Two years on…….

Research Report: The Health and Care (Staffing) (Scotland) Act 2019 — Two Years In

Prepared for Mac Research and Consultancy Limited blog development. Audience: registered managers and sector leaders in Scottish care homes (adults and older people), care at home and housing support services, plus practitioners and policy-engaged readers.

The Health and Care (Staffing) (Scotland) Act 2019 (HCSA) commenced on 1 April 2024, replacing Regulation 15 of the 2011 SCSWIS Regulations and giving Scotland the UK’s first cross-system statutory safe-staffing framework. Two years on, the picture is mixed: most providers report broadly positive engagement with the Care Inspectorate’s Safe Staffing Programme, but the Act is being implemented into a sector in financial and workforce crisis — and inspection enforcement is starting to bite.

- Care Inspectorate data for inspection year 2024/25 show a small but rising number of HCSA-linked requirements, complaints and enforcements in adult services, with concrete examples already on the public record (e.g. Lochbank, Forfar — registration cancelled August 2024; Carlingwark House, Castle Douglas — Improvement Notice 6 September 2024;, Inverness — Section 62 Improvement Notice April 2024; Cameron House, Inverness— multiple “weak” gradings and requirements). Common failure themes are insufficient staff numbers/skill mix, weak quality assurance, poor escalation, agency over-reliance, and absent professional-judgement records.

- The decisive shift for managers is that staffing is no longer a one-page rota question but a statutory cycle: assess (using needs, dependency, environment, local context), deploy, monitor in real time, escalate, evidence and review — triangulating quantitative rota data with qualitative outcome data. Services that cannot show that cycle on demand will struggle when inspectors arrive — and “the funding doesn’t allow it” is not a defence under the Act.

Key Findings

1. The Act is now the legal benchmark for staffing in social care. Section 7 imposes a duty on every care service provider to ensure that “at all times suitably qualified and competent individuals are working in the care service in such numbers as are appropriate” for the health, wellbeing and safety of service users, the provision of safe and high-quality care, and — newly — the wellbeing of staff. Regulation 15 of the SCSWIS (Requirements for Care Services) Regulations 2011 has been **repealed** and is replaced by the Act’s requirements.

1. The Care Inspectorate’s Safe Staffing Programme is the practical engine of implementation. Its End of Year Report 2024-25 (published 30 September 2025) shows 99 external sessions delivered, 1,775 attendees, six published Information Guides, and 64% of surveyed providers agreeing the Programme has improved their understanding of the Act. A Staffing Method Framework (SMF) for adult care homes is recommended (and viewed by 58% of respondents to the 2024 Annual Return), but is not yet a mandated method.

1. Enforcement is real and rising. In 2023/24 the Care Inspectorate issued 48 letters of serious concern, 32 Improvement Notices and cancelled four registrations (Fulcrum Care/Care Inspectorate analysis). Internal CI data published with the Safe Staffing End of Year Report show HCSA-linked requirements made through inspection, complaint and enforcement routes throughout 2024/25 in adult services, children/young people and ELC. Adults services bore the largest volume.

1. Self-reported compliance is high — but limited.* Of the 89.9% of registered care providers who responded to the Care Inspectorate’s 2024 Annual Return, 3.7% self-assessed as not meeting their duties under the Act (Scottish Government Ministerial Report 2024/25, published 27 November 2025). Scottish Ministers explicitly note the limitations of self-assessment.

1. Workforce reality is the elephant in the room. SSSC’s Scottish Social Service Sector: Report on 2024 Workforce Data* shows the workforce at a record 214,750 (a 0.9% increase) but the care-home-for-adults sector grew while care-at-home/housing support shrank in the public and voluntary sectors. The 2024 vacancy report (CI/SSSC) shows housing support, care at home, care homes for older people and care homes for adults face the highest vacancy pressures, with “too few applicants with experience” the leading cause. 64% of providers responding to the Safe Staffing Programme survey (March 2025) cited recruitment and sector shortages as the **#1 risk** to implementing the Act, with staff costs (49%) and time to train (43%) close behind.

1. Sector bodies are blunt about the funding tension. Dr Donald Macaskill (Scottish Care) has warned that the “bottom could fall out” of the sector “in three months” without action on National Insurance Contributions, the National Care Home Contract and immigration restrictions; Scottish Care’s January 2025 research found 49% of care homes reporting decreased placements and 1,463 placement vacancies across 403 homes. CCPS’s Social Care Benchmarking Report shows 95% of organisations finding it “very” or “quite” difficult to recruit frontline staff; 81% reported recruitment needs as higher or the same as the previous year. RCN Scotland’s Nursing Workforce in Scotland (May 2024 / Nov 2024 update) shows registered nurses in adult care homes continuing to fall while resident acuity rises.

1. The Act sits inside a wider regulatory architecture. The Health and Social Care Standards (2017/2018), the Care Inspectorate’s Quality Frameworks (Quality Indicator 3.3 — *Staffing arrangements are right and staff work well together*), the Public Services Reform (Scotland) Act 2010 (under which Improvement Notices and Condition Notices are still issued), and now the Care Reform (Scotland) Act 2025 (Anne’s Law, ethical commissioning duties) all interact with HCSA duties.

1. What the Act actually requires of care services

Core duty (Section 7). Care service providers must ensure at all times that suitably qualified and competent individuals are working in such numbers as are appropriate for: (a) the health, wellbeing and safety of service users; (b) the provision of safe and high-quality care; and (c) so far as it affects either, the wellbeing of staff (a new addition versus old Regulation 15). In determining “appropriate numbers,” providers must have regard to the nature, size, aims and objectives of the service, the number and needs of people experiencing care.

Guiding principles (Section 1, applied to care via Section 3). The eight guiding principles state staffing must be arranged to (1) improve standards and outcomes; (2) take account of people’s individual needs, abilities, characteristics and circumstances; (3) respect dignity and rights; (4) take account of the views of staff and people experiencing care; (5) ensure staff wellbeing; (6) be open with staff, individuals and families about staffing decisions; (7) allocate staff efficiently and effectively; and (8) promote multi-disciplinary services.

Training duty (Section 7(1)(a)–(b) and Section 8). Providers must ensure staff receive appropriate training for the work they perform, with suitable assistance — including time off — for further qualifications.

Section 9 / Section 3 duties on Local Authorities and Integration Authorities. When commissioning or planning care from a third party they must have regard to the guiding principles, the staffing duties on providers (Sections 7–10), and equivalent duties under the Public Services Reform (Scotland) Act 2010. They must publish annual reports (e.g. City of Edinburgh Council’s HCSA 2024/25 Annual Report; Shetland Islands Council).

Real-time staffing.*Although the explicit statutory “real-time staffing assessment” duty is in Part 2 of the Act (Section 12IC, NHS-facing), the Care Inspectorate’s guidance for care services makes clear that real-time allocation and risk-escalation procedures are part of evidencing Section 7 — “Effective procedures for rostering and real-time allocation of staff to respond to risks” is listed in the statutory guidance.

Professional judgement. The CI’s Information Guide 2 specifies: “This requires providers, leaders, and managers to assess staffing requirements. It will be based on their professional opinion of the current workload and the local context. It is important to record staffing information, decisions and outcomes based on the management of risk and professional judgement.”*

Common Staffing Method (CSM). The CSM is currently NHS-facing only, governed by the National Health Service (Common Staffing Method) (Scotland) Regulations 2024 (in force 1 April 2024, with 2025 amendments). For care services, Section 82A of the 2010 Act (inserted by Section 12 of the Act) gives the Care Inspectorate the power to develop a staffing method for adult care homes. The CI has done so — the **Staffing Method Framework (SMF)** — but Scottish Ministers have not yet made regulations mandating its use, so it is currently a recommended framework, not a mandatory method.

2. Implementation, statutory guidance and the regulatory ecosystem

- 1 April 2024: Act provisions commenced (S.S.I. 2024/20, reg. 2(2)). Statutory guidance issued by Scottish Ministers under Sections 3 and 10 of the Act applies from that date.

- Care Inspectorate Safe Staffing Programme (commissioned by Scottish Government). Programme lead Stephanie Thom; safe staffing advisor Gloria McLoughlin. Outputs include six Information Guides for managers and inspectors, the SMF (Draft v6) accessible via the *Right Decisions* app, “Safe Staffing cards” for self-evaluation, podcast series, and webinars.

- Quality Frameworks. Each registered service type has a Quality Framework (care homes for adults and older people; support services with care at home including supported living; support services not care at home). HCSA performance is principally evaluated under Key Question 3 — How good is our staff team?, particularly Quality Indicator 3.3 (“Staffing arrangements are right and staff work well together”) and 3.1 (recruitment), but also pulls through into KQ 1 (wellbeing), KQ 2 (leadership/quality assurance) and KQ 5 (planning).

- Health and Social Care Standards (2017). Standards 3.14, 3.15 (“My needs are met by the right number of people”), 3.19 (consistency), 4.14, 4.27 are the practical reference points.

- 2024-25 Ministerial Annual Report (published 27 November 2025). The first under Section 9. Reports that no Local/Integration Authority indicated they were *unable* to comply, but acknowledges challenges including UK NIC increases, immigration changes (ban on care workers bringing immediate family), inflation, and the SSSC Have Your Say survey finding 24% of leavers said they were overworked.

- Care Reform (Scotland) Act 2025. Passed June 2025. Doesn’t directly amend HCSA but introduces Anne’s Law (statutory visiting rights — Care Home Services (Visits to and by Care Home Residents) (Scotland) Regulations 2026), ethical commissioning duties, sectoral bargaining provisions, and abolishes SSSC’s national workforce planning duty (replaced by the National Care Service interim Advisory Board, established May 2025).

3. Wins and what’s working well

- Provider engagement is broad. 99 external sessions and 1,775 attendees in 2024/25. 64% of survey respondents agreed the SSP improved their understanding of the Act; 58% reported using the Staffing Method Framework via the 2024 Annual Return.

- Wellbeing has gone from soft language to lived practice. Provider responses to the SSP survey describe structured supervision, open-door policies, wellbeing champions, mental health/counselling access, trauma-informed practices, flexible rostering, and reflective sessions. The new staff-wellbeing limb of Section 7 is genuinely changing how care managers talk about workforce planning.

- Stronger triangulation. Good services are explicitly linking quantitative (rotas, hours, vacancies, agency use) and qualitative (Care Opinion feedback, family meetings, complaint themes, falls/medication/IPC audits, supervision themes) data. This is consistent with Quality Framework expectations and the SMF’s emphasis on data analysis, assessment, risk management and professional judgement working together.

- Cross-sector improvement programmes. The joint Care Inspectorate / HIS / NES *Reducing Stress and Distress* improvement programme (Dec 2024 – Dec 2025; cohort 2 in 2026) explicitly links staffing competence to dementia outcomes and is open to services graded 3 or above.

- Positive sector commentary. RCN Scotland called the Act “the first legislation in the UK to set out requirements for safe staffing across both health and care services” and credits members for shaping ~85% of the final Bill. Scottish Care has welcomed the principle (while warning it cannot be delivered without funding reform).

- *Examples of good practice. Letham Park Care Home (Edinburgh, October 2024 follow-up): improvements after an earlier requirement included reorganised rotas demonstrating staffing levels corresponding to assessed needs; investment in nursing staff so that nursing was now available across both units; reallocation of catering staff to free up direct care time at mealtimes — explicitly noted as compliant with Section 7(1)(a) of the Act.

4. Losses, challenges and what’s going wrong

Sector-level concerns:

- Funding gap. SSP survey: 49% cite staff costs and 43% cite “time to train” as top risks. Provider quote: *“The whole of this Act depends upon a funding model that links to staffing resources. For example, having a funding model that only funds a manager for les than 25 hours per week in a 24-bed care home is scandalous.”*

- Workforce shortages. 64% cite recruitment and sector shortages. SSSC 2024 data shows registered nurses in adult care homes continuing to fall despite rising acuity. Scottish Care: 49% of care homes reported decreased Local Authority/Health Board placements (Jan 2025).

- *Employer NIC and immigration. Scottish Care’s Macaskill: increased eNICs, NMW rises, energy/food inflation, plus the immigration ban on bringing immediate family is “becoming unviable” — *“providers are being expected to meet the Act with not one, but both hands tied behind their backs.”

- Two-tier system. Survey respondents repeatedly contrast NHS funding protection with independent/third sector exposure. This creates an equity dimension: workers doing equivalent (often more complex) work in care homes are paid less than NHS counterparts.

- Equity/equalities considerations. The CI Information Guide explicitly references diversity in the workforce across protected characteristics to support choice, privacy and dignity. The workforce remains predominantly female (~84%) and ageing. Reduced overseas recruitment has disproportionately affected services in rural areas (Highlands, Lanarkshire, Fife identified by JLL as worst-affected). Anne’s Law and the Health and Social Care Standards’ rights-based architecture put particular weight on continuity of relationships for people living with dementia, learning disabilities and at end of life — exactly the cohorts most damaged by understaffing.

Common compliance gaps in inspection (themes from published reports April 2024 onwards):

- Insufficient staffing levels and skill mix to meet assessed needs; failure to flex staffing to changing dependency.

- Weak or absent dependency assessment / staffing assessment processes and an inability to evidence professional judgement.

- Over-reliance on agency staff with poor handover, induction or familiarity with residents.

- Quality assurance not picking up serious concerns; managers not having protected oversight time.

- Failures to notify the Care Inspectorate of significant events (including unexplained bruising, ASP concerns).

- Poor staff handover and communication systems; gaps in cleaning records and IPC checks.

- Limited meaningful activity; people with dementia left for long periods with no interaction.

- Medication errors, weight loss, missed observations.

- Recruitment/induction weaknesses; inadequate training records.

5. Specific Care Inspectorate enforcement examples since 1 April 2024

- Lochbank Care Home, Forfar (Kennedy Care Group). Unannounced inspection 22–24 April 2024 with five visits 9–15 April. Findings included “serious concerns about the staffing arrangements” so people did not always receive responsive care; failure to identify/report eight ASP concerns; medication and staff conduct issues. Improvement Notice issued 3 May 2024. Registration cancelled 8 August 2024. Liquidator appointed; 23 residents and 32 staff relocated.

- Carlingwark House Care Home, Castle Douglas (Park Homes UK). Unannounced inspection August 2024; evaluated weak across all five key questions. Improvement Notice issued 6 September 2024. Required improvements covered: personal plans/needs assessments, IPC and environment, staffing arrangements to ensure responsive care, recruitment and induction, meaningful interaction. Notice subsequently extended to 9 November / 30 December 2024; new admissions suspended.

- Care Home, Inverness (Renaissance Care). Unannounced inspection 9–15 April 2024. Findings: staffing levels and skill mix not sufficient; basic care needs not met; concerns about moving-and-handling competence; limited meaningful activity. Improvement Notice issued under Section 62 of the Public Services Reform (Scotland) Act 2010 on 24 April 2024 directing the provider to “urgently assess the current needs of the people to inform how many staff hours are needed to meet people’s needs.”

- Cameron House, Inverness (CrossReach / Church of Scotland). Inspection in 2024 graded “weak” in four of five key questions. Specific staffing-linked criticisms: fewer staff on duty than rota planned; failure to consider skill mix; staff not always responding to stress and distress; “people left on their own for much of the time” with limited interaction “due to limited staffing.”

- Real Care Agency (Housing Support). Unannounced inspection 20 May–4 June 2024; Improvement Notice issued 5 June 2024 covering medication management, oversight of incidents, ASP notifications, and complaint handling.

- North Inch House (Perth). Unannounced inspection 20–21 August 2024. Letter of serious concern issued 20 August 2024 with a 24-hour deadline for cleaning/IPC remediation; follow-up 21 August 2024 confirmed compliance.

- Orchil Care Home (Perth). Inspection 29–30 October 2024; medication-administration requirement by 2 December 2024 covering staff training, oversight and audit.

- Letham Park (Edinburgh).Earlier requirement under Section 7(1)(a) of the Act; October 2024 follow-up showed improved nursing levels, redeployed catering staff and improved rotas — a useful “what good looks like” example.

The CI’s published HCSA-requirements data (in the Safe Staffing End of Year Report 2024-25) shows requirements running at single digits per month per sector across Apr 2024–Mar 2025, with peaks in adults services. By way of system context: 86.9% of all registered services were rated “good” or better in early 2025 (Care Inspectorate quarterly statistics).

6. Evidencing compliance — what the inspector wants to see

The Care Inspectorate’s Information Guide 2 sets out an explicit checklist of evidence:

- Care plans involving the person and those closest to them, with up-to-date assessed needs and goals

- Staffing resources matched to those plans

- Variation in staffing for day/night, social events, mealtimes, end-of-life care

- Following good practice for recruitment, induction, training, competency observations and supervision

- Diversity in the workforce across protected characteristics

- Staff wellbeing promotion (champions, resources, specific assessments)

- Flexible rostering with shift-changeover time

- Senior staff/key workers attending professional meetings and reviews

- Use of technology to enhance care and maintain safety

- Quality assurance and audit, with managers having protected time to evaluate findings

- Tracking data over time to identify trends or inconsistent practice

- Communication of findings to staff, families and people experiencing care, with safe routes to raise concerns

- Records of professional judgement: decisions, the workload and local context informing them, mitigations and outcomes

Quantitative evidence: rotas vs planned-vs-actual, dependency tools, vacancy/sickness/turnover trends, agency use, hours of training delivered, supervision/appraisal completion, response times (e.g. call bells), incident counts (falls, medication, pressure ulcers, weight change).

Qualitative evidence: Care Opinion feedback, resident and relative meetings, complaints themes, staff survey results, supervision themes, observation of practice, mealtime observations, audit findings.

Triangulation example. A rising agency rate + increasing falls + complaints about call-bell response + supervision themes about “rushed care” should trigger a documented staffing reassessment with explicit professional-judgement reasoning, mitigations, and review dates. That paper trail is what differentiates a “good” service from a “weak” one in inspection.

7. Warning signs that your staffing model is failing

Synthesising published inspection findings since 1 April 2024 with the Quality Framework expectations, the leading indicators are:

- Resident outcomes: rising falls, medication errors, weight loss, deteriorating skin integrity, unexplained bruising, unmet hydration/nutrition needs, missed observations, missed care visits (care at home), people left without meaningful interaction (especially for dementia).

- Workforce signals: increasing vacancy rate, sickness absence, turnover and exit interviews citing workload; reliance on the same agency staff to plug gaps; gaps in supervision; trainees or newly qualified staff with insufficient mentoring; staff reporting they feel unable to raise concerns.

- Process signals: rotas that no longer flex to dependency; staffing assessments that are static documents; absence of recorded professional judgement; flash meetings or allocation sheets dropped; quality assurance not picking up complaints.

- Cultural signals: staff “participating in or unable to challenge poor practice” (a phrase used in the Kingsmills report); relatives reporting they don’t feel listened to; “false promises” about improvements.

- Operational signals: notifications to the Care Inspectorate not being made; complaints handling weak; ASP referrals missed.

A robust dynamic review process runs (a) daily/shift huddles, (b) weekly governance reviews with key indicators, (c) monthly triangulated staffing assessment using both rota data and outcome/complaints/feedback data, (d) quarterly board-level review against Quality Indicator 3.3 and Section 7 evidence requirements, and (e) annual return preparation woven through the year, not done as a panicked exercise in February.

8. Practical takeaways and a self-assessment framework

A practical compliance cycle for registered managers and providers:

1. Map your duties. Who in your organisation owns each statutory duty (Section 7 staffing, Section 7 training, Section 3 wellbeing principle)? Is there a board-level lead?

1. Adopt the Staffing Method Framework as if it were mandatory. It’s not yet, but it embodies what the Care Inspectorate expects to see and is the path of least resistance to evidencing Section 7. Use the Right Decisions app version.

1. Set up a professional-judgement log. Every change to staffing should be recorded with: trigger, data considered, judgement made, mitigation, review date, and outcomes observed. This is the single most valuable artefact in inspection.

1. Triangulate monthly. A one-page dashboard combining workforce data (rota fill, vacancy %, agency use, sickness, turnover, supervision %, mandatory training %), quality data (falls, medication errors, IPC audits, weight, pressure ulcers, complaints, Care Opinion), and people’s voice (resident/family feedback, staff survey themes).

1. Test escalation routes. Walk through what happens at 0700 if two staff phone in sick. Document. Use the SSSC whistleblowing route as a backstop.

1. Invest in supervision and reflective practice. This is both a quality intervention and a Section 7 wellbeing-of-staff evidence point.

1. Use commissioning conversations with HSCPs. Local authorities and IJBs have their own Section 3(2) duty when commissioning. If your fee level cannot fund the Section 7 staffing your assessed-need profile demands, that is *their* compliance issue too. Bring data, not anecdote.

1. Equality lens.Specifically check whether your staffing model supports continuity for people with dementia, complex needs, learning disabilities or specific communication, cultural or LGBTQ+ needs. Diverse workforce is explicitly cited in the CI guidance.

1. Train, then evidence the training. Section 7 training duty is now binary — either you can produce records of appropriate training and time off for further qualifications, or you can’t.

1. Self-evaluate against Quality Indicator 3.3 quarterly using the SSP’s “safe staffing cards” and the Quality Framework illustrations.

Recommendations

Stage 1 — In the next 30 days. Run a 90-minute board/SMT session asking: “If an inspector arrived tomorrow and asked us to evidence how we comply with Section 7 of the Act, what would we hand them?” If the answer is a rota and a training matrix, you have work to do. Threshold: be able to produce on demand a current staffing assessment, a documented professional-judgement log entry from the past month, evidence of a staff-wellbeing intervention, and triangulated data linking workforce to outcomes.

Stage 2 — In the next 90 days. Adopt the Care Inspectorate’s Staffing Method Framework via the Right Decisions app and complete one full cycle. Build a one-page monthly triangulation dashboard. Train all line managers on what professional judgement looks like in practice and how to record it. Threshold: you can demonstrate two consecutive months of dashboard data and at least three logged professional-judgement decisions.

Stage 3 — In the next 6–12 months. Embed the cycle in governance, link your annual return to a year-round evidence pipeline, and use your Section 7 evidence to renegotiate fees and commissioning conversations with HSCPs. Engage with Scottish Care, CCPS or your trade body on collective representations about commissioning sustainability. Threshold: any fee uplift conversation references your Section 7 evidence; your next inspection cites Quality Indicator 3.3 at 4 (Good) or above.

Trigger to escalate further. If your dashboard shows two consecutive months of: agency use above 20%, sickness above 8%, supervision compliance below 80%, or rising falls/medication/complaints concurrent with vacancy growth — convene an extraordinary staffing review, formally notify your inspector if appropriate (the Care Inspectorate views proactive engagement positively), and document the mitigation plan against the eight guiding principles.

Caveats

-Self-assessment limitations. The Scottish Government’s Ministerial Report explicitly notes the limitations of self-assessed Annual Return data; the 3.7% “not meeting duties” figure is likely an undercount.

-Enforcement data is partial. The Care Inspectorate publishes enforcement notices and inspection reports individually but does not yet publish a consolidated, searchable thematic enforcement report specifically on the Act. The Safe Staffing Programme End of Year Report 2024-25 charts HCSA requirements but does not publish raw absolute totals across all sectors. Numbers cited (48 letters of serious concern, 32 Improvement Notices, 4 cancellations in 2023/24) are pre-commencement and drawn from secondary analysis.

- Sector commentary is contested.Scottish Care and CCPS commentary on funding/sustainability, while well-evidenced, comes from membership organisations with a clear advocacy position. The Scottish Government’s 2024/25 Ministerial Report frames the same picture more conservatively.

- The Common Staffing Method does not (yet) apply to social care. It is an NHS-side mechanism. The Staffing Method Framework for adult care homes is recommended but not mandated. This nuance is sometimes blurred in commentary.

- The Act does not place duties on individual frontline staff.** Accountability sits with providers and commissioners, not nurses, carers or social workers as individuals (RCN Scotland FAQ).

- Future statutory changes. Care Reform (Scotland) Act 2025 ethical commissioning and sectoral bargaining provisions, plus regulations under the National Care Service Advisory Board, may materially change the duties on commissioners (and indirectly providers) over the next 12–24 months. The HCSA itself may also be amended; secondary regulations affecting the Common Staffing Method were already amended in 2025.

- Forward-looking phrasing throughout official documents. Several Scottish Government and Care Inspectorate publications use language such as “could,” “will” and “intends to” — particularly around National Care Service, sectoral bargaining and the development of a validated dependency tool. These should not be presented as completed work in the blog.