§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. McNulty.]
10.53 pm§ Mr. Steve Webb (Northavon)As you will be aware, Mr. Speaker, there has been much discussion in recent months about the effects of the proposed care standards on elderly people, nursing homes and elderly residents in residential homes. However, a group that has, not for the first time, been paid rather less attention is people who are under pension age but also live in residential care. For brevity, I shall refer to them as young residents, although they span the age range. They can be anything up to pension age, but include younger adults and some children.
I bring that group to the House's attention because many younger people may spend many years, and possibly the rest of their lives, in care. They need security and stability, but I fear that they do not have that. I seek assurances from the Minister that she will consider the Government's proposals and ascertain whether that insecurity is justified and whether the anxieties can be tackled. The debate refers especially to younger people in care homes in the Avon area, which covers more than 2,000 young people in the independent sector alone. However, the issue obviously has a nationwide relevance.
I do not want to imply that the Minister or the Department have anything other than the best intentions. I do not suppose for a moment that they support anything other than the best care for residents of the homes that we are considering. That is also my objective. My purpose tonight is merely to ascertain whether the Government will achieve their objectives through their proposed standards. The debate is not party political, and I hope that the Minister will gather from my tone that I am worried about some of my constituents who live in care homes and about whether the proposals are in their best interests.
Many of my comments are coloured by a visit to one care home, the Manor House, in my constituency. It cares for adults with learning disabilities from a variety of age groups. I want to raise two specific issues. First, I am worried that, in some cases, the proposed standards may close homes, especially those in the smallish category, with perhaps nine to 15 residents. The standards suggest that those homes might have to shrink to eight residents or that the required structural changes will cost them one or two bedrooms. Consequently, homes that provide a relatively homely environment, which we all want, may be jeopardised.
The sort of proposals that will cause the problems that I mentioned include a requirement for one toilet for every two clients next to their bedroom, one bathroom for every three clients, no more than eight people sharing a staff group or a dining area, respite care with separate facilities from long-stay residents, and no double rooms after 2004. The case for each standard is understandable, but together, they could mean the end of the road for homes such as the Manor House.
Why would the Manor House face problems? It is a listed building. Many buildings in which people are cared for are old, and the Manor House has specific problems. Any structural change takes twice as long and costs twice 687 as much. We all support higher standards, but how will they be financed? The list of standards that we can improve for free is probably short. Most of the proposed care standards have a price tag. For example, different staff for different groups, and more toilets for fewer residents have a price tag. That also applies to management time spent on many of the aspects that we have discussed.
Many care home places are barely adequately funded through local authorities. With the best will in the world, it is unlikely that there will be an increase in local authority fees to care homes to pay for the improvements. Those running the homes believe that they will lose revenue and not have the money to pay for the changes. I fear that some will simply close.
What would be the effects of closure? I have received dozens of letters from parents and other relatives of residents at the Manor House. I have brought one with me that gives a flavour of the anxieties that are being raised. It was written by constituents who have a grandchild in her late teens, to whom I shall refer as Mary. The grandparents state:
We looked after Mary until she was 19 and we realised we were getting old and might soon be unable to look after her. We looked around for a suitable home … but we were dismayed to find there were no 'Happy' homes … until we 'found' the Manor House at Frenchay. Here was a happy home where they loved each other and were so concerned when someone was unwell; where they had lovely surroundings and the freedom to move around.There is no question of this being a bad home or an exploitative one. It has emerged in letter after letter from relatives of the residents that this is a good home. The grandparents make this interesting observation:
The owners and operators of this home are best qualified because they have a handicapped son of their own and know how to make a happy home for them all.This proprietor and their family have been in the business for decades; they know what is needed and provide a good quality of service. In the context of whether people are getting a good enough standard of service at the moment, the grandparents say that their granddaughter
has a lovely large room with two big windows and a full view of the garden in this beautiful old listed manor house.That is going to be part of the problem.In all the letters that I have received, this part of the grandparents' letter jumped out at me the most. They say:
In October … I shall be 83 and my wife 72. We thought we had Mary settled for the rest of her life, but now we are worried that The Manor House will not be able to meet the new requirements so recently laid down and may have to close.If my fears are unjustified, and if the Manor House can carry on, I will be delighted to write back to the grandparents, and to many others who have written to me, to say, "You need not worry. Your fear is that you may not be around for much longer, but your granddaughter will be properly looked after in a place where she is happy." I would love to be able to say that, but I have the anxiety that I may not be able to. I would be grateful for the Minister's reassurance on that. If places such as the Manor House close, I am not convinced that suitable alternative provision is likely to be in place in the foreseeable future.I want to raise another specific concern about the regulations, with reference to the case of another resident at the Manor House, of which I became aware in the last 688 few days. A lady in my constituency contacted me about her son, Mark, who is 15 and has a mental age of three. In the past week, she has been told by the local social services that homes will not be able to have dual registration for adults and children, and Mark is the only under-18-year-old in the building.
If I have misunderstood this, I have done so in all innocence, but I believe that Mark's mother is worried and has rung me to say that her 15-year-old may not be able to stay there if the new rules come in straight away. I am unclear about when and how they will come in. She says that the Manor House is the right place for him. He has been there for about five years, and it took him three years to settle. She says that he is not " a change person"; he likes stability, and to be in ones place. Any disruption, any change, even to somewhere brand spanking new and apparently brilliant, would be a serious problem for this family.
Mark's mother says that, yes, some of his peers in the home are 18 or 19, but many of them have similar mental ages—chronological age is not the acid test here—and get on very well and are well suited to each other. She also says that some of the slightly older or more mature residents are good role models for him. Saying that he should not mix with those people is not in his interests. His mother would not believe anyone who said that it was in Mark's interest to be moved out.
I understand the argument that says we should not house teenagers with 60-year-olds and try to claim that we can cater for those two very different groups with the same sort of provision. I understand the thinking behind that, but my theme is that, when we apply these generalities to specific cases, we have to ask whether such sweeping generalisations work in every case. When they do not work, how much scope is there for flexibility?
I have raised this issue with the Minister, and responded to the consultation process. The Minister wrote back to me in mid-October; I am sure she has a copy of the letter to hand. The one slightly bitter comment that I might make is that one of the sentences in her reply states that
homes that provide good quality care should have nothing to fear from the introduction of national standards.The providers to whom I have talked take great exception to that sentence, because they say that the homes that go under will be the ones that are on the brink financially. They will be the ones that cannot afford the alterations; the ones that will lose some of their fee income when they lose a bedroom; the ones that simply cannot make ends meet. They say, "If I go out of business, it will not mean that I ran a bad home." If the Manor House closes, it will not be because it was a bad home; it will be because it could not make ends meet, perhaps because it was a listed building and could not afford the structural changes. Any suggestion that the homes that go under because of the regulations are bad homes would be bitterly resented. I hope that that was not what the Minister was saying.The Minister also says in her letter that it will be for the Care Standards Commission to decide
in the particular circumstances of each individual home whether the home conforms to the standards necessary to meet the assessed needs of its residents.I must stress that although I talk about the care home owners—with whom I have had dialogue—we are concerned about the residents; the owners are the intermediaries. The key question is how much discretion 689 or flexibility the inspectors will have. If a home meets 90 or 95 per cent. of the standards, but fails on two or three of the long list, will the inspector be able to say that. having talked to the residents, he has found that it is a good home, providing good quality care? If so, will he be able to allow the home to continue? Or will the inspector have to say that the home fails to meet the standards and that unless it meets them within a specified time, it cannot carry on? There is a danger that in the laudable attempt to raise standards, we are over-prescriptive.For example, shared rooms are to be phased out. However, what if brothers want to be in a shared room, and their family and social workers think it works for them? Will the standards stipulate not merely that nobody should be forced to be in a shared room, but that nobody may be in a shared room? Is the system being too prescriptive when what works for the individual might be something different from the national model?
The Minister may ask what I would do, and one day I might get the chance. However, for the moment, I offer a suggestion. When we build new homes, we could build in the structural features that make sense. With existing homes, I envisage a situation in which every home that does not meet every standard has to report that fact in all the literature it produces, or whenever its staff talk to new or existing residents. The home would have to list any standard that it did not meet and say when it would meet it, and if it thought that it could. If the home could not meet the required standard, it would have to say why not, and why it did not think that that failure would be detrimental to the care it provided.
From the inspection point of view, I would argue that people who go into the homes should be asking, "What works?" The Government have been known to say on occasion that what matters is what works. What works in the Manor House may be an evolution of the present set-up towards ever-higher standards, but not a step change. If the sums do not add up now, they probably will not add up in 2007 either. However, inspectors will need to exercise some discretion.
There are very good homes throughout Avon, such as the Manor House at Frenchay, that risk closure because the Government's best intentions may have unintended consequences. I would be grateful if the Minister clarified the areas of uncertainty to which I have referred and perhaps offered some reassurance that the Government are still thinking these things through. I hope that she may be able to offer some flexibility on the interpretation of the standards.
§ 11.8 pm
§ The Minister of State, Department of Health (Jacqui Smith)I congratulate the hon. Member for Northavon (Mr. Webb) on obtaining a debate on this important issue. There is not much dispute about the principle of national minimum standards for people living in care homes. The old regulatory system evolved over the years in a rather ramshackle way and is riddled with gaps and anomalies. It is important to set the improvements we are making in that context. Existing standards for care homes are set and administered in inexplicably different ways by different authorities, and some homes are not regulated at all.
The Care Standards Act 2000 allows us to change that. It created the new and independent National Care Standards Commission to regulate care services, and introduced the 690 concept of national minimum standards that can be applied consistently to all providers of services in Avon or anywhere else. I will return to the hon. Gentleman's point about the approach that the commission will take to the regulation and inspection process.
The standards put residents' interests at the heart of the regulatory system. I make no apology for that. We should never forget that we are talking about people's homes, where they live, possibly—hand we hope—for many years. I certainly share the hon. Gentleman's objective of safeguarding good provision. We must also ensure that inadequate provision is improved through the implementation of our new care standards.
People who need residential personal care are entitled to as many as possible of the comforts of home life that the rest of us take for granted, and that is a big part of what the standards are about. The draft—I emphasise draft—standards for care homes for young adults were issued for consultation. I can assure the hon. Gentleman that the consultation was genuine and we have listened carefully. We talked, we listened and we reviewed the evidence. We consulted a wide range of service groups, carers, providers, purchasers and regulators of the services.
Many of the hon. Gentleman's points echoed what we heard from others. We will publish the final version of the standards within the next few weeks. Without being too cryptic, the final version will not be identical to the draft version. This evening I will go as far as I can to suggest the direction in which we have been moving, but I hope that the hon. Gentleman will understand that, much as I would love to, and despite his view that he may one day be in my position at the Dispatch Box, I cannot give him a sneak preview of the detail.
I will write to the hon. Gentleman about the specific issue of the home with the young man aged 15.
The hon. Gentleman asked about the cost of implementing the standards. We are well aware of the difficulties with which many homes are struggling. That is why earlier this year we set up the strategic commissioning group, which brought together some of the key individuals and organisations involved in commissioning and providing care services for adults, including representatives from the private and voluntary sectors. The group considered local commissioning arrangements and their impact on service users and providers. It published its report last month, supported by £300 million to smooth the flow of patients from hospital to care home. Its work will also help to bring some much needed stability to the sector by encouraging more long-term agreements between local authorities and providers.
We know that meeting the new standards will have cost implications for some homes, and we 'accept that ultimately they may need to reflect those costs in their fees. This is an issue that should be considered in what in some cases should be a much more participative commissioning process in local areas.
It is worth remembering that we have already raised funding for social services by nearly 18 per cent. in real terms since 1996–97. Next year and the year after we will raise it even more, by an average of 3.5 per cent in each year, giving local authorities some ability to reflect the increased costs in their fee levels.
The hon. Gentleman was concerned about the effect of the standards limiting the overall size of homes and, within homes, the size of the groups of residents sharing 691 staff and living areas such as dining rooms. The draft standards suggested that new homes should accommodate up to 16 people in groups of up to eight. Existing larger homes would be expected to organise into groups of eight residents by 2007. I am convinced that the principle behind that standard is right. It can make all the difference between an establishment looking and feeling like a large, anonymous institution and it becoming at least a little more like a family home. I know which I would rather live in, and I expect most people would feel the same.
Most people would sympathise with the principle, but many of those who responded to the consultation exercise felt that we had set the numbers too low. The concern was perhaps felt most acutely, although not only, in the substance misuse sector. Respondents from that sector argued that their residents tended to stay for limited periods of treatment rather than indefinitely, and that some forms of treatment depend on groups of more than 10 residents living and working through their therapy together.
I also recognise the points that the hon. Gentleman made about other care homes for young adults. The concerns were sincerely and persuasively expressed, and I can tell him now that the standard will be modified accordingly while staying true to its guiding principle. The limits will rise, and there will be some extra leeway for shorter-term stays.
The hon. Gentleman also raised the issues of the number of toilets and bathrooms available to residents, and that has generated much debate, both during the official consultation period and since. The draft standards suggested one toilet for each two people and one bathroom for three people, in both cases adjacent to bedrooms. Many people felt that we were aiming unreasonably high. It is an important question of balance. Not many of us—not even Ministers—have completely unlimited access to our own individual, private facilities 24 hours a day. On the other hand, not many of us would be thrilled about constantly using public toilets and baths, even when we were at home. At the risk of repeating myself, we are talking about people's homes, not somewhere they spend the odd night or week.
We believe that we can find a sensible compromise. Many people told us that the requirement for toilets and bathrooms to be next door to bedrooms was not practical, and we have been looking closely at that. Many people told us that one toilet per two people was a higher standard than exists in many private residences, so we have looked closely at that too. We have also been thinking about whether we can give existing homes more time to meet the standards, for some of the reasons that the hon. Gentleman outlined. In other words, we are willing to reconsider when people make a good case, but what still matters most is that service users live in as homely and comfortable an environment as possible.
The hon. Gentleman also raised the issue of single rooms, and the argument about single versus shared bedrooms has been one of the more lively ones. Not many of us would want to share our bedroom with someone we had not chosen to share it with, but it is not hard to see how providing single rooms for all from day one could make life very difficult for some homes. 692 The draft standards say that all service users should be offered a single room. Existing shared accommodation is to be phased out by 2004, unless people choose to share. I hope that that covers one of the points that the hon. Gentleman raised. New provision will be built with single rooms.
The objections have not all been financial or technical, although such objections are important and need to be considered. Providers of substance misuse services have argued that service users often need to share with a buddy—someone to discourage regression or self-harm. That seems like common sense. There is no actual evidence to suggest a link between how many people share a bedroom and how successful the outcome of their treatment is, but that is an important issue. Few things are more fundamental to privacy and a genuinely homely atmosphere for adults than having their own space which they share only with those whom they invite to share it.
Different circumstances might arise for special residential colleges for people who need care, and we are looking at that. We are also considering whether the standards could embrace the idea of a clinical need for sharing, as a form of protection for the service user. However, in general, we are clear that new build should be for single occupancy. Existing sharing might have to continue for a few years, but in future people should only share if they want to.
I hope that I have gone some way towards reassuring the hon. Gentleman to some extent, although I guess that he, and others who have expressed concerns, will reserve judgment until they see the final standards. I hope that I have at least convinced him that our consultation was not a cosmetic exercise, and that we valued and listened to all the responses and kept an open mind.
Once the final standards are published the focus will, of course, shift to the National Care Standards Commission, whose job it will be to interpret and use the standards as it inspects and regulates residential care for young adults. When the commission is deciding whether any regulation has been breached, it must take the standards into account, but the standards are not regulations.
The section from my letter that the hon. Gentleman read out still represents the Government's position. It will be important for the commission, as it develops its work, to work with providers, to use the standards and to ensure that the assessed needs of users, which are at the centre both of his approach and of the Government's, are fundamental
It is right both to issue regulations and to set national minimum standards, because there are homes that are not good enough for users, and it is clear that action needs to be taken. The objective is to ensure, first, that we have a coherent set of regulations and standards across the country wherever such provision is made, and secondly, that we implement those in a way that is both flexible for providers and enables users to—
§ Mr. WebbIs the Minister saying that one cannot under any circumstances breach a regulation, but that the regulations will not necessarily be absolutely exhaustive in defining standards?
§ Jacqui SmithThe national minimum standards and the regulations are different. Given the consultation process that we have gone through, the minimum standards are important.
It will not be for me to tell the commission how to go about its day-to-day business, but I am confident that it will act reasonably sensibly, and in the best interests of 694 service users. That is something to which we can all look forward as we move towards raising standards for service users while maintaining good-quality provision.
§ Question put and agreed to.
§ Adjourned accordingly at twenty-two minutes past Eleven o 'clock.