Care Bill [HL]

Baroness Howarth of Breckland Excerpts

Wednesday 3rd July 2013 Lords Chamber

[Lord Campbell-Savours]

My Lords, the need for the specialist staff referred to by the noble Lord clearly lies behind the tabling of Amendment 76ZB. It is precisely why we need to pilot the proposed system.

My noble friend on the Front Bench referred to the system being created as a new system. We were told that we were going to get a new system in 2009. I sat on the third Bench behind my noble friend—the noble Earl was on the Front Bench on this side—and pointed consistently to the deficiencies in the system while it operated under CSCI and the inevitability of further problems arising under the new structure that was being created. Indeed that is precisely what has happened.

It seems to me that it can only get worse. The report of the Select Committee on Public Service and Demographic Change sets out the scale of the problem that confronts us in future. It prays in aid the Office for National Statistics updating its projections up to 2021 based on a recent release of data from the 2011 census on the ageing population. It says that, by 2021:

“There will be 24% more people aged 65 and over”,

and,

“39% more people aged 85 and over”.

It goes on to say that by 2030 there will be,

“will be 51% more people aged 65 and over”,

and that the population over 85 will have doubled. This means, to put it bluntly, that a lot more people will go into a lot more nursing homes throughout the country. Therefore, we have an absolute responsibility to make sure that the structure that we establish on this occasion is fit for purpose.

At the moment, I understand that there are 2,400 nursing homes catering for approximately 220,000 residents. That is going to increase, and I am still not convinced that the structure that this new so-called CQC is to set in place will be fit for purpose for taking on that task. Nor has the structure been defined in the legislation, as my noble friend has referred to. When I say fit for purpose I am reminded of the comments made by the noble Earl when we met on the last occasion to discuss this Bill, when he talked of a new broom at the CQC. As I understand it, it is not a new broom but an old broom with a new handle, because the person who is now running the operation is in fact the same person, I am told—and the information is available on the internet for anyone to read—who was responsible for the structure, which we are now debating, which has failed miserably over the past four years and is the subject of the complaint.

Mr David Behan, who runs the new operation, prior to his current appointment at the Care Quality Commission, was director-general of Social Care, Local Government and Care Partnerships at the Department of Health. As the director-general—and I read these words very carefully, because I do not want in any way to misrepresent the position—he had lead responsibility for the social care aspects of the Health and Social Care Act 2008, which created the CQC, the very organisation that we are having to review today because of its total failure and the scandals that have been drawn to our attention in the national media over recent years. I understand that he should have been aware of the Act’s requirements for the CQC to perform its functions for the general purpose of encouraging the improvement of health in social care services. This failure is implied in the Department of Health capability review, which in effect admits that the Department of Health was not sufficiently challenging and strategic in the way it supported the CQC.

David Behan is not new to social care regulation. Before taking up his appointment at the Department of Health, he was chief inspector of social services at the Commission for Social Care Inspection—CSCI—the organisation that we criticised in 2009 when the Act was going through on the basis of its failure in this particular area. I remember Ministers going to the Dispatch Box—Labour Ministers, yes—reading briefs produced by civil servants, in which they repeatedly assured us, as they did in personal correspondence to us, that the new structure that was going to be set up would work. It has not worked. It has been a complete and utter disaster area, which is why we are now faced with problems in this particular area that are reflected almost daily in the national press.

There is a very reputable organisation called the Relatives & Residents Association. Before anyone seeks to discredit its operations, it is worth pointing out that it is quoted in the most recent report by the House of Commons Health Select Committee. Its comments are prayed in aid in the committee’s criticism of the CQC. On 18 May 2009, in a letter to me following my criticism in the House, it affirmed its view. Four years ago, it said:

“we are concerned that … inspectors judge homes as delivering an adequate standard of care even when they are failing to meet national minimum standards for care homes”.

We were assured that that was going to be stopped. It has not been stopped under the structure that was established. The letter continued:

“the overall number of inspections of care homes has reduced. Homes that are failing to meet minimum standards are now inspected less often than used to be the case”.

We know that over the past 10 years, there has been a steady decline in the inspection of care homes nationally. We were told when the Act was passed in 2009 that it was going to be a risk-based system with a minimum of one inspection every three years. We know what a disaster that has been. We need an absolute minimum of unannounced inspections of care homes of at least twice per year, irrespective of the grading and irrespective of the ratings that have been applied to a particular home, because we all know that the management of a home can change over months, weeks or even overnight, and the home may drop in ratings dramatically as standards of care fall, depending on the financial considerations of the management of those homes.

The 2009 letter to me, four years before we stand here now, continued:

“requirements made by inspectors for action to improve care homes are often not met, there is little evidence of systematic follow-up by inspectors and requirements left unmet from one inspection to the next are common”.

That has happened over and over again over the past four years, and I am convinced that it will carry on happening until we set clear targets and a requirement of two unannounced inspections annually with a proper rating system, which is precisely why I support the amendment tabled by the noble Baroness, Lady Greengross, on the need for a pilot system for inspections.

I would now like to place on record the latest views expressed by the Relatives & Residents Association about what it believes the new structure should be. I do so because I understand that under the provisions of the Bill, the CQC will itself, following consultation with Ministers and others where necessary, be taking decisions on those very important areas. What does the Relatives & Residents Association say? I think that what it says should be implemented. It calls for the,

“reinstatement of regular twice-yearly inspections of all care homes to ensure compliance with regulations and standards. This case and others show that CQC needs to listen, record and act quickly on complaints which show older people are not receiving”,

the quality of care they should receive.

I add at that point that we are talking about complaints. I could never understand why we established the CQC without a proper complaints remit. According to the Relatives & Residents Association, people ring up to complain about the fact that the CQC is not dealing with complaints. The CQC says, “We do not deal with them, you have to go to the local authority”. The structure is wrong. The CQC should be the body that deals with those matters and should be given that responsibility. The association calls for investment and more and better training of all care home staff, with vastly improved training in leadership skills of care home managers and operators and up-to-date inspection reports which are easy to understand, with any action required by the provider clearly highlighted. It also wants to see:

“Care homes focusing on individual care rather than putting pressure on staff to complete daily tasks such as dressing and feeding.

Statutory registration of all care workers”—

a matter that we were dealing with on the last occasion we met as a Committee—

“by a professional body which can set standards for competence and hold individual care workers to account for their own practice.

The reinstatement of specific standards for care homes for older people”.

That might seem a particularly substantial agenda. However, if the Select Committee’s views on the ageing population are true and there is going to be a vast expansion of the care business in the future, more and more homes will have to open to deal with that increased population. We should be setting in place in this Bill a structure that is capable of dealing with that expansion in care. If we do not, we will be back here again in five years’ time arguing about a deficiency in the system. If I am still alive, I will be on my feet again complaining about the fact that the Bill we introduced in 2013 miserably failed. That is the route that the Government have set out to go down. Unless they make the resources available to address this, the CQC will inevitably fail again.

[Baroness Howarth of Breckland]

My Lords, I had not intended to speak in this debate and will do so briefly. We need to allow the CQC time to settle down under its new management. We should also remind ourselves of the rest of the history, because it is important to put it in context.

I was the deputy chair of the National Care Standards Commission, the first organisation that brought together the inspectorates for homes under the previous Government. It was also the previous Government who, after two years, made the decision concerning the organisation—which had been quite successful. It had established a baseline of inspection. It had integrated the inspectorates, which several other organisations which had tried to integrate the different teams had failed to do. Like other noble Lords, I would also cite CAFCASS in that regard. The commission did all of that. We should remind ourselves that it was only a year later that the previous Government announced through a newspaper, not directly to the staff, that the organisation would be merged with CSCI.

The merger took place and I think that it was extremely successful. David Behan was involved in ensuring that it went well. CSCI then took on the starring system which was put into place and was having some success. By that time, we had closed 400 poor establishments. The work was continuing in terms of co-operation when it was again decided that there should be a restructuring, this time to bring the inspectorate into health.

I think that we have two lessons to learn. The first is not to restructure yet again on a political basis. If there is good leadership and the lessons have been learnt, let the organisation settle down. The second lesson is clear. If you are going to inspect anything, you need to have the expertise within the teams to carry out the inspections. Again under the previous Government, it was a sort of theory that if you had somebody other than a nurse looking at nursing, a social worker looking at a social work establishment or a teacher looking at teaching—indeed, you usually did have teachers looking at teaching; that always seemed to be an exclusion—then you could get a better answer than if you had a professional do it.

I think that the present leadership at the CQC has learnt that lesson and understands that you need the professional expertise to know what you are looking for, although that should certainly be cross-checked by independents. I hope deeply that we will be able to keep that steadiness, because I understand absolutely what happens to organisations when they are in constant flux and change.

Perhaps I may make one other point while I am on my feet. I support anything that we can do about integration. We have singularly failed to reach some complex conclusions about how health and social care can truly be put together for the benefit of those who are the recipients of that care. We should ensure that we put into the Bill whatever we can about integration. I would support all of that.

--- Later in debate ---

[Lord Bichard]

My Lords, I rise briefly to support this amendment as a mere vice-president of the Local Government Association. Very few Members of this House were here a week or so ago when the noble Lord, Lord Bates, sponsored a debate on the increasing complexity of legislation and, indeed, the increasing volume of legislation. It is a shame that more noble Lords were not there. In that debate, the noble Lord referred to a recent report from the Office of the Parliamentary Counsel, which pointed out that when the Queen came to the Throne in 1952, after 740 years of legislation we had 26 volumes of Halsbury’s Statutes; we now have 74 volumes. In 1952, the average Bill was 22 pages long; it is now 122 pages long. In 1952, there were 29 statutory instruments; last year there were 3,328. This is an astonishing increase even on 2008, when there were just 1,325. On that last statistic, I can bear witness as a member of the Secondary Legislation Scrutiny Committee. Indeed, my postman particularly asked me if I could do something about the volume of secondary legislation.

We have reached a point where we need to think seriously about the volume of legislation and its complexity, and whether we can carry on imposing new burdens and responsibilities, not least on local authorities. It would be fine if all this additional legislation was actually removing some of the red tape and bureaucracy that previous legislation had provided, but we know that it is not doing so and that it does not do so. We need to do one of two things. Either we genuinely reduce the volume of legislation and the additional responsibilities that it places on all sorts of bodies, or, as the noble Lord, Lord Best, suggests, we have realistic costing of what these new responsibilities entail and ensure that resources are available. If we do not, we remain in a cycle of despair and decline where we expect others to deliver new responsibilities, which they are just not able to do. We also raise the expectations of clients and users, who believe that things will change, when in all honesty they probably will not. That, I think, is a cycle of despair and decline, and it is the reason why I support this amendment.

[Baroness Howarth of Breckland]

My Lords, I rise briefly, as yet another mere vice-president of the Local Government Association, to bring a slightly different dimension to this debate. The noble Lord, Lord Best, pointed out that local authorities are finding a variety of different ways of delivering services. I have been looking at some of those and listening to messages about them. One issue is that they are delivering cheaper services, which often means commissioning them from providers which will then deliver them at a different level of quality. I declare an interest as a provider in the charity Livability, which delivers services to the disabled, the elderly and some children from residential care.

We need to know whether we are prepared to open the debate. Have the Government as a whole given thought to discussing with the community at large what we really can and cannot afford for the future? The noble Lord, Lord Campbell-Savours, raised the issue of the numbers of inspections. When I was involved in inspections, one issue was that you could deliver as many inspections as you had funding for. Now you can use that funding in a variety of different ways to get better options but, at the end of the day, resources count and, unless we know how far the resources will go, it is pointless to try to descend into the abyss, as the noble Lord, Lord Bichard, said.

If we are going to take this forward, we have to know what level of quality people are prepared to accept. Then, when there are failures in organisations, people are not blamed, because the failure is not necessarily one of individuals or even of groups but of the corporate whole simply not having enough resources to work across the whole piece. Until we start that debate, we will not be able to intervene in discussions about criticisms of local authorities giving only 15-minute slots to people when they have only enough resources for 15-minute slots. In residential care, we are taking away some of the extra services because there is no more money them. We are reducing staffing in various institutions because there are simply not enough resources.

I am not denying that because of the deficit we have to look at funding; I think we do. However, we have to open up the debate. Otherwise, we raise expectations in the country of what we are entitled to. I sat in this Chamber until 11 o’clock last night discussing the Children and Families Bill, and we were having exactly the same discussion. We all want these wonderful things. I want things in this Bill, but somehow we have to decide on some priorities between them all. Whatever we say, we cannot go on expecting to get the same out of the same.

[Lord Rix]

My Lords, I support this amendment in particular. I declare an interest as the president of Mencap. There is no doubt that the services that we are able to provide are being severely cut back because local authorities simply do not have the money to support those services. Where we used to get, say, £15 an hour, we now get £12 an hour. The implication is that we can lower the standard of our services, but we are not prepared to do that. Therefore, we will end up reducing our services and, as a result, people with learning disabilities, their families and their carers will suffer. This is exactly the situation at the moment. Local authorities will try to provide the services, but they are making it much more difficult for voluntary organisations such as Mencap.