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Lord Campbell-Savours: I intervene briefly in support of my noble friend Lady Jones of Whitchurch. I previously drew the attention of the Committee to the

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fact that my mother is in a nursing home and I toured a lot of homes prior to placing her there. Indeed, this weekend, I am going back to the Lake District and will probably visit a couple more homes. I feel passionately about this business of inspections. Ministers have simply failed to understand the scale of concern on this issue among many of my honourable friends in the House of Commons and among Members of this House.

The only protection and assurance that someone in a nursing home, without a relative to visit them regularly, can have regarding the quality of service provided by that home is from the knowledge that the home is regularly inspected. I strongly object to a reduction in inspections.

The theory is that because a home achieves a top score for one year, it might as well not be visited the next year because it did well before. That is a nonsense because the conditions inside that home could have changed. The manager could have changed, as could the carers, the kitchen staff, the owner of the home or the shareholding control, whereby new pressures are exerted by a new management style. I see nothing in this legislation that even begins to dismantle the arrangements recently brought in governing the inspection of these homes. All the organisations I talk to have expressed their concern. The only people who seem to have no concerns about this are in the Government.

I believe that this part of the Bill is driven by people in the Treasury who have no idea what they are talking about. If a Treasury official comes up with an idea to make an economy in the use of taxpayers’ money, it is quickly given to civil servants in order to implement a change in the legislation and thus secure that economy. It is driven through the House of Commons on the back of a whipped vote. It comes into the House of Lords and is considered in committees like this one. The only people who have an opportunity of even knowing what is happening are those who attend the Second Reading debate in the House of Commons or committee sessions here. The proposal is put into legislation and the next thing we know, we see more and more newspaper articles drawing attention to the fact that an even higher number of homes are found to be operating to poor standards. I object very strongly to any reduction in the number of inspections that take place.

My noble friend might respond by saying that there will not be a reduction. However, I do not know the source of the term used by my noble friend, “light touch”. I am sure she has taken it from somewhere. “Light touch” must be a term used by someone in authority at some point who thought that the light-touch inspection of homes would satisfy the public’s expectation of what we want to see when an inspection is carried out. I am sorry, but a light touch is not what I want and it is not what my colleagues want. I believe that Ministers should go back to their department and the Treasury and take a new look at the whole area. Again, I strongly object to what is happening.

I have tabled a Question for Written Answer to which my noble friend may have the opportunity of replying. It deals with a home in north-east England.

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I want to know about the inspection record of that home. What happened there, and how often was it inspected? I understand that in a state of panic it had to be closed down and people were prosecuted. So the question I have put down asks about the incidence of inspection over recent years. It will be interesting to see when the Answer comes through to what extent that home was inspected, how long it took to find out what was happening there, and why it subsequently became a scandal reported on national television.

The amendment of my noble friend is very important because in some ways it addresses the issues that I am raising.

The Earl of Onslow: It is not often that I completely agree with the noble Lord, Lord Campbell-Savours, but when we were both on the listing to look at the issue of the care of older people by the Joint Committee on Human Rights, we heard about cases of bad homes. The reasons were absolutely crystal clear. There is increasing demand for places alongside a Treasury clampdown on costs. The wages paid to people working in these homes are not high, with many on the minimum wage, and a lot of them are foreigners.

I can tell the noble Lord what light touch means. It is the exact opposite of being a recruit at Caterham Barracks and having your bed space inspected by a Grenadier Guards sergeant. He would look for every single speck of dust and check whether a touch of Blanco had been left behind. You were put on a charge if anything was the slightest bit wrong. That is the direct opposite of light touch.

If there is a tendency for standards to slip because of the pressures I have outlined, inspection standards must be high and enforced more vigorously. We all know that we are facing a very serious problem of old age. People are living longer; people are, happily, being kept alive longer; as the noble Lord said, a large number of people have no one coming to see them and no one to look after them except the people in the care home. Obviously, there is an improvement on what happened 20 or 30 years ago, but it is still not satisfactory. The fear of inspection will maintain high standards. Light touch means doing practically nothing about it.

4.15 pm

Baroness Barker: I was tempted to support the amendment tabled by the noble Baroness, Lady Jones of Whitchurch. I thought about it a lot because, with some notable exceptions, in my professional life I have come across the most downright harrowing incidents of treatment of older people in residential care. Because of that, I have arrived at the view that good organisations have absolutely nothing to fear from unannounced visits but bad organisations have everything to fear from them.

Bad residential homes are often very good at passing inspection visits, because an inspection visit is only an inspection at a particular time. For example, an elderly person I know told me about a home in which a friend of hers was. She said: “It is absolutely awful. Every older person in the area knows that it is

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awful. You know what? One day, they got up and everyone had brand-new sheets put on their bed. We all wondered whether the people coming round might wonder why everyone had brand-new sheets on the bed, but we are not sure whether they did”. I do not have an aversion to light touch in the sense that it is proportionate, so that bad homes get frequent inspections, but the key thing is that those inspections are unannounced.

I do not question the intentions of the noble Baroness for a moment, but the second reason why I think that the amendment is wrong is that what passes for poor quality and bad practice in one home may not in another. They are people's homes; sometimes homes can be not exactly up to pristine scratch. Why? Because they are places where people live; there may be good reasons for that. The process of judging overall whether a home is, first, of good quality and, secondly, whether people are subject to abuse is quite subtle. What we really do not need is a replication of a very crude Ofsted tick-box approach. We are talking about people's lives.

I do not think that a list is right because I have not seen any evidence that the transfer of ownership of a home is necessarily an indicator of a change in practice. I am willing to be persuaded otherwise, but I have not seen it. I want an inspection regime that is effective because it is a deterrent. I very much fear that if we take the approach proposed by the noble Baroness, we may end up with an inspection approach that is very predictable. That would not serve people well. The noble Earl, Lord Howe, is absolutely right to ask his question about the documents.

This is probably one of the single most important aspects of the Bill, which will have an effect on people's lives. It is important that we have completely different inspection regimes for acute hospitals and small places; but it does not matter whether it is St Thomas’s or somewhere little, it is unannounced visits that are fundamental to and at the heart of all of this.

Baroness Howe of Idlicote: Having listened to the passion of the noble Lord, Lord Campbell-Savours, I very much agree with what he said, as well of course with the amendment, particularly because it reminds me of when I chaired a local authority investigation, on behalf both of the unions and the local authorities, into local authority care homes of all ages. We have all heard of the terrible things that are happening in many homes, and equally we all know of the marvellous things that are happening in many homes, but this problem of more and more elderly people going into care with very few people to look after their interests is not going to go away.

We all know what happens during inspections. I have served on hospital authorities and everything else, and I know that everything is cleaned up and made nice and tidy for the inspection, so I entirely support the point made about uninspected visits. Why should local authority members not be responsible for one of the homes in their area and make a friendly visit at any time of the day or night? It always struck me as very odd indeed that it is always the officials who make the inspections. I am sure that some

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members of local authorities do visit their homes, but if they were allocated a particular home and a particular responsibility and formed a relationship, that would be one way of looking at the whole matter. I merely throw that open to the Minister to think about. Perhaps he will take up some of the ideas.

Baroness Howarth of Breckland: I apologise to the Committee for arriving late and therefore for not hearing all the interventions. I have taken part in debates on most of the rest of the Bill, so may I be forgiven and be allowed to intervene on this amendment? I regret not having heard the noble Earl, Lord Howe, who usually informs my thinking. Perhaps he has not yet spoken.

One of my great concerns about the Bill is that we will have such regulation from the Secretary of State that the governing board and the executive of the new commission will not be able to take a strategic overview of what they find and will not be able to adapt and be flexible in their interventions and inspections in what will be a vast organisation. I speak particularly from my understanding of health and social care. I am not an expert in the health service, but I was one of the people who set up the National Care Standards Commission and who insisted that there were a number of unannounced inspections: people do now arrive on your doorstep. I am the chair of Liveability and know that at any moment you can expect someone to turn up on your doorstep on an unannounced visit, which means that you need quite properly to be on your toes most of the time.

Some information is historical. When I joined the National Care Standards Commission, I remember that we were criticised heavily for the number of homes that closed. Quite honestly, none of us would have wanted anyone whom we cared for or loved—or even if we did not love them—to live in a number of those homes. Many of them were closed, and members of the Government and the Opposition criticised what happened at that time because of the diminishing number of establishments.

At the moment, you will find on average that standards are reasonably good, if not excellent in many places. When Members have a complaint, they should ask to visit—you can visit—and ask the commission to observe the inspection. Indeed, inspections are published, so you can see what is happening. I only hope that as a result of the amendments we do not end up with a more restrictive regime that adds to the structure of the inspection, and that the new commission can put together an inspection in a way that responds to the new organisation and gives the best possible care to those for whom it will be responsible. Thank you for allowing me to intervene.

Baroness Meacher: Perhaps I may take one minute of the Committee’s time quickly to make two points. I strongly support the point made by the noble Baroness, Lady Barker. I was a Mental Health Act commissioner for about five years and from time to time visited such institutions where we would find a little thing missing or a legal point out of order. However, that was quite

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different when we made an unannounced visit. Then we found that someone had committed suicide because, because, because—we gained a whole raft of information on those unannounced visits. I cannot say what a difference that made to the efficacy of the commission. So, any more visiting should be of an unannounced kind.

My second point concerns the LINks that some of us talked about at great length on previous legislation. I have trouble thinking about how the LINks people are going to be affected. It may be that with the CQC, possibly being invited by the CQC to make unannounced visits on its behalf and report back, there could be a really valuable role for the new LINks. I do not need to take up any more of the Committee’s time.

Baroness Thornton: This has been an interesting debate. Members of the Committee will not be surprised to hear that I thought the noble Baronesses, Lady Howarth and Lady Meacher, put their finger on some of the key points. Both amendments deal with the inspections that the Care Quality Commission will carry out as a vital part of fulfilling its functions both to ensure compliance with registration requirements and in some cases to contribute to its review activities.

I sympathise with the intention behind Amendment No. 103 to allow the ability to set specific triggers for commission inspections, and the remarks of my noble friends Lady Jones and Lord Campbell-Savours. Neither I nor my noble friend the Minister has at any point used the term “light touch”. It is not part of the terminology that we use to describe what the Bill seeks to do, and it is not part of the regime that we are hoping the commission will establish. The person who used the right word was the noble Baroness, Lady Barker; it is “proportionate”.

A similar amendment was debated in the other place, and my honourable friend the Minister for Health was at that stage able to provide sufficient reassurance for the amendment to be withdrawn. However, I appreciate that people remain concerned that certain circumstances—for example, a change of management or ownership of the social care provider—can have a huge impact on the quality of care. But they may not have—they may improve the quality of care and could well be triggers for a new regulator to want to carry out an inspection. Other triggers might include serious incidents, staff turnover or sudden increases, which often indicate that something else is going wrong.

I understand the concern that without the commission recognising such triggers, serious problems might not be spotted. That would of course be of particular concern if inspections otherwise happened only in a fixed cycle. However, I should stress to Members of the Committee that we are certainly not intending to set fixed cycles for inspections. Indeed, we are committed to giving the regulator greater freedom to develop a proportionate approach to regulation, building on the good work of the current commission in the case of social care—

Lord Campbell-Savours: I thank my noble friend for giving way. In many documents, articles and journals of organisations involved in the care of the

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elderly, my noble friend will have seen reference to the fact that the resources to be given to the inspectors are to be reduced. Is that true?

4.30 pm

Baroness Thornton: Part of the original reason for this exercise was to make savings, but those savings have already been made by the existing organisation. So the answer to the noble Lord’s question is, in fact, no. There is no intention to reduce the resources that will be available to this organisation to build its work.

Lord Campbell-Savours: If the cuts have already taken place—I presume they are cuts, because if the reductions have already taken place, they are cuts—are we seeing an increase in the number of complaints arising out of those reductions?

Baroness Thornton: I do not know the specific answer to that question, but I do not think that that is the case. We have three regulators who do an excellent job and through CSCI’s work in social care, for example, it is the intention that its methodology will be used to inform the inspections that take place under the new regime. The development of its work will very much inform what will happen next.

Lord Campbell-Savours: I have another question to which I know the Minister will not have the answer to hand, but perhaps she can ask her officials to establish what it is. What has been the saving to date arising from the reduction in the inspectorate or those responsible for inspecting? What moneys have already been saved and are likely to be saved over 12 months?

Baroness Thornton: I can make those figures available to my noble friend but I do not have them in front of me.

Lord Campbell-Savours: Thank you.

Baroness Thornton: The noble Lord might get them quicker than he expects. I return to the question, the Bill allows the commission to focus its inspection activity where it is most needed. Let us not forget that the Bill in Clause 2 makes clear that the commission must in everything that it does pay particular heed to the need to safeguard the rights and welfare of vulnerable people. It is highly likely that as part of its methodology the commission will want to develop a sensitive range of triggers for a range of different settings and, indeed, we would encourage it to work with staff, Unison, other unions, residents and relevant organisations and others to develop this.

I really do believe that if the commission is to be the independent, intelligent regulator that we all want it to be, it is vital that there is flexibility to develop this methodology and not set it in secondary legislation—or to involve the tick-boxes that the noble Baroness, Lady Barker, mentioned. After all, as the nature of services evolves, we would like the commission’s methodology to evolve, and while it is tempting to specify particular triggers for inspections,

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doing so could unwittingly tie the commission’s hands or cause it to devote less attention to emerging risk factors.

Amendment No. 104A probes the purpose of one of several provisions in the Bill designed to maximise coherence and transparency for all those with an interest, particularly the providers who are being regulated. The provisions for the commission to have inspection programmes and inspection frameworks mirror provisions for other public sector inspectorates. For example, Ofsted’s chief inspector and the Audit Commission are each required by the relevant primary legislation to produce “inspection programmes” and “inspection frameworks”.

Similarly, a separate document setting out the planned frequency of the commission’s reviews provided for in Clause 43 will be informative to those who are being regulated. Noble Lords will appreciate that knowing how often you are likely to have comparative information published about you in a review and what additional reporting this might involve is important to a provider. Periodic reviews, special reviews and investigations will draw on existing sources of information and, wherever possible, minimise the burden of the reviews to the providers. The current regulators have developed methodologies that help them to achieve exactly this. That said, because a review might involve some inspection activity, there is a link between the commission’s periodic reviews and its inspection programmes.

Noble Lords will also note that under Clause 77, the commission will similarly publish its programme of other reviews and studies. It is important that each of these different areas of the commission’s responsibilities is made transparent. Each of these documents will, therefore, play a role in ensuring that service providers understand the wider work programme that the commission will undertake and they will help to reduce the burdens on front-line providers. In principle, I see no reason why the commission would not combine one or more of these into a single document. If the commission felt that it could still fulfil its responsibilities in this way, that would be a decision it would be able to take.

Nothing in these requirements prevents the Care Quality Commission making unannounced inspections, as sub-paragraph 5(5) makes clear. I hope the Committee will appreciate that these provisions are intended to help the relevant regulators minimise burdens on the front line by enabling them to co-ordinate their respective activity. They also provide clarity for providers so that they understand what level of inspection activity they might expect and when. I hope that with those assurances my noble friend will feel able to withdraw the amendment.

Baroness Jones of Whitchurch: I thank the Minister for those comments but wish to clarify a couple of points that have been made in the debate. I did not suggest that we should move away from unannounced visits. At the heart of what I was proposing was the idea that we should retain what we have at the moment; namely, unannounced visits, primarily with inspectors trained to ask the right questions and to probe the right issues when they appear on premises. We are trying to retain that in the amendment. I take the

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point made by the noble Baroness, Lady Barker, that a home is a home and sometimes people like it to be organised in different ways, but key to all that is to talk not to the people who run the home but to the residents. There is a skill involved in doing that but I believe that our inspectors are trained to ask the right questions, to make residents feel at ease and consequently to find out what they really think about where they live. If they are happy with their home, that will come across and there should be no further worries.


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