Previous Section Back to Table of Contents Lords Hansard Home Page

Amendment, by leave, withdrawn.

Clause 57 [Inspections carried out for registration purposes]:

[Amendment No. 39 not moved.]

Lord Campbell-Savours moved Amendment No. 40:

(a) that the arrangements for, and location of, the display be agreed by the Commission;(b) that the information made available on the display be in a form prescribed by regulations;(c) that the inspection made available on display be from the most recent inspection report of the Commission;(d) that the service provider display any additional information which the Commission shall require.”

The noble Lord said: My Lords, the amendment gives me the opportunity once again to argue the principle of transparency in private care. It is one of a series of transparency amendments that I am moving to various Bills as they make their way through the House, and it stems directly from my own experience of having to place my mother in care—a matter which I dealt with at some length in Grand Committee. I should repeat that I do not have a background in social care. My background is in industry, so I come to this debate as a consumer.

24 Jun 2008 : Column 1355

Like most people who are faced with placing a relative in care, I found myself submerged in glossy brochures from many providers. It was a particularly difficult decision to take, which was not helped by the unwillingness of social services departments to guide or advise on where a self-funder could find the best. It was also not helped by the fact that only one—a BUPA home—out of the 19 homes I visited volunteered the CSCI report. In Committee, I reported that I had visited 19 establishments.

Some homes were a disgrace, some were very good and some stank of urine. One in central London was appalling and some others appeared cosmetically to be little better. I cannot imagine what was going on behind the scenes. As a Member of Parliament until 2001, I had been vaguely aware of an inspection regime. I should have been aware of the CSCI inspection report system, but I was not. Subsequently, I found out that that is the case for most others in my position. We all find out after placing someone in a home, but often that is too late.

I am convinced that most relatives who are placing—certainly self-funders—have no idea how to choose. Thankfully, after many unannounced visits to homes, I found a first-class institution, with a first-class CSCI report, where my mother is very happy. However, I repeatedly ask myself how many others have been in a position to tour the south of England visiting homes unannounced like I did. I suspect that that would be a minority of people, yet they are paying fees of anything between £800 and £1,200 a week, which is equal to £100,000 per annum pre-tax annual income. That is a lot of money.

There needs to be far easier access to independent information about homes and greater transparency. Some would argue that nursing home websites should carry or refer to the availability of their CSCI reports. Last week, if I recall correctly, my noble friend undertook to refer that matter to the new chairman of the Care Quality Commission, particularly the issue of the websites of homes being required to refer people to the CSCI report.

Under Amendment No. 40, there would be a statutory responsibility on providers to provide information of an independent nature on home standards and conditions in an easily comprehendible form to prospective clients or their representatives. It would place on the home’s management a statutory obligation to provide that information in a place that is accessible to the public. It would help choice and create the conditions for raising standards. It would deal with the seven assessment headings set out under the national minimum standards for care using the scoring system, but it should also flag up in a more informative way information on kitchen cleanliness standards from local authority inspection reports under Section 32 of the Food Safety Act; information on staff turnover; staff-to-client ratios with benchmark guidance; weekend cover arrangements; the use of bank staff; access to outside recreational areas; the frequency of case reviews; the dates of previous CSCI inspections; the complaints procedure; the role of the key carer and named nurse; personal and room cleaning arrangements; the incidence of

24 Jun 2008 : Column 1356

medication errors and of accidents; the number of individuals who make complaints; and information on sickness absence, all of which can indicate stress levels.

I have gone into these areas in detail because these are the issues which arise. As I said in Committee, I placed my mum, but I have also been to many homes since that placement because I have found this area fascinating. Other professionals may have another view about what is important, but as a consumer I believe that these are important issues. The BUPA care home checklist system provides us with some guidance on what potential clients are looking for over and above the existing CSCI inspection report arrangements. What would be the effect on home management of being required to put the report in a place which was accessible to people coming in, where they could see it and be guided towards it?

Staff would find themselves more openly accountable. Many carers are unaware of the availability of CSCI reports. I find that worrying because they do not realise the extent to which they are already accountable as individuals. I am talking about people who might be on £6 or £7 an hour, even less sometimes. Some people in these homes are incredibly poorly paid. Management would be ever conscious of the greater access to this information by potential clients and would be inclined to avoid poor scoring in a highly competitive market. In other words, standards would, in my view, inevitably rise. Relatives would have a checklist against which they could refer in times of concern without having to go to home managers which, in itself, can often be full of difficulties.

I know this is controversial. I have discussed this with a number of home managers. Some believe it is a very good idea, because they know that the poorer homes avoid at all costs revealing the contents of these standard reports. Many homes would not want it. It might affect their ability to attract custom, but then, so be it. They would have to raise their standards to attract the custom. It would inevitably lead to higher standards and in the long run would make the task of inspecting homes far simpler for the inspectorate. I beg to move.

Baroness Masham of Ilton: My Lords, how lucky the mother of the noble Lord, Lord Campbell-Savours, is to have a caring son who took the trouble he did. It is our responsibility to protect those people who are not so lucky as to have a son like hers. There are many of them.

Lord Neill of Bladen: My Lords, I should like to add one word in support of the amendment moved by the noble Lord, Lord Campbell-Savours. The circumstances do not matter, but arising from them I have had occasion to deal with a care institution, a provider of carers, a high percentage of whom come from either South Africa or Zimbabwe, which I found quite surprising. I was very startled to learn from one or two of them that they were not willing to work in institutions in the United Kingdom, whether public or private, because the standard of care, diligence and sympathy was not up to what they expected. I am absolutely sure that the experiences that the noble

24 Jun 2008 : Column 1357

Lord, Lord Campbell-Savours, recounts could be matched many times over by many other observers. If anything like this is to be adopted, this information ought to be easily accessible. It could be on some site where people could read it, although not everybody has the machinery. I would like to feel that it was not only on display on a noticeboard somewhere within the premises, but you could take away a copy so that it was easy for everybody to refer to what had been said about this institution in the last report. It is a highly important idea.

Baroness Thornton: My Lords, Amendment No. 40 concerns the display of information on providers’ premises, which we discussed earlier in relation to healthcare-associated infections. This amendment would require providers to display information on their premises in relation to the findings of inspections by the commission, and, as my noble friend outlined, by several other people as well.

As I said in relation to Amendment No. 21, I agree with my noble friend Lord Campbell-Savours that it is important that people can access information about what the commission has said about a provider or facility. I agree that the information should be easily available; the noble Lord, Lord Neill, also mentioned that. The CQC would be wise to listen to the list that my noble friend outlined.

The Bill already requires the commission to publish inspection reports under Clause 57(3), and Clause 80 requires the commission to make its reports available to the public, just as the current commissions do. I expect that, as now, reports will be available via the commission’s website and the public will also be able to request hard copies. The same would apply to the findings of assessments under Clauses 42 or 45, or indeed of any other review or investigation that the commission might undertake. In addition, under Clause 54 the commission will be able to make available to the public any information that it holds about the provision of NHS care, adult social services or other regulated activities. The commission will make available a wide range of information on providers to the public, users, potential users and their families, to support them in making informed choices.

As I said earlier, we will consult on the detail of regulations under Clause 16, but there is scope for them to include a requirement such as this. Indeed, once regulations under Clause 85 are in place, the public will be able to access information about how the commission is using the new powers to tackle providers that are failing to meet the necessary requirements.

From that combination of reassurances, I hope that my noble friend will feel that we want to ensure that the public, potential users and their families can access as much information as possible about the services they use, from an independent source that they can trust. The current commissions place great emphasis on that and we want the Care Quality Commission to build on their good work. I hope that he will therefore agree to withdraw the amendment.

Lord Campbell-Savours: My Lords, I listened carefully to what my noble friend said. She emphasised more than once that the commission will make information

24 Jun 2008 : Column 1358

available to the public. The problem is that it is the commission doing so; I want the home to do it. As the noble Lord, Lord Neill of Bladen, said, when you walk through the door of the home you should see the information there, be guided to it, or read that it is available. I want that to be a statutory obligation on the home.

My noble friend referred to the commission’s website. I am afraid that most people do not use or have access to websites. We presume that everybody uses a computer, but I am sure that many who place people in homes simply do not have access to that kind of arrangement.

My noble friend said something positive—that there was scope for such a requirement. I hope that the new person responsible for all these matters—the noble Baroness, Lady Young—has taken that on board and that, wherever possible, she places a requirement on homes to make sure that such information is available to people such as me when we are placing our relatives. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 60 [Power to require documents and information etc.]:

Lord Darzi of Denham moved Amendments Nos. 41 and 42:

On Question, amendments agreed to.

Clause 66 [Co-operation between the Commission and the Independent Regulator of NHS Foundation Trusts]:

Earl Howe moved Amendment No. 43:

(c) the Independent Regulator and the Commission must have regard to the need to promote the efficient and effective use of their resources in the exercise of their respective functions.”

The noble Earl said: My Lords, I return without apology to an important set of issues debated in Grand Committee on the potential for conflict in the roles of the CQC and Monitor. The Bill provides the CQC with intervention powers that can be exercised in relation to NHS foundation trusts. In doing that, it will oblige NHS foundation trusts to report to two regulators—the CQC and Monitor—whose powers overlap, and where the statutory underpinning for those powers provides no basis for separating their respective accountabilities.

The noble Baroness, Lady Murphy, and others argued powerfully in Grand Committee that this will not do. Effective regulation demands, above all, clarity as to where roles and responsibilities lie. It also demands that one regulator is accountable for performance in a given area. In the case of NHS foundation trusts, having two regulators will achieve the opposite. It is a recipe for duplication and delay. As was argued in Grand Committee, there are strong reasons for Monitor

24 Jun 2008 : Column 1359

retaining the primary accountability for NHS foundation trusts. In assessing the performance of foundation trusts, Monitor can look across the piece not only at service quality, but also at financial performance. Its powers are wide-ranging; much more so than those proposed for the CQC. Monitor’s compliance regime has, by common consent, already proved effective. There is absolutely no sense in altering it.

We all understand that there have to be common standards across all NHS bodies. However, that is not the same thing as arguing that the same body must be responsible for enforcement of standards in all cases. As the noble Baroness said in our earlier debates, the regulatory regimes for foundation trusts and other NHS providers are simply different. What is wrong with respecting that difference? Put another way, what is right about putting foundation trusts at risk of double jeopardy? The Bill requires the CQC and Monitor to co-operate with each other and to share information. I have considered this carefully and simply cannot persuade myself that those provisions are enough. The two bodies can co-operate, but they can still duplicate each other’s roles; they can share information, but still cause confusion and unnecessary burdens for the management of foundation trusts.

The noble Baroness, Lady Thornton, argued in Grand Committee that the Bill,

She said that the two bodies would simply have to work out for themselves what their relationship should be. With great respect, I do not think that that approach is adequate. It is a cop-out. Why is it not possible to define in statute precisely where the respective responsibilities of the CQC and Monitor should begin and end? Why are the Government avoiding clarity in this area and leaving open the possibility that foundation trusts could find themselves subject to duplicated intervention and duplicated enforcement?

I make clear that the amendment, as tabled, is not intended as a substitute for proper legal delineation, which clearly needs to be drafted by government lawyers. In my respectful submission, it is merely a means of flagging up some of the adverse consequences of the Bill as drafted. I hope that the Minister will agree to think again about these issues. I beg to move.

Baroness Meacher: My Lords, I support the noble Earl, Lord Howe, in his Amendment No. 43. He has put a powerful case for clarity about the respective roles of Monitor and the CQC. We have a pretty good arrangement now, because the Healthcare Commission is in effect the inspectorate and feeds information to Monitor, which is clearly the regulator. I, too, find it difficult to understand why, in the case of foundation trusts, the CQC could not perform the same inspecting function, taking data from foundation trusts, as the Healthcare Commission does now, but leaving the regulatory sanctions role clearly with Monitor. I strongly support the noble Earl, Lord Howe, and sincerely hope that Ministers will think again about the absolute importance of clarity.

24 Jun 2008 : Column 1360

4.30 pm

Information is another potential source of confusion between the two bodies. I suggest that a small amendment might be made to the amendment to remove the word “their”. The amendment requires the CQC to promote the efficient and effective use of its own resources. If we removed “their”, the amendment would require the CQC to promote the efficient and effective use of resources. Let me explain why I think that change could be helpful. In a sense, this is about duplication of functions.

The Healthcare Commission and Monitor have worked well to try to ensure that they do not duplicate the demands for information from provider trusts. Each provider trust has to provide information to the Department of Health, Monitor, the Healthcare Commission, perhaps three, four or five primary care trusts—each of which may demand information in a slightly different way—and local authorities. That is an enormously complex set-up. I thought that I would illustrate the point by bringing with me a few pages of our targets from Monitor, the Healthcare Commission, the PCTs, and so on. We are not talking about a few lines of information but an enormously complex set of demands that every provider trust across the country has to tussle with. Each set of demands is not included in the demands of the above organisation, so there is far more to it than at first appears. If these demands are co-ordinated, it is just about manageable. However, it is not difficult to imagine a new, incoming organisation hurling out a lot of demands for information without fully taking on board the impact that would have on all the other demands. The information then has to be collated, entered on to computer, analysed, tabulated and put into documents that people can understand.

I strongly support the amendment of the noble Earl, Lord Howe, but argue that there is a bit more to this aspect. It is not just a question of double jeopardy in relation to sanctions.

Lord Ramsbotham: My Lords, I, too, support the noble Earl, Lord Howe, in his amendment. My support relates to our previous discussion about inspection. The bodies would have to co-operate over resources for inspection. One aspect of resourcing inspection is that it is inevitable that where those resources come from will have a bearing on people’s perception of independence. If it is felt that inspection will take place depending on how many resources are put at the disposal of the inspectors by people who have to co-operate over what resources are made available, I fear that there could be problems. Therefore, I hope that before this co-operation on resources takes place, resources for inspection will be ring-fenced so that they are not subject to the negotiation which is the subject of this part of the Bill and of the noble Earl’s amendment.

Lord Warner: My Lords, I do not think that this amendment is the right way forward, but the points made by the noble Earl, Lord Howe, and the noble Baroness, Lady Meacher, are worthy of further consideration by the Government. We have already gone down the path of history once this afternoon; I would like to take us there again. Sometimes the

24 Jun 2008 : Column 1361

collective memory of that great and august organisation, the Department of Health, is less good than it might be, so it is worth dwelling on this issue. In some ways, it was the forerunner of the move to merge the three regulators. Way back in 2003, there was great concern across the political spectrum at the demands being made on the NHS in relation to information from regulators of various kinds, including central government. I brought together all these various characters, including the medical royal colleges which were also making quite a lot of demands both in their inspection and data collection. A concordat was agreed in which people would co-operate a bit more about the collection of data and to reduce the Piccadilly Circus effect of one inspector following another inspector—as one went out of one door, another would come in through the front door. That is a real issue for an organisation like the NHS.

The second point is what I think I said at an earlier stage—the tendency of regulators to mission creep. This is bad news for people delivering operational services. There are issues about who has precedence and whose information is used by whom in the area between the Care Quality Commission and Monitor. I am not sure that legislation is the way to deal with that: indeed, I suspect that it is not. The reason I am standing up here, however, is to try to get the message across to my noble friends on the Front Bench that there is an issue for the department to grapple with in terms of the expectations that it sets for the two regulators.

Next Section Back to Table of Contents Lords Hansard Home Page