Care Bill [Lords]

Emma Lewell-Buck Excerpts

Monday 10th March 2014 Commons Chamber

[Mr Robert Buckland (South Swindon) (Con)]

My amendments 27 and 28 are on safeguarding. Clause 42 contains a raft of measures that will go some way to enhancing the powers and role of the authorities in dealing with disturbing and worrying cases of abuse or neglect, which we hear about all too often when it comes to the care of vulnerable adults.

Amendment 27 relates to the definition of abuse in clause 42(3), which rightly makes reference to financial abuse. We are all aware of the rising phenomenon of financial abuse, where older people and those with learning difficulties have been preyed on, sometimes by their own family, for financial gain. My worry is that, while a distinct reference to financial abuse is welcome, there is a danger of creating an imbalance that will make other forms of abuse less relevant or important.

Statistics from the Health and Social Care Information Centre on the number of safeguarding referrals in the last year for which records are available show that the most common causes or types of abuse are physical abuse and neglect. My concern is that they do not appear in the Bill. It would perhaps be better to have an amendment, along the lines of the one I have tabled, that acknowledges different types of abuse and refers the matter to guidance that could be carefully and comprehensively drafted, so that practitioners can be safe in the knowledge that one type of abuse does not take precedence over another. This is an issue that has been raised in the other place and in Committee here. The Government have said they are concerned that defining abuse further might restrict the scope of a local authority’s duty to inquire, but my concern, and the concern of organisations such as Mencap, is that not having a reference to other forms of abuse might lead to an undue focus on financial abuse only, to the detriment of others.

Amendment 28 would place a duty on relevant partners, such as those providing care and support, to notify the local authority if they believe an adult is at risk of abuse. It is clear that local authorities cannot be expected to identify all types of abuse themselves, or to rely on the good will of other people or agencies. If relevant partners, including providers of care, had a duty to report that adults were at risk of abuse, that would make their responsibilities clear, and would help to secure greater transparency. I, and others, fear that leaving the matter to guidance would pose a risk that the duty would not be taken seriously enough. A legal duty for relevant partners has already been introduced in Wales, and the amendment seeks to mirror that.

We are familiar with the existing framework relating to adult safeguarding boards and the joint agency working that takes place, but concerns that arise day in, day out are not always reported, and, sadly, there is also under-reporting of concerns from hospitals. While there are many examples of local excellence in the development of safeguarding procedures, I fear, as do others, that there will be too much of a patchwork and not enough of a national framework. It is essential for us to know, wherever we live, that the standards of reporting and obligations placed on agencies and other partners to make that all-important report about abuse are consistent. Because adults are often much more isolated than children and young people who are surrounded by a framework, a duty to report when an adult is at risk could be considered to be more crucial.

[Mrs Emma Lewell-Buck (South Shields) (Lab)]

I shall speak briefly about new clauses 17 and 18 and amendments 31 to 33, which stand in my name.

New clauses 17 and 18 go to the heart of the social care profession. They say a great deal about how much we value the care of vulnerable and older people. New clause 17 would reveal the full extent of poor employment practices in the care sector, including zero-hours contracts and failure to pay the national minimum wage. Good social care thrives on the provision of well-trained, motivated staff who can develop proper relationships with the people whom they visit, but we know that that does not happen. According to the Social Care Workforce Research Unit, more than 150,000 people in the care work force earn less than the national minimum wage. Poor pay not only affects employee morale, but makes it difficult to attract skilled staff and encourages high staff turnover. None of that is good for service users, who need to have confidence and trust in the people who visit them.

The Government promised to get tough on employers who do not pay the national minimum wage, but so far only five employers have been “named and shamed”. Not one of them was in the care sector, which is worrying given how widespread we know the problem to be. New clause 17 would give a clear picture of the state of the sector, and would create a foundation for possible action.

New clause 18 would create a requirement for local authorities to consider how the employment practices of providers they commission might affect the quality of care. The aim is to build checks into the system so that standards are not allowed to slip. Training is a particular concern: more than 40% of respondents to a Unison survey reported that they had not been given specialised training to deal with the specific needs of clients with conditions such as dementia. Nearly a quarter reported that they were required to carry out medical procedures or give medicine to clients when they had not been trained to do so. More worryingly, a care worker who spoke to me recently told me that it was standard practice in the agency to leave tablets for clients by their bedsides to save the cost of another visit later in the evening to ensure that the client had taken his or her medication. That means, essentially, that hundreds of vulnerable, confused people who are not in control of their own care are left to control their own medicine.

The issue of 15-minute care visits has rightly attracted considerable attention, not just because they often make the practicalities of care impossible, but because they eliminate almost any chance for a relationship to develop between carer and client. An under-reported crisis among older people is growing isolation, and the carer may be the only person to whom many of them speak on most days. That has real, measurable impacts on people’s well-being, and is made worse by those flying visits. New clause 18 would force authorities to take such factors into account when commissioning services.

A care worker on a zero-hours contract told me that it was common for 15 or 30- minute visits to be scheduled back to back, which gave him time to do only the bare minimum. He had no time to speak to his clients, or to go the extra mile to keep them comfortable. He often drops in on them in his spare time just to ensure that they are okay. On one occasion, he arrived at a client’s home to find that the man had fallen and needed to go to hospital. The man asked whether the care worker—a constituent of mine—could go with him, and my constituent rang his employers to see whether that was possible. He was told that it was not. It is extremely worrying to see cases in which social care has lost that basic element of compassion. Employers must be required to build some kind of flexibility into their practices.

My own experience in adult social care has convinced me that a general duty of well-being is simply not enough.

[Mrs Madeleine Moon (Bridgend) (Lab)]

Because of the local government cuts, people are no longer thinking about that general duty of well-being. What is almost a “something is better than nothing” attitude has crept in and replaced concern for the well-being and care of the individual, who should be receiving quality care.

[Mrs Lewell-Buck]

I entirely agree. The budgets of council adult social care departments are now so stretched that they fill a gap wherever they can, as cheaply as they can.

[Andrew George (St Ives) (LD)]

The hon. Lady is making an excellent point. In new clause 32, I propose that the Secretary of State should undertake a review of care standards, including hourly pay and other kinds of remuneration for home care workers. Does she agree that unless we have decent national standards for visiting times and remuneration, we shall be faced continually with a race to the bottom?

[Mrs Lewell-Buck]

I apologise for not having read the hon. Gentleman’s new clause. I have been focusing on my own new clauses and amendments, but I will look at his new clause at a later stage.

Amendments 31 to 33 would establish firm time scales for assessments and reviews of service users’ care needs. During the Bill’s passage so far, the Opposition have repeatedly tried to raise the issue of the funding gap in adult social care, which threatens some of the positive changes that the Bill would bring about. In my constituency, our local authority has been forced to make £24.3 million-worth of savings, with predictable consequences. One of the consequences for local authorities has been a decline in the regularity of assessments and reviews. I have spoken to people whose assessments have been grossly delayed; I have also visited care homes in which some residents have not been reviewed for up to three years, during which time their needs may have changed dramatically and their support may have become inadequate.

It is easy to understand how that happens. Under-resourced departments must set priorities, and routine steps such as the reviewing of someone’s care plan are often at the bottom of the list because there is no pressure for them to be taken in a timely way. However, those steps are very important, because they identify changes in a person’s condition which, if ignored, might lead them to a crisis point. The amendments would reverse a worrying trend which has seen delayed assessments rise significantly since 2010, when 18.7% of new clients waited four weeks or more for an assessment. By 2011-12, the latest year for which figures are available, the figure had risen to 22.7%. In some individual local authorities, the change is even more worrying. In one authority, the number of new clients waiting to be assessed jumped from 12.6% to 70.7% between 2010 and 2012. It is important to remember that those are not just percentages, but represent vulnerable people whose needs are not being met.

In Committee, the Minister said that he was concerned about assessments being rushed to meet the timetable, and that a simplistic time scale would not be tailored to meet individual needs. I agree that that is of concern, but it should not be necessary for the time scale drawn up by the Secretary of State to be a “one size fits all”. The timetable for more complex cases could take into account the more complex nature of the assessment and allow more time for completion. It would be much more dangerous to have no benchmark at all and for those people to have their assessments delayed and their needs not met. The amendments would improve the situation for people with more complex needs, for whom putting support in place quickly is most important.

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[Norman Lamb]

Thank you very much, Madam Deputy Speaker.

For some people, the care planning process may be relatively simple, but for people with complex needs it is important that the plan is carefully produced and agreed with the person in order to meet their care and support needs effectively and appropriately.

[Mrs Lewell-Buck]

Will the Minister give way?

[Norman Lamb]

I do not have time, I am afraid.

We will set out in guidance best practice on conducting care plans. I hope that that reassures the hon. Member for South Shields (Mrs Lewell-Buck).

Amendment 26 is unnecessary because the concepts of independent living and inclusion in the community are already core parts of the duty to promote individual well-being. We have merely captured them in more concrete ways rather than using those terms, which are too unclear, as the Law Commission agreed.

Schedule 2 to the Children Act 1989 requires local authorities to keep registers of sight-impaired children, and amendments 22 to 25 would only duplicate that. We have committed to explicitly reinforcing this duty in the forthcoming code of practice for children and young people with special educational needs or disabilities.

I turn briefly to the Government amendments. Amendments 1 and 2 simply clarify the scope of the regulation-making powers as set out in the other place by Lord Howe, the Under-Secretary with responsibility for quality. They ensure that regulations can specify where local authorities do have the power to be more generous and contribute to the costs of an adult with resources above the financial limit, as well as where they do not.

Amendment 3 allows regulations to specify where certain costs do not have to form part of the personal budget and thus do not count towards the cap on care costs. It has always been the intention that some provision, such as reablement, should be a universal, free service and therefore should not be incorporated in the personal budget. Such exemptions will not apply to general care and support that a local authority can charge for.

Amendments 4 and 5 correct small drafting omissions in clause 34. Amendment 6 will enable us to make provision in the regulations for the appeals system for the investigation of the appeals body itself—for example, regarding allegations of maladministration. Amendment 14 sets out that, as per usual practice, we will use affirmative regulations if we need to amend primary legislation as part of the appeals regulations.

Finally, on amendment 7, the feedback from local authorities is that it would make sense for them to have flexibility to be able to delegate functions relating to direct payments if they so wish. We agree and have accordingly tabled an amendment to remove the prohibition related to that.

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[Mr Dorrell]

I am grateful to the Minister for his encouragement that I am on the right path.

There is a serious question here. I agree with my right hon. Friend the Member for Sutton and Cheam that, at a local level, the health and wellbeing board is the organisation best placed to move forward with the process of more joined-up commissioning. How we, as MPs, satisfy ourselves that this is happening to the required standard, with the required levels of economic efficiency across the system as a whole and above the level of the health and wellbeing board, is one of the questions left unanswered by the institutions we currently have. I am not entirely persuaded that the CQC should be encouraged into what I regard as a vacuum.

[Mrs Lewell-Buck]

I will speak to amendment 19 and echo some of the excellent comments made by my hon. Friend the Member for Copeland (Mr Reed).

Amendment 19 would reinstate the Care Quality Commission’s duty to inspect the commissioning of adult social care services by local authorities. The case for the amendment is very simple: the quality of commissioning has a huge impact on the quality of care that people receive. It is extremely important that our adult social care system includes checks to ensure that commissioning is of a high standard. At present, this is not the case.

The current model of sector-led improvement introduced by this Government in 2010 leaves it to local authority peer reviews to identify failure. In practice, this means that neighbouring authorities that already work in close collaboration inspect each other, but only when a neighbouring authority volunteers for inspection. Of course, local authorities that are confident in their commissioning practices are happy to volunteer themselves for scrutiny, but what about those that do not volunteer? It is surely those authorities that we should be most concerned about, yet under the current system they are not subject to proper oversight. Worryingly, the majority of authorities have not been assessed under the peer review scheme. In total, 127 local authorities have not had their commissioning reviewed since 2010. We would not allow this type of reckless leniency with any other service that looks after our most vulnerable. I am certain that it should not continue.

It is clear that when it comes to inspecting local authorities’ commissioning practices, some uniformity and impartiality are needed. The CQC is best positioned to carry out that duty. Certainly, the chief executive of the CQC thinks so, commenting that he has not

“spoken to any national provider association who doesn’t think councils should be inspected”

and believes that

“the removal of that power from CQC was seen as a retrograde step”.

When this proposal was raised in Committee, the Minister insisted that it was unnecessary. He argued that CQC inspection of providers could identify patterns of poor commissioning that would be grounds for a special review.

[Mr Tom Clarke]

My hon. Friend is making a convincing case. I have a background in local government. Does she agree that if statutory obligations are placed on local authorities, it is important that that they should be followed by the appropriate resources, but that that is not always the case?

[Mrs Lewell-Buck]

I agree completely, and I will echo my right hon. Friend’s comments later in my speech.

I have some doubts about how effective CQC inspection of providers would be in practice. It is not clear at what point the CQC would recognise that poor provision was caused by poor commissioning practices. A handful of poor examples could be just that, or it could be evidence of a more systemic problem. Given the need for the Secretary of State’s approval before a special review is undertaken, I am concerned that the threshold of proof needed will be extremely high. Furthermore, CQC inspectors will not visit all providers in a single local authority area at the same time. In practice, it could take some months before information is collated and a pattern of failure detected that might indicate sub-standard commissioning. There is also a doubt about who will be joining up the dots to link months’ worth of inspections to a local area’s commissioning practices. In short, how will anyone ever know that poor providers are linked to poor commissioning by a particular local authority? The reality is that by the time the CQC recognises that there is a case for a special review, numerous safeguarding issues could have arisen.

I am concerned that, under the model the Minister advocated in Committee, action will be taken only once patterns of poor care have already taken root in a local authority. Surely that is the wrong way round. We need to prevent poor care arising from substandard commissioning, rather than wait for problems to become embedded in the system. This not only makes sense financially: from a safeguarding perspective, it is essential. I am concerned that without rigorous oversight, social care departments will find it easier to allow standards to slip.

In Committee, the Minister argued that the duty for local authorities to consider well-being would incentivise good practice. I do not believe that this is enough. I do not want to be critical of any local authority’s will to ensure the well-being of their service users, but I know from personal experience that these departments face intense pressure. If something is not built into the system, it is less of a priority. If departments know that the CQC will not be knocking on the door this year, they will concentrate on more urgent matters—trust me, in adult social care there are always urgent matters. Knowing that they are subject to regular oversight makes departments foster a culture of good practice.

In discussions I have had with providers and commissioners, they say they are in favour of reinstating the clause. Commissioners, whose day job is to fill gaps in services and to do so in the most cost-effective way, are worried that their decisions are not properly scrutinised, and that any mistakes they may unwittingly make will go unchallenged. Providers want it to be clear when they are at fault or when failure is down to poor commissioning. They do not want under-resourced providers to be punished simply because the rates that they receive from the local authority are too low to provide decent care.

I remain puzzled about why, although in June last year the Minister admitted that sector-led improvement had serious shortcomings for weaker-performing councils and, presumably because of his doubts, the Bill originally included the new clause, yet in October, for some reason, it was removed on Report in the other place, and the Minister has now moved from being in favour of CQC inspection of commissioning to being against it. I was also puzzled when the Minister repeated his concern about sector-led improvement in Committee. Following an intervention from the right hon. Member for Sutton and Cheam (Paul Burstow), he said that he shared the right hon. Gentleman’s view that

“the danger with sector-led improvement is that those bodies who are up for change and improvement take part and those who are dysfunctional and failing do not engage.” —[Official Report, Care Public Bill Committee, 28 January 2014; c. 442.]

Given that the CQC, providers and commissioners—along with the Minister— recognise the blind spots that exist in the sector-led improvement system, I hope that the Minister is open to convincing on the issue. If he is not convinced, I hope that he will be able to explain what he could not explain in Committee, namely why he and the Government changed their minds.

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[Paul Burstow]

rose—

[Mrs Lewell-Buck]

rose—

[Norman Lamb]

I will give way to my right hon. Friend the Member for Sutton and Cheam (Paul Burstow) first.

[Norman Lamb]

Subject to the fact that the CQC is an independent body, I will certainly reinforce that point in my discussions with it. In the context of mental health, we were discussing with the CQC only last week the importance of the role of commissioning as well as that of provision. I entirely accept that good care can be provided only if we get both the commissioning side and the provider side right: the two must go together.

Is it appropriate to set out the specifics of a review of commissioning in the Bill? I do not believe that it is. Flexibility is vital. While the CQC has a power to conduct special reviews and investigations of commissioning, that must be set in the context of other measures in the Bill that will strengthen the duties that local authorities must fulfil in exercising their care and support functions.

[Mrs Lewell-Buck]

Perhaps I am being impatient—the Minister may deal with this point later in his speech—but I should like to know who will routinely review local authority commissioning. If no one will be doing that, how will the CQC know that poor commissioning is taking place in a local authority area?

[Norman Lamb]

I take very seriously the point that the hon. Lady has raised, but if she will allow me to continue to present my argument, I shall be happy to return to it later if necessary.

The important new measures include an express duty to promote people’s well-being—a duty to shape local care markets to ensure that they are sustainable and diverse, and offer high quality care and support. The Department will work with the local government and adult social care sector to produce statutory guidance on local authority commissioning of care and support. However, a CQC review of commissioning remains an option. I reassure right hon. and hon. Members that we will review evidence of concerns about local authorities’ commissioning practice to establish whether it is appropriate to ask the CQC to undertake a targeted review under section 48 of the Health and Social Care Act 2008. Getting the message out to commissioners that the powers will be used is important in itself to concentrate minds. They will be under the spotlight if they fail in their commissioning responsibilities.

New clause 12 would require the CQC to consider integration of care as part of its performance assessments of registered providers of health and adult social care. In Committee, my right hon. Friend the Member for Sutton and Cheam made a strong case for the new system of performance ratings to be carried out by the CQC to look at care pathways, rather than focusing on separate institutions in isolation. He makes a very good case. I explained that a central tenet for the Government is that the independence of the CQC improves its effectiveness as a regulator. Clause 89 removes nine separate powers for the Secretary of State to intervene in the day-to-day workings of the commission, and we have deliberately removed the Secretary of State’s power to devise or approve the system for performance assessments and ratings.

The CQC has to be responsible for the system of performance assessment that it introduces, and placing specific requirements on the commission in legislation would not help in that regard. That is not to say that the CQC should not look into the integration of care. I told the Committee that I would pursue that matter in my discussions with the CQC, and I have done so. I have spoken to the CQC chair, David Prior, and to the chief executive. I am pleased to say that in that regard we are pushing at an open door. They absolutely understand the case that my right hon. Friend makes.

In recent weeks, the commission’s chief executive, David Behan, has set out plans for the CQC to carry out thematic inspections to look at the care pathways for different conditions. One such thematic programme will look at how people with dementia are handled by relevant services in a geographical area—acute health care, primary health care and adult social care, for example. Another is looking at how people move across transition points, such as when a disabled child becomes an adult—a point at which too often services fall down.