§ Mrs. Gillian Shephard (South-West Norfolk)I am extremely grateful to have an opportunity to raise this matter, which is of enormous interest and great concern to my constituents.
It is my intention not to pre-empt consideration in the House of the Care Standards Bill, which is passing through the other place, but to focus on the impact on privately run care homes in Norfolk of the draft rules for such homes, which are contained in the consultation document "Fit for the Future". That document was commissioned by the Government from the Centre for Policy on Ageing and published in September 1999.
I emphasise from the outset that I fully support the objective of achieving higher and more uniform standards in care homes. The Minister of State will know that all the relevant bodies share that objective, including the National Care Homes Association, Help the Aged, the Registered Nursing Homes Association and the Royal College of Nursing. People in such care homes are, by definition, among the most vulnerable in society and they deserve the protection of verifiable standards.
It would be hard to overstate the anxiety among private care home owners that has been provoked by the rules that are proposed in "Fit for the Future", especially those regarding physical accommodation. The Minister will be aware that their anxiety has been in no way allayed by the fact that, for reasons that are best known to the Department of Health, many care home owners were unable to get copies of "Fit for the Future" until after 3 December last year, which was the closing date for consultation. I am glad that the Department took the welcome step of extending the consultation period.
"Fit for the Future" states that single rooms in care homes must have at least 10 sq m of usable floor space, and that there must be 12 sq m for wheelchair users. New single rooms must have at least 12 sq m of usable floor space, rooms should not be shared by more than two people and people should have made a positive choice to share. Communal space must amount to at least 4.1 sq m per resident. Those requirements sound extremely reasonable. Of course, those of us with experience of care homes, or who have relatives or friends in such homes, want people to be comfortably housed in rooms that are sufficiently large, and which equate with the people's choices. However, the rapid—or, worse still, retrospective—imposition of such standards would impact on the vulnerable members of society whom the Care Standards Bill is designed to protect.
Staffing requirements would include one member of staff to every five residents for morning work, one to every seven for afternoons and evenings, and one to every 10 at night, with a minimum of two remaining awake. Additional staff would have to be on duty at peak times, and at least one third of care staff would have to be registered nurses. In my experience of private care homes in Norfolk, staffing ratios and the requirement for additional staff at peak times would present little difficulty. In fact, most homes already work in that way, and it is clearly sensible to have more people 177WH on duty when they are needed. However, the requirement for registered nurses presents some difficulty in respect of costings, and so on.
In Norfolk, there are about 415 private homes. The majority care for the elderly and the remainder look after people with learning disabilities, mental health problems or physical disabilities. In its response to "Fit for the Future", a consultation document that was sent to the Department of Health last month, Norfolk Independent Care Homes calculated that the average-sized home registered in Norfolk has about 20 residents. It is interesting to note that, although there are about 1,000 places in local authority homes in our country, there are 4,800 places in private care homes. That gives added point to private care home owners' anxieties, and must be of concern to Ministers. Although there are some new purpose-built care homes, given the rural disposition of a county such as Norfolk, the vast majority are evenly spread throughout the county in converted manors, halls or old rectories. Therefore, one home might serve three, four or five small village communities within a five-mile radius.
Norfolk care home owners have calculated that they employ one member of staff for each resident, which is another issue of concern. By definition, many of those staff are women, who work flexible hours and frequently walk or cycle to work. Given the even spread of provision, the homes form a source of employment that is easy for people to access. Each home is well known in its locality, and it is important to prospective residents to know that, on entering residential care, they will meet local friends and acquaintances. It is not putting the matter too strongly to say that the choice of a residential home is one of the few freedoms left to those who enter them.
§ Mr. Keith Simpson (Mid Norfolk)I wish to support my right hon. Friend. In my constituency I have shared a similar experience. Does she agree that it is not merely the owners of small homes but residents and their families who feel vulnerable, and that we must not only enhance standards in care homes but protect their local nature?
§ Mrs. ShephardI agree with my hon. Friend, and I suspect that the Minister, who has taken a good deal of trouble to meet associations and proprietors of care homes, is also well aware of the problem. He, too, represents a rural and far-flung constituency, so he will appreciate the force of my argument. In rural counties such as Norfolk, requiring the removal of two, three or four beds might render the home in question unviable as a business. It would have to close down, and the geographical relevance of the home would be gone. The home would cease to serve the locally based needs of the residents. The magazine Caring Times, in its edition of 2 February 1999, quoted an anonymous source as saying that if the Centre for Policy on Ageing were to succeed in introducing the standards, the only people who would be able to meet them would be those running 100-plus bed purpose-built homes, thereby restricting individuality and choice. I agree with that comment. In Norfolk, there are a number of well-run large purpose-built homes. Although those would be the choice of 178WH many, at least as many people would choose smaller, more individualistic accommodation for their relatives, especially if it is close at hand, as frequent visiting would be easier. Many people entering residential care prefer a homely atmosphere to more institutional care.
Norfolk social services responded to the Government's consultation, and in a letter dated 20 November 1999, it stated:
Norfolk is a geographically large and predominantly rural county. The current stock of residential care homes is diverse in terms of both size and location. In a county where elderly people still predominantly have their family roots within a particular village or small cluster of villages, the location of a residential care home is a critical element of choice … The proposed standards are likely to speed this trend and cause significant disruption to existing residents as small businesses fail as well as limit choice to prospective residents. There has been a need locally to formulate specific strategies to redress the forced migration from villages of young couples—the forced migration of our elderly people through the lack of local residential care homes must be avoided.Since the Government took office, residential care home owners in rural areas have had to deal with a number of difficult issues. They have had to deal with the impact on their businesses of the working time directive, and the Government's reduction of council grant to shire local authorities, which has resulted in social services cuts. Hikes in fuel taxes have affected all rural businesses. Pay increases for nurses, which were richly deserved, mean, of course, that more care homes are being forced to provide only residential care, as they simply cannot afford to pay the staff to provide nursing care. All that is within the context of rising numbers of frail, elderly people in society, and falling numbers of hospital beds. Instead of piling further pressure on care homes, the Government should be seeking to demonstrate that they have understood the impact on frail and elderly people and their families, as my hon. Friend the Member for Mid-Norfolk (Mr. Simpson) pointed out, not to mention that on the NHS and local authorities. By forcing the pace of improvements in the private care sector, they might push hundreds of private care homes out of business.We need to be aware of the findings of the Forum of Private Business care sector survey dated July 1999. Seventy-five per cent. of respondents claimed that if the "Fit for the Future" proposals were carried out, their businesses would no longer be viable. What would happen to the 500,000 or so frail people who would have to be rehoused? Extraordinary distress would be caused to the families. Who would re-employ those thrown out of work? The Norfolk Residential Care Homes Association welcomes the introduction, in principle, of mandatory minimum standards. Mr. Colin Gething, the association's chairman, points out in a letter dated 12 January 2000, that
it does appear to our membership that, whilst the emphasis may not be biased towards physical standards, the degree of variation of the physical and measurable aspects from that which is currently required by many authorities will impose unrealistic demands both practically and financially, and yet not improve the standard of care one iota.For many small to medium-sized homes of 10 to 18 registered places, the imposition of standards such as minimum sizes for rooms and communal space will be unattainable, and the loss of two or three rooms to a financially marginal business will culminate in the 179WH closure of a home and the loss of not two or three, but all. Sadly, such a closure has already taken place, in my constitutency, even before the end of the consultation period. The proprietor of the former Lion House residential home in Downham Market wrote, on 16 October 1999:The national standards room size of 10 square metres for existing homes will leave us only 5 registered rooms, from 15. This will bankrupt us. Therefore, I am closing Lion House at the end of November … Two years ago, it was valued as a business at £345,000 … Now, as a house with vacant possession, it is valued at £200,000. So not only have we lost a good business which we have spent 15 years building up, we have also lost £145,000.The arrangements for finding alternative accommodation for the frail, elderly residents were handled by social services with extreme difficulty, although that is not a matter for this debate.That example illustrates the difficulties posed by the present approach. Mr. Barry Hartley of the National Care Homes Association said, in the October 1999 issue of Caring UK:
I'm very disturbed that the Government has missed a golden opportunity to look at the true values of care and whether people are being cared for appropriately. One of our prime reasons for wanting national standards was to ensure a system which measured those things which are important rather than those things which can easily be measured. We are disappointed that standards have not been developed which relate to individual personal quality of care … The 'apparent intention to cull between 12 and 23 per cent. of the sector' is alarming.Those and other matters will be thoroughly debated when the Care Standards Bill comes from the other place to be debated in the House. However, I want to demonstrate that the Government's handling of the consultation process on this vital issue, in addition to their apparent lack of concern about the fate of 12 to 23 per cent. of the sector, does not bode well. I am talking not only about the businesses but about the frail people for whom they care.I hope that the Minister will dispel some of our fears in his response to the debate. Will he make it clear that the Government have understood, from the response to their consultation, the disastrous effect on the sector of over-hasty implementation of the accommodation requirements? Will he also make it clear that there is a need for careful consideration of the effect on the overall availability of residential care places of imposing the new standards? Will he also consider the alternatives that the public would expect the Government to provide in the event of large numbers of homes going out of business? Will he give an estimate of the cost to the sector of implementation? Will he set out a timetable, first for publishing the final standards so that home owners will know what is required, and, secondly, for the implementation time proposed, so that they can begin to plan the development of their businesses? Does he plan to compensate private care home owners for the loss in value to their businesses, or for the loss of their business altogether?
I believe that the Minister understands the importance of the role played by the private sector in residential care, and the problems that the Government would have if they ignored the sector's difficulties in maintaining the current number of places under the "Fit for the Future" proposals. I hope that the Minister also understands that behind my concern is the knowledge that to enter residential care is a massive step for anyone 180WH and their family. To plunge the sector into anxiety or uncertainty, for an unspecified period, is unacceptable. I hope that he will be able today to dispel some of that uncertainty for the sake of everyone concerned.
§ The Minister of State, Department of Health (Mr. John Hutton)I warmly congratulate the right hon. Member for South-West Norfolk (Mrs. Shephard) on choosing this subject for our debate today and on the way in which she has addressed her concerns.
I am particularly grateful to her for accepting the argument for national standards, because we should not allow that issue to go by default. We are not trying to do any of the things that she suggested: we do not intend to cause concern, anxiety or fear for the future in this major sector of the social care industry. The services provided by private care homes, both nursing and residential, are hugely important in our country, and the Government do not intend to jeopardise the sector's ability to respond to our population's social care needs. We would be crazy and stupid if we were to develop national minimum standards from that starting point. We do not intend that the "Fit for the Future" proposals should have the unforeseen consequences suggested by the right hon. Lady. Therefore, I shall try to reassure her and her hon. Friends about some of the concerns that she has raised today.
The right hon. Lady is right to say that Norfolk and Cumbria, the county in which my constituency is based, have many similarities. Although my constituency is not predominantly rural, the county of Cumbria is, and she is right to say that in rural counties there is a particular dimension to the argument about the provision of longterm residential care services, to which the Government are sensitive and of which they are mindful.
The right hon. Lady raised a number of detailed points, and I shall return to some of them during my remarks, but today's debate also gives me the opportunity to correct some of the misconceptions and misunderstandings about the "Fit for the Future" proposals and to address the legitimate concerns expressed by many in the industry over the past few months. As the right hon. Lady was gracious enough to point out, I have made every effort to resolve those concerns in my meetings with representatives of this crucial industry.
We start from the point that the development of national standards for care homes and other social care services is long overdue. Enforceable national rules should ensure that poor standards and shoddy treatment are rooted out for good and that, regardless of location, all residents in care homes will be afforded the same protection and access to decent facilities.
National minimum standards for care homes are, therefore, part of the Government's plans for reforming the current regulatory arrangements for social services, nursing homes and the private health care sector. The reforms, first announced in the White Paper "Modernising Social Services", were put in train on 2 December, when the Care Standards Bill was introduced in another place.
The Bill will introduce new systems that will help to deliver our aims for a modernised regulatory framework. The current system has long been the subject of criticism by regulators and care providers for lacking independence, consistency and coherence.
181WH The Care Standards Bill will establish an independent National Care Standards Commission responsible for regulating social care and private health care. The commission will be responsible for laying down standards of care and ensuring that those standards are met through a system of registration, inspection and enforcement. In addition, in line with the recommendation made by the royal commission on long-term care, it will also have responsibility for monitoring and reporting on trends in the provision of long-term care, investigating complaints and taking tough action where necessary, reflecting the views of service users and encouraging better services through reporting on service performance.
We want the National Care Standards Commission to be a powerful new body which will make a major contribution to improving standards of care and informing and empowering consumers. Raising the standard of social care provision and increasing the protection of vulnerable people are paramount considerations for the Government, and the main reasons for having national standards.
National standards will be central to the commission's responsibility for ensuring minimum standards of care. They will form the basis on which the commission's inspectors judge the fitness of the homes and agencies that they regulate and make decisions about registration and cancellation. The standards will be applied consistently to service providers across the country. At the moment there is often a wide variation in the standards required by different local and health authorities, leading to confusion and frustration between providers and regulators. National standards will mean that providers will be clear about the standards that they have to meet and that users and their carers will be clear about the standards that they can expect.
I think that the right hon. Lady referred to the National Care Homes Association. It welcomes the Government's commitment to national standards and notes, in its response to "Fit for the Future", the importance for the public of knowing the minimum level of service that they can expect to be provided. The Independent Healthcare Association also welcomes the principle of national standards and notes that many of those proposed are standard practice already. Counsel and Care, another major organisation, welcomes the establishment of national standards as part of the determination to modernise social services and engender confidence for older people and their relatives in the home that they have chosen.
The consultation document "Fit for the Future" sets out the proposed standards of the Centre for Policy on Ageing for older people in residential and nursing care homes. It was sent to all major interested organisations on 8 September and has been widely circulated. The right hon. Lady correctly referred to some of our earlier problems with distributing the document. We eventually produced 10,000 copies of it, distributed it widely and also exended the consultation period by six weeks. I shall come to the consultation responses later. It turned out to be one of the largest consultation exercises that the Department of Health has organised for a long time. We took great efforts, as the right hon. 182WH Lady will be aware from her time as a Minister, to ensure that everyone with an opinion and an interest in this subject could comment on the proposals.
The proposed standards are aimed at promoting better quality care and helping to prevent abuse by grounding practice in the important principles of dignity, choice and respect. Older people and other adults in residential care are especially vulnerable to abuse and poor practice because of their physical and mental conditions. The proposed standards in "Fit for the Future" seek to protect residents more effectively in a number of ways.
First, they will guarantee residents access for the first time to an effective complaints procedure, which will be monitored by inspectors who will have the power to investigate unresolved complaints and take any necessary remedial action. Secondly, the standards will ensure that vulnerable people are cared for by reliable and trustworthy staff who have been carefully recruited and properly trained to do this difficult and sensitive job. Often at present, inspectors find that staff have been casually employed and are engaged in providing personal, intimate care—sometimes, sadly, with no check on their suitability and no induction or training. That is not acceptable.
The standards will ensure that residents have the right to choose the way in which they live their lives, as do you or I, Mr. Deputy Speaker—for example, when they get up or go to bed, what they would like to eat, when their relatives can visit and so on, all the details of life that go to make up one's sense of identity and individualism.
The consultation period for "Fit for the Future", as the right hon. Lady said, ended on 21 January. We have received more than 1,400 responses to the consultation document, which provoked a large response from care provider organisations and individual care providers. While there is widespread support for most of the standards proposed, it is clear that there is real concern about some of them. In particular, the physical standards, such as room size, and standards on staffing have attracted criticism from some sectors of the care industry and certain parts of the country. Again, the righ hon. Lady referred to her concerns in that regard as well. The varying levels of concern illustrate graphically the current variation in standards across the country.
We are determined to set standards that promote better quality care, but they must be realistic and affordable. We do not intend to impose unreasonable or heavy financial burdens on providers and we intend to keep the number of enforceable standards to a minimum.
§ Mrs. Caroline Spelman (Meriden)The responses to the extended period of consultation on "Fit for the Future" will be important to inform the debate on the Care Standards Bill, which is being discussed in the other place. Will the Government publish the findings of that consultation? If so, will they do so by the time the Bill is debated in this House?
§ Mr. HuttonI am grateful to the hon. Lady for making that point. I intend to refer to it. The document "Fit for the Future" identified as many as 260 possible national minimum standards. It is highly unlikely that we shall need as many as 260. Some of the proposed 183WH standards are unnecessary and may have only a marginal impact on promoting good-quality care, which must be the main purpose of the entire exercise. I cannot specify today which standards we shall adopt because we are still considering the matter. We have 1,400 responses to go through and the consultation period expired only on 21 January.
I hope that I can give the right hon. Member for South-West Norfolk an idea of our initial thinking on two of the issues to which she referred. I refer first to staffing. I confirm that we do not accept that fixed ratios are the best means of specifying the number of qualified nurses who should be employed in nursing homes. That should relate instead to the assessed needs of the residents in each home at any one time and we are considering what models of assessment should be recognised by the commission for that purpose. Similarly, we are considering how nursing needs are defined initially, so that staffing levels can be best set accurately and realistically. Nor am I convinced that ancillary staffing levels, including catering and domestic staff, should be specified by fixed ratios. Instead, they should take account of the degree of efficiency and effectiveness shown by operators in managing such tasks, as observed in the outcome of the quality of the care that is provided.
As the right hon. Lady would expect, we are considering carefully the standards concerned with the physical characteristics of a home. In doing so, we must take account of the high levels of physical frailty of many older people when they enter residential and nursing homes. Room size is an important aspect of the quality of life. Hon. Members have only to think about the significance to them of their own home and work environments to know the importance of a minimum standard of space. It is also an important aspect of safety for staff and residents, when special aids and adaptations for lifting and handling must be used.
While I cannot yet make an announcement, I can assure right hon. and hon. Members that we do not intend to impose on existing providers physical standards that are not already being met by their 184WH competitors. They will be standards that they should be able to meet over time. I can also announce today that any requirement to meet new standards on room sizes in the future will apply only after the end of the transitional period and not, for example, on the sale or transfer of an existing home to a new owner.
None of the standards will be implemented until at least 2002 when the National Care Standards Commission takes on its regulatory role. Some standards, particularly the more challenging and those relating to the physical environment of a care home will not be introduced until some time after the commission has started its work in 2002. In deciding on the time scale for introducing the finalised standards, we will ensure that providers are given sufficient time to meet those requirements. We aim to publish the finalised standards and their implementation timetable later this year. But—to respond to the hon. Member for Meriden (Mrs. Spelman)—I intend to make an announcement about room sizes during the spring, which may be of use to those who debate the Bill in Committee.
The right hon. Lady alluded to other issues to which I shall not have time to respond fully. Naturally, I stand ready at any time to discuss such matters in greater detail with the right hon. Lady, who has certainly shown that she has a sound grasp of the subject. She referred to Lion House in Downham Market in her constituency. It is unfortunate that people have read the standards in "Fit for the Future" and assumed that they will be the final minimum standards. I have tried to make it clear today that that is not the case. In any event, the standards could not apply until after the National Care Standards Commission is set up in 2002. There will then have to be a transitional period before some of the more demanding standards could realistically be implemented. We are talking about years, not weeks or months. Decisions by inspection units to move to adopting those standards now or by care home owners to change the ownership of or close a home, taken simply on the basis of the consultation document, would be premature. We will respond fully to the concerns expressed.