Escalation Procedure
Purpose & definition
This document describes the procedure that the Healthcare Environment Inspectorate will follow to escalate issues or matters of
evident concern arising from the inspection of NHS hospitals.
This procedure should be read in conjunction with the HEI managing concerns procedure, the relevant memoranda of
understanding (local Fires Authorities, the Health and Safety Executive (HSE) and the Mental Welfare Commission) and the
procedure for follow up activity, set out in our inspection methodology.
The HEI managing concerns procedure provides operational guidance for inspectors on how to manage and escalate any
safeguarding issues identified by them or another person during inspection about the protection of children and vulnerable adults in
healthcare settings.
Stakeholders
We work with a range of external stakeholders, including:
• Patients and the public including representative groups for the voluntary and independent sector
• Scottish Government
• Health Protection Scotland
• Health Facilities Scotland
• NHS boards
• NHS Education for Scotland (NES)
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• Health and Safety Executive
• Mental Welfare Commission
• Care Inspectorate
• Scottish Local Authorities
Aims of Informal and Formal Escalation
The HEI can escalate matters of concern via both formal and informal routes. The severity of the issue arising will determine how
and to whom the concern will be escalated to. In some circumstances, the HEI may pursue formal escalation of a serious issue
without first engaging in informal escalation activity with the NHS board.
The HEI will inform the NHS board on the day of inspection or as soon as possible of our concerns. This is to allow them to take
immediate steps to address the issues, and protect the safety and welfare of patients, staff and the wider public.
The aims of informal escalation are:
• to achieve resolution of the issue through dialogue and cooperation between the NHS board, HEI and external stakeholders
as appropriate
• to maintain transparency and oversight of the process and to provide assurance for external stakeholders, and
• to promote public assurance through the timely reporting of inspection findings and improvement action plans.
Formal escalation will occur when:
• legislation defines the appropriate action in response to the issue arising
• serious issues are identified which pose a threat to patient safety and public health, and
• there is a failure to take action to resolve issues.
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Definitions and levels of escalation
Level 1 (Informal) - Concerns arising from inspection or engagement with the NHS board accountable officer and/or
Executive Lead prior to publishing the report
Action: Senior NHS board staff will be informed of the concern to allow them to take appropriate remedial steps if the issue arises
during an inspection.
Timescale: on the day of inspection.
Action: The lead inspector will arrange to meet with senior NHS board staff to discuss and agree an improvement action plan
Timescale: As soon as possible after the inspection and within 5 working days
Action: The Chief Inspector will alert the HIS Chief Executive and Director of Scrutiny and Assurance who may arrange to discuss
with the NHS board Chief Executive and/or Chair concerns arising from the inspection.
Timescale: As soon as possible after the inspection and within 5 working days.
Action: The Chief Inspector will inform the Scottish Government in order that policy leads are sighted on the issues of concern prior
to publishing the inspection report.
Timescale: prior to report publication date.
Level 2 (Informal) – Improvement action plans are inadequate or not developed or not progressed within the required
timeframe.
Action: The lead inspector will contact the NHS board to discuss the content and timescales for submission.
Timescale: within 5 working days of receipt of action plan/timeframe limit
Action: HEI may undertake further follow up inspection activity to assess progress with the improvement action plan
Action: The Chief Inspector will alert the Healthcare Improvement Scotland Chief Executive and Director of Scrutiny and Assurance
who may arrange to discuss with the NHS Board Chief Executive and/or Chair .
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Timescale: within 10 working days of receipt of the action plan or if no action plan is developed
Action: The Chief Inspector will inform the Scottish Government policy lead of the issue
Timescale: within 10 working days of receipt of the action plan/timeframe limit
Level 3 (Formal) – Serious issues (including health and safety) identified during inspection – inspection activity
Action: The lead inspector will inform Senior NHS board staff of the issue to allow them to take appropriate remedial steps to
safeguard patient, staff and public safety.
Timescale: on the day of inspection.
Action: The Chief Inspector will inform the Scottish Government policy lead and Healthcare Improvement Scotland Chief Executive
and Director of Scrutiny and Assurance. This may be followed up by a formal letter from the lead inspector or the Chief Inspector
including supporting evidence, outlining requirements for action.
Timescale: on the day of inspection. Letter will be sent within 5 working days.
Action: The Chief Inspector will advise other agencies of the issue (eg Health & Safety Executive) as appropriate.
Timescale: on the day of inspection or as early as possible thereafter
Level 4 (Formal) – Serious issues are not taken forward in a timely manner and in line with the agreed improvement action
plans – Follow-up activity
Action: The Chief Inspector will formally advise the policy lead at the Scottish Government of the issue, supported by requirements
for action.
Action: The Scottish Government will determine appropriate action and follow up.
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LEVEL 3 – FORMAL LEVEL 1 – INFORMAL ESCALATION –
ESCALATION – serious issue Safeguarding or concern arising from inspection or
identified during inspection YES matter of engagement with the NHS board prior
evident concern? to publishing the inspection report
YES
Outcome
Follow up activity (as Inspection satisfactory? NO
Progress
per methodology)
satisfactory?
INSPECTION
PROCESS
YES
NO (continuous)
Action plan Outcome
Report NO
submitted satisfactory?
published
LEVEL 4 – FORMAL ESCALATION
– serious issues are not taken Action plan
YES YES
forward in a timely manner and satisfactory?
in line with the agreed
improvement action plans LEVEL 2 – INFORMAL ESCALATION –
LEVEL 1 – INFORMAL ESCALATION –
Improvement action plans are inadequate or
NO concern arising from inspection or
not produced or not progressed within the
engagement with the NHS board
required timeframe
prior to publishing the report
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