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I am pleased to confirm on the public record that Clause 4(1)(a) already enables the commission to take into account those views as part of the regard it must have to views expressed by the public. I emphasise that this provision is sufficiently wide to include staff, and we would certainly expect the commission to engage with them as part of its overall responsibilities. I can also confirm that this provision would cover trade unions and professional organisations, as the commission must also have regard to views expressed on behalf of the public. I hope this clarifies the issues that my noble friend has raised.

I would like to refer to several other provisions. Of particular relevance is our proposed registration requirement 17, which is about supporting workers to give people the care and treatment they need. The commission will need to engage with staff in assessing this and will be able to take action where this is not the case. We would also expect the commission, as CSCI currently does, to take into account the views of staff in gathering evidence to ensure that providers comply with all the registration requirements. Also, under Clause 24, the commission is required to consult on guidance as to compliance with requirements, and we would expect that to include providers and their staff. This is just one of a number of provisions in the Bill requiring consultation. I am sure that the commission will value staff input on many of these issues. I am sure that the noble Baroness, Lady Young, will carefully consider the views expressed today.

The importance that we place on engaging widely with everyone with an interest is exactly why we introduced the new requirement for an advisory committee. When establishing that committee, the commission will want to draw on a range of expertise from different sides. We have always been clear that we want the advisory

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committee to include a range of people with expertise relating to health and social care services, including providers of services, representative bodies and other interested observers. I expect that this will include people with front-line experience of delivering services.

I would be cautious, however, about naming a particular group in the Bill, which Amendment No. 11 seeks to do, as this goes against the concept of an independent regulator. I am confident that we can trust the commission to determine who is appropriate. If needs be—if the advisory committee were felt not to be providing the robust and representative sounding board we anticipate it should be—a power is provided for the Secretary of State to prescribe the sort of people that it must include.

As part of the wider picture, I refer noble Lords to the report launched yesterday by the Minister, my noble friend Lord Darzi, much of which is about engaging with staff about the changes they want to see to the NHS and empowering them to provide the highest quality of care. I hope that I have been able to reassure my noble friend Lord Campbell-Savours that the Bill as drafted meets the intention behind both these amendments, and that the Government are serious about empowering staff to help shape their workplaces. I hope that he will withdraw his amendment.

Lord Campbell-Savours: My Lords, in the light of that very comprehensive response, which I am sure will be welcomed by members of trade unions, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

3.30 pm

Clause 20 [Regulation of regulated activities]:

Baroness Thornton moved Amendment No. 2:

The noble Baroness said: My Lords, it will be convenient also to consider further government Amendments Nos. 10 and 12.

Amendment No. 10 has been tabled in response to constructive debates in Grand Committee and on Report about how best to ensure that the commission maintains a balance in its work. I very much appreciate the attempts on all sides to find the most appropriate way of doing this. The commission will be held to account for the delivery of its main objectives and statutory functions, which we have clarified in the Bill, through the close scrutiny of this House. These include the tasks of regulating adult social care, continuing to take an overview of adult social care in England through its reviews and through the vital Mental Health Act role.

The commission cannot fulfil its statutory responsibilities if it fails to dedicate sufficient priority of resources and attention to social care or mental health. We all agree that in bringing health, adult social care and mental health regulation together, it would be wrong to “insulate them from change” as the noble Earl, Lord Howe, put it. There has been some recognition that it therefore might not be appropriate

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to specify in primary legislation that there should be commissioners or sub-committees with specific remits. However, we recognise that it is important, to quote the noble Earl again,

As so many noble Lords have acknowledged, particularly in the later stages of the Bill, it is vital to secure proper representation while maintaining the flexibility for the commission itself to decide how best to deliver its statutory functions. In government Amendment No. 10 I hope we have arrived at a solution that we can all agree to. This is very much in the spirit of the amendment tabled by the noble Earl, Lord Howe, on Report. However, rather than concentrating expertise on the commission’s review functions, it would require the Secretary of State, in appointing members of the commission, to ensure that they include people with experience and knowledge relating to the commission’s key areas of business: healthcare, social care and monitoring the application of the Mental Health Act. Such knowledge and experience could, for example, include a person’s involvement with relevant stakeholder groups who represent service users or carers, or perhaps their direct experience as a service user or carer themselves. I hope that noble Lords will agree that this amendment leaves no doubt as to the importance that we place on representing all aspects of the commission’s remit at board level, while leaving flexibility for the commission to still organise itself how it sees fit and ensure that the organisation can adapt as the services it regulates develop over time.

We have also tabled Amendment No. 2 in response to debates in Grand Committee and on Report, in this case about complaints. Clause 20(1) states:

Moreover, we have set out that the proper handling of complaints is one of the key issues that those regulations may, in particular, include. Furthermore, our recent consultation, which closed on 17 June, made clear our intention that those regulations should include requirements about acting on and learning from complaints. However, I appreciate that noble Lords felt that the Bill could be more explicit on this point to reflect the importance that we attach to it. I am happy to be able to bring forward government Amendment No. 2, which, as I hope noble Lords will appreciate, aims to do just that.

I want to refer to the letter that I sent yesterday, which many noble Lords may have seen, following my commitment on Report to make an announcement relating to the independent resolution of complaints by people who arrange and fund their own adult social care services. I am pleased to confirm that we will take the next available legislative opportunity to extend the remit of the Local Government Ombudsman so that he or she can investigate complaints by self-funders. I know that many noble Lords have expressed concerns about this issue. I therefore trust that this proposal, which is certain to make a real difference to people who arrange and fund their own care, has the support of the House.



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This group of amendments contains the minor, technical Amendment No. 12. I trust that noble Lords will accept these amendments. I beg to move.

Earl Howe: My Lords, I thank the Minister most warmly, in particular for Amendments Nos. 2 and 10 and for her welcome announcement about the future role of the Local Government Ombudsman in relation to complaints by those who fund their own care. I am sure it is extremely gratifying to Members of the House that the Government have been so responsive to the concerns raised during our debates.

Lord Walton of Detchant: My Lords, I simply add to what the noble Earl has said in thanking the Minister and her noble friend Lord Darzi. They have both been assiduous in sending us letters of reassurance during the various stages of this Bill, which have been extremely helpful. I wish that to be formally recorded because these two amendments meet many of the concerns expressed in previous discussions on the Bill.

Baroness Masham of Ilton: My Lords, I, too, congratulate the noble Baroness on her splendid work in this Bill. She really has excelled with her communication. With health and social care, communication at all times is so important, and she has led the way.

Baroness Tonge: My Lords, I echo the remarks of other noble Lords. This has been a long Bill, but the amount of work that the Ministers have done and the way in which they have listened to us and taken on board our suggestions have been exemplary. In particular, I thank the Minister for the wonderful flow chart, which she sent me yesterday, on complaints. It is a masterclass in complexity—I have not yet learnt how to make a complaint but I shall master it.

Baroness Thornton: My Lords, I say to the noble Baroness that you have to be careful what you ask for sometimes. I thank noble Lords for their support.

On Question, amendment agreed to.

Clause 45 [Standards set by Secretary of State]:

Lord Campbell-Savours moved Amendment No. 3:

The noble Lord said: My Lords, it may take me longer to move this amendment than I had otherwise planned. It was not until yesterday that I thought that I would be moving this amendment, when I received from CSCI a briefing paper on my contribution last week to the House. I thought that I should not leave it without response, particularly because it deals with what I believe to be an issue that is at the heart of this whole debate; that is, the frequency of inspections in care homes. I remain utterly opposed to the regime that has been established in recent years, and which I believe is of increasing concern to those who know what is going on in this whole sector of care.



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CSCI sent out a briefing, which most noble Lords will have received, entitled,

Members will recall that the BBC transmitted a programme making a number of allegations about conditions within the inspectorate, drawing on the statements of people within the inspectorate. Those statements have been challenged by CSCI. I asked Unison, one of the unions, for its response to CSCI’s accusations against the unions, one of them being that they were aligned with the BBC in the formulation of the questions. CSCI’s response, in my view, questions the integrity not only of the four unions involved but also of the BBC, which will no doubt wish to respond directly to CSCI.

The “Today” programme report on this vital issue—on the frequency of the ability of the inspectorate to carry out its work—was based on more than 200 questionnaire returns. The questionnaire was written and paid for by the BBC. The unions had no input; they simply sent it to their members. The wording in the questionnaire was approved by the director of political research within the BBC, who is a well respected individual in Westminster. The focus of the questionnaire was on the impact of inspection and regulation changes on service users. It was not to do with internal industrial relations issues, which is what CSCI said in its briefing. The report mirrors many of the findings of an earlier survey conducted by the joint unions, based on 250 responses. These concerns are widespread and cannot be dismissed as comments of one or two people. Again, CSCI’s report misrepresented the position in terms of the number of people who spoke to the BBC. The unions have been complaining since last year about the effects on service users of the new inspection methods. CSCI’s own 2007 staff survey, which had 1,200 responses, had a different focus.

Nevertheless, some results backed the view that there are problems within the inspectorate that should be investigated.

I have not had time to check these data: this is what the unions told me this morning. In CSCI’s own survey, only half the staff agreed that CSCI delivers a good quality of service to its customers; only 35 per cent agreed that CSCI could deliver what it has committed itself to; only 25 per cent had confidence in the senior management team; only 15 per cent agreed that change is well managed within CSCI; and only 15 per cent agreed that CSCI values its own employees. I have not seen the data, but that is what I have been told. I shall check the data myself if possible.

The budget set by the Government, and the Government’s blanket approach to deregulation, have shaped the inspection regime. CSCI has responded to these pressures, rather than designing a system that meets the particular and unique circumstances of the care sector. In other words, what is happening is Treasury-driven, and I object.

The claim that the new methodology had widespread public support does not stand up to scrutiny. CSCI commissioned a MORI poll of service users for its 2004 report, When I Get Older. It showed that 79 per cent

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of respondents said that services should be inspected at least twice a year and that more than a third wanted monthly inspections, yet, under the current system, many services are inspected only once every three years. Moreover, respondents said the best way for inspectors to judge the quality of care was to speak privately to service users and spend time observing what goes on. These practices were rated much more highly than talking to owners or checking paperwork. Yet we now have a system that relies on a service review, which is a desk exercise based on provider self-assessment.

Yesterday’s CSCI briefing claims that its approach works, because two years ago there were 1,500 poor services and now there are only 600. The concern of union members is that this reduction does not necessarily show that services are getting better; rather, it shows that CSCI is getting worse at identifying poor services.

The claim is made that poor performers are inspected more often. This is doubtful. Under the new system, the default is twice a year for poor performers: the same as under the old system. The fundamental concern of union members is that the systems for assessing and monitoring providers are insufficiently robust. The frequency of inspection is determined by the service rating. The whole argument relies on being confident that a good or excellent rating, first, is justified, and, secondly, can be sustained for two or three years. It is this that concerns the members of the unions involved in these inspections. Poor or deteriorating services will slip through the net.

The number of inspectors has dropped from 1,400 in 2004—I emphasise this—to just over 800 now. In addition to concerns about frequency of inspections, inspectors report that they do not have enough time to spend on each inspection visit. The pressure of meeting targets means that they no longer have time to follow up on concerns or issues. The CSCI briefing refers to evidence from a range of sources, including the provider self-assessment surveys. The unions say:

A key feature of the new methodology was to have been a new IT system known as ICAP. Cuts in administrative staffing were made on the basis that the IT system would streamline systems. This was to have been introduced in 2007, yet it still has not been rolled out.

3.45 pm

There are some concerns about the overall rating methodology. A provider in breach of key standards, such as the safe administration of medicine, can still be rated as adequate. I do not know whether that is true but, if it is, I find that appalling. CSCI talked about unannounced inspections at any time—indeed, there was much emphasis in Committee and on Report about the need for such inspections—but it has to be asked how often they happen, given the staffing constraints. Furthermore, I emphasise that providers are tipped off about the scheduling of a key inspection by receiving the self-assessment questionnaire in advance.

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In the view of people involved in the inspectorate, the annual service review is a desk exercise. The briefing claims that a change of manager or owner automatically triggers a fresh key inspection, but those involved question whether that is automatically the case.

The last time we debated these issues, I said to my noble friend that those who had replied to the BBC questionnaire were lying, telling the truth or exaggerating. The more I hear, the more I think that there is an element of truth in what they are alleging. I cannot see how it is possible to leave on the record accusations of this gravity without Ministers wanting to know precisely what is happening within the organisation. We know that very often those who lead any organisation simply push the party line, although I do not mean that in a political sense. They push the case for the organisation, very often knowing that complaints are occurring but, because of all sorts of considerations—relationships, budgets and whatever—they simply peddle the same old tune.

I believe that there is something wrong within this organisation that should be addressed and that the department should send people in to find out whether there is any truth in these allegations. I hope that my noble friend will be able to deal with that specifically when she replies from the Dispatch Box. However, I say to the noble Baroness, Lady Young, who I know is taking on a huge responsibility here, that many of these things will be left for her to sort out. I am confident that she will do so but she should have the benefit of knowing that people from outside have gone into the organisation and are able to provide her with information over and above that which may be fed up the line but which, by the time it gets to her office, may not altogether reflect the reality. I beg to move.

Baroness Masham of Ilton: My Lords, I have a small rural riding centre in North Yorkshire and we are inspected twice a year. One of the inspections is done by a veterinary surgeon. It seems extraordinary to me that frail, vulnerable people in residential care should not be inspected more than my small riding centre.

Lord Ramsbotham: My Lords, I emphasise, as I did at earlier stages of the Bill, that inspection must not be confused with regulation and audit. To my mind, the tick-boxes of regulation and audit are wholly unsuitable and unsatisfactory for the type of inspection required of these care homes. I know that my noble friend Lady Young will be going into this in some detail and I hope that, when she does, she will consult other inspectorates involved in other activities in the public sector in addition to CSCI. She will have to balance the resource issue between the needs of the healthcare, mental health care and social care commissions, which will not be easy. I recognise all the points that have been raised. Having spoken to CSCI about this, I know that it has been concerned about the impact of resources on the time that it is able to spend on essential inspections. Cutting those short is almost as bad as not doing them at all, and I therefore entirely support the wording of this amendment. I hope that the Minister will recognise it as being desperately important when the new commission takes up its post.



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Baroness Young of Old Scone: My Lords, because I am conscious of the Addison rules, I have had rather a self-denying ordinance on this Bill, but I have to say something on this amendment. I cannot speak on behalf of CSCI, which is a statutory body led by its own board, and I do not want to comment particularly on the issues that the noble Lord, Lord Campbell-Savours, has raised about CSCI itself. I simply want to reflect on the issue from my background in regulation and from the five weeks’ experience I have had of looking at the future role of the Care Quality Commission.


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