Care Homes (Regulation)

Andrew Percy Excerpts

Wednesday 4th November 2015 Westminster Hall

[Peter Heaton-Jones]

My hon. Friend makes an extremely good point. This must be about the elderly people who are in the care homes. They must be the entire focus of those who work in, manage and own those care homes, not the bureaucracy and the paperwork.

[Andrew Percy (Brigg and Goole) (Con)]

I congratulate my hon. Friend on securing the debate, and it is a pleasure to serve under your chairmanship, Ms Vaz. You will remember that we looked at this issue in the Select Committee on Health in the last Session, as will the shadow Minister. We welcomed the new inspection regime, but I seem to remember that one criticism we had in discussions in the Committee related to the fact that we are dealing with often very elderly, very frail people who cannot speak for themselves, and one thing that the CQC could perhaps do better is engagement with families. That is not just after an inspection, when everything is all right. It needs to ensure that family members of those in care homes understand what the inspection regime is and how they can engage with it before, after and during the process. Although some of the changes have been positive and there is now perhaps better regulation in England, the people whom we ask to give feedback are often not able to speak for themselves, so we need to engage families much better.

[Peter Heaton-Jones]

My hon. Friend makes an extremely pertinent point, and I will talk about some challenges in the entire system when it comes to engaging with people. As he rightly says, people have difficulty in understanding the best way to engage with the system.

When things go wrong and a member of the public needs to raise a complaint against a care home, I am afraid the system becomes even less satisfactory. The CQC’s website says that it

“is unable to investigate individual complaints”

against providers. So how does someone complain if something goes wrong and they are worried about the care that is being given to an elderly relative in a care home? It is difficult. What can someone do if they fear that an elderly relative is being neglected, mistreated or not given the right healthcare, or if they fear that their relative’s life might even be in danger and the care home provider has dismissed the complaint or will not listen to it? The CQC has that said it will not handle individual complaints, so should they go the Parliamentary and Health Service Ombudsman? No, because the ombudsman says:

“By law, the Ombudsman cannot look into complaints about privately funded healthcare.”

If someone tries to go to the ombudsman they reach a brick wall. The CQC will not handle individual complaints and the ombudsman does not accept them. There is one possibility: an organisation called the Independent Healthcare Sector Complaints Adjudication Service. The ombudsman’s website states that “you may”—I stress “may”—

“have the option of going to the Independent Sector Complaints Adjudication Service…which represents some independent healthcare providers.”

If someone’s healthcare provider is not one of them, they are stuck.

The system is bewildering. It lacks accountability and transparency, and would leave most people confused and frustrated. How are people in care homes supposed to deal with that bewildering system? They may be vulnerable, old and frail and perhaps suffering from dementia. Their loved ones might put all their time and energy into caring for them, but how are they supposed to navigate the system? It needs to change.

What changes am I proposing to try to put right some of the issues I have highlighted? Despite the best efforts of the CQC—I say again that this is not a criticism of individuals at the CQC, much less those who work in care homes—I am afraid that, as currently manifested, it is simply not fit for purpose when it comes to the regulation, inspection and investigation of standards in care homes. Its focus recently has rightly been on NHS hospitals and providers. In light of the Mid Staffordshire scandal and the findings of the Francis report, that is hardly surprising—indeed, it is right—but the unintended consequence has been insufficient focus on the private care home sector.

In the short term, we must hold the CQC to account and insist on significant improvements now, because the situation needs to be addressed immediately. In the long term, it seems to me that the solution is to create a new, single, dedicated body whose sole responsibility is the registration, regulation and inspection of private care homes. Crucially, that body should also be the first point of contact for anyone wanting to raise a complaint about a specific establishment or the care of an individual patient. It would have the responsibility and necessary powers and resources to investigate those complaints thoroughly and rigorously, and in real time.

At the moment, if someone has an immediate concern about the care being given to an elderly relative and the care home either disagrees or denies that there is a problem, there is nothing to be done and nowhere to turn. That could be a matter of life and death. It needs to change, and it needs to change urgently. When things need to be taken further, we need a complaints system that is easier for the public to access and more transparent, and whose findings are accountable to Parliament in individual cases. The current complaints infrastructure is bewildering and is just not working.

My constituent to whom I referred at the start of my speech has lived with the problem for the past six years. Over that time, he has invested a great deal of work, research and thought in it. It has been his life, and it has undoubtedly been part of the grieving process for his mother. He has produced a document that is the product of a lot of work, and I have it here. It contains 24 very detailed points, questions, proposals and recommendations. He is frustrated that despite his best efforts and with a few notable exceptions, the issue has been largely ignored by the media and not given sufficient focus by politicians. That is something I want to put right today.

In the many hours my constituent and I have spent discussing the issue, we keep coming back to one thing. It is not about processes, systems or organisations, it is about people—people who do not have a voice in a system in which, let us remember, four in 10 care homes currently fail to reach a satisfactory standard on the CQC’s own measures. That means that people—vulnerable, sick and elderly people—are not being properly cared for. That cannot be right. We must do something about it. I believe we have a moral duty to do something about it, and that we must act now.

[Jim Shannon (Strangford) (DUP)]

Thank you for calling me, Ms Vaz. I congratulate the hon. Member for North Devon (Peter Heaton-Jones) on bringing this topic to Westminster Hall, setting the scene and explaining its importance from his personal experience and knowledge.

Care homes should and must provide care and services to some of the most vulnerable in society. I believe and the House believes that those who have worked hard and have contributed to society and the economy all their lives deserve appropriate care and dignity in their old age. We have the opportunity to be a voice for those who cannot be a voice for themselves. That is the issue the hon. Gentleman has brought to the House today. The people involved are often at the fringes of society and are of all ages. Many people in care homes do not have immediate family and that is another concern. We read stories in the press and we may be suspicious of them, but they illustrate the problem. There is no smoke without fire, so if there is a story in the press there must be at least some truth in the story.

Some people may be physically unable to look after themselves, including those who are elderly or have learning difficulties, dementia or Alzheimer’s. They deserve the very best care in care homes and their families need the assurance that they are well looked after. If someone has dementia, Alzheimer’s or a physical disability, they deserve the same treatment and care as others to ensure that their meals are correct and that they are given a wee bit of time, compassion and understanding, as the hon. Gentleman said. It is imperative to do all we can to protect those in care homes and to ensure that they receive the care and dignity they deserve.

I welcome the opportunity to question how the Government intend to improve regulation of the industry so that the people who are cared for are protected. I am always a bit suspicious of statistics—as the saying goes, there are lies, damned lies and statistics—but they are clear. Only 64% of care service providers in England are registered with the Care Quality Commission, so there is a question to be answered. I have great respect for the Minister’s understanding and I think the world of him, so I am sure that in his response we will hear the compassionate understanding that he feels personally and as a Minister. I look forward to that.

The Care Quality Commission monitors and regulates care organisations to ensure that they are continuing to meet national standards, and herein we encounter the first issue about regulating care homes. We need to press for much higher levels of registration if we are even to think about improving regulation. We cannot improve regulation if we do not have registration. I hope that we can make higher levels of registration a key part not just of this debate, but of the Government response. We cannot improve regulation if 36% of care service providers are not registered with the main body for monitoring and regulating the industry. Indeed, we should express immediate concern about whether those unregistered care providers are up to the national standard. I am not saying that they are not, but Government observation and monitoring is needed to ensure that they are.

Last year, following years of scandals, the Care Quality Commission announced that it would reinspect all care services and then rate them individually. We do not want to go into too much detail about the most horrible stories and incidents, but they do resonate with all of us as elected representatives. Care homes judged to be inadequate would be shut down and their directors banned from working in such positions again.

[Andrew Percy]

The hon. Gentleman is making a very important speech. He references the examples of abuse, mainly involving physical abuse, that we have heard about. Does he share my concern that in other care homes the problem is not physical abuse, but people not receiving proper nutrition? It is a national scandal that £13 billion of NHS money is spent every year dealing with poor nutrition, much of it in the elderly population. There are no doubt some very good nursing homes and care homes, but the quality of the food in homes often contributes to the decline of residents, and the CQC needs to get a handle on that as well.

[Jim Shannon]

I thank the hon. Gentleman for his intervention; he is right. I tried to make the point earlier about the food that residents eat and its nutritional value, and about the time that may need to be spent looking after someone and feeding them. I thank the hon. Gentleman for highlighting another very important issue.

The National Audit Office found that just 9% of services had been assessed as of July this year, despite the deadline for inspections being February next year—a deadline that has been pushed back. Obviously, the February deadline cannot now be met, because 91% of homes cannot be inspected in that time, but perhaps when the Minister responds we can get an idea of a new deadline in relation to the inspection regime.

However well intended the Care Quality Commission system is, there are clear failings in the current way of doing things, and today’s debate gives us the opportunity to discuss the way ahead in terms of improving the poor rate of inspection. The right hon. and hon. Members who are here will illustrate that very clearly. Concerns have been raised across the political spectrum, both in newspapers and by political representatives, and I hope that the solution to those concerns can also be found on a cross-party, bipartisan basis. After all, this matter concerns us all. It is not a matter of scoring points—it is never that with me anyway, but it certainly is not with anyone in this debate, because we all have the same focus and commitment to delivery of the same level of care and to ensuring that all homes reach a certain level.

We have had many issues in the past in Northern Ireland. I know that this is a devolved matter and the responsibility of someone else, but having the appropriate protection and regulation is so important to ensuring that abuses are not happening. The historical and the up-to-date abuse cases that we see in the papers need to become a thing of the past.

We can come together from both sides of the House, set the right course, address the issues and hopefully, through the Minister and the shadow Minister, the hon. Member for Worsley and Eccles South (Barbara Keeley), provide some direction in relation to the solutions. I hope that my contribution and the issues I raised have been noted by the Minister—indeed, I know that they have been—and that they will prove useful to eliciting a strategy and a response from Government to ensure that this matter is addressed correctly as a matter of urgency, as the hon. Member for North Devon said, and to the best of our ability.

--- Later in debate ---

[Andrew Percy (Brigg and Goole) (Con)]

I will be very brief, because I have already made the points I wanted to make about nutrition, and about family involvement and engagement in the inspection process. I congratulate my hon. Friend the Member for North Devon (Peter Heaton-Jones) on securing this debate on a subject that has always bothered me in my other role, which members of the Health Committee have heard a lot about, as a volunteer first responder with the ambulance service in Yorkshire. In that role, I have spent a lot of time in care homes, and there is a real mix of standards.

There are two things worth raising with the Minister that bother me and that, I hope, broadly come within the scope of this debate. One is the quality and dignity of care for elderly patients in care homes. When they need to be taken to hospital, they are often, sadly, taken on their own. I remember watching a very elderly lady who was having a suspected stroke on a hospital trolley at Scunthorpe hospital. She was alone and obviously very distressed. The ambulance crew were doing the best that they could, but they were booking her in and all the rest of it. I remember looking at her and thinking, “I would not want that to happen to my grandma.” That happens too often.

The second point is about the need for an understanding of palliative and end-of-life care in care homes. That is an issue of training and standards. I have been called to care homes where I have had to try to resuscitate people who are clearly at the end of life in a very unpleasant situation. We must get better at that, because we know what inevitably happens to many people in care homes before they even get to nursing homes, so proper training must be given. In that respect, proper standards of care and the quality of training of people working in care homes are in desperate need of improvement. In some areas and some care homes, those things are very good. I have a wonderful care home in my constituency, which has a cinema and a hairdresser, and it is lovely to go into. It does not have some of the problems found in other care homes. People have to pay for that, however, and only those who can afford to do so get it. Too many people cannot afford that, so they do not access the same quality of care or staff training. I hope that the Minister can respond to those two brief points.

--- Later in debate ---

[The Minister for Community and Social Care (Alistair Burt)]

It is a great pleasure to serve under your chairmanship, Ms Vaz. You will not find a lack of consensus here today; I am glad to start off in that way.

I congratulate my hon. Friend the Member for North Devon (Peter Heaton-Jones) on securing this debate, which has been really good. Colleagues have made some very moving and pertinent points. I find myself in the position that Ministers find themselves in; understandably, I have responsibility for an inspection and regulatory regime that we are all working hard to ensure does its job of protecting people in the manner that we all described. Inevitably, however, the issues that arise are always the things that go wrong. The question is how to strike the balance between, on the one hand, giving an assurance about the chief inspector of the Care Quality Commission, and the assurance that our degree of concern about what happens in care homes is absolutely appropriate, and, on the other hand, in no way being complacent about the issues that colleagues spoke about, and about where the problems are. That is what I hope to address.

I am really appreciative of the contributions made. I will come to the contribution of my hon. Friend the Member for North Devon in a moment. The hon. Member for Strangford (Jim Shannon) spoke with his usual decency and compassion. He wants speedier action, and he recognised our non-partisan sense of interest in those who require care. My hon. Friend the Member for Newton Abbot (Anne Marie Morris) made a number of interesting points, including about managers in care homes. When I have spoken to CQC officials and others, I have found that issue to be vital. If there is good management, it will be a good care home; if there is not, it will not be. The lack of registered managers is a genuine problem, and we are on to that. The issue of commissioning is also underplayed.

My hon. Friend the Member for Brigg and Goole (Andrew Percy) spoke movingly about the issue of loneliness and isolation. He talked about someone who was taken from a home in an emergency, needing urgent care, who found themselves on their own. That raises questions about the extent of care delivered to individuals in those circumstances, and I hope that anyone who heard that would question their procedures to ensure that it did not happen to anyone they were looking after.

This morning, I met Unison officials in the office and we had a word about training standards. We have to be absolutely certain that training is available for all who are active in care homes. As we know, there is the skills care certificate. However, I am led to believe that we cannot be sure that everyone is getting the training they need, and as a result of this conversation, I am really interested in finding out what more we can do to ensure that training is available for all.

[Andrew Percy]

One area of training where we really could help to take the pressure off the ambulance service is in relation to falls, which place a huge demand on our local health services. Paramedics often say to me that they feel those falls could be dealt with more appropriately by care home staff—or even avoided—if staff were trained properly.

[Alistair Burt]

I take my hon. Friend’s point, which confirms what I was saying about the need for training, and for appropriate treatment and rehabilitation to be available after falls. The role of occupational therapists should not be minimised after such incidents.

I am all too willing to hear from the hon. Member for Glasgow East (Natalie McGarry). The fact that this matter is devolved is of no interest; what is important is that we share best practice and best standards of care. I very much appreciate her contribution. The hon. Member for Worsley and Eccles South (Barbara Keeley) again challenged me on what we are doing, and really that is the meat of the remarks I prepared to give in response to the comments of my hon. Friend the Member for North Devon; I am grateful to him for sharing those with us before the debate.

Let me put one or two things on the record. The Government are committed to improving the quality of adult social care, and to ensuring that people receive high-quality and compassionate care. We have taken a number of firm steps in that regard, and that is partly because of the sort of issues raised today. However, we are in a relatively early phase of the use of the new powers given to the CQC, and in a sense this debate reflects the sort of baseline from which we all have to work.

My hon. Friend referred to the experiences of his constituent, whose mother died in a local care home, and he spoke powerfully about the frustration that his constituent experienced in raising concerns with the care home provider and other bodies, such as the CQC and the local clinical commissioning group. We offer our condolences to my hon. Friend’s constituent, and I share his frustration that the experiences of service users and their families have not always been central to the provision of care or the oversight of regulation. I know that my hon. Friend’s constituent has met senior staff at the CQC on more than one occasion, and I hope that those meetings were helpful to him. However, I appreciate that this debate is not an opportunity to reopen this case, which I know the CQC has investigated extremely thoroughly.

Picking up on some of the concerns expressed today, I want to reassure my hon. Friend that we have come a long way; we have made real improvements in the regulation of adult social care in quite a short time, but of course there is more to do. Our reforms to the CQC have been central to those improvements. The regulation of adult social care has three key roles: first, to identify poor practice and take action to protect service users from the risk of harm; secondly, to encourage improvement by identifying areas of weakness; and, thirdly, to highlight and share good practice and success. All these roles are built on the foundations of effective use of data and rigorous inspection. In that respect, the CQC has been transformed in recent years, not least by having been given new powers in 2014, which is obviously not all that long ago. Those powers need to be built on.

The CQC has put in place specialist inspection teams under the leadership of the chief inspector of adult social care. These teams include “experts by experience”—people who have personal experience of care—and inspections now take particular account of the views and experiences of the users of services and their families.

The great majority of CQC inspections are unannounced. In a very small number of cases, when there are good practical reasons for doing so, notice may be given, but in the vast majority of cases services are not tipped off or warned that an inspection team is on its way. Providers registered with the CQC are required to meet a new set of fundamental standards that govern the quality and safety of services. These standards only came into force on 1 April, but they are the standards of safety and quality that providers must always meet. The CQC has a range of enforcement powers that it can use against providers that breach these fundamental standards. These powers vary from issuing warning notices and fines and imposing conditions on a provider’s registration, to cancelling registration, which withdraws a service’s permission to operate, thus closing it.

The new fundamental standards include two important new registration requirements. The first—the duty of candour—requires providers to be open with service users about all aspects of their care, and to inform them when there are failures in their care. The second—a “fit and proper person” requirement for directors—ensures that accountability for poor care can be traced all the way to the boardroom if necessary.

The CQC’s model does not just assess whether providers are meeting the fundamental standards. The CQC asks five key questions of each service: is it safe? Is it caring? Is it effective? Is it responsive? Is it well led? All inspections deliver a rating for each of these five key questions on a scale running from “inadequate”, through “requires improvement” and “good”, to “outstanding”. Inspections also result in an overall rating for each location.

There was much talk about what has been found so far in relation to those ratings, with a small number of providers deemed to be “outstanding” and more providers deemed to be “good”. However, a number of providers were deemed to “require improvement” or be “inadequate”. In starting its inspection process, the CQC looked first at those providers that might have more difficulties than others. The CQC is aware of what is going on, and it started its inspections at the end of the scale where it expected to find difficulties. That was designed not to force closures, but to recognise where improvement and support, which my hon. Friend the Member for Newton Abbot mentioned, is so important. In 40% of those cases, improvement has been made; on a subsequent inspection, things were found to have improved. However, that still leaves a percentage of those providers having not improved, and I think it is those providers that have been highlighted today.

Having met Andrea Sutcliffe, I am quite confident that her determination is exactly the same as that of everyone in this room. However, it is clear that there are so many places to cover that we have to be certain of ensuring that the standards that we have spoken of, and that the CQC is working to, will be delivered by all providers. Those are standards in training, management and ensuring effective monitoring.

My hon. Friend the Member for North Devon used the phrase, “There’s nowhere to go”, in relation to someone having concern about an individual. I would not want that to be the message; I would not want anyone to feel that they had nowhere to go if they felt that someone was at risk of being, or was being, ill-treated in a care home. That is not the case. The truth is that if someone has such a fear, they can contact the CQC, which will act if it agrees that a person’s safety or wellbeing is at risk, and if need be the CQC will contact the police. I would not want anyone to think that if they knew of someone in a care home being ill-treated, there was nothing they could do as of this moment. They can and should do something.

However, it is also clear from the nature of the debate that if the CQC’s most recent report has set a baseline, there are things that we need to do and improve. The sort of information available to us through our constituents, and the sort of interest that specialists such as those here have taken, will give me good guidance on how to ensure those improvements are seen through.