officers always have to be able to prove good use of public money but I suppose we were working with individuals. So we were looking at: is there a problem across the piece, is it a problem with an individual area? Taking it right down to, is it, do you know, is there something we can do with individual teams?

What I would say is that in many cases the teams that were processing the grants for social care providers were the same teams that were then being asked to issue payments for other sectors that had potentially come through. So there was definitely an issue around about capacity and the ability, do you know, deliver for different sectors – particularly in the smaller local authorities.

Counsel Inquiry: And do you think that those issues were improved on during the pandemic?

Ms Nicola Dickie: I think we got better as we were going, but again, we spent a lot of time trying to get to the bottom of, was it relationships in a particular area that were causing issues? Was it the way the applications were coming in? Was it the way the applications were being assessed? So I would love to say we fixed it in the first week and it was once and done, but that was not how things played out, as pressures came back in, in a fresh winter period, you would potentially have to reach out to individual areas and say, “Can we help? Is there something with the process that you’re not sure of?”

Counsel Inquiry: And if there was a future pandemic, would you state that that kind of funding should remain being funnelled through local authorities or do you think it should be done on more of a, sort of, national level down?

Ms Nicola Dickie: I think it’s right that local authorities will understand the providers in their area, and there’s an element of, if you try to do it nationally, it would have to be checked by the local system anyway, and colleagues in government didn’t have the capacity to deliver payments directly at that point.

So it’s not unusual for my organisation to say that things should be done local by default, and national by agreement. I didn’t see that it would have been any better a process had it been done at a national level because there would still have been the need to check with the local system about occupancy rates, et cetera.

Counsel Inquiry: And similarly, there was an enhanced Statutory Sick pay scheme –

Ms Nicola Dickie: Yes.

Counsel Inquiry: – or the social care staff support fund, which was introduced because of concerns about care staff having to self-isolate because they’d only be entitled to Statutory Sick Pay. Those are also funnelled through local authorities in a similar way.

I’m not going to pull it up on screen but Scottish Care also mention that there were long delays in payments being reimbursed. Do you think that those payments should also remain funnelled through local authorities, or do you think they should go directly to staff during a future pandemic to ensure that they get their Statutory Sick Pay, or enhanced sick pay, I should say?

Ms Nicola Dickie: I suspect we would build in a different type of delay if we were moving halfway through to some – a completely new organisation, potentially making a payment to staff, we had all the bank details, we’d done all the due diligence, we knew who these care providers were. I think if we could have got the capacity up and running quickly, we wouldn’t have seen some of the delays that we saw.

Counsel Inquiry: Thank you. I’ve got one question in respect of changes to the regulatory inspection regime. I’m not going to pull the COSLA survey up again, but 38% of local authorities felt that the suspension of inspections of care homes had a negative impact on safeguarding.

What, if anything, did local authorities do to mitigate this?

Ms Nicola Dickie: So I think we had our chief social work officers who were meeting regularly to think about and discuss what were the areas that were potentially being missed with the fact that we had stood down those visits. And I think if you take the enhanced clinical governance for care homes, there was a bit of a safeguarding there, that other teams that were going in that were multidisciplinary. But I think as we move forward it’s one of the things that we should be agreeing in – agreeing in extremis: if – if we get to a situation where we do that as a minimum, what are we doing over here to make sure that those safeguards were there?

Counsel Inquiry: Thank you. And my last area to ask you questions on is in respect of easements, and these were – basically section 16 and 17 of the Coronavirus Act allowed for local authorities to dispense with particular social care assessment duties covering social care for adults, children and support for carers. This was, I understand it, removed on 30 November 2020 in Scotland; is that right?

Ms Nicola Dickie: Yes.

Counsel Inquiry: My understanding is that COSLA and Solace were consulted on developing a survey for local authorities to complete on a monthly basis regarding the use of easements?

Ms Nicola Dickie: Yes.

Counsel Inquiry: But you state that the results were collected by the Scottish Government. As such, you were unaware of how many local authorities enacted easements during the pandemic.

Do you think COSLA could have had a greater role in respect of easements?

Ms Nicola Dickie: So I think, from memory, we probably thought about a third had, but in many respects, for some, that was for a two-week period or something like that. So I think the fact that Scottish Government were collecting the data didn’t mean that we were absolutely unaware of what was happening. But obviously we’re not an improvement organisation; we’re a membership organisation. So we don’t perform that function.

Counsel Inquiry: If I can pull up my final document on screen, please, it’s the Inclusion Scotland witness statement.

That’s INQ000520202, paragraphs 85 and 86, in which Inclusion Scotland state:

“The emergency legislation allowed local authorities to relax certain duties, but the duty to provide support still applied under section 12 of the Social Work (Scotland) Act. Despite this, Glasgow Disability Alliance found that approximately 2000 Disabled people in Glasgow had their care reduced or completely withdrawn from March 2020 onwards and many were forced to rely on family members or neighbours or to go without care.”

On paragraph 86 they state:

“The easements which allowed care assessments to be put on hold had an immediate impact on care users as well as raising questions about whether support would be available in the longer time, with social workers in Scotland reporting that some of their service users were ‘left in limbo’.”

What are your views on the reduction of care and also the pausing of assessments during the pandemic?

Ms Nicola Dickie: So I think the statement there from Inclusion Scotland talks to some of the survey results that you’ve gone over. We did have difficulties in accessing workforce. I think it’s difficult to understand, of the 2,000 people who had their care reduced, what were their support needs. Were they in the low and the medium category? We moved to a system using the easements or where we were looking at people who had high support or extremely high support needs. It’s difficult to know, but I think the pausing of assessments was something that we were really, really keen to limit the amount of time that we did that, least not because we had people who, because of Covid, their support needs had gone up, but we also had people on the other side who – they potentially didn’t want access to the social care that they were getting before and they wanted to have their changes there.

So we did try to narrow the amount of time that the assessments were put on hold, and then I think I remember in 2021 we did a kind of go-through in terms of how many assessments needed to be redone.

Counsel Inquiry: My final question: if there was a future pandemic, do you think that easements should be enacted in order to allow local authorities to reduce some of their services?

Ms Nicola Dickie: I think it would be an option that nearer the time that we would need to think about. And I say that because – we’re going to come on to lessons learned I hope, because I think the fact that – if you don’t have your social care system running so hot, I don’t know that you would be in a system – and you would be in a situation where you would need easements. I think the problem is, is that the system has been running too hot. As you can see from the local authority surveys, so when the easements came in, I suspect there were – not a lot of local authorities put easements in because they were already providing support to the people who were in the most need, there probably wasn’t any higher you could go.

Counsel Inquiry: Just to clarify, when you say so “hot”, what do you mean by that?

Ms Nicola Dickie: So we were already in a situation in Scotland where most local areas were only providing support through adult social care to those who were in desperate need, if you like, or, do you know, at the higher end of the needs threshold.

Counsel Inquiry: Pre-pandemic?

Ms Nicola Dickie: Pre-pandemic. So when the easements come in, if you’re only providing those who are at the most extreme – I’m not sure that easements make that any different if people are already accessing it at that level.

Ms Shotunde: My Lady, those are my questions.

Lady Hallett: Thank you very much.

Mr Weatherby, who is just there.

Questions From Mr Weatherby KC

Mr Weatherby: Thank you, my Lady.

Good afternoon. I ask just a few questions on behalf of the Covid Bereaved Families for Justice UK.

Two topics: hospital discharges to care homes or care settings without testing, and visitation.

So hospital discharges first. So paragraph 3.10 of your statement, in respect of hospital discharge, is you say, and I quote:

“… this is a matter that will have come up at the weekly meetings between the COSLA Spokesperson and the Cabinet Secretary for Health and Sport, given the concerns connected with this …”

Can you help us what the nature of those concerns was?

Ms Nicola Dickie: Sorry, was that in terms of visiting restrictions or …?

Mr Weatherby KC: No, in terms of the hospital discharges into the social care settings without testing.

Ms Nicola Dickie: So I think as we alluded to elsewhere in our statement, and indeed if you look at some of the minutes from those earlier meetings, there were two concerns. One was there wasn’t access to testing, so the actual physical capacity to test wasn’t there. And the other would be: if we were in a situation where people weren’t being tested, were we clear that the infection prevention and control measures that we’ve discussed were such that we could prevent it?

Mr Weatherby KC: Yes, right.

Were these concerns that COSLA itself had, and was raising? Or were they the concerns of others that you were aware of and put forward?

Ms Nicola Dickie: So we were gathering feedback from our member authorities, be that from paid officials in those local authorities or indeed from our own elected members. It was 1,200 – just over 1,200 elected members in Scotland who were obviously getting feedback from their constituents.

Mr Weatherby KC: Yes.

Ms Nicola Dickie: But as well we were also getting information from the social care providers through the weekly meetings.

Mr Weatherby KC: And so far as you’re concerned, were the concerns that you raised with the Scottish Government or the Cabinet Secretary for Health and Sport, were they acted upon, and if so, to what effect?

Ms Nicola Dickie: So I think the fact that you can see that we set up the care home action group and we had specifically, on infection prevention and control – I think as we’ve alluded to in terms of why did local authorities in Scotland have a difference in access to testing that we saw elsewhere in the UK, I suggest that – that suggests to me that the social care provision was understood by the Cabinet Secretary, and we acted upon those concerns.

Mr Weatherby KC: Yes. Okay. I think you may have answered my next question but, just for clarity, I’ll ask you again.

Were members of COSLA raising concerns about the hospital discharges without routine testing, and also the adequacy of IPC measures at this time?

Ms Nicola Dickie: Very early in the pandemic?

Mr Weatherby KC: Yes.

Ms Nicola Dickie: I suspect a lot of it was potentially coming through word of mouth, as it were, because not necessarily all of our elected members would have been in care homes or hospitals given the fact that we had restrictions.

Mr Weatherby KC: Yes.

Now, paragraph 2.27 of your statement you say that:

“COSLA’s role is to represent the views of its member councils and to ensure that any strategic decisions that are capable of being operationalised by local authorities [were].”

Were you aware of any barriers to operationalising guidance put out by the Scottish Government in March 2020, which noted that facilities would be advised of IPC measures when hospital patients were discharged to care settings without testing?

Ms Nicola Dickie: No.

Mr Weatherby KC: Not. And again, I think, to round off this subject, this topic, I think you have probably covered this already but just for clarity, is it your evidence that all care homes did have appropriate isolation facilities and sufficient resources, beds, PPE, staffing, to have undertaken a precautionary approach in every instance of hospital discharges prior to May of 2020?

Ms Nicola Dickie: I think the guidance that was drafted was drafted with support from professionals who were working in the system. Can I say that every single care home in Scotland was in a position to apply that? No, I can’t.

Mr Weatherby KC: Yes.

Ms Nicola Dickie: What I can say is that the guidance was drafted with those who could say to a degree of certainty, in terms of representatives of the workforce from across the sectors.

Mr Weatherby KC: Yes – that wasn’t quite the point. Did they have the appropriate isolation facilities and sufficient resources to carry through on that guidance and in terms of taking a precautionary approach?

Ms Nicola Dickie: As far as I’m aware. But that would be for the Care Inspectorate, potentially.

Mr Weatherby KC: In terms of visitation, paragraph 4.2, you state that:

“… COSLA officers had to remind officials and clinicians that care homes are not purely clinical settings but the homes of the residents. Ensuring that they continued to feel like that, even in the midst of lockdowns, was of vital importance to the overall wellbeing of the residents.”

Firstly, do you agree that relatives being able to visit their loved ones is an example of this, what you say the vital importance to the overall wellbeing of the residents?

Ms Nicola Dickie: Yes.

Mr Weatherby KC: And secondly, the Inquiry has heard evidence that visiting policies were inconsistently applied between care homes. Was that an issue in Scotland, so far as you’re aware?

Ms Nicola Dickie: So again, I think if you look at the minutes of the meetings that were taking place, I think that was raised, in terms of different care homes applying different visiting restrictions.

Mr Weatherby KC: So that was a –

Ms Nicola Dickie: Some of that was later on in the pandemic where we had different tiers though, as well, so it’s important to tie it to the right timeline.

Mr Weatherby KC: Yes. Thank you.

Now, Kevin Mitchell from the Care Inspectorate has told the Inquiry in his witness statement that you were briefly referred to earlier – and just for the record it’s paragraph 295 of that statement – that guidance issued on 26 March of 2020 suspending routine visits in care homes:

[As read] “… did not achieve the correct balance of managing risks with the rights of individuals and did not sufficiently consider the unintended consequences of the visiting restrictions.”

Were you and COSLA aware of those concerns from the inspectorate?

Ms Nicola Dickie: Yes.

Mr Weatherby KC: And did COSLA respond to that guidance or raise those concerns with the Scottish Government?

Ms Nicola Dickie: So again, I think if you go back and look at the minutes, we were having those ongoing conversations in terms of the balance between the two, two things.

Mr Weatherby KC: So you raised those concerns. What was the outcome of raising those concerns with the Scottish Government?

Ms Nicola Dickie: So I think the outcomes took a lot – a bit longer than we would have expected to see, but we were absolutely clear as we came out of the first lockdown that visiting restrictions needed to be one of the first areas that we looked at.

Mr Weatherby: Thank you very much.

Lady Hallett: Thank you, Mr Weatherby.

Mr Straw. Mr Straw is over there.

Questions From Mr Straw KC

Mr Straw: Good afternoon. I represent John’s Campaign, The Patients Association, and Care Rights UK.

You say at paragraph 4.24 of your witness statement that the Scottish Government’s emphasis was on stopping the spread of the virus. And you also say in your statement that COSLA is fully supportive of the proposed Anne’s Law, which will ensure that in the future there will be a different approach as to how restrictions on visits will be managed in care settings.

You appear from this to consider that the government focused too narrowly on infection control and neglected to properly consider and address indirect harms. Is that correct?

Ms Nicola Dickie: I think the four harms we – Scotland approached the pandemic was – was useful. I think in terms of visiting restrictions, it’s an area where we perhaps allowed the infection prevention control to be given a higher weighting than potentially of the outcomes for people.

Mr Straw KC: And do you know why that balance wasn’t correctly struck and what can be done to ensure that it is correctly struck in future?

Ms Nicola Dickie: I think the difficulty we had was anecdotally we knew what it was going to mean, not least because my own grandmother was in a similar situation, but we didn’t have the evidence necessarily about how visitors were or were not transferring the virus in care homes. So there’s something for me about us understanding that as we move forward, because if we’re going to implement Anne’s Law in Scotland, which we are, we need to understand what are the – do you know, what are the practical ways in which we can make visiting during a pandemic or any other outbreak safe.

Mr Straw KC: So is this right: getting better data and information on both the indirect harms –

Ms Nicola Dickie: Yes.

Mr Straw KC: – of restrictions and then also understanding how they can be managed?

Ms Nicola Dickie: Yes.

Mr Straw KC: Thank you.

A different topic. In your statement you mention a range of engagement that COSLA undertook, but none of the organisations that you actually mention in your statement include people living in care homes and their chosen supporters. Could or should COSLA have done more to listen to and learn from lived experience from people like that?

Ms Nicola Dickie: So I think COSLA as a membership organisation were working at a national level. We’re probably one stage removed. But what we were doing was taking regular feedback from our 1,200 elected members, who live and work in the communities that they represent, or professionals that were working in those systems and indeed speaking daily with people who had lived and living experience. So I think at a national level, it is something that COSLA have reflected on and will continue to reflect on, but we were absolutely taking feedback from our member councils on what they were picking up from the ground, and therefore from relatives and residents of care homes.

Mr Straw KC: Okay, so you consider that was an important thing to do and you have – (overspeaking) –

Ms Nicola Dickie: Absolutely.

Mr Straw: Okay, thank you very much.

Lady Hallett: Thank you, Mr Straw.

That completes the questions we have for you, Ms Dickie. Thank you very much for your help for the second time.

I haven’t checked, I’m not sure whether I can say that’s it. But if it is it, thank you so much for all the help you have provided to date. Very grateful.

The Witness: Thank you.

Lady Hallett: And thank you for travelling down to see us.

The Witness: Thank you.

Lady Hallett: Very well, I shall return at 3.40.

(3.27 pm)

(A short break)

(3.40 pm)

Lady Hallett: Ms Hands.

Ms Hands: My Lady, good afternoon. If I may call Ms Nadra Ahmed.

Ms Nadra Ahmed

MS NADRA AHMED (sworn).

Lady Hallett: Ms Ahmed, I’m sorry you’ve been kept waiting. I hope you haven’t, but you’re our last witness of the day, that’s why.

The Witness: That’s all right.

Lady Hallett: I don’t know if that’s a privilege or a disaster.

Questions From Counsel to the Inquiry

Ms Hands: Thank you.

Ms Ahmed, good afternoon. You are here today as the executive co-chair of the National Care Association, or NCA for short, to tell the Inquiry about your members’ experiences during the pandemic. And you have produced a statement which, for those following, is at INQ000515683.

Ms Nadra Ahmed: I have.

Counsel Inquiry: Thank you. And just starting with some of the work of the NCA, is it right that it represents and supports small and medium-sized care independent – sorry, care providers in England –

Ms Nadra Ahmed: Yes.

Counsel Inquiry: – and has approximately a thousand members?

Ms Nadra Ahmed: Yes.

Counsel Inquiry: The majority of your membership are nursing or residential homes?

Ms Nadra Ahmed: Yes, it is.

Counsel Inquiry: And the remainder are home care, but essentially 92% of care in residential homes?

Ms Nadra Ahmed: Yes, and learning disability services.

Counsel Inquiry: Thank you. You have told the Inquiry that smaller care homes have around 20 to 40 beds and medium-sized providers have 50 to 150 beds; is that right?

Ms Nadra Ahmed: Yes.

Counsel Inquiry: And is that in England?

Ms Nadra Ahmed: Yes, it is.

Counsel Inquiry: You have described the pivotal contribution of the SME sector, as you refer to it, in your statement, and how it is the backbone of care provision. Can you briefly explain why it is so important?

Ms Nadra Ahmed: Yes, thank you. We use that quite a lot because over 80 – I think it’s 83.4% of the sector is made up of small to medium-sized care providers across the country, and they are set in all sorts of different areas. So accessible through most communities, and that’s how they are located.

But they’re also owned primarily, either individually or with small boards, so there’s not private equity in the people that we were work with. It is investments that are made by the providers themselves.

Counsel Inquiry: And you have told the Inquiry that during the pandemic you had almost daily contact with civil servants about issues in the care sector. We’re going to come on to more detail with those issues but what were some of the issues that you raised?

Ms Nadra Ahmed: I think it was primarily because information was so slow, and actually very, very inconsistent. So as from the perspective of how we were going to handle it, because initially, when the pandemic was talked about, there was – late February, we were still kind of talking about Brexit, and we were talking about the challenges for the sector from that perspective. And that included shortages of staffing. And so we were very concerned when the pandemic was kind of announced as being there. We were told that it wouldn’t have an impact on our bit of the sector initially.

There was very little information coming. There was a little bit of a panic amongst our members because we have things like norovirus that are around, we have all those kinds of issues that come into our settings and we’ve always managed, through infection prevention and control mechanisms, to keep our residents safe. But of course, the pictures that were coming out from across Europe were quite challenging, and the smaller providers, you know, weren’t, for example, there was something that came across from a care home in Spain and all those issues, they were causing people quite deep concerns.

And as small providers, what we have to remember is they are it. There isn’t an HR department. There isn’t anyone else there from a regional office, generally speaking, able to deal with the challenges that they were facing.

So we started to get a slow trickle of concerns that were coming through to our membership. So we were pointing it out on a regular basis, asking for information, mostly about the virus, mostly about what, you know, the symptoms might be, what people needed to be looking out for. All of those kinds of things.

Counsel Inquiry: And did you get that information when you asked for it?

Ms Nadra Ahmed: I think initially it was, initially it was really quite – it was downplayed, that, you know, this was not something that was going to impact on our piece of the sector, and we didn’t need to worry about it. We needed to support the NHS. That was primarily what we kept being told.

I think families were beginning to see some challenges, as well. We didn’t really get – I guess, the shortest answer is no, we didn’t get what we were looking for. We were given explanations that actually were not consistent.

Counsel Inquiry: And is that at the start to the pandemic?

Ms Nadra Ahmed: Yes.

Counsel Inquiry: Did it improve?

Ms Nadra Ahmed: It started to improve with more regular meetings.

Counsel Inquiry: Can you remember when that was?

Ms Nadra Ahmed: It was probably the second week of March or so, sort of 13, 14, 15, something like that, that we suddenly started to get a lot of meetings appearing in our diaries from departmental colleagues, and a little bit from – we had very little contact, as the National Care Association, we have never been seen as the organisation that kind of really needed to be talking to the NHS, for example. You know, very little contact with the NHS except at local levels where our members did that.

Certainly we were beginning to get that sort of linkage.

So we were trying to work quite dynamically with the kind of messages that were coming through, and I think the issue was there was quite generic information that was really much more suited to larger establishments because it was coming down from the NHS kind of perspective.

Smaller providers, where you’ve only got ten residents, or you might only have 20, or you’ve got a learning disability service with four or five, there was no tailoring towards that messaging.

Counsel Inquiry: Did you have the opportunity at those meetings, or perhaps in email correspondence outside of the meetings, to provide any feedback on the guidance or decisions that were being made to represent the views of the providers that you represent?

Ms Nadra Ahmed: Yes, yes, we did. And we worked with colleagues in the sector, also representatives, and we worked really hard to try to make sure that our views were being reflected and we were getting real intelligence from people on the ground, you know, when somebody rings you up, and says, you know, “I’ve just taken somebody back from the hospital, and now we’ve got five – five of our residents are poorly, you know, what do we do? How do we deal with this?” People were kind of doing this, it was a fast-moving scenario, so by the time you actually went back to a meeting to talk about the challenges, the provider would already have to have made some decisions.

And I think there was a lot of clash on the way that we were being told to look at things. I think one of the problems that was really clear to me was that there were people who were being asked to write guidance, to talk about these things, who had no experience of either the social care sector, or certainly not smaller providers. So they were quite new into these roles, they were being brought in, they were having to do quite a lot of research. And I think picking up so many different messages for them was difficult.

But for us, on the ground, for our members, it was becoming quite impossible, because we also had a workforce that was really worried, you know. What we have to remember is our workforce were the ones that were on the ground. They didn’t have any kind of support except us trying to support our members.

Counsel Inquiry: And I’m going to come on to ask you about that, but two things, please, if I may on what you’ve just said.

The first is around the staff structures within the smaller providers. And I think you’ve said in your statement that the lack of administrative staff in some of those care providers made it more difficult to implement and communicate changes in guidance in a timely manner.

So what support do you think could have been provided to them to have helped with that?

Ms Nadra Ahmed: Well, I think with that, I think plain English would have been really good, as well, you know, just being able to pass things through in a timely manner. You know, for our administrative staff who were used to dealing with rostering and residents and, you know, making sure the files were right to suddenly have to deal with quite medical terms, you know, quick implementation methodology, I think it was really beginning to – I think it was challenging because their roles were changing so quickly, as well.

Counsel Inquiry: Okay. And is it right that you set up a WhatsApp group, or the NCA board set up a WhatsApp group for managers and owners to help with interpretation and dissemination of information and guidance?

Ms Nadra Ahmed: Yes. One of our colleagues on the board who is a nurse herself, Anita Astle, she set up the WhatsApp group and very quickly, it picked up momentum and we had people – it wasn’t just NCA members; it was – just everybody was joining it.

It was the only – it was the only mode at that point that was immediate. So everything we were doing at the national level and talking to colleagues in the department or, indeed, in the NHS, it took time because it had to be signed off, you know, and sometimes that would take a long time. We’d get all sorts of things coming through which contradicted each other. Sign-offs were taking a long time. But that particular WhatsApp group suddenly got momentum and it also had doctors on it that would come on and give – geriatricians who were actually giving really good advice, as well.

So they were able to – so a lot of them are care home providers or staff, but they were also people that were happy to do some of the research behind some of the guidance to try and interpret it into simple English, into plain English, and get it back.

Counsel Inquiry: I’d like to just ask you now about the hospital discharge policy that was introduced in March 2020 in which care homes were asked to take patients that were in hospital.

To your knowledge, what were some of the practical difficulties for small and medium care providers in following the discharge requirements, for example, around isolation or cohorting of staff?

Ms Nadra Ahmed: I think the difficulty – there were various issues around this, because obviously by then there was more concern. People weren’t very keen on taking people out of hospital, but I think we were being vilified by everybody if we didn’t take them. And some providers chose not to take them and kept the virus out of their services. But those that did, to try to support the NHS, because that was the mantra, were then having to look at the way that they were isolating.

So initially you could isolate in a room, and the other residents were able to kind of go mingle. And then, you know, very quickly that began to change because the more people that were becoming infected, you’d have to cohort them, create zones where only certain people worked.

So that – it had an implication on the staffing as well, because you’d have the people who were working in a red zone and – you know, all of those things.

But the other channel for our providers, SME providers, were – you know, we had converted buildings, and those converted buildings created challenges. You know, narrow corridors, potentially. Room access being very different to a purpose-built building.

So providers and their workforce were doing the very best they could, quite quickly, to accommodate people who had come out of hospital. You know, we were told that they didn’t need to be tested initially, they could just be discharged, because if they didn’t show symptoms, they didn’t need to be tested. Which was – you know, it was a bit crazy at the time, because of course if they were – and, you know, we have examples where a provider who has only 20 beds had to get somebody – you know, had somebody come back from the hospital, and they brought Covid with them, and within three or four days, he was – he messaged me to say that 15 of his residents now had Covid, he didn’t know how to deal with it, half of his staff were now isolating. And he was in a really, really challenging position.

And so we were trying to pick up these messages and see what we could do. There was no local authority support that was coming through. There was nothing that was actually – there was nothing present in mind or in soul or in word that made us feel that we were being looked at or supported.

So, you know, that particular individual, he – you know, he phoned me – the last time that he phoned me was at about 11 o’clock one night because he was on his own in the home trying to deal with Covid-positive patients.

So it was really challenging, you know, to try – what do you say to somebody at that time of night? How do we kind of translate some of this really late stuff that was coming through to us to say “It’ll be fine, you’ll be fine”? How were we going to translate that into helping that individual?

Counsel Inquiry: And you attended meetings later in 2020 regarding the development of designated settings. That’s alternative accommodation, facilitated by local authorities to receive discharge from hospital, if the patients couldn’t be isolated in the care home. You raised some concerns at those meetings about the policy, so I want to ask you whether, overall, the NCA supported the development of designated settings?

Ms Nadra Ahmed: I think we were concerned. I think it was something that was evolving and providers were willing to provide it. So that’s the position statement, if you like. If providers were willing to provide it, because it would support the NHS at the time.

I think our concerns were very much as to how it was going to be managed. This wasn’t something a smaller provider could have done. This was going to be something that had to be invested in a very different way.

Where were the staff going to come from? Because we were already having challenges around staffing. And I think, for – for me, there was an issue about putting everybody who’s Covid positive and the mental health of those individuals that were getting better and, you know, being transferred into a service, I wasn’t sure about the wellbeing side of it for those people as well.

Did I support it? I think I supported it because it was a potential solution to a very, very chaotic period. I was extremely concerned about the insurance implications for people. I was worried about families, and how they would feel if loved ones were being transferred into a Covid-positive environment, and how that visiting might – you know, how that might impact on them.

So my honest answer is I wasn’t sure about it. But I think, in the position that we were in, it was a solution.

And not – initially, there was a lot of interest in it but I’m not sure how many people eventually did take the option to open them.

Counsel Inquiry: Okay. Moving on, then, to the suspension of routine inspections by the CQC, so a letter was written by the CQC in the middle of March 2020 which your organisation were invited to consider and to look at with, I think, one day’s notice.

In your feedback you asked whether care providers needed to notify the CQC of Covid-19 deaths, and the response from them was that they would come back to the sector shortly.

Can you recall why the NCA was asking that in particular?

Ms Nadra Ahmed: Because they are required to give notifications of death when that occurs in a service. And of course providers, by the very nature of the role that they do and the way that they’re regulated, do not want to fall out of regulation with the CQC. And there seemed to be this kind of – the CQC went AWOL. There was no support for the sector. They were basically shutting down, although they were telling us that they would be around.

Calling them became quite an issue. So how were we going to deal with this? Because we knew that in certain environments there would be more deaths. You know, how did they want to be notified of them? You know, the timely way in the way – because these are all things that were happening – you could have two deaths in a day. You know, you’ve got to sit down. You’ve got to be dealing with other people who might be Covid positive.

You know, we needed better – we needed more clarity. I think CQC was very remiss in that they just shut the doors and decided that’s how they were going to implement it.

Counsel Inquiry: So it wasn’t until 9 April that providers were informed that when making a notification, they should use a revised form to notify the CQC if the death of an individual was as a result of confirmed or suspected Covid-19. So do you think that was introduced soon enough or confirmed soon enough?

Ms Nadra Ahmed: No, I don’t think so because it was really difficult. We also, you know, we must remember that GPs had stopped coming to care homes, as well. We were in a state where confirming death had become an issue, as well. All of those things. I think it should have been done quite quickly, because the deaths had already started, so a month later is a long time for a provider to be wondering how they were going to, you know, make sure that they were doing the right thing and they were staying within their regulatory responsibilities.

Counsel Inquiry: And I think in your feedback in the middle of March you actually asked that any information the CQC provides is unambiguous and provides clarity to avoid adding to mixed messaging. So did the messaging from the CQC do that?

Ms Nadra Ahmed: To a degree. I think we were making – we were being stronger by then to make sure that we were making the rules in a way that was going to suit the providers. And I think you know. For example, when you – you’re getting something from CQC that’s saying “You must close your doors” and then you’re getting something that you must enable visiting. You know, all of those kinds of things. We needed much more clarity about how and where we sat.

I think we were – I think we were really trying hard to get CQC to work with us in a way that would support the smaller providers with limited admin support.

What we got were ambiguous answers which really didn’t make it any easier for us to be clear that we were doing the right thing.

Counsel Inquiry: Did that improve as the pandemic progressed?

Ms Nadra Ahmed: I think it improved slightly. It did improve slightly. But there was always a massive pushback to us, you know. Whenever we asked questions about something. I think one provider actually sent me a note saying he’d notified his CQC inspector about something or other, and said, “How do you think I should deal with this?” And the note he got back was, “Well, you’re the professional. You should know how to deal with it”, which really, you know.

So I guess the best anyway to answer this is the challenges were that we had inconsistent inspectors giving responses. So the responses were not, they were not consistent in different areas. So if you’ve got homes in two or three different areas you would get two or three different answers.

Counsel Inquiry: Moving on now to a slightly different topic and that’s around the implementation of IPC measures. What issues or barriers, if any, did you hear from some of the providers that they were having around implementing IPC measures particularly, perhaps, those providers that care for people with dementia or learning disabilities?

Ms Nadra Ahmed: I think that the challenges – what we have to remember is that we, as a sector, we deal with infection prevention control as a norm, you know, there is training for our staff. This was a completely different thing. This was a completely different beast that we were trying to come to terms with. So it was becoming very evident that we needed more, you know, hand gels, gloves. We have gloves and aprons and things in our services but then, of course, the mask thing was coming in.

One of the difficulties around the masks – we had to have – we had long conversations about this – is, if you’ve got somebody with dementia and you’ve got members of staff wearing masks, you know, how do we make sure that we can safely be talking to them, helping them understand things, all of those things? Because that’s quite challenging. But, of course, from our workforce perspective, we needed to keep them safe, as well.

Dementia was really difficult because people didn’t understand why we were walking around in that kind of way, as well, trying to keep people calm about, you know, about the methodology that every home was having to adopt in its own way.

If you were cohorting people with dementia, you know, what did that – the impact on them, how do you keep them safe in a particular area? We know lots of providers were putting up those kind of baby gates, almost, so that people didn’t venture forth, and – or keeping, trying to keep everybody safe in the environment they were in.

I think staff found it quite different because when they were talking – masks were a premium anyway – that created quite a lot of challenge because – and we talked about transparent masks, we talked about – the trouble was, if I’m absolutely honest, there was a huge amount of talk. When it came to action, we had to actually take our best guess as what we could do to make sure that we could keep the 20, 30, 40 people that were in our care in the best way that we could.

So there were lots of conversations.

Counsel Inquiry: And in fact you did raise the issue of the need for training on infection prevention and control with the Department of Health and Social Care very early in March in email correspondence.

So, in your view, was there sufficient training on IPC, either at the start of the pandemic, and for staff, or did it develop later on?

Ms Nadra Ahmed: No, there wasn’t. There was no – there was no resource put into it, and it was quite piecemeal.

Counsel Inquiry: And on a slightly different topic but still around IPC is testing. You were involved in attending meetings alongside the Local Government Association, and ADASS, around kind of September 2020 where testing was discussed. And one of the issues that arose in early September was that just under 400 homes had not yet done any testing. So what were your members’ experiences around accessing testing and why do you think perhaps they weren’t testing?

Ms Nadra Ahmed: Access to testing came very, very late for our bit of the sector. We had – deliveries were delayed, really badly delayed, to small and medium sized providers. We were getting regular emails from providers who were telling us that they had not received anything. I think they felt quite isolated. They felt like they had been forgotten. They were – there was some very angry emails, very long emails from people who were desperate. From the very outset, where – as soon as we heard about testing, we knew it was one of the ways that we might be able to support people and keep more and more people safe. But we were very much an afterthought.

You know, we know that it was all about keeping the NHS safe, but it was our workforce that was on the ground. It was – you know, we were the ones doing that sort of caring responsibility for one of the most vulnerable groups.

So the 400 – you know, I’ve got no specific idea of why they didn’t, but every provider that contacted our offices was just desperate for tests. We also had some tests that were not working, they were giving wrong readings. We had tests that, when they were sent back, didn’t arrive in a timely manner, and we were told that they weren’t right.

So the whole testing scenario, until quite late on, until later on into October, November time, when we started to really get what we needed, the initial stages, people were desperate. You know, providers wanted to be the test sites for it.

So we were – we were finding that – we knew that this was the way that we needed to work to get people tested. It also had implications for the home itself, obviously, because there was a routine, and there is a regime that has to be put in, but we – we were certainly not prioritised.

Counsel Inquiry: I’d like to ask you now about one of the recommendations, in fact, in your statement, and that is for there to be clear guidelines and protocols for care providers to minimise staff movement.

So can you describe for us what the experience was for providers of staff movement or restrictions on staff movement during the pandemic?

Ms Nadra Ahmed: Well, we were short staffed, of course, and we were working under quite – very difficult circumstances. We had staff that were living in homes, in gardens, in tents. You know, we had staff that were trying to – were actually keeping away from their own loved ones in order to keep the people that they looked after safe, and they weren’t going home.

So we had all of that.

What we also, you know, we – the use of agency staff became very difficult, because we couldn’t – we couldn’t be very clear about having agencies coming in to our services. Everybody was trying to create a bubble so that we didn’t create the challenges. Movement of staff was – by that I’m assuming what you’re meaning is them going from one home to another?

Counsel Inquiry: Yes, indeed, yes.

Ms Nadra Ahmed: Yes, so there was always a risk attached to that. And so that would be something that you wouldn’t do unless you were absolutely desperate. But most providers did not want to be doing that either. They were trying to keep – create – you know, it was creating bubbles. Home care, you know, we had, again, the guidance was really difficult. There were some people who were sharing cars and we were being told that, you know, you had to sit in the back seat and the front – you know, you can’t keep changing the rules. You either do it or don’t. If you’re sitting in a car and there is infection there, then surely that infection will spread if you’re sitting in a car. It just didn’t make sense.

So movement was always an issue. We were trying to make sure that people understood to limit it and not have people going into too many different services.

Counsel Inquiry: And it’s been suggested to the Inquiry that one potential way to achieve that in future would be for a care home to take a fewer number of staff, but who are employed to work full time, or that the worker could continue on a zero-hours contract and take up another job if they didn’t have any hours from that care home. Do you think that would be practical for the providers that you represent?

Ms Nadra Ahmed: I think that’s a really strange – it’s a very strange suggestion. We have to remember that the workforce chooses how they work and where they work. We can’t just make assumptions that they’ll be happy to do what we want them to do, you know. The duty of a care provider is to try and keep their home fully staffed in order to meet the needs of the people that they support, and so to try to tinker around the edges with how you might get it round in a different way to, you know. I honestly don’t know how to answer that question, you know. For example, zero-hour contracts, some of our workforce choose to go on zero-hour contracts because it suits their working – their work-life balance.

I’m not sure a methodology, that one you’ve described, kind of sits with me as being a solution.

Counsel Inquiry: Just briefly in terms of PPE which you’ve touched on already, how practical would it be for small and medium care providers to have, say, a month’s worth of emergency supply of PPE, and would that be helpful in a future pandemic, do you think?

Ms Nadra Ahmed: I think access to PPE has to be one of the recommendations if we came to something like this again. With the stock, I mean, I’ve thought about this quite a lot because I think one of the challenges we faced when we were given a drop of PPE was that it was out of date, you know, that the care providers were sent PPE that was out of date. And we had providers sending us pictures of this. I think there has to be a stock. I think what we have to be really, really clear about is that social care looks after some of the most vulnerable people, and it has to be treated as a priority, not as a secondary. It has to be moved in a way that the public and those that are making decisions understand the importance of us having access to resource, for us to be funded appropriately in order to make sure that we have that resource, when we need it. And we need it in a timely manner. We don’t need it three weeks down the road when somebody suddenly thinks, “Oh, actually, it is going to affect the social care sector, better do something about it.” It doesn’t work.

Lady Hallett: Forgive my interrupting, I think the point of Ms Hands’ question was an answer from Mr Hancock, which was that the care homes should have – I think he put it as a cupboard in which they could store a month’s worth of PPE. In other words, it wasn’t getting access to the emergency stockpile or supplies, it was having a month’s supply in a cupboard.

Ms Nadra Ahmed: Well, most providers would have a reasonable amount of – thank you for clarifying that for me. Most homes would have a supply because that’s what you do. You have a month or six weeks’ supply, just in case something goes wrong. We didn’t have that supply of masks, though. So, you know, this was a new, new way of doing it.

So actually, in answer to Mr Hancock on his point, had we known that we might be hitting something like that, I think providers would have done that, you know. But they did have sufficient for their daily use, and had the government not told us not to worry about it, we may have been a slightly different situation, because accessing that PPE became an enormous challenge for us straight away, especially when we started to hear from our suppliers that they could no longer supply to the social care sector because it was being rerouted to the NHS. So if we – you know, how much would have been recruited if it was due to come to us for a stockpile?

I think those things are the reality that was on the ground, and that’s – and we ought to speak the truth about it. We ought to be telling the truth about this. That PPE was diverted away from the social care sector in the early stages to go to the NHS. And that is a fact.

Ms Hands: Ms Ahmed, you mentioned in your previous answer funding, so if I may ask you briefly about that.

You have included in your statement some evidence from a survey that you conducted with your providers around whether they’d had access or been able to access the government funding that had been made available.

Could you briefly just describe some of their experiences of accessing the government funding.

Ms Nadra Ahmed: I think it wasn’t the easiest methodology, but actually, you know, I have to say that it was the only bit of money that came to the front line, and was really helpful to the sector. So from that perspective, it – I – you know, we’re grateful for that.

But it wasn’t an easy – it was routed through local authorities. We understand that – I think it was 30% from our – from memory, from the survey, of people who said they didn’t get it, and it was held back. Which is quite worrying, why it was so inconsistently distributed. So certain local authorities didn’t distribute it in the way that they did. Others did really well.

And I think that inconsistency, god forbid we have anything like this in the future, must be ironed out. It has to be. If it’s ring-fenced, it needs to come to our sector.

Counsel Inquiry: You have also provided some examples of the types of additional costs that were incurred by providers, such as reconfiguration of care settings, buildings, specialised equipment and increased staffing costs as well. Were small and medium providers disproportionately affected by that?

Ms Nadra Ahmed: I believe so. I think we were. We were having to – the adaptability of our services were quite challenging. Our insurance costs went up, I don’t know, tenfold. People tell me a hundredfold. Insurance companies weren’t willing to insurance our service because they wouldn’t do the Covid, so reinsurance became really difficult. That hit us quite quickly. And providers were paying – I think where somebody – one of the examples I remember was somebody who had paid £1,800 for their insurance the previous year were being asked for 8,000, 9,000, and then the following year it went to about 20,000 or 30,000. So that was an enormous cost.

Food costs were affecting us as well. Of course, you know, the delivery chain impacted on us as well.

There were – the reconfiguration, you know, for example, putting out pods and things, that all came in for the visiting – people were already starting to look at window visits, putting up perspex in between. So all these were additional costs that we weren’t supported with.

Counsel Inquiry: And at the end of your statement you have provided a very helpful list of recommendations which the Inquiry will publish in full but I’d like to ask you about one of those, if I may, and that’s that the NCA would support a database of all adult social services, including those that are not registered with the CQC. Is that right?

Ms Nadra Ahmed: Yes.

Counsel Inquiry: And in regards to that register, would that also include social care workers?

Ms Nadra Ahmed: Yes.

Counsel Inquiry: And do you have a view as to who would be best placed to collect that data?

Ms Nadra Ahmed: I don’t have a view on that. Not a strong view, no. I think there are various people, various bodies out there who could do the job.

Counsel Inquiry: And do you have a view as to whether it should be mandatory or a choice, voluntary?

Ms Nadra Ahmed: I think that’s a much more difficult question. I think, thinking back to mandatory vaccinations, I wouldn’t want to lose 40,000 staff because of something that we were mandating which wasn’t mandated anywhere else. I think, if we showed the benefits of it being a useful collection of data, and then people move towards it, that might be a better way. I don’t like – since the mandatory vaccination scenario and the fiasco that that was, with social care being deliberately targeted to have that inflicted on them, and the loss of a very good workforce that we had who are never going to come back because they could go into the NHS and they could work there, and not be vaccinated. Why would they come back to social care, where that – other mandatory things could be thrown at them?

Counsel Inquiry: And just finally, how do you think that would help in a future pandemic if there were such a register?

Ms Nadra Ahmed: I think we’d know where people were and how we could access – the data could be used in so many different ways of making sure that some of the things that happened didn’t happen again. I think having that – I mean, data collection has become a big thing. It’s great to collect data but it’s how you use it that makes the difference, and if we have it, then we must have a methodology that goes with it. So we prevent the challenges that we faced at that point.

Ms Hands: Ms Ahmed, made thank you.

My Lady, those are my questions.

Lady Hallett: Thank you very much, Ms Hands.

Mr Weatherby.

Mr Weatherby is just there, just a few more questions.

Questions From Mr Weatherby KC

Mr Weatherby: Thank you very much and good afternoon, Ms Ahmed. I ask questions on behalf of the Covid Bereaved Families for Justice UK group.

Continuing with the theme of data, in terms of data and ethnicity, the Public Health England report beyond the data published in June of 2020 noted that there was only one study which reported mortality in health care workers in the UK by ethnicity, and that further analysis was urgently needed to understand the morbidity and mortality of health and social care workers due to Covid, with a particular focus on BAME groups.

Was there, in your experience, a general lack of recording of the ethnicity of not only healthcare but also social care workers at the start of the pandemic?

Ms Nadra Ahmed: Well, it was never mentioned. It was never – it never figured; it never factored in any discussions or debates that we were having in any meaningful way.

I think it became much more apparent when the mandatory vaccination thing came into place, because there was a lot of concern that a lot of people from ethnic backgrounds were not willing to take. And that was the first time that data was starting to be produced about how Covid would impact people from ethnicity more.

Mr Weatherby KC: Yes. In terms of further analysis recommended by PHE, did the NCA involve itself with that?

Ms Nadra Ahmed: We’ve always – yes, we did.

Mr Weatherby KC: Yes. The PHE report recommended the routine collecting and recording of ethnicity data as part of routine NHS and social care data collection systems, and the sharing of data across local health and care partners to inform and mitigate the impact of Covid-19 on BAME communities. And do you know if that recommendation was actually carried through?

Ms Nadra Ahmed: No, I don’t.

Mr Weatherby KC: Would you have supported that recommendation at the time or going forward?

Ms Nadra Ahmed: I think I would have. I am always concerned about – again, I repeat what I just said, data collection is important. But it’s why it’s used.

Mr Weatherby KC: It’s what you use it for.

Ms Nadra Ahmed: And that’s where you’ve got to be very clear and careful that data is not misused.

Mr Weatherby KC: Yes. Finally, in terms of PPE, the Inquiry has heard evidence in previous modules of healthcare workers from ethnic minority backgrounds not having culturally competent PPE, particularly at the start, in the first wave. Was this, to your knowledge, addressed across the care sector?

Ms Nadra Ahmed: No.

Mr Weatherby: Thank you very much. That’s all I ask.

Lady Hallett: Thank you, Mr Weatherby.

And then I think Mr Straw, who is over there.

Questions From Mr Straw KC

Mr Straw: Good afternoon, I act on behalf of John’s Campaign, The Patients Association and Care Rights UK.

At paragraph 72 of your witness statement you state that the consultations and guidance regarding the reintroduction of visits by loved ones were consistently behind the reality on the ground. Is one reason for this that there was no mechanism which ensured that organisations who represent social care users and their carers were speedily consulted for changes to the guidance?

Ms Nadra Ahmed: I’m kind of missing a few words that you said there, sorry, at the end. Was the consultation?

Mr Straw KC: Was the reason why that guidance didn’t reflect the reality on the ground that speedy consultation didn’t happen with organisations who represent care users and also carers?

Ms Nadra Ahmed: I think the visitation consultations were very haphazard, and certain parts of the sector were potentially talking to interested parties and certain bits of the sector weren’t.

What was very evident for us was that some of that was contradicting each other. Some of the – you know, some of the recommendations were challenging each other.

And one of the things that kind of is really important, I think, in all of this, is that we were concerned that providers, certainly my members, the SME part of the sector, were trying their best to try to facilitate visiting for people, because we could see the difference it made. Suddenly, you know, you’ve got the staff are being all things to everybody, and so the pressure on our staff group was also great, but being able to have people coming in was seen as a benefit. It was always seen as a benefit.

But then some of the consultations put barriers in the way. There was such negativity around it in some cases. So I think it wasn’t – I don’t think the consultation was carried out to the best – in the best way that it could have been.

Mr Straw KC: Okay, thank you. Then coming on to visiting and, you’ve just touched on it, some of the benefits of visiting, do you consider that the visiting restrictions struck the right balance? And I’m particularly interested in the exclusion of essential carers, family carers, for people who had significant care needs, like dementia sufferers; did those visiting restrictions strike the right balance, in your view?

Ms Nadra Ahmed: I’m sorry, as you taper off, I didn’t hear the final bit.

Lady Hallett: Did the visiting restrictions strike the right balance? So, for example, with essential carers not being allowed to care for their loved ones when they had experience of doing so at home?

Ms Nadra Ahmed: Well, I think it would have been – it would have always been beneficial for people to be able to visit their loved ones had they been caring for them at home. It was a risk to their own health that was causing the issues for people.

But actually, we had – a lot of the smaller providers were telling us they were being told that they were in breach because of – they were allowing people to come in – tested. You know, by the time the testing had come in, I do believe that if somebody has been caring for somebody in their own homes and they then find them in a care setting, that they should be enabled, if, God forbid, this all happens again, they should be enabled to be – able to support their loved one.

Mr Straw: And this may be obvious but you touched earlier on the importance for staff of a family or other carers being allowed in. It takes the burden off staff. And I think you were also pointing there to the benefit for the individual themselves, if they have that essential or family carer support. Are those two of the reasons why it’s important to have access to essential carers?

Ms Nadra Ahmed: Yes, I mean I lived through it. My father was in a care home. He was there, and I remember the visits to him.

I remember the visits when he was at home, and trying to

get food through the door for him, and then going into

the care home and not being able to go in to see him.

So absolutely, I think – I think it’s quite – it is

quite difficult to argue against having – taking the

pressure off some of the workforce, as well, but also

taking – enabling people who are willing and able.

And one of the things that, you know, I think it

would be prudent to mention is that some of the people

who initially were coming to visit, in care homes, their

loved ones, were of an age that was considered to be at

risk, and so they had to be, you know – so the rules

were that they needed to isolate or whatever. And it

did have – it has a detrimental impact on the person.

You know, I know what my dad felt like because he would

stand at the window and keep shouting to me to come up

because he couldn’t understand why I couldn’t come up.

So those are the challenges that we were facing, but

absolutely, we’ve got to get it right. We’ve got to get

it right if this happens again, and people benefit from

seeing their loved ones. I don’t know whether that

fully answers your question. I’m kind of probably

repeating myself.

Mr Straw KC: It does. Thank you very much. And I’ll move on to the

final topic, and I’ll try and speak directly into the microphone in the hope that helps.

Ms Nadra Ahmed: I’m sorry, I’m also hard of hearing, so – but I have got hearing aids in, but it’s not picking it up, so it’s partially my fault.

Mr Straw KC: I’m going to shout. Earlier you mentioned – earlier today in your evidence and also in your statement you mentioned innovations such as visiting pods to facilitate visits. Were you aware that these pods were considered to have major disadvantages for some people, people with cognitive hearing or visual impairments, such as dementia, and people considered that they didn’t enable carers to provide care in an effective way?

Ms Nadra Ahmed: I wasn’t aware of that. I wasn’t aware that the pods were considered to be not a good way of facilitating visiting, no. It was something that was certainly used quite a lot throughout the sector, especially in SMEs where space was limited. It was creating additional space so that people could also not have to come in through the building. They were going from outside in order to make that happen. And I wasn’t aware of the study that you’ve – potentially the study that you’ve just spoken of.

Mr Straw KC: Just one broader and final question, then. Would you agree that face-to-face or in-person care is really important for certain types of people needing care,

particularly people with dementia?

Ms Nadra Ahmed: Absolutely.

Mr Straw: Okay, thank you very much.

Lady Hallett: Thank you, Mr Straw.

That completes the questions we for you, Ms Ahmed.

I’m really grateful to you. I appreciate how

distressing it must be for a lot of witnesses who have

to think back through those really difficult times, and

I’m sure that all the people that you represent had

a really tough time, as did their residents and their

loved ones. So thank you very much for all your help,

and I’m sure there will be some support for you when you

leave the hearing room.

The Witness: Thank you, my Lady, for the opportunity.

Lady Hallett: Thank you. I shall return at 10.00 tomorrow.

(4.35 pm)

(The hearing adjourned until 10.00 am the following day)