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On the attitudes of the elderly, one inspector said:
“Elderly people may not see an inspector for two or three years. One lady recently said to me, ‘at least I knew if I had problems, you would visit the home in a few months. Now I know no one’s there to help me. I’m very frightened what might happen’”.
“Good homes can very easily slide when they know that it is likely to be 3 years before another inspection will be carried out”.
Changing regimes in a home was a matter we laboured over in Committee.
One inspector was particularly critical when he said:
However, what I really found disturbing was this. The interviewer said:
“I was very concerned about what I was being told so I arranged a meeting with a number of inspectors. I assured them they would remain anonymous but they were becoming increasingly worried about the implications of talking to me. Our meeting was called off. Two other inspectors told me about what they described as a ‘witch hunt’ within the organisation”.
It may be untrue, but this is what the journalist said he was told by an individual inspector:
“I was asked if I knew that the BBC were doing a programme and I said yes. I was then asked if I knew of any colleagues who were or had contemplated speaking to the press. I said no”.
“I needed to find out whether what I had been told reflected wider opinion within the Commission for Social Care Inspection. So, I wrote a questionnaire for its employees. Three unions—UNISON, the Royal College of Nursing and Prospect—agreed to allow me to send it to all their members within the Commission. The BBC’s Editor of political research helped ensure the questions were posed fairly and neutrally. More than half of the organisation’s employees would have received it. And 30 per cent of the questionnaires were returned to us. More significantly around a quarter of all inspectors responded—that’s more than 200 of them. Many of the comments we received were, again, disturbing”.
I put it to my noble friend that something, somewhere, is wrong. In all these interviews, inspectors talk about the inadequacy of resources, which directly influences inspection. We know about the reduction in resources from a Written Answer to me by my noble friend. In Committee, the noble Baroness from the Liberal Benches and many Cross-Benchers referred specifically to their concern about the amalgamation of these three organisations into one. Everybody was concerned that this part of the budget, covering these areas of inspection, might suffer. Ministers should be equally disturbed at what is happening and what might become worse.
We all know the reality: a good home today can be a bad home tomorrow. It can be due to a change of management, a change of proprietor, a sudden turnover
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The care sector is crying out for greater regulation, not less. A reduction in frequency of inspection would inevitably lead to a reduction in standards. I believe that there needs to be a review of the whole inspectorate system’s resources following the amalgamation. We need a minimum frequency of unannounced visits that is considerably more than the current arrangement.
In responding to this report, CSCI’s chief inspector, Paul Snell, said:
“The quality ratings, together with our more detailed inspection reports will give current and prospective users of care services and their families every opportunity to check up on the quality of care provided”.
Well, I am very sorry, but if the reports are deficient in many areas because the resources are not available to carry out effective inspection, they will not be of much use to those of us who have to place our relatives in institutions of care. I beg to move.
Lord Ramsbotham: My Lords, I support the noble Lord, Lord Campbell-Savours, in his amendment. I do so from a background as an inspector in a different organisation but one which worked closely with the then inspector of social services. I must admit that, when joint working, one of the things that concerned me was a tendency to tick-box rather than inspect, particularly when we were inspecting places in which children were held. I stated at an earlier stage my concerns about this merger of the three commissions into one and that there is a danger that, in doing so, the three separate functions of regulation, audit and inspection are being confused. Tick-box methods are perfectly all right for regulation and audit, because that is what they are, but they are not good enough for inspection, which requires detailed examination by experts, followed by judgments. Those are not fuelled by tick-boxes.
I am extremely glad that the noble Lord, Lord Campbell-Savours, mentioned unannounced inspections. When I was Chief Inspector of Prisons I was meant to inspect every five years, but I did not have the resources for enough teams to do even that. I had to appeal for resources to get a third team in order to get the frequency down to five years. One of the reasons for that was that I insisted that five years was too long and that one needed to insert unannounced inspections during that period, particularly to monitor that the recommendations I had made in the previous inspection were being followed through.
It seems extremely unwise, therefore, for any organisation, if it is responsible for something of such sensitivity as care homes, not to include that sort of
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Baroness Barker: My Lords, I share with the noble Lord, Lord Campbell-Savours, a passionate wish to protect very vulnerable people—some of the most vulnerable people in our society. That includes people who may have mental and physical frailties and who are in residential care. I have a great deal of sympathy for what the noble Lord is trying to do.
As I said in Committee, however, I do not entirely agree with him because over the past two or three years CSCI inspections have moved on. There was a time when CSCI inspections were, as the noble Lord, Lord Ramsbotham, said, primarily tick-box affairs. They have changed quite a lot. The new commission has an unprecedented opportunity to develop a range of inspection methods and to concentrate on that which we know to be the most revealing—unannounced inspections. I know we are not allowed in this House to compromise the independence of the commission in any way but I have one word of advice for its new chair. I hope that one of the first appointments is that wonderful lady who was part of those very revealing programmes on Radio 4. I am very sorry, I cannot remember her name. She is the actress who mugs up and goes into old people's homes. She has probably done more to protect vulnerable people than just about anybody else. I hope that she and a load of people like her are on the CQC’s books very quickly. I think that they would do more than anything else to raise standards.
Mr Paul Snell, in response to the points made about CSCI, pointed out that it is trying to concentrate inspection and remedial action on the minority of homes that are poor performers. The noble Lord, Lord Campbell-Savours, is absolutely right: this whole system depends on having complaints procedures that are sufficiently robust and on ensuring that carers and members of the public can bring poor practice to the commission's attention. The commission relies on having good inspectors, and the noble Lord talked about professionals. I would not use that word. I have watched lay inspectors be far harsher on service providers than my fellow professionals would be. There also has to be a system to protect whistleblowers. Many years ago there was not a system but now there is. Finally, there has to be a means by which service users can be part of that circle of information, flagging things up and following through the report’s recommendations.
I do not disagree with the noble Lord’s motivation at all. I want to see poor service providers hounded mercilessly until they either change or go out of business. On the contrary, I want to see good providers enabled to get on with their job. I shall give one reason why I think he may be wrong. He said that care standards can change when the regime changes in a care home, which is true, but ownership can change also for benign reasons. Contracts end and are given elsewhere. We do not want to spend the inspectorate's limited resources gumming up the works of people who are
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Baroness Meacher: My Lords, I rise to make one point very much in support of the point made by the noble Lord, Lord Campbell-Savours. It is fundamentally important that any home that falls into poor practice should be visited and dealt with fast. My request to Ministers has to do with LINks, which we discussed under the local government Bill. We do not want a lot of duplication of visitors to homes; they have enough to do as it is. However, if the Minister would consider putting into regulations something about the CQC working with LINks and ensuring that if, for example, there is a change of management or there are complaints or concerns about a home, the CQC can get on to LINks and ensure that a visit is made by a LINk and a report made to the CQC, then that would be an inexpensive way of doing things and a very effective way for LINks to operate. In Committee, I and, I think, other noble Lords were concerned that LINks should really get stuck into the areas of greatest neglect and greatest need. I would argue that this is where such needs are: small homes for very vulnerable people. I suggested that they did not have to be bothered too much with the big hospitals, because there are all sorts of people visiting those, but there are incredibly vulnerable people in these tiny homes. If noble Lords would consider this, I really do think it could be a major contribution to improving the quality of services for these very vulnerable people.
Baroness Howe of Idlicote: My Lords, I, too, listened to that very moving and extremely perceptive report by the BBC. I am sure that it upset many of us because it confirmed some of our worst fears about what might be going on. I very much support what the noble Lord, Lord Campbell-Savours, said, which was followed up my noble friend Lord Ramsbotham.
I still have a concern. Where local authorities are involved with some overall responsibility for small homes, surely another way in which a slightly broader view could be taken is through the elected members and not just the staff. If an elected member of a local authority befriended a particular small nursing or residential home with the ability to go in and out at differing times, that would have a much greater effect on the standard of care because of the local accountability. That may be totally inappropriate because of the existence of LINks and the new organisation which can do it all. But they have been turned over and changed so many times that one is left with quite a degree of doubt.
3.30 pm
Baroness Masham of Ilton: My Lords, I, too, should like to support the amendment moved by the noble Lord, Lord Campbell-Savours. Last night I was with a mental health social worker who strongly supports the need for unannounced inspections. Prisons have monitors who are members of the public. They come in when needed or when there is a problem. They also have monthly meetings.
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Surely those who live in care homes and who are sometimes very vulnerable should be protected from uncaring staff and badly run homes. People are frightened of complaining in case those in the care homes suffer more. The Government should look at this very seriously indeed.
Baroness Howarth of Breckland: My Lords, I apologise, in particular to the noble Lord, Lord Campbell-Savours, for arriving late—I was delayed on the way in. I want to make two points.
First, I say gently to my noble friend Lady Howe that we have to remember that these establishments are people’s homes. Many people in them intensely dislike strangers, as they see them, coming in and out. I know that it is quite difficult to get volunteers to be consistent in their approach, having tried to do so in a number for which I am responsible in a different capacity. There are very real difficulties about engaging the public in what are quasi-inspections.
Secondly, we are not accepting that the majority of our inspectors are not highly professional and that most of the homes are not extremely well run. However, that does not mean I do not accept that, from time to time, there are issues in particular homes. We should also look at the background of the making of the BBC programme, which has some interesting flaws. We have to be supportive of the staff who are carrying out the inspections and recognise that most providers are very keen to do a good job by the people for whom they are giving services.
Again,I apologise once again for arriving late, but I particularly wanted to make those two points.
Baroness Thornton: My Lords, I know that my noble friend feels passionately about inspections. I have listened to and considered his concerns very carefully. We fully appreciate that those who live in care homes are particularly vulnerable. The Care Quality Commission will have a vital role of ensuring that those who receive social care are safe. The noble Baroness, Lady Barker, gave a very good account of what the CQC needs to be aiming for. She is absolutely right.
As we have previously discussed, there is no intention to reduce the total amount of inspection activity. Indeed, we want to create a regulator that focuses its attention where it is needed most to get the greatest benefits in terms of safety and quality for patients and service users. At the same time, the commission needs to allow—as the noble Baroness, Lady Howarth, said—good providers to get on and deliver their services. This is in the interests of everyone, but particularly service users.
In response to some of the concerns, I shall quote Paul Snell, chief inspector of the CSCI. He recently said:
“Now we’ve taken a much tougher approach. We don’t tell people we’re coming, we turn up unannounced, and we’re focusing our attention on the poorest of services. And we’re seeing some real improvement in relation to poor services”.
The programme referred to by several noble Lords did not reflect the whole story, as some people have said. As my noble friend admitted, most care homes are excellent. Therefore, while I do not believe that it will
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Several noble Lords referred to LINks. I agree with the noble Baroness, Lady Meacher, that they have a great role to play. As noble Lords may recall, we discussed LINks on the first day on Report last week, and have introduced an amendment that makes—if noble Lords will excuse me—the link between LINks and the CQC, and highlights the need for them to work together and for LINks to send reports to the CQC. I have no doubt that LINks will play an important role in ensuring that the CQC takes users’ and the public’s voices seriously. They also have access and can arrive unannounced where appropriate.
I regret that I am unable to accept these amendments. We currently intend to leave these decisions to the discretion of the commission, and provision already exists to set specific frequencies if required. I hope that I have been able to reassure my noble friend that the Bill will allow the new commission to take action where it is needed, and that it gives the commission powers to encourage services to improve and focus attention on the poor services that fail to meet those requirements. I therefore ask my noble friend to withdraw these amendments.
Lord Campbell-Savours: My Lords, I am indebted to the noble Lord, Lord Ramsbotham, and the noble Baronesses, Lady Barker, Lady Meacher, Lady Howe, Lady Masham of Ilton and Lady Howarth of Breckland, for their comments. I press my noble friend on one thing. The noble Baroness, Lady Meacher, referred to the need for the CQC to work with LINks. Will my noble friend impress that principle on this new organisation and perhaps come back to us at Third Reading? She may then have the opportunity to comment further on that issue.
My noble friend said that there was no intention to reduce inspection. My amendment is not about the reduction of inspection, but increasing it and securing more resources for this inspectorate. A lot of people have answered the BBC’s questionnaire. They are lying, telling the truth or exaggerating. From listening to the interviews, many believe that they are reflecting the reality. If they are, there is something wrong within the inspectorate. Nothing my noble friend has said suggests that the Government intend to find out whether there is any truth in what is being said about problems within the inspectorate. I ask my noble friend to arrange for those inquiries to be carried out. I would like to know whether those allegations are true or false. There is no need for the Minister to reassure us now, because I hope that she will come back to this at Third Reading. On that basis, I beg leave to withdraw my amendment.
Amendment, by leave, withdrawn.
Lord Darzi of Denham moved Amendment No. 32:
Clause 42, page 20, line 27, leave out from “care” to end of line 28 and insert “provided or commissioned by the Trust”
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The noble Lord said: My Lords, I shall speak also to government Amendments Nos. 34, 36, 37, 41, 42, 50, 51, 52 and 54, as well as to Amendment No. 38, tabled by my noble friend Lord Warner. The government amendments in this group are in response to concerns raised in Grand Committee.
It is quite right that a regulator’s first priority should be the safety of people who use the service, so patient and user safety will be the Care Quality Commission’s prime concern. However, the commission will, of course, also make a wider contribution to driving up the quality of health and adult social care services. Through its powers to undertake reviews and to publish reports, it will publish independent information about the performance of providers and commissioners, which will inform patient choice and create an incentive for organisations to improve quality.
The Government have been clear throughout that commissioning is definitely within the scope of the new regulator’s reviews and investigation functions. However, we acknowledged in Grand Committee that the Bill could be clearer, so I am pleased to bring forward government amendments that are intended to provide that clarity. I am delighted that my noble friend has been satisfied enough that these meet his concerns to be happy to withdraw the majority of his planned further amendments on commissioning.
Amendments Nos. 32 and 34 make it explicit that the new regulator must conduct periodic reviews of care commissioned by primary care trusts or by local authorities. Amendments Nos. 50, 51, 52 and 54 relate to the definitions of NHS care and adult social services in Clause 92, which are used throughout Part 1 of the Bill. The amendments make it clear that the same applies to special reviews and investigations under Clause 44, as well as standards under Clause 41, advice to the Secretary of State under Clause 49 and inspections under Clause 56. For completeness, because Clause 60 does not use those specific definitions, government Amendments Nos. 41 and 42 clarify that the regulator’s powers to require information also extend to anyone providing care commissioned by PCTs or local authorities.
It is also helpful to put on the record points about what the Care Quality Commission’s periodic reviews, and special reviews and investigations under Clause 44, can cover in respect of commissioning. As an example, a review could ask whether a PCT had assessed the health needs of its population and consider whether those needs were being met. Similarly, as we discussed in relation to Amendment No. 33, the new regulator’s reviews may cover how well local authorities are carrying out their duty to assess the needs of those who appear to them to need adult social services and, therefore, how well they are commissioning services for those who meet the eligibility criteria. The regulator’s reviews or investigations could also consider value for money of commissioned care, quality, availability and access, and overall care outcomes.
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