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Perhaps I could just take a moment to give your Lordships an illustration from my own life, as I suspect that a lot of other people will have similar stories surrounding their lives as well. After Christmas, I had an elderly relative move into residential care. She was not actually receiving any formal care and was getting very little informal care in her own home, being a fiercely independent woman, but it was the house that drove her out and required her to move into expensive residential care. It was just unsuitable. It was a cold house and one with steps in every possible direction-upstairs, downstairs and all around. She is suffering from quite severe arthritis, finding it extremely difficult to get around and to turn the taps. There are no grab rails on the walls. I could see the expenditure that might do the trick, but it is too late as she has gone into residential care. The real problem that she faced was a housing problem, even though she now finds herself in an institution, receiving expensive care. I think this joining-up of housing with health and social care is an underlying principle that this piece of legislation with its words "personal care at home" should embrace.

I recognise that this is something of a probing amendment. I would argue for more funding for the disabled facilities grant programme, which is very underfunded, and more resources for the home improvement agencies, such as Care and Repair. Money can be so well spent in housing in its relationship to care within the measures enshrined in this legislation. I understand that it is in the reablement section that one finds the opportunity for some funds for aids and adaptations to people's homes, including telecare censors and alarm systems that can alert care providers elsewhere. However, on looking at the numbers, I note that the funding for reablement at £130 million for 130,000 people at £1,000 per head, based on 30 hours at £30 per hour with £100 to spare for little extras, does

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not leave any room for the aids and adaptations that one would hope to see as part of a package providing the support that older people are going to need.

Baroness Greengross: I rise to speak to Amendment 33. I want to speak particularly about people suffering from dementia. There is quite a concern that many people with dementia will not meet the four ADLs or the critical criteria for an inability to carry out vital personal care or domestic routines, as described, despite having a substantial level of need. That is obvious when one thinks about the symptoms of dementia in its various forms. Your Lordships will recognise that one of the key reasons for this is that many people with dementia find that they can carry out some personal care routines with various degrees of difficulty, but only when they are prompted by care staff or carers. Providing personal care to someone with dementia is often very different from providing care for a frail older person, because the person with dementia can easily become confused and distressed and very often resists the essential care that he or she needs.

Careful prompting and supervision play a critical role in the care of many such people. There are all sorts of things that they can do-they are very simple things when you are well-such as swallowing medication, chewing properly, preparing food for themselves, washing properly, and dealing with and maintaining continence, if they are carefully prompted by trained people. The amendment would ensure that dementia is recognised as the illness that it is. It is essential that it is inserted. I hope that the Government take it seriously, so that the supervision and prompting that are necessary can be provided.

Baroness Barker: I shall speak to Amendments 37 and 42, which stand in my name. I am pleased, as always, to follow the noble Baroness, Lady Greengross. It is fitting that I, too, want to talk about people with dementia and the importance of having staff who are trained and who understand the nature of dementia in the delivery of services.

I used to have an office whose window looked across the street. Twice a week, a little van would turn up from social services. A lady would get out and ring the door of a house that was divided into flats. She would wait for quite a while while the gentleman inside came to answer. All the time, she would continue to talk to the driver of the van. When the gentleman came to the door, she would hand him his package of dinner while continuing to talk to the driver. She would then turn around and walk away. That gentleman had dementia. She did not even know whether he ate that dinner, fed it to his dog or threw it in the bin. She had no idea of what his life was like inside his house. It was the absolute epitome of a service being delivered so badly and so wrongly for somebody who had dementia. I would hope that that sort of thing would not be so common these days, but who knows? Hard-pressed staff might find themselves in a similar position.

I wanted to table the amendment because it is important that we remind ourselves that we are talking in this Bill about two very distinct groups of people. There are adults with disabilities who for the most part will have conditions which are life-long and stable. Their needs may change, but probably not much over

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time. We are talking also about older people whose conditions can change quite rapidly, and older people whose conditions might be limiting and long-term, and change gradually. Their needs are very different. I hesitate to say it in front of the noble Baroness, Lady Murphy, but, in lay terms, the needs of people with dementia can change. The noble Earl, Lord Howe, was absolutely right: the distinction between substantial need and critical need is very difficult to determine, particularly when people have fluctuating needs.

When speaking to an earlier group of amendments, I asked the Minister how many of the FACS-critical criteria one would have to meet. Those criteria include:

""Life is, or will be, threatened".

That is a comparatively easy thing for a member of staff or an assessor to find out. However, there is also the criterion that:

"There is, or will be, an inability to carry out vital personal care or domestic routines".

Is that so clear and easy to determine, and are the consequences of it so great? Therefore, I tabled this amendment and Amendment 42, which is similar to that of the noble Earl, Lord Howe, to determine exactly what is meant by personal care. There is, as noble Lords are aware, no definition of personal care in primary legislation in England. As several noble Lords have already spotted, the definition in this amendment is the definition in the Scottish legislation from the Community Care and Health (Scotland) Act 2002, as amended in 2009. The significant amendment in 2009 was the consideration of the preparation of food. When looking at an amendment such as this, it is perhaps very easy to dismiss as insignificant each individual sub-clause of each individual part. However, in terms of the life of a person who is likely to be eligible for free personal care-and for their carers-each and every one of these small things is an extremely important part of life.

The Government have always resisted having a definition of personal care in primary legislation, and I am sure that they will do so now. I would be staggered if they did not. However, one of the excuses that they have always run in the past is that putting a definition into primary legislation would by its very nature be exclusive and would probably be unworkable. In Scotland, however, that has proven not to be the case; it has proven that the lawyers, sadly, have not made that much money from bringing cases to contend what is meant by an unclear definition.

I also wish to echo the points made by the noble Earl, Lord Howe, that the definitions proposed in the Bill and in the regulations do not equate to the six basic categories of activities of daily living. That is pretty well bound to cause confusion, if one is not being too generous.

As I did at Second Reading, I echo the point made by the noble Earl, Lord Howe. Help with the provision of medication is a critical part of life for these people, and it therefore seems to me that it is a major omission. The prompting and supervision of people who have dementia to do some of the personal care tasks of which they are capable but which they cannot do if they are not prompted seems to me to be a critical part

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of this. I echo the point made by the noble Baroness, Lady Greengross, that prompting somebody to do that must be one of the areas of personal care.

Baroness Gardner of Parkes: My Lords, I strongly support Amendments 32, 33, 37 and 42. I was very interested in the comments of the noble Baroness, Lady Greengross, who knows so much about dementia; her remarks were very sad. Amendment 37, tabled by the noble Baroness, Lady Barker, also deals with dementia. It is important that there should be special provision for dementia, because there has to be recognition that people suffering from dementia have different requirements.

I like the way in which Amendment 42, tabled by the noble Baroness, set out a great catalogue of things-that is practical. I am not sure, however-I am only speaking from my past experience of Bills in this House-about that approach. Usually, when someone sets out a provision listing everything that one could possibly think of, someone else says "Oh no, you should not make it like that, because there will be other things that you have not thought of, so you should put it in some other way to cover that". Moreover, there should perhaps be a code of practice or something like that, which would include all of those things-this might not be completely appropriate even for a schedule. However, it is right that people should view those topics that she has listed there.

10 pm

Having made those comments, though, I want to say that I really stood to support the noble Lord, Lord Best, on the provision of appliances and adaptations in a home. I repeat my comments from Second Reading: it is important that if a home is completely unsuitable and cannot be adapted in the way that he described for that elderly relative of his, then other housing should be available. Going right back to my social services days on the council, we were aware that housing, health and social services must be linked-a point that has been made now-and until they were linked it was pretty hopeless trying to run any of them, because each was affected by the others. I strongly support the point that has been made about linkage.

The housing issue is wider than just this Bill. I read in this morning's paper of some family that has lived in a tiny flat for 12 years waiting for a house-or it might have been five years, with an estimated wait of 12 years. Many people are looking for more space, and it should be possible to provide the ideal space for older people in great need in order to free up some of this other space, particularly in terms of social housing, where large properties are often occupied. People cannot be forced out of their houses but they should be persuaded that there is merit in the idea of leaving. If an attractive alternative were available that was better in health terms, I think that they would be willing to accept that.

The noble Lord's relation opted for a home simply because that was the only thing available. I am sure that if she had had the offer of a small self-contained warden-covered area, she would have been very happy to accept that. As I have said, in other countries, and

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to a certain extent in this country, people can buy units of special housing in the same way that, when they vacate them, the units must go on to someone else in special need.

These are interesting amendments so, although they have come up so late in the day, I felt that I had to say something about them.

Baroness Murphy: I strongly support the amendment of the noble Lord, Lord Best. He is right about the importance of the built environment in order to support people receiving appropriate care.

The other amendments all go to the difficulties of the definition of the problem and how it relates particularly to people suffering from mental health problems in addition to physical health problems. Activities of daily living were originally used to assess people's physical states.

It is not just dementia; dementia is merely the commonest and most obvious condition. Take, for example, an older person with a depressive illness or a paranoid disorder who is not eating or drinking without help because of ongoing delusional beliefs about food-or, even commoner, a person with cerebrovascular disease who apparently has nothing wrong with them at all but sits all day and does nothing as the result of profound motivational difficulties that are of cerebrovascular origin. The latter is a remarkably common complaint from families: "Me mum seems all right but she doesn't actually do anything, doctor", is how it is usually described.

It is a devil of a job sometimes to get this right. I refer to attendance allowance because that has been one of the great banes of the help that people have had available to them. I worry that we will have a rigid interpretation in the guidance that will make it easy to tick boxes and do the assessment, but will not be sensitive enough. So much will depend upon it. If we are going to have a dividing line between three ADLs, four ADLs and five ADLS, we have to be sure that this is a sensitive way of assessing people and that people have clear guidance. Personally, I think it will be a nightmare to make decisions of this nature. We should have some sort of definition in the Bill, and I support the amendment of the noble Baroness, Lady Barker, and the amendments of the noble Baroness, Lady Greengross, and her intention to get some support for people with more difficult assessment problems.

Baroness Wilkins: My Lords, I will be brief. I strongly support Amendment 32, in the name of the noble Lord, Lord Best, which would ensure that home adaptations are effectively integrated into the new free personal care arrangements.

As the Government made clear in their excellent strategy report, Lifetime Homes, Lifetime Neighbourhoods, housing adaptations are an essential component of the triangle of support, with heath and social care, in enabling people to remain living independently in their own homes, a point that has been made by a number of noble Lords. Many noble Lords will have had the experience of breaking their leg or their ankle and finding how difficult it suddenly becomes to do the basic essentials of washing and going to the loo

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because of the flight of stairs that they hardly ever noticed going up and down each day. Sadly, many noble Lords will have had the experience of finding that the home they have lived in happily for many years with their partner suddenly becomes the major barrier in helping them to care for that partner, when they become seriously ill.

By chance, this Committee falls on the day that will no doubt always remain a significant anniversary in my life, as it was 44 years ago today that I fell off a carnival float and broke my neck. If my parents' home had not been adapted to provide a bathroom and a bedroom downstairs, the amount of personal care which I would have needed would have been considerable, and would then have been a continuing and recurring cost. The ODI report of 2007, Better Outcomes, Lower Costs, by the University of Bristol, reviewed the evidence of the implications for heath and social care budgets of investment in housing adaptations. It set out a wide range of evidence and states:

"Adaptations that remove or reduce the need for daily visits pay for themselves in a time-span ranging from a few months to three years and then produce annual savings. In the cases reviewed, annual savings varied from £1,200 to £29,000 a year".

Housing adaptations need to be an essential part of this Bill and I very much hope the Minister will accept this amendment.

Lord Sutherland of Houndwood: My Lords, I want to support the probing in relation to housing and dementia. I will say no more about it, other than that I hope it will continue.

I will comment briefly, I promise, on Amendment 42. I admire the thoroughness with which the noble Baroness, Lady Barker, conducts herself in proceedings such as this, but I wonder if she has perhaps gone a step too far in this amendment. Despite the fine provenance that she quotes for much of the material, there will inevitably be gaps-for example, there is no mention of insulin injections, which some would regard as fundamental. I do not want to see that added to the list; I am just making the point that there will always be gaps if you make a list. I would prefer a series of general points that have to be covered.

Baroness Thornton: My Lords, I will reply to the group which comprises Amendments 19, 32, 33, 37 and 42. I have taken out about two-thirds of my notes because I am conscious of the time, so if I seem a bit truncated that is because I am.

I start by saying that the proposals in this Bill are for England and are not the same as they are in Scotland. In Scotland they offer a much different system, which is about the provision of full care free of charge, not personal care, as we are proposing, which is a much more targeted approach.

The Government entirely agree that a range of services and support needs to be available to help people to maintain their independence and, crucially, to help prevent their care needs from increasing. We know, for instance, that an older person who is losing some of their mobility, but is otherwise capable of looking after themselves, can be helped by the provision of home adaptations to continue living independently in their own home.

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As well as these sorts of adaptations, early intervention and support services, such as balance training to help someone recovering from a fall, are known to be a worthwhile investment which both helps people to get back on their feet and continue living independently, and saves money in terms of preventing admissions or readmissions to hospital or residential care.

We know that prevention and early intervention are not only good for people but make absolute economic sense. However, we are not starting from scratch. The Government have been promoting and supporting this approach in a variety of ways. In the Putting People First programme we defined prevention as one of the essential elements of what a transformed social care service for adults would look like. We have given local authorities more than £500 million to support that transformation and, all around the country, have been developing preventive services to support people's independence. Where this involves adaptations to the home, it is often done in partnership with housing providers, who can draw on disabled facilities grants. The allocations for 2010-11 will be announced shortly. We have also specifically promoted the development of telecare and other technologies through the £80 million preventive technologies grant made some years ago. On top of this, the Bill offers further support for reablement services, which include home adaptations and technologies. We are not just talking about the amount of money allocated by the activities of this Bill, but about building on other resources which are already available for adaptations to people's homes.

Amendment 19, moved by the noble Earl, Lord Howe, seeks to insert a power for the definition of personal care to be included in the regulations. Of course, the noble Earl is right: it is necessary that we clarify our definition of personal care but it is not necessary to do so in the Bill. The definition is in the working draft, which reflects our current thinking. It may be subject to change following the close of the stakeholder consultation tomorrow and our review of the responses. I ask the noble Earl to withdraw his amendment on the basis that we will include a definition of personal care in regulations, as indicated in the current working draft.

Amendment 32, tabled by the noble Lord, Lord Best, raises several different issues. The first part of the amendment would require regulations to give local authorities the power to assess the suitability of an individual's home for independent living where they have been determined to be eligible to receive free personal care at home. Clearly, it is important that, while many people wish to stay in their homes for as long as possible, they should not be living in an inappropriate setting. We would expect councils to look at the impact that suitable alternative housing or adaptation would have on helping to keep people in their homes. We completely agree with the noble Lord about both the importance of housing and the necessity of including it in the assessment. We would expect local authorities to check whether there are any needs that could be helped by aids and adaptations or additional services when they carry out their community care assessment. That is one of the reasons why we include reablement in these proposals-to encourage councils

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to think more broadly about the type and range of support that they should provide. The second part of the amendment refers to the need for personal care to include the provision of aids and adaptations. I think I mentioned our view on this in my previous remarks on this amendment. We agree with the noble Lord.

I turn now to Amendment 33. In the draft regulations, which we have made available to Peers, we have set out the eligibility criteria which we propose will determine who has the highest care needs and will qualify for free personal care. Our proposals require that, to be counted as having the highest needs, a person must first be within the Fair Access to Care "critical" band, and-as we have proposed and already discussed-need significant help when prompted to carry out four or more activities of daily living. The noble Baroness, Lady Greengross, is rightly concerned that any assessment of a person's ability to carry out activities of daily living should be able to capture whether they have difficulty because they need prompting in addition to any physical difficulty that they have. I reassure the noble Baroness and the noble Baroness, Lady Barker, who voiced their concerns on this matter, that, as part of our wider discussions with stakeholders, the regulations will need to cover supervision and prompting in relation to daily activities as part of the eligibility criteria.

Amendment 37 tabled by the noble Baroness, Lady Barker, would insert a requirement for local authorities to ensure that staff have an "understanding of dementia" when delivering personal care to those with a dementia diagnosis. The noble Baroness and the House will know that the Government have already taken major steps to transform the quality of care for those with dementia through our strategy and through the start we have made in building on that strategy.

Section 15 of the Community Care (Delayed Discharges etc.) Act 2003, which the Bill amends, is about the free provision of services and not about particular types of service provision. The guidance accompanying the regulations enabled by the Bill will need to consider how local authorities may best ensure the delivery of free personal social care at home and ensure that it takes into account the Dementia Strategy. We think it is unsuitable to place this in the Bill, but we completely take on board the concern raised by the noble Baronesses, Lady Barker and Lady Greengross, on this issue. We are absolutely in sympathy with it.

Amendment 42 by the noble Baroness, Lady Barker, inserts the definition of personal care into the Bill. As I have already said, the definition of personal care is included in the consultation document which is currently open for comment. We have been working with stakeholders to ensure that this definition is accurate and appropriate and meeting the Bill's aim of providing personal care to those with the highest needs. Following our analysis of that consultation we will look to amend the definition of personal care that we have set out in our working draft. However, we do not believe it is appropriate to put this in the Bill. We ask the noble Baroness to withdraw the amendment.

Baroness Masham of Ilton: My Lords, will the Minister confirm that the Bill covers Wales? I do not want it to feel left out, as she did not mention it.

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