Select Committee on Health Second Report

8  The contribution of regulation

Protection registers and registration

114. A number of initiatives have been taken by the Government over recent years that have contributed significantly to the prevention, recognition and, we hope, the reduction of abuse of older people. A number of these stem from the provisions of the Care Standards Act 2000 (including the establishment of the National Care Standards Commission and the General Social Care Council); other initiatives such as the policy guidance No Secrets and the NSF for Older People's Services are all making a contribution to improving practice and raising the standards of the delivery of care.

115. We took evidence on the contribution, actual and potential, to the reduction in levels of abuse offered by the statutory provisions for professional registration of workers, and the procedures for checking personal and professional suitability to work in care services. Although these provisions have not been introduced with the prime intention of preventing abuse, they are intended to raise the quality of services delivered by social and healthcare workers and thus contribute to the standards of care and protection of vulnerable people.

116. In view of the particular concerns that surround the protection of older people living in the community, and their vulnerability because of care taking place out of sight and 'behind closed doors', we were especially concerned to explore the issue of registration of social care workers.

Registration with the General Social Care Council

117. The GSCC was established by the Care Standards Act 2000. It brought into being, for the first time, a regulatory body for the social care workforce. As Lynne Berry for GSCC told us, the establishment of the GSCC reflected the recognition that there needed to be greater regulation of the broader social care workforce — of the 1.2-1.4 million people working in social care — instead of just the 60,000 qualified social workers. There was considerable uncertainty as to the extent of abuse and poor practice in this sector, so systems needed to be created to enable people to be trained, regulated and to have known standards across the whole range of social care.

118. Ms Berry told us that qualified social workers are the first group to register with the Council (and the process of registration began in April 2003). They will be required to undertake continuing professional education to remain on the register and to comply with its professional standards. Consultation had been undertaken to introduce protection of title for social workers. This had now ended, and the Government had confirmed that protection of title would be introduced from April 2005. This would mean that only registered social workers would be able to describe themselves as social workers, and in effect it would introduce compulsory registration. A disciplinary committee of the GSCC had been established with powers of sanctions including removal of social workers from the register if it was satisfied that breaches of professional conduct warranted such a course of action.

119. Both prior to the Care Standards Act 2000, and in the period since, there has been considerable debate about how registration should be approached. We recognise that the task of registering and regulating a social care workforce of perhaps one and a half million people is a considerable undertaking. Moreover, if the register is to signify anything more than simply a list of names, and is to provide some level of professional and personal accreditation indicating that the registrant is qualified and competent to provide social care, then the process of registration clearly needs to be approached methodically. Whether starting with qualified social workers is the best way of approaching this is a matter of much debate.

120. Gary Fitzgerald, for AEA, considered that it would make more sense if the initial registration process had focused on care staff within residential and nursing homes and domiciliary workers rather than social workers.[94] In support of this view, Mr Fitzgerald said that it was apparent through his charity's helpline that this was where most abuse took place. He considered that professionally qualified social work staff rarely had access to vulnerable people on a daily one-to-one basis. Bill McClimont, for the UK Care Homes Association, also supported this view.[95]

121. Lynne Berry acknowledged that there was a debate as to whether it was better to get all categories of social care staff on the register and then deal with issues such as training, or whether it would be more effective to develop standards and training and then register those who reached these benchmarks, allowing their regulation by the possibility of their removal from the register.[96] She explained that her organisation had begun its registration process with social workers since this was a requirement of the Care Standards Act.[97] We were surprised that Dr Ladyman took issue with this statement, since it is our understanding that the requirement to register social workers is indeed on the face of the Act, and that registration of other groups can be prescribed through regulation.[98] In correspondence with the Committee, Dr Ladyman subsequently argued that because qualified social workers are "the largest and most easily identifiable section of this workforce" it had been agreed "that this group would be the most appropriate place to start." The explanatory notes to the Act therefore addressed a process of "incremental registration of occupational groups."[99]

122. Ms Berry explained the rationale she understood to have underpinned the decision to begin with social workers as the first group to be registered by the GSCC. The focus for the establishment of a regulatory council had originally been concerned not with the social care workforce in general, but specifically with social workers. She also felt it might also be argued that the initial focus on social workers made sense as they were the gateway to other social care services: "and that by concentrating on social workers, we were able to establish standards for those who are already coming into positions not only of direct relationship to service users, but also those who were the gateway to other services."[100] Ms Berry emphasised that while the legislation caused the registration process to begin with social workers, it also required the GSCC to establish a code of practice and a code of conduct that applied to all social care workers, whether or not they were qualified social workers.

123. Ministers have powers of regulation to determine the timetable for the subsequent waves of registration, and have already indicated that the next groups to be registered will be residential childcare workers and managers of care homes. Beyond these, Ms Berry commented, "the next groups, which could well include domiciliary workers, and could include a whole range of others, are for Government to determine."[101]

124. In making such decisions the Government will no doubt take account of advice from various quarters, including from the GSCC itself. We understand that the GSCC is undertaking public consultation on the question of which groups should be next to register, based on a 'matrix of risk' that takes account of vulnerability and isolation of service users. We believe that it is probable that any such risk assessment ought to prioritise domiciliary care workers for registration given their lack of routine supervision and the extent to which they work one-to-one with vulnerable and frail clients in their own homes.

125. A further impediment to the early registration of domiciliary care workers could be the expectation that staff should be qualified before they can be registered. Dr Ladyman told us that "It has been and remains the Department's opinion that, as part of our drive to raise standards, NVQ level 2 should be attained before an applicant can register." While we recognise that the possession of an appropriate NVQ or other appropriate qualification is very important over time, we are concerned that introducing such pre-requisites for registration will ensure that a large proportion of this workforce remains unregistered for the foreseeable future. Dr Ladyman acknowledged the arguments in favour of applying a lower level of qualification (such as proof of completion of an induction programme) in order that there should not be further barriers to registration of care staff. Dr Ladyman told us that "this debate continues and no decision has yet been taken." Any decisions will only be made after consultation with stakeholders and advice from the GSCC.

126. A code of practice, prepared by the GSCC at the instigation of Parliament, is an important reference point for all social care workers, their employers, and indeed users of social care services. The Social Services Inspectorate and the NCSC use compliance with the code as a standard both for qualified social workers and for social care workers. We welcome this position which adds to the awareness of the good practice standards expected of both employers and social care staff in all care settings.

127. We recommend that signed-off induction training of domiciliary and other social care workers approved by the appropriate sector skills council rather than attainment of NVQ level 2 should be sufficient for them to apply for registration with the GSCC (together with any other requirements from the GSCC relating to the applicant's fitness to practice), with a requirement that such registered staff achieve appropriate qualifications prior to the renewal of their registration.

128. We recommend that the Government should attend to the issue of registering domiciliary and other social care workers as a matter of the utmost urgency. We recognise that the Government wanted to approach registration in a measured and systematic way, and that starting with the (mostly qualified) social workers was one way of doing that. However, we are especially concerned that service users may be placed at continuing risk from day-to-day contact with unregistered care workers, a small minority of whom may be abusive working with them on a one-to-one, unsupervised basis. We do not believe that it is acceptable to delay their registration. We recommend strongly that the Government should move to require the registration of domiciliary care workers and their managers concurrently with the other groups that it has already identified as the next priorities for registration (residential childcare workers and managers of care homes).[102]

Fitness to work checks: the Criminal Records Bureau and the Protection of Vulnerable Adults list

129. We welcome the implementation of criminal records checks as part of the pre-employment screening of candidates for any post concerned with the care of vulnerable people and find the categorisation of standard and enhanced checks useful. The early months of the operation of the Criminal Records Bureau (CRB) were less than successful in terms of efficiency and turn-round of applications. As AEA told us: "The Government raised expectations of protection but then failed to deliver on those expectations and vulnerable people have been left directly at risk as a result."[103] Despite this poor start, the bureau now appears to be offering a turn-round on applications that enables employers to plan recruitment.

130. No information was available to us about the number of applications for employment rejected on the grounds of the existence of a criminal record. In any case we doubt that such information would be reliable, as it seems to us that the mere presence of CRB checks will have deterred a number of potential or known abusers from attempting to enter the sector in the first place.

131. The National Audit Office published a report in February 2004 covering the setting up of the CRB and the problems which it experienced during 2002. The Bureau was initially intended to start operation in September 2001, but owing to a series of technical difficulties operations commenced only in March 2002.

132. The result of these problems was that checks on existing healthcare and social care workers due to commence by April 2003, began only in October 2003. The Government had intended that the CRB would undertake checks against the Department of Health's list of persons considered unsuitable to work with vulnerable adults, provided for in the Care Standards Act, from early 2003.

133. The Care Standards Act made provision for a list to be established of individuals judged to be unsuitable to work with vulnerable adults, the Protection of Vulnerable Adults (POVA) list. Employers of staff working with vulnerable adults will be required to refer to the list the names of people they believe have caused harm to vulnerable adults. These people would be provisionally included in the list, and that inclusion would be confirmed following further investigations by the Secretary of State. Employers would then be required to check potential recruits against the names on the list as part of their pre-employment checks.

134. However, partly because of the difficulties in introducing the criminal records checks, the implementation of the provisions relating to the protection of vulnerable adults contained in the Care Standards Act has yet to be made effective. The development and maintenance of a list held by the Secretary of State for the protection of vulnerable people was seen by witnesses as a valuable safeguard. But the delay in the introduction of the POVA list was widely criticised in our evidence. The Relatives and Residents Association, for example, expressed disappointment at the delay in its establishment, and identified the message which this appeared to convey of "disregard for the welfare and safety of older people."[104] Bill McClimont, for the UKHCA, commented: "The problem we have at the moment is that we have nowhere to report people we have identified as being unsuitable. We have placed a great deal of belief in what the POVA list was going to do for us and we have not had that delivered." [105]

135. We were pleased, if a little surprised, that on the day that we held our first oral evidence session (11 December 2003), the Government announced that the POVA list would be introduced from June 2004. Our witnesses welcomed this decision. Frank Ursell of the Registered Nursing Home Association, for example, thought it was particularly important in the absence of GSCC registration of care staff:

    We have access to registers in relation to the nursing staff we employ, but we have no access to a register about the care staff we employ. In the absence of that, at least a list of those people about whom we should be more suspicious would certainly help the home owner to discharge the responsibility he willingly accepts to make sure he does not employ anyone who might cause abuse.[106]

136. However, the Government's announcement made clear that the POVA scheme would not be introduced in its entirety in June 2004, but on a phased basis. Implementation in the first instance would be in the social care sector, applying to:

·  care workers in registered care homes, including workers supplied by agencies; and

·  care workers of registered domiciliary care agencies.

137. Sue Fiennes, for the ADSS, told us that there had been consultation with a range of interested parties prior to the announcement about implementation, and that the Department recognised that there needed to be various changes made to the arrangements, and so had opted for partial implementation.

138. In view of the concerns about the POVA register, we asked the Minister about the reasons both for the delay in implementing POVA and the exclusion of the NHS and the independent healthcare sector from its operation in the first instance. He acknowledged that there had been considerable, practical difficulties to be overcome, not least associated with delays in the operation of the CRB. The Minister commented that he would have liked to introduce it earlier but "it is better that we do it when it is going to work."[107]

139. Dr Ladyman also emphasised that practical difficulties underlay the delay in application of the list to the NHS and the independent health sector. Raymond Warburton, for the Department, explained that there were some technical issues, particularly with respect to trainees in the health service. The way in which the Care Standards Act was currently drafted would necessitate new POVA checks being carried out each time a student moved to a new training post. The Minister explained that the NHS was therefore not being excluded indefinitely, but "until such time as we can bring forward the appropriate regulations."[108] When pressed further, he stated that implementation "Next year, I think is reasonable."[109]

140. The consultation document on the introduction of POVA, issued by the Department in December 2003, explained further the reasons for the phased implementation:

    there is strong evidence that most abuse of vulnerable adults occurs in care homes or people's own homes. Phased implementation, therefore, represents the Government's commitment to prevent and tackle the abuse of vulnerable adults in the most effective way possible.[110]

141. Whilst we acknowledge the dangers of rushed measures, as the CRB experience highlighted, we remain concerned at the delay, not least in the light of evidence from CHI that older people's health services have "become a significant concern," and that CHI receives "continual requests for investigations in this area."[111] While we do not believe that the abuse that occurred at Rowan ward in Manchester is in any way typical of the NHS, we do agree with CHI that it is not unique. The Department has stated that "POVA will significantly enhance the level of protection for vulnerable adults." We agree with this, and therefore cannot accept that such protection should be withheld from older people using health care services.[112] It will be five years from the inclusion of the POVA list in the Care Standards Act until its full implementation, which suggests to us that the needs of older people are treated with less urgency than those of other groups.

142. POPAN noted that 19 doctors were found guilty by the GMC of sexual abuse in 2002.[113] In the face of this evidence, we reject the reasoning contained in the consultation document. Neither can we support the intention to defer the implementation of POVA for staff within the independent health care sector, which includes, for the purposes of regulation, mental health services of the independent sector. The vulnerability of such patients is apparent. We believe that the delay in the inclusion of the NHS and the independent healthcare from the operation of POVA, might prompt individuals who are on the POVA list, or believe they might be listed, to seek employment in the health rather than social care sector.

143. We are surprised and disappointed that the Government has not already used legislative opportunities to correct the technical and operational difficulties that are acknowledged to exist in the wording of the provisions of the Care Standards Act. During the considerable delay that has already occurred in the implementation of POVA, there was surely ample opportunity to identify the difficulties, and to redress these.

144. We remain unconvinced that the Department could not have commenced its preparatory work for implementing POVA sooner, so as to identify and address the concerns that are now further delaying its full implementation. We welcome the announcement that the Protection of Vulnerable Adults list will be introduced from June 2004, but we are extremely concerned that this will not provide full implementation. While we accept that some adjustment of the regulations may be required in order for POVA to operate efficiently in health and social care settings, we are uncomfortable at the prospect of any further delays, and believe that the necessary regulations should be introduced as a matter of urgency. In the light of continuing concerns about potential abuse of older people taking place within the NHS and in the independent health care sector, we urge the Government to take all possible steps to expedite the implementation of POVA as quickly as possible fully across both health and social care settings. We also recommend that the Department keeps under review the operation of the scheme.

Direct Payments

145. In the course of our inquiry, we were struck by various gaps in the existing legislation governing regulatory requirements. In particular, we are aware that the existing arrangements do not regulate day care, health care assistants,[114] or personal assistants employed under the direct payments arrangements.[115]

146. Agencies that provide domiciliary care workers, including those employed through direct payments, are required to register with the NCSC. However, where care workers are independently employed by a service user utilising direct payments, there is currently no registration requirement. Jenny Potter, for the CDNA, told us that there were concerns over people who had left agencies in order to work privately for people in the community, perhaps as a way of avoiding regulation.[116]

147. Our witnesses expressed a range of views about the position of direct payments and registration. Jonathan Coe, for POPAN, remarked that he believed that anybody working with people in social care should be properly accountable: "they need to be regulated and they also need to be subject to Criminal Records Bureau checks." He found it incredible "that people are allowed to work with very vulnerable people with none of these checks and with no framework of accountability."[117]

148. Tessa Harding for Help the Aged commented that provided the CRB checks and the POVA register were available to people using direct payments, they would be in as a good a position as any (with the support of appropriate independent agencies) to manage. Bill McClimont, for the UKHCA, agreed with this view and pointed out that at the present time direct payments users did not have a legal right of access to CRB checks. The UKHCA was currently in discussion with the Home Office on this issue and was proposing that they might be able to "provide a vetting service that would effectively carry out the CRB check and say yes or no; this individual is suitable or is not."[118]

149. Mr McClimont also commented on the wider issue of regulation of workers employed through direct payments:

    I believe the register should be open to care workers who are outside of formal services so that if they wish to, a user can apply to the GSCC and obtain information on a care worker who wants to demonstrate their bona fides and that they have induction training and so on. The kind of conditions that GSCC would place on such a worker to achieve training would be the same but they would not be compulsorily registered in the way that those formal services, I believe, should be.[119]

150. Anne Parker, for the NCSC, suggested that the feasibility of using the code of practice might be explored, whereby people would be required to subscribe to the code, but not be fully registered, thus making possible the monitoring of compliance with the code.[120]

151. We recognise that during the passage of the Care Standards Act there was discussion of the issue of direct payments, and that there was considerable pressure (not least from some organisations representing disabled people) that there should not be compulsory registration of people employed through direct payments. The key attraction of using direct payments is precisely the choice and control that they give to the service user, in terms of the type of help that is provided, when and how, and by whom. We accept that some users of direct payments will wish to retain this freedom to employ the worker of their choice. However, we are concerned that other users of such payments are not offered the protection of being able to employ registered care workers.

152. We recommend that when the General Social Care Council opens the register to domiciliary care workers it should also ensure that care workers who are employed through direct payments are also able to register should they wish to do so, and indeed should be so encouraged. We anticipate that over time this would lead to many such personal assistants choosing to register because of the advantage that it would offer in demonstrating their competence and reliability to a prospective employer. Users of direct payments would be able to check that the person they wished to employ was registered with the GSCC, and that they would have the same protection as any other service user, whether or not they were using direct payments.

The National Care Standards Commission

153. The National Care Standards Commission was also established by the Care Standards Act and has complementary responsibilities to those of the GSCC. Through its registration and inspection activity it is the main focus for ensuring that care providers meet national minimum standards. As the providers which it regulates include all care homes for older people, whether in the independent sector or directly managed by local authorities, as well as domiciliary care and nursing agencies, the NCSC is well placed to attend to the management and care practices which take account of the possibility of the abuse of older people.

154. In providing assurance to the public that a care provider is operating to acceptable standards, the NCSC has statutory powers to require service providers to notify it without delay of events which could be indicative of unacceptable circumstances, including abuse.[121] Notifications of particular relevance to abuse, include:

·  the death of any service user (this includes the deaths of residents of care homes transferred to hospital), including the circumstances of his or her death;

·  any serious injury to a service user;

·  any event in the care home which adversely affects the well-being or safety of any service user; and

·  any allegation of misconduct by the registered person or any person who works at the care home.

155. In addition, the national minimum standards specify, through requirements placed on the service provider, that service users are to be protected from abuse. These include requirements to ensure that:

·  service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self-harm, inhumane or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies;

·  robust procedures are in place for responding to suspicion or evidence of abuse or neglect including passing on concerns to the NCSC in accordance with the Public Interest Disclosure Act 1998 and Department of Health guidance No Secrets;

·  follow-up action takes place in respect of allegations and incidents of abuse;

·  staff who may be unsuitable to work with vulnerable adults are referred for POVA list consideration (when this has been introduced);

·  policies and practices are in place so that physical and/or verbal aggression by service users is understood and dealt with appropriately;

·  policies and practices are in place to protect abuse of service users' financial affairs; and

·  complaint procedures are in place and made known, including a requirement that written information should be provided to all service users for referring a complaint to the NCSC at any stage, should the complainant wish to do so.

156. The NCSC is the major guardian of the vulnerable person against abuse in social and certain health care environments.[122] We therefore explored the extent to which the NCSC was able to meet these expectations. We asked the Commission how many such notifications they had received, what action with what outcome had been achieved and how these had affected its regulatory practice.

157. It told us that of 12,685 complaints received in 2002-03, one in ten (1,278) made a specific allegation of abuse, whilst the majority alleged poor practice or neglect, which in our view is within its definition of abuse.[123] Each complaint would be investigated and appropriate action taken in the light of findings — for example, the service provider might be required to correct deficiencies through improvement notices or other sanctions.

158. The regulation of domiciliary care agencies has more recently been introduced but we note that the powers of the NCSC are confined essentially to the fitness of the agency rather than the standards of the services delivered to the person in their own home. There is, for example, as yet no regulatory requirement for notifications of adverse incidents equivalent to that which exists in relation to occurrences in care homes as outlined above. We were told that the progress of registration of such agencies is proceeding extremely slowly. Bill McClimont, for the UKHCA, told us, he understood that by the end of November 2003, the NCSC had completed about 240 of the 4,100 applications for domiciliary agency registration and that there was serious concern about the standard of the applications received.[124] He urged that the NCSC and its successor body should speed up the process of registration so that standards for the future could be improved.

159. On the wider role of the NCSC, AEA recognised the contribution the Commission made to improving practice but considered there were inherent limitations on what could be validated through an inspection process.[125] In their view, much of the inspection work of the NCSC focused on processes rather than outcomes. They illustrated this by citing the NCSC survey of 100 inspection reports, randomly selected, which showed that in only 7% of cases had the inspector sought to validate what was being said by homes staff through conversations with service users. A similar view was put to us by Frank Ursell of the Registered Nursing Homes Association, who argued that the NCSC has been driven by reporting on policies, not by seeing if policies work.[126]

160. We recommend that the shadow Commission for Social Care Inspection, the successor body to the National Care Standards Commission, should review its care home inspection methodology and ensure that where possible more conversation takes place with service users to validate their findings.

The Commission for Health Audit and Inspection and Commission for Social Care Inspection re-organisation

161. Government policies on the development of services to older people have emphasised the importance of joined up health and social care in order to deliver seamless services. Indeed, this is at the heart of the NSF, with its standards of integrated services, as standard II makes clear:

162. The Care Standards Act brought together the regulatory work of health authorities and local authorities, and removed the statutory distinctions between residential and nursing homes. The NCSC was charged with the registration and inspection of a wide range of independent health and social care providers, including local authority and independent care homes and those providing nursing. In the two years since its inception the Commission has started an ambitious programme of implementing the reform of regulation, producing inspection reports and working to achieve improved and consistent standards across the services it regulates. In the inspection of, and in the investigation of complaints of untoward incidents in, care homes and homes providing nursing, inspectors include or can call upon the specialist health care skills of its division of private and voluntary health care.

163. Just a few weeks into the operation of the NCSC, the Government announced its intention to legislate to separate by statute the health and social care elements of the NCSC, and to allocate these to two new regulatory bodies — the Commission for Health Audit and Inspection and the Commission for Social Care Inspection.

164. We explored with the NCSC Chair, Ms Parker, and with the Chair of CHI, Dame Deirdre Hine, how the corporate knowledge they had acquired during their existence would be safeguarded.[127] Both commented that they had established good communications with their shadow successor bodies and that all inspectors would move across. There had been many opportunities to present policies, issues and work that had already been done. However, concern was expressed by some witnesses that the change represented a weakening of the arrangements for the regulation of healthcare where it was provided in settings registered as social care, especially in care homes providing nursing. The Relatives and Residents Association commented that the impending changes to the structures of care inspection might have a deleterious effect, deflecting energy and attention away from basic oversight of homes in the short and medium term, even if in the longer term there would be improvements.[128] Ms. Fiennes, for the ADSS, told us: "Colleagues are quite rightly pointing to the fact that now we have two organisations and some things that were in a whole system are now split. It is important that we do not lose the whole system approach to inspecting and regulating older people's care in whatever setting."[129]

165. The potential loss of organisational knowledge and memory is an issue of the utmost importance. In the light of the events in Soham, and the murders of Jessica Chapman and Holly Wells, it is apparent that the failure of organisations to share information, their interpretation of the provisions of the Data Protection Act, and their inability to identify patterns that should have given cause for concern, can have catastrophic and tragic consequences. We are aware that these issues are currently being investigated by the Bichard Inquiry, and we await the findings of that review. However, in the interim we underline the need to pay particular attention to the appropriate transfer of information at a time when there is major organisational change taking place. The disappearance of both NCSC and CHI, and their replacement by the new regulatory bodies of CSCI and CHAI, raises just such issues.

166. Dame Deirdre Hine assured us that risks would be minimised through the transfer of the whole of CHI into the successor body. Ms Parker similarly emphasised the excellent working relationships which NCSC had established both with CHAI and with CSCI, and the deliberate attention that had been paid to identifying lessons from work that has been done. The potential for organisational change to be very damaging was widely recognised. As Dame Deirdre commented, two of the investigations undertaken by CHI (North Leighton Trust, and Rowan ward) took place in trusts where there had been recent mergers and a disturbance of the management system.[130]

167. In the light of these issues we asked the Minister what overview he would exercise to minimise disruption, or what review he would carry out to ensure that CSCI and CHAI collaborated adequately to regulate the care of older people. The Minister replied that as they were both independent organisations the control he could impose on them was limited. He pointed out:

    In the recently passed Health and Social Care Act 2003, both bodies have not a power to co-operate but a duty to co-operate and I will certainly expect them to honour that duty to co-operate. They also have the power to inspect on each other's part when necessary, so it will not always be necessary for CSCI to go in one day and CHAI to go in the next day; they can come to a decision that it is better for one or the other to look at a particular institution at a particular time and they can exercise their duties on behalf of the other. So they have both the powers and the duties they need to co-operate and I will certainly be expecting them to honour those duties. [131]

168. In view of the concerns expressed about medication management and the need to ensure that the healthcare needs of those accommodated in social care settings are safeguarded against abuse which may arise from poor healthcare practice, we note the provisions of the Health and Social Care (Community Health and Standards) Act 2003 in relation to the Minister's comments. In particular section 120 of the Act provides for co-operation between CHAI and CSCI and proposed regulation of parts of this section are currently the subject of consultation. However, section 120 (1) is not touched by the proposed regulation and provides that: "The CHAI and CSCI must co-operate with each other where it seems to them appropriate to do so for the efficient and effective discharge of their respective functions."

169. This appears to us to emphasise the separate functions of CHAI and CSCI, rather than their common purpose. Nowhere in the Act is there a requirement for co-operation or joint working to ensure that the healthcare needs of people in social care settings are safeguarded in the regulatory processes. With the statutory independence of CHAI and CSCI, the regulation of health and social care arguably will move further apart, with consultation and permissive delegation of one to the other supported by the emerging regulations. The integration of health and social care to meet the needs of older people, those with disabilities or chronic illness, is fundamental, yet the Act drives these responsibilities further apart. We are concerned about the effect of this position in relation to the safeguarding of care home residents.

170. We recommend that CSCI and CHAI publish at an early date their joint plans for regulating and ensuring that the health care needs of residents in those settings registered as social care provision are met; that the Minister requires the annual reports of CSCI and CHAI to include details of their joint working and of the experience of the adequacy of the regulation of the health care aspects of care home services provision; and that the Government keeps under review the operation of the respective Commissions.

171. In evidence to us, the Department of Health's guidance, No Secrets, was widely welcomed as providing a framework for developing adult protection services. In its memorandum the Department gave its assessment on progress with implementing the guidance based on work it commissioned from the Centre for Policy on Ageing:

    The analysis indicates that by and large local councils have met the requirements required by No Secrets and that considerable progress has been made towards improving co-ordination between agencies when dealing with adult abuse cases.[132]

However, while progress has been made the analysis found that for a significant number of Councils there had been a lack of progress putting in place the information systems necessary for strategic and operational planning. More worrying still, only a few Councils had given any thought to how they would communicate their work on adult protection to staff and the wider public. The analysis also found that the role of contracts staff had largely been overlooked. There was little or no sign that there was any intention of reviewing purchasing agreements and service specifications to ensure compliance with the framework provided by the local code of practice. Of particular concern was the finding that only 21% of partnerships provided evidence that training was being resourced and that a strategy had been set in motion. Overall the analysis found that over a quarter of all local authorities had made very little progress across a broad range of areas key to translating No Secrets into practice. Whilst the majority of Councils had made a start, progress was patchy. It is hard to see how the Department could have concluded that 'considerable progress had been made.' This conclusion appears rather complacent. We are concerned that the Department has no plans to follow-up the implementation of No Secrets.

172. We recommend that a joint inspection of the implementation of No Secrets be undertaken by CSCI, CHAI, HM Inspectorate of Constabulary, the Housing Inspectorate and Audit Commission along the lines of the Safeguarding Children review.

94   Q 34 Back

95   Q 87 Back

96   Q 116  Back

97   Q 103 Back

98   Q 164 Back

99   Ev 207 Back

100   Q 104 Back

101   Q 106 Back

102   HC Deb, 28 June 2001, Col 170W Back

103   Ev 34 Back

104   Ev 160 Back

105   Q 72 Back

106   Q 76 Back

107   Q 148  Back

108   Q 149 Back

109   Q 151 Back

110   Department of Health (2003), POVA Draft Guidance, para 13 Back

111   Ev 111 Back

112   POVA Draft Guidance, para 1 Back

113   Ev 50 Back

114   Consultation is currently taking place on regulation of health care assistants: see Department of Health Press Release 2004/0086, 2 March 2004. Back

115   Direct Payments were introduced by the 1996 Community Care (Direct Payments) Act. The legislation allowed local authority social services departments to make payments, in lieu of services, to some groups of physically disabled people, and people with learning disabilities aged under 65. Since 2000 further legislation has removed the upper age limit for eligibility and extended entitlement to older people. Local authorities now also have a duty to offer the option of direct payments to those who meet the eligibility criteria, rather than simply a power to do so. People who receive direct payments are able to use them to employ personal assistants to provide help, and to tailor the support to their individual circumstances and needs, rather than fitting in with standard services that might be provided. Back

116   Q 30 Back

117   Q 33  Back

118   Q 94 Back

119   Q 94 Back

120   Q 113  Back

121   The Care Homes Regulations 2001 (S.I. 2001, No 3965) Back

122   In addition to the two inspections per year, the NCSC has the power to inspect at any time or with whatever frequency it decides, should there be cause for concern. Back

123   Ev 107 Back

124   Q 90 Back

125   Ev 38 Back

126   Q 82 Back

127   Q141  Back

128   Ev 160 Back

129   Q 88  Back

130   Q 143 Back

131   Q 197 Back

132   Ev 130 Back

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