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Care Homes

Volume 489: debated on Tuesday 17 March 2009

This debate proves to be slightly more timely than I had anticipated—I must thank Mr. Speaker for selecting it for today—as a major report on dementia has been in the national papers this morning. In addition, Prince Charles will this afternoon address a debate on that subject, which will be one of the issues that I discuss in relation to residential and nursing care homes.

Care homes have not had a particularly popular image among the general public in the past. The view in the 1970s and 1980s was that they were places that one sent people to as a last resort. They were basically designed to bring profit rather than to provide proper care and services for elderly people. Indeed, my earliest experience of anyone running a care home was in the early 1970s, when I worked for a firm of architects in London, and one of the partners declared that he and his wife were buying a care home. His views about why they were doing it would not have given me any confidence that anyone I knew should reside there. I never spoke to his wife—I am sure that she had a rather different view—but he thought that it was going to be easy money.

In the 1980s, there was a vast expansion of care home provision. As in any industry in which there is vast expansion, not everyone who goes into it does so for the right reasons. By the end of the 1980s and early 1990s, the transition of hotels due to the decline of the tourism industry in the south-west led to the small port and fishing town of Teignmouth, where I live, having the highest number of care beds per head of population anywhere in Europe and therefore, I suspect, in the world.

Times have changed dramatically since then. The Governments of the 1980s and 1990s regulated harder, and we moved away from the easy option of moving people into care homes to a policy of caring for them in their own homes. The quality of care homes has increased dramatically. Those that might have been a little on the dodgy side in the past have struggled, so I am sure that few exist today. However, that does not mean that the care home sector gets an easy press—one has only to read the sort of headlines that are written about care homes in the newspapers: “Nurse who ran care home accused of murder after seven suspicious deaths” and “Illness kills half the residents at nursing home”. And, of course, The Times has run a care home campaign.

Most of the care homes that I visit in my constituency are not like that at all. They provide personal care of a high quality, and they care about the residents. The Minister shakes his head; I am not sure whether he disagrees or wants to intervene. Those care homes care about the people who reside in them, but that does not mean that there are no issues to address. They are concerned about how they can provide the high level of care that they seek to achieve.

The Government are pressing ahead with improvements. I am sure that the Minister will regale us later, given the opportunity, with all the improvements that have occurred in the past 10 years. I do not wish to steal his thunder, but let me give a few statistics. According to the 2007-08 report of the Commission for Social Care Inspection, in the past six years,

“there has been steady improvement in the overall performance of councils in addressing current policy requirements and in regulated care services meeting national minimum standards.”

It goes on to say:

“There have been some tentative steps to address the new personalisation agenda which have meant more people are able to control and choose their support through, for example, Direct Payments, Individual Budgets and good person-centred assistance…There are some outstanding examples of people’s lives being radically improved where they have been able to direct their own support, including those people with multiple and complex needs… However, councils are at an early stage in transforming social care and developments are patchy and vary between different groups of people.”

It continues:

“People, whether they pay for their care or are publicly funded, are not always getting the individualised help that they need to make decisions about their support which in the long term can be costly to individuals, family carers, councils and the NHS.”

I know that a significant number of people do not like direct payment because they find it difficult, but that a number do when the services are there to be accessed. Like other MPs, I am sure, I have people coming to me saying, “Yes, I have the money, but there is no one I can buy the service from,” so giving them money is largely a waste of time, because there is nothing for them to spend it on to provide the relevant service.

I congratulate my hon. Friend on securing this timely debate, and I invite him to add a rural dimension to the problem regarding the availability of services. It is a patchy picture. Does he share my concern about the lack of elderly mentally infirm nursing places across much of rural Britain, and about the spectacle of families and relatives having to travel vast distances—sometimes hundreds of miles— to visit relatives who suffer from Alzheimer’s? Does he agree that that is not ultimately sustainable, and should not be?

It is not sustainable, and the situation is going to get worse, as I shall discuss later. It is very much a growing problem in our ageing population. The lack of specialist nurses comes out in Laing and Buisson’s report, which I shall discuss in a moment.

CSCI points out that in 2007-08, 1.75 million older people and people of working age used different social care services, and that £16.5 billion was spent on social care for adults. Other moneys provided through private expenditure and top-ups added up to a further £5.9 billion, so we are talking about fairly large sums of money, and even the Government projections predict higher figures. The university of Kent’s personal social services research unit says:

“The numbers of functionally disabled older people in England are projected to”


“from approximately 2.3 million in 2002 to approximately 4.6 million in 2041”.

It says:

“To keep pace with demographic pressures over the next 40 years, assuming unchanged rates of functional disability”—

that is a big if—

“residential and nursing home places would need to expand by around 115 per cent. and numbers of hours of home care by around 100 per cent. The numbers of staff working in social care for older people would need to increase by around 110 per cent. between 2002 and 2041”.

Also, expenditure for the same period

“would need to rise by around 325 per cent. in real terms…to meet demographic pressures and allow for real rises in care costs of 2 per cent. per year for both social care and health care.”

In the long term, that means that care expenditure would need to increase

“from 1.4 per cent. of gross domestic product in 2002…to 2.6 per cent. in 2041.”

I hope that the Minister has his crystal ball and will say what the Government are doing to lay the foundations for that necessary growth in residential care. If the Government are not certain that they want to believe university of Kent figures, Age Concern says that significant funding is required to meet our obligations to older people and that expenditure of £7 billion to £8 billion now should rise to £14 billion to £16 billion in 2026. That is a shorter time span, but it is still virtually a doubling of the figure of about 1 per cent. of GDP.

Not to miss out on the matter, the Joseph Rowntree Foundation has had its own research done, again by William Laing of Laing and Buisson. Laing states that about £540 million of extra funding is still needed in the system for local authorities to fund a modernised care home sector. Since that report, the Minister has announced £520 million of funding, but that is for different expenditure and is not the same expenditure that Laing and Buisson said was missing last September.

The care sector faces problems across the board. Before I get into the detail of private care homes and the problems that they face, I will mention charitable care homes. The Charity Commission wrote to me about this debate. It said that there are a number of issues, but that the key issues identified in its survey,

“which would affect care homes, were funding (whether full costs were paid by the public body and whether contracts were short term), independence (whether the charities felt that they could still take decisions independently), and mission drift, (whether the charities were being led by available funding, rather than their charitable objectives).”

Lack of funding is a key issue in relation to that.

I particularly thank the Local Government Association, which provided the most extensive brief for the debate, for its work on the matter. It has pointed out that there are currently 448,000 care home places in England and that 231,000 of those adults are financially supported by councils. If we consider how councils are paid, we will see that some of the 217,000 remaining places were the subject of a contract between councils and care homes to provide intermediate, respite care or other temporary placements. However, as I said, the majority of people arranged to pay for their own care.

Between 2006-07 and 2007-08, the unit cost paid by councils to care homes increased by an average of 7 per cent. However, there is a wide variation among councils and the type of care purchased. The greatest increase in unit cost was between 11 and 14 per cent., which went to care homes providing nursing care for those with physical or learning disabilities. Contracts and fees are a matter for local negotiation and councils with limited budgets—increasing by 1.2 per cent. in real terms over that period—need to negotiate fee levels carefully in relation to quality of care.

The Minister might wish to address how the rising fee levels and costs of care homes are not matched by Government grants to local authorities. That situation puts stress on social services departments. The Minister might say that that is new, but I can take him back to one of my earliest questions in the House when I asked the then Health Minister, who is now Secretary of State for Communities and Local Government, about a statement from the 15 social services departments in the south-west.

The directors of those 15 social services departments said that there was pressure on elderly care and that the budget constraints were such that their obligatory, legal duty to provide services for children meant that they were having to divert funding from elderly care to child care. That led to a lack of funding. At that point, I think that the estimate was £1 billion of underfunding. As I mentioned, the Joseph Rowntree Foundation has said that the figure has been reduced to about £500 million of underfunding, but there is still a big hole. That means that people are not necessarily getting the level of care that they feel they deserve, having worked all their lives.

We might not necessarily have much sympathy with care homes when we say that we want to improve standards and we expect them to improve the services that they offer, but care homes have their own problems. Some care homes improve services willingly and some do so while pointing out that having the additional funding to improve standards would be beneficial and appreciated. However, some care homes say that other problems have been created for them—for example, the bureaucracy that is put in their way and problems relating to employment issues. When the Government decided to crack down on immigration and change the rules, I doubt whether there was an MP with a care home in his constituency who did not find a care home worker on his doorstep saying that their work permit would not be renewed and that they would be sent back home to the Philippines or wherever.

Migrant workers comprise a significant proportion of the social care work force. The Association of Directors of Adult Social Services estimates that one in two care staff in London is a non-EU citizen. The Government published the shortage occupation list for tier 2 of the points-based immigration system in November 2008. The list contains skilled occupations where vacancies can be filled by migrant workers from outside the European economic area. The LGA welcome the fact that skilled senior care workers are included in the tier 2 list, but to be “skilled” requires that the individual must earn at least £8.80 an hour after deductions for accommodation, meals and so on. There is also a requirement for a national qualifications framework level 3 or above.

Martin Green, the chief executive of the English Community Care Association, has said:

“We cannot understand why skilled work riders and frozen fish cutters are deemed to be skilled workers without an attached required salary while senior care workers will in essence be prevented from entering the country to undertake the valued work that those currently here already do.”

Although people might say, “Yes, we recognise that this is a skill and accept that the qualifications are necessary,” the salary level being put with such jobs is causing problems in the care sector.

I ask the Minister to consider that if £8.80 is the requirement and that is based on the industry, why is it that those who run care homes—certainly those in my constituency and I believe those in other constituencies—will say that that figure is more than they are currently paying their European qualified staff for work? The amount seems to be set at an arbitrary level that is designed purely as a cut-off point to stop people coming into the UK or to be used as an excuse at a later date to remove care workers from the UK. I will come on to dementia in a moment because it is particularly important that there is not a continual change in care home staff who work in that area.

The LGA has questions about funding. It says that

“adult social care services are funded through a combination of central and local government funding”

and that total adult social care spending for 2008-09 was £13.78 billion. Of that figure, central Government general grant funding was £6.29 billion, specific grant funding was £2.15 billion and the contribution from local government £5.33 billion, which is approximately 20 per cent. of total council tax receipts. The Government are applying greater pressure and saying to councils, “You must limit your council tax increases.” However, as I said, council tax funds a service that increases in cost, in real terms, by 7 per cent. a year. That is rather more than the amount by which local authorities are being told that they are allowed to increase council tax and by which they are trying to increase it. Even greater pressures are being applied to local authorities. They are being told that they cannot raise the level of council tax—they are not allowed to increase the element that they control—but that the Government will not adequately increase funding for care. The people who will lose out are those in care, because, at the end of the day, we are squeezing the care homes.

The surveys clearly say that where there is poor care, the residents blame the low wages that some of the care homes have to pay because they are not funded to pay adequate wages. It is still true that people can earn more money at night stacking shelves in large supermarkets in my constituency than they can earn during the day caring for people in homes. Many young people will opt for the easy job in the evening rather than the job during the day.

I wish briefly to discuss Laing and Buisson’s report. I have not been able to see the detailed brief. Someone in my office went online to see whether the full report was available and found that apparently we have to pay £100 to see it. I assume that a copy will be available for Members in the Library and that we will be able at some point to read it without having to spend that money. It did not seem practical to pay £100 to read a thick wodge of a report all the way through this morning.

Some quotes from the report were put on the website, and there was also a stimulating discussion of the issue on Radio 4. The most telling point was that there is not enough training in the sector. A statistic from the radio programme—I have this as close as I could get it—is that only one third of the homes that are designated to care for Alzheimer’s patients are providing staff with the necessary specialist training. That is a severe condemnation of our current system.

As I said earlier when discussing other issues, there is improvement, but the Government need to grasp the report that will be published today, listen to the Alzheimer’s Research Trust debate this afternoon and come up with answers about how we can make further improvements. The Minister has already stated in his response to the report:

“The national dementia strategy will improve the quality of care in care homes.”

That quote was on a website this morning. That is fine. The strategy is there, and the 17 points are vital. We buy into them—no problem at all—but my purpose in going through all the funding arguments that I raised earlier is to say that, unless funding follows, the strategy is not worth the paper it is written on.

I beg the Minister to step up his argument with the Treasury that this issue should not be forgotten. Alzheimer’s is probably the disease that most of us fear getting. To most people, cancer is a big fear, but the idea that we could slowly lose our mental capacity puts dread into the hearts of most people. The issue must be fully and properly addressed.

The majority of care is done in the community—people are looked after in their home—but a significant number of people are in care homes, and there will be a substantial increase in the number who will need to go into them. Unless we start saying that the money will follow, those people will lose out.

I mentioned immigration policies. The Alzheimer’s Society website gives three principles for good-quality care. The third states:

“Staff caring for people with dementia should be trained in supporting people with dementia.”

As I said, that is not happening adequately at present. It goes on to state:

“Continuity of care, which allows relationships and trust to build up between the person with dementia and care staff, is also important.”

I would ask the Minister to come to south Devon to visit the care homes in my constituency, to look at the bonding between care workers and residents, and then to go back to the Home Office and ask the immigration officials whether it is really right, for the sake of the figures, to send those care workers home because care homes will not be able to pay them £8.80, and his colleagues in the Treasury will not provide the funding.

I would ask the Minister to think about the family who have grown reliant on and developed friendships with care workers, to look them in the eye and say, “Terribly sorry,” and then tell them that the person whom their mother or father has grown to depend on and with whom they have developed a relationship, the person who engages with their mother or father every day, who speaks to them and encourages them so that they are not left to rot—the worst that we could do for people with dementia—or left on the shelf but can have a reasonable quality of life, will be sent back to the Philippines, China or wherever. I ask the Minister to visit the care homes, speak to the people and then tell the Treasury and the Home Office that that is not good enough.

I am delighted to take part in this debate, and I, too, take particular interest in it. I have a 99-year-old father whose birthday we celebrated yesterday. He is looking forward to his 100th birthday and already has me organising for it. He is in a nice St. Monica Trust care home in Bristol, which is a model that many others could follow. Not every area offers such an opportunity.

I thank the hon. Member for Teignbridge (Richard Younger-Ross) for choosing this subject at this time. Besides my personal interest in it, I have several constituency cases, which the Minister knows something about and which I shall discuss with him in confidence. These things are difficult and we have to be careful about what we say.

To add to the list of events taking place today, the all-party group on dementia will be taking evidence on the future of dementia care, so it seems that the hon. Gentleman has hit the jackpot: there is every possible reason for today being a good day to debate residential and nursing care.

I agreed with nearly everything that the hon. Gentleman said. I probably err on the side of caution when criticising particular nursing and residential care homes. Some in my constituency have shut, and for good reason. Sadly, I have also lost some good care homes for various reasons, but I support the Government’s strategy and look forward to the care Green Paper, whose publication is imminent—no doubt my hon. Friend the Minister will say when it will be published.

We need that Green Paper, because anyone who is involved in this area needs to know what the Government’s direction of travel is, particularly in respect of funding to support the strategy. I believe that we all agree that nursing and residential care are underfunded, and that the time bomb that we face means that they will be ever more so. The trend is inevitable and relentless. We have moved on from the small, neighbourhood family-run care homes that started the process, long before Government became interested and when not that many people thought about going into care homes. I would argue strongly that many people who went into care homes did not need to; it was just perceived to be the best way to give care. We know otherwise now.

We have moved along the continuum to a much smaller number of larger care homes that are not necessarily locality based and many of which are in the not-for-profit area, as the hon. Gentleman said, but some of which are still private. There are now several different models and the state has begun to get involved again. Having in a sense washed its hands of the matter from the 1980s on, the state has had to recognise, because of the shortfall, that it cannot entirely leave its responsibilities.

Because of the changes, we have had to look quite hard at three key issues that always underwrite the social care we are debating. One is running costs, and certainly the cost of charging, which I know about very well. Another is location—as neighbourhood homes have gone, we have had to consider where people will go if they want to stay locally.

There are still good examples of local care homes, such as Uplands, run by Lynne Gardiner, in my constituency. That is an ideal location for people who have lived in the area and want to stay in the locality in the remaining years of their life. However, for every place with an Uplands, there are many other areas that have lost such locations.

The third issue, which the hon. Gentleman talked about, is staffing. I shall intertwine that into my short speech, because staffing is everything. We should also consider management. I think that we would all agree that a weakness in the area we are discussing is the fact that good managers are at a premium, and good managers who can be retained are at even more of a premium.

I know of some cases that I think are good examples of the problems. I hope that the Minister may want to examine not the particular cases, but the context that they give for understanding how the care sector operates. I call the first the Crystal Fountain case. It is a real-life case and I am still critical of the organisation.

Crystal Fountain care village was set up in my constituency. I believe that it got planning permission on the basis that it would provide a continuum of care from some bungalows and houses, with support, through more sheltered accommodation to, ultimately, a care home at the centre of the care village. Two years ago, having achieved planning permission, it announced that it was closing the care home, which is a purpose-built facility.

The residents, and certainly the relatives of the residents who remained there, were very disappointed, to put it mildly, because they felt that they had purchased their place on the basis of a continuum of care. The disappointing thing was that there was nothing that could be done about it. The company decided to charge individuals in the care home facility for every facet of the care on offer. That was clearly likely to mean that much more money could be made out of the individuals, but those people felt completely let down by the changed nature of the care. I suggest to my hon. Friend the Minister that we need to match planning and delivery to the eventual care outcome. Otherwise, we end up with a deficient number of care home places, which causes upset and removes any semblance of choice.

Another concern that I have is about the remnants of the outcomes of outsourcing stage 2 homes from the county councils, which always had the responsibility. That happened in the 1980s and we had a pretty bloody set of consequences in Gloucestershire. There was a takeover—in an in-house bid for an outsourcing contract, if that is not a contradiction in terms. Former social services staff ran an outfit called Coverage Care. The idea was that they would pay to take on remaining residents, but would rebuild and refurbish homes, and pay a bounty to the county council. It all ended in tears, but I will not go through the history of it.

Now, thankfully, a much better organisation—the Orders of St. John Care Trust—runs the homes. The old problems of homes in need of refurbishment remain, however. Where is the money to come from? The Orders of St. John has some ambitious plans, but I have now been talking to the trust for 18 months and there is not apparently a great deal of movement. That may be because of the market at the moment, but if there is a commitment to improving the quality of the care, we need to know where the funding will come from.

I am asking the Minister to help me with that dilemma. If the money is put in and is then reflected in increased fees, a quite difficult problem will result. Obviously, the self-funders will be the ones to pay for the increase. However, adult care—social services as was—must also make a commitment to make up the additional fees. That is problematic in the context we are discussing and such matters are not always as easy as they sound.

We want better quality, but we certainly want to know how it will be paid for. In my area, the cost of care has risen dramatically, which leads to unavoidable consequences. Sometimes, one wonders whether people who should be in care are not, because they do not want to pay. That can be a problem.

A county councillor on the executive in Devon, Sally Morgan, pointed out to me that people going into care have greater problems, and that only people with severe or critical needs are being placed in care by local authorities. If people have such needs, that leads to greater requirements and increases care home costs.

I agree. As a former county councillor, I remember going to what was effectively a rationing panel, although we did not call it that. It decided who went where and whether there was enough money for that provision. Then the issue arose about where the extra money was to come from if people’s needs increased dramatically once they were placed. To some extent, we were reliant on the homes effectively to subsidise some care, because there was never enough money to put in the pot.

The next area that I want to talk about is the inspection process. I am not critical per se of the idea of the Commission for Social Care Inspection. I dealt with several difficult cases during its previous incarnation, and I think that the inspection process must be independent and must be carried out in the way it is. I used to visit care homes as a county councillor; it was one of our responsibilities. We just took it on. We had no particular expertise, but it was important that we should try to do it to the best of our ability.

I welcome the setting up of CSCI, but the problem is that as we drive up standards, we drive some homes out of the marketplace. Even if they are not driven out directly—if some CSCI powers are not used carefully—what is written in the reports drives them out, because people are not encouraged to send their nearest and dearest to those homes.

I have talked to the Minister confidentially about the matter. I know of some cases in which inspections have been quite harsh and have quickly led to a legal process. My criticism is that there is not much room for negotiation. Once there is a bad report for a home with no stars, the legal process that gets under way and the quick progression to an independent tribunal give little room for manoeuvre. We must understand that we cannot have it both ways. If we want the homes at the cheaper end of the market, we cannot drive up the standards so that they cannot survive alongside the more expensive homes.

The hon. Gentleman is making an important point about the effect of the inspection regime under CSCI. Most of us agree that that is an important part of the process. He has pointed out the problem, but has not given an alternative that would assist in driving up quality. We all agree with the hon. Member for Teignbridge (Richard Younger-Ross) that we want a rise in quality in all care home provision in this country.

There is a role that must be filled in adult care and there are issues with how county councils or unitary authorities are inspected. The dilemma is whether to support homes that need assistance by putting resources into them or to support the more expensive homes, which tend to be run better, although I do not want to cast any aspersions. The dilemma is whether local authorities want those homes to survive and flourish. That is true of Gloucestershire, where the authority is taking legal action over the loss of one of its stars.

There is a huge role for local authorities, but my argument is about whether they can dispense that role as well as they could and should. When a legal process is entered into, the clock cannot be turned back easily. Homes that could stay in place and provide a valuable service are sadly driven out for all sorts of reasons.

My last point on the inspection process is that it is quite closed; everybody knows everybody else. With the best will in the world, care homes know their inspectors and the inspectors know the home’s background. That may not always be healthy.

Specialist homes have not been mentioned. We are talking mainly about older people, but care homes contain many other people with different disabilities. My worry is that when one discipline takes the lead, the other disciplines tend to hide from their funding responsibilities. If there is a health-led funding arrangement, adult and children’s care tend to hide from their funding responsibilities.

I am dealing with a sad case of somebody who is disabled from the neck down. He is in great need of educational help and is very bright, but he can receive no help to get to the local college where he could carry out a course of study. That is belittling for him and unfair. I hope that the Minister will say how we can get more joined-up thinking and action.

I will finish on a positive note. For the last 20 years, I have been involved in the Standish project, which hopes to turn a former hospital site into an integrated care setting. In future, there must be better partnership between the public, voluntary and private sectors to run genuine integrated care. There are good examples, such as Horsfall House in my constituency. Sylvia Morris and Chris Booth, a local GP, saw that there was no care home facility and so provided it. It offers a genuine continuum of care that provides for people who are fit and able but in need of TLC, through to those with care needs who need to be in an intensive setting. I believe that that is the future. The issue is how we get there and who will fund it.

We would all agree that there is a huge onus on the person who is being cared for and their relatives to provide the lion’s share of the funding, unless they are entirely reliant on the state. That can be unfair and can leave people with dilemmas about how much they are prepared to pay, where they are prepared to send their relative and who they are prepared to pay.

I am grateful for the opportunity to take part in this debate, Miss Begg. I congratulate my hon. Friend the Member for Teignbridge (Richard Younger-Ross) on requesting the debate and on being drawn out of the hat. It is serendipitous that the debate is taking place on a day when there is media focus on the subject. It deserves far more media coverage than it attracts, not only on the bad things and the problems, but on the positive elements. All too often, debates of this sort are couched in terms of old age being a problem and a ticking time bomb that will explode under our welfare state and make it impossible for us to provide dignity in old age. Such debates focus on the need to find funding.

I agree with one of the concluding remarks of the hon. Member for Stroud (Mr. Drew) on the need to see the development of care as a continuum. I will take that idea one step further. As human beings, we are more capable than any other species of controlling our lifecycle. The effectiveness with which we have extended our lifecycle over the last century is of great note. We must now look at how we can reinvent the lifecycle and redefine what we mean by old age.

In this debate about care home settings, we must recognise something that was missed in the early ’90s, was not understood in the mid-’90s and is just beginning to be understood now. Although providing more care in people’s homes and supporting independence through personalised budgets are essential in creating and supporting a wider lifecycle, a proportion of the population will need more intensive forms of care that are more appropriately provided in care home settings. The care homes of the last 30 years are not the ones that we will need in the next 30 years. Nevertheless, because of the ageing population, a substantial number of people will still need care homes, even if the proportion of those people is a smaller share of the population.

I agree with my hon. Friend the Member for Teignbridge that there are many good care homes. I have the privilege of visiting some in my constituency and seeing good caring practice. That practice is rightly driven by assiduous attention not to ticking boxes, but to the needs, wishes, wants and feelings of the people who live there because it is their home. That is an important point. He was right to highlight the growing demand for specialist residential care and for elderly mentally ill beds and facilities. In a way, we all hope to go through that part of the life journey, when we will be more out of sight and out of mind than at any other point in our lives.

I will touch briefly on standards, ask a few questions about dementia and the Government’s strategy, which is welcome, and speak about dignity in the context of the personal expense allowance, which is important and overlooked. Last Friday, I attended a breakfast seminar organised by Anchor, which is doing some good work on dignity. There was an American speaker from the Eden project called Dr. Bill Thomas. He spoke about the changed expectations that have come with the baby boomers, not just because they are beginning to contemplate their need for care, but because their parents are experiencing care now. Many baby boomers find it hard to accept the limited choices with which their parents have been presented. Dr. Thomas also underlined a point that the hon. Member for Stroud made—that leadership is the absolutely essential element in organisations, that it is needed to drive changes in culture and behaviour and to make the changes stick, and that the issue is not just about dry regulations on a page, but about how human beings interact.

One point that has struck me about the standards regime in the 12 years since the National Care Standards Commission has been in existence is that, on the knottiest issues, such as medication, nutrition and hygiene, care homes have become more and more like Sisyphus, pushing the rock to the top of the hill only for it to roll back down again. The Commission for Health and Social Care Inspection has documented that in reports and pointed to care homes that can improve their performance in medicine management one year, only for their standards in that area to fall back the following year. That is a fault in the system, and it has yet to be satisfactorily addressed.

When one looks more closely at issues such as medicine review in care homes, it is remarkable just how few visits GPs pay to care homes. I am particularly concerned about that. The number of visits is extraordinarily small, yet that is the population most at risk of poly-pharmacy, of becoming the victims of the inappropriate use of drugs and of suffering from the overuse of drugs. From the figures in parliamentary answers that I have received, however, it appears that GPs do not cross the threshold of care homes frequently enough to do the necessary medicine inspections and reviews that are a key part of appropriate practice.

One reason why care homes’ standards slip is changeover of staff. If we look at the figures, which I did not have time to discuss in my speech, we find that the turnover rate in the independent sector is almost 18 per cent.—17.9 per cent. If a care home has that turnover of staff all the time, it is difficult for the organisation to be consistent and to keep training the staff all to the same level.

My hon. Friend earlier drew attention to what Laing and Buisson identified—namely, fragmented training at specialist units in this country—and also rightly identified from that research the fact that many of those homes do not have formal training programmes. I hope that the Minister will say something reassuring about how the new inspection regime will ensure that that finding does not become a long-term trend.

The Minister knows that for some years, I have raised questions about the appropriateness of using anti-psychotic medication in care homes, and I was pleased last year when his predecessor, the hon. Member for Bury, South (Mr. Lewis), announced a review of their use in the draft dementia strategy. The terms of the review, as I understood them at the time, were not so much to ask whether change was needed, but to plan for change. Although the review was and is long overdue, it was and is welcome, because those drugs reduce people’s quality of life, increase costs due to the need to treat side effects and cut lives short.

It is surprising that we tolerate the continued use of drugs off licence for a purpose that a growing body of evidence suggests is not appropriate in the long term. We know, however, that 100,000 people are routinely prescribed them and, from academic studies, that perhaps as many as 23,000 people die prematurely because of their excessive and inappropriate use. I hope the Minister will state when we might see a light at the end of that tunnel—when we will see the action plan that will produce the necessary change to practice.

That brings us to the wider issue of dementia, its care management and the study that Laing and Buisson published today, identifying the training issues that we have already talked about. I want to ask the Minister about the dementia strategy, because it is not a national strategy. It is not a national must-do: it is not in the Department’s strategy framework as something that must be done; it is on the framework’s next tier as something to be decided locally. Local decision is generally a good thing, but, on the national strategy that the Minister has rightly advanced, I should like some clarity about timelines, because that is what my constituents expect.

I want to ask about the implementation programme board, which I understand has not met yet. I assume that it will have a monitoring role, even if it will not provide an overly disciplined and prescriptive framework, because that is not the Government’s intention. When will its terms of reference and membership be finalised? There is a meeting on 31 March of the other body that is responsible for such matters That must mean that the implementation programme board will not meet this month, and that yet another month will have gone by without the monitoring framework to drive the strategy forward having been published. It would be good to hear what the Minister has in mind.

[Mr. Edward O’Hara in the Chair ]

I shall touch briefly on nutrition. A couple of weeks ago, the hon. Member for Eddisbury (Mr. O’Brien), the official Opposition spokesperson, and I addressed a meeting organised by the British Association for Parenteral and Enteral Nutrition, which has conducted some very good research, demonstrating malnutrition’s burden on our taxes. The group has created a nutrition action plan, which the Minister is considering. Until he has done so, however, he is unable to confirm whether that group will be able to continue tackling malnutrition in a multi-agency way, so it would useful if he said whether he believes that it has done a good job and whether he will allow it to continue.

From written parliamentary answers, I am surprised that malnutrition data are not routinely reported to Ministers or senior officials, and that there is no regular auditing of the adequacy of data that are collected. It seems extraordinary that while we focus on obesity, we know that there is a £13 billion cost associated with malnutrition. Surely that should be addressed.

The hon. Gentleman has made an excellent point about nutrition and malnutrition, and he is well aware of how keenly I follow the issue. I am concerned as to whether the Government have had a chance to uprate their performance in producing statistics and to monitor the situation, because the issue has effectively been unnoticed by them for more than a couple of years. More recently, their publication of statistics was delayed and, although we have now managed to extract them, they did not come via the normal parliamentary channels. There is deep concern about malnutrition becoming a head-in-the-sand issue, rather than something that we should tackle now.

The hon. Gentleman is right to challenge the Minister. I am sure that the Minister will respond by demonstrating that his head is not in the sand, and that he is as anxious as all of us to ensure that we use the data that we have to deliver a strategy that bears down on the problem of malnutrition. I hope that he says that.

On the personal expense allowance, I asked a written parliamentary question of the Minister’s predecessor in January 2008 about whether he would undertake a consultation on the level and adequacy of the personal expense allowance, which is paid to people in care homes who are in receipt of a pension that they must forgo because of the rules for determining state support. They are left with £21.15 a week—just £3 a day—to cover the costs of toiletries and food, which are the little things that make the difference between being alive and having a life.

The question is whether the proposed 75p a week increase is sufficient to meet the needs and dignity of 250,000 vulnerable and frail adults who live in care homes throughout the country. I do not think that it is, and Age Concern and many others in the movement campaigning on this issue agree with me. Such groups feel a sense of betrayal, because they were offered a clear undertaking by the previous Minister, which was reaffirmed in June last year, as reported in Hansard, that there would be such a consultation, only to see that snatched away by the Minister who is here today.

The opportunity for the Minister to learn more about the views, experiences and feelings of those who have to live on £21.15 has been denied. I hope that, although it may be too late to address the increase from 1 April, the Minister might use the opportunity in the coming months to embark on that dialogue with people who have been lobbying him on this issue, so that we can have a more meaningful debate, a more meaningful consideration and a proper review of the personal expense allowance.

It is not only me and Age Concern who are concerned. In a report published on 4 March, the Joseph Rowntree Foundation identified the doubling of the personal expenses allowance as a way of giving more dignity to people in care homes supported by local authorities. That is right—it is a small price to pay for dignity. This is an important thing that we should be doing, and it is a great shame that the Minister has not done it. I hope that he will respond positively to that point and the others raised in this debate.

I congratulate my hon. Friend the Member for Teignbridge (Richard Younger-Ross) on securing this important and timely debate. How often have we said how important and timely this subject is? It is not only an enormously important subject for hon. Members, but an important and emotive subject for families throughout the country. More than 400,000 people are living in care homes in the United Kingdom. As all hon. Members know, and as has already been mentioned, with almost a quarter of the population estimated to reach pensionable age by 2032, we have to address this matter now.

I shall start by echoing some of the comments made by other hon. Members about the wonderful work that goes on. It is always important to say that. I echo comments made by the hon. Member for Stroud (Mr. Drew) about care homes in his constituency, and comments made by other hon. Members who have made it clear that there are wonderful examples of care homes in the public, private and voluntary sectors that are delivering excellent care. It is always important to say that and use those as real examples. Unfortunately, I am sure that I am not the only hon. Member who is sick of having to highlight the fact that too many care homes—perhaps a hard core of care homes—repeatedly fail to meet the basic standards of hygiene and infection control.

Only last week, a freedom of information request to the Commission for Social Care Inspection revealed that 169 homes in England had recorded major failures in unannounced inspections—28 of them on more than one occasion. Inspectors in those cases had found residents forced to wear coats because the homes were so cold and found homes that smelled of faeces and urine. One home had such appalling standards that inspectors issued a notice under the Police and Criminal Evidence Act 1984 to take photographic evidence of, for example, bags of used incontinence pads left outside attracting vermin, dining rooms with food stuck to chairs and walls, commode bowls and urine bottles left to soak in a bath and dirty razors that may have been shared by residents left in bathrooms. The research also uncovered one case where major failings had been noted, but CSCI does not appear to have returned to re-inspect the home for over two years. The inspection process has not been working adequately. Perhaps more worryingly, follow-ups are not necessarily happening. The inspections are identifying problems, but action is not being taken in respect of the follow-up.

I am sure that the Minister agrees that we must, regardless of the effect on the profitability of private homes, have basic minimum standards of care for hygiene, nutrition and malnutrition, as my hon. Friend the Member for Sutton and Cheam (Mr. Burstow) has mentioned—I pay tribute to him for his work leading on that issue—and for dignity and respect. It is vital that we have that. If homes cannot meet that standard, their business model is wrong. I have no qualms in saying that the worst homes should be shut down.

From 1 April, we are moving to the Care Quality Commission, which is currently consulting on standards and, specifically, on how it will enforce them. I am sure that all hon. Members agree that it is vital that the CQC uses the new powers to ensure that those key principles—those minimum standards—are adhered to. I ask the Minister to outline progress on that and what we can expect from 1 April.

My hon. Friend the Member for Teignbridge has already mentioned staff training. I am sure that we all agree that there are concerns that the stipulations on care staff are not adequate. The story today, in terms of the lack of specialist instruction with regard to people with dementia, as the findings of the research show, is that the training is “fragmented and ad hoc”. Clearly, under the remit of the national dementia strategy, which we have all welcomed as an important step forward, we need to move away from training being fragmented and ad hoc. Will the Minister give us his thoughts on that? He has made positive comments about the need for specialist dementia training in particular, but generally how will that lead to a much better national framework of training for people?

My hon. Friend the Member for Sutton and Cheam, who has highlighted this issue powerfully, made the point about the use of anti-psychotic drugs, which is a scandal in our care homes. As we thankfully move away from this practice—all hon. Members warmly welcome that direction of travel—we have to face up to the implications of doing so, which mean that there will be a need for better services for people with dementia and therefore for better staff training. That will put the situation in greater focus.

We had much discussion about the human rights loophole, which I am pleased was closed by amendments in the House of Lords that meant that people in private and voluntary care homes providing services to local authorities were covered again by the Human Rights Act 1998. I want to bring to the Minister’s attention self-funders, who are 40 per cent. of people in care homes. Some 115,000 self-funders—27 per cent. of care home residents—are still not covered by the Human Rights Act. The Government have said that that will be dealt with in the equality Bill, but I ask again for reassurance that that is going to happen and for the Minister to say when it will happen.

Funding is important. It is not possible to take this debate forward without a genuine commitment to funding, and we are all on tenterhooks waiting for the Government paper looking at that. I am sure that the Minister accepts the frustration felt by organisations about this having taken so long, because we still do not know what levels of funding we need. The simple reality is that the system is broke and it needs fixing more quickly than is currently suggested by the direction of travel.

The Minister may wish to criticise and make party political points about where money is coming from and realistic levels of funding, but the Liberal Democrats have committed in our manifesto for the next election to £2 billion of investment into the care system to pay for a personal care grant that would give a minimum standard of care—going back to that vital word—for everyone over 65 who is assessed as needing care.

The reality is that, at local authority level, we are seeing the narrowing of criteria and increasing problems with people not getting care that we all agree in principle that they need. I ask the Minister to bear that in mind. We hope that there will be a significant commitment to filling that funding gap.

Immigration is an important issue. One of the problems in care homes is not only recruiting staff, but retaining them. There is an unfortunate issue with the points-based immigration system. I support that system, because it is clearly a sensible way of dealing with immigration and the skill needs of this country, but is there a way to recategorise senior care workers in particular, so that they can work in care homes and plug the gap? That would be a big step forward.

This is an enormously important debate. We agree on an awful lot, and all hon. Members in the Chamber are passionate about people in care homes. I simply ask the Minister to take our points from this debate and to answer our questions. The issue will become even more pressing because of the numbers involved, so will he give as much positive news as possible today, particularly about standards and what will happen on 1 April when the Care Quality Commission comes into being? With only a few weeks to go, it would be great to hear about the positive changes that it will make.

I congratulate the hon. Member for Teignbridge (Richard Younger-Ross) on securing this important and timely debate. It has been important and timely for 11 years, and it will continue to be so, particularly when the Government publish their Green Paper. The hon. Gentleman covered the three main areas of funding, quality and work force, and touched on immigration issues. Given the regularity with which we have debated the matter, I will focus my comments on those issues.

We should not have to discuss the matter again today, because the Government have been promising to sort it out for 11 years. As far back as 1997, Tony Blair promised to end the practice of people selling their homes to fund their long-term care, but he rejected the findings of his own royal commission, and the Government have been accused of ducking the issue ever since by putting it in the “too difficult to deal with” box. The former Minister with responsibility for care services, the hon. Member for Bury, South (Mr. Lewis), had the temerity to suggest on 29 March last year that the Government have recognised that problem “belatedly”.

Instead of planning reform, the Government in their 2005 manifesto gave a commitment to continue to provide health care free in care homes. That is what happens anyway, and we all agree with it, so it was interesting to promise in a manifesto to maintain something that is not an issue. The current Prime Minister failed to address the matter in the Government’s latest spending round in 2007, despite the fact, which I acknowledge, that Health Ministers badgered the Treasury and raised expectations of a new settlement, which were later dashed.

The Liberal Democrats—the party of the hon. Gentleman who secured this debate—have not delivered when they have had the opportunity to do so in government in Scotland. It has been shown that their free personal care model from the last election is not without it is problems and costs. It is not free, because it does not cover hotel costs and so on. The hon. Member for Romsey (Sandra Gidley) used the word “dishonest” in this very Chamber; other hon. Members did not dare to use that word—

No, because the hon. Gentleman knows the point that I am making, and we have discussed it many times. It is vital to put it on the record that the current policy has been dropped, and that the pledge now is for a “care guarantee”, which he suggested would cost £2 billion. [Interruption.]

As has been said, the main point about the care guarantee is that it is important to understand absolutely what might be contained within such a guarantee and how it would interact with a localist agenda. The Minister took a slight intake of breath when that was mentioned. The important question is always where the money will come from, which is why we have these debates. It is a real challenge to find the funding for what we all want to be changed. We must all wrestle with that, and I am glad that the Liberal Democrats have moved from saying that it will come from efficiency savings—

No, I will not give way; I want to make my point. The hon. Member for North Norfolk (Norman Lamb) said last month that funding will come from savings on the identity card scheme, which we would also scrap. It is important to identify clearly and fully where the pots of money will come from to support the guarantee. The hon. Member for Sutton and Cheam (Mr. Burstow) has referred to that, so it is fair to continue to challenge that fundamental area of policy.

We have all hashed out funding models following the Wanless analysis, which is broadly the basis on which most people debate the matter. The debate circles around the partnership model, the limited liability model and the free personal care model from the Wanless report, as well as the national care fund, which the International Longevity Centre has proposed. Work has not been done on what a basic package of care would look like, what it would cost, how it would be flexed and what the overall uptake and cost are likely to be.

I fear that there has been a tactical approach—perhaps even a safety-first approach—by the political think-tanks, and the issues are not even party ones. I hope that the Green Paper will provide the Government with the opportunity to do that work, and I hope that the Minister will take the opportunity to confirm that it is happening.

The paucity of commissioned academic work does not bode well for the Green Paper. I was pleased to discover through parliamentary questions that the Government have

“commissioned two academic studies to inform the green paper process. The purpose of one piece of work, being undertaken by the personal social services research unit, is to make projections of likely future demand for long-term care and associated expenditure under a range of different funding scenarios. The other piece of work, undertaken by Les Mayhew of Cass Business School, concerns the financial products that could potentially support private contributions in a new care and support system.”—[Official Report, 23 February 2009; Vol. 488, c. 253W.]

“Inform” is an important and well-scripted word. I hope that the Minister will confirm that those pieces of work, paid for by taxpayers, will be published as soon as they are completed and that they will certainly be published alongside the Green Paper. I hope that that assurance will be forthcoming.

The Minister is aware that we often talk about the need for consensus, and it is important to consider that whether we are discussing a Turner-like model or whatever. I am well aware from informal discussions with my Liberal Democrat counterpart, the hon. Member for North Norfolk, and the Minister that not only should that consensus consist of a shared analysis, but the Opposition parties should be invited to a round table, because the present fear is the introduction of a policy that will put up dividing lines, which are so beloved of the Prime Minister.

On the impact of funding streams on care homes, we are rightly moving to a system in which funding follows the user in the form of individual budgets, direct payments and so on. Care homes will increasingly lose the security, and local authorities will increasingly lose the bargaining power, that comes from block purchasing. I hope that the Minister will touch on those issues in his response and certainly in the Green Paper. I have received an e-mail from Anne Marie Morris, of whom the hon. Member for Teignbridge is aware. I have only just realised that, because it says that she is from Newton Abbot, which I gather will be the new name of the hon. Gentleman’s constituency. She has written to say that there are big concerns about the change in the funding formula for care homes, which I think we all agree causes grave difficulty for people in care homes, because so often the service user must pick up the bill.

The hon. Gentleman talked about quality, which causes deep concern with the demise of the Commission for Social Care Inspection. One could rehearse the various arguments about what will happen to CSCI, but we all believe that the challenge for the future will be to ensure that the CQC continues to build on the good work of CSCI and does not let social care and social care inspection become a second-order issue within its overall work.

The hon. Gentleman rightly mentioned immigration and training pressures, the high turnover of staff—that was highlighted in the e-mail—and that the quality of the work force is vital. I hope that Dame Denise Platt’s recommendations, not least from her 2007 review of the status of social care, which have yet to be implemented by the Government, will be a deep influence for action by the Minister in the coming months. The litmus test for him will be to give as much of a clue as he can, in addressing the issues raised by the hon. Member for Teignbridge, about what the Green Paper is intended to cover and whether it will include costed options, so that we can at last have a conversation with the British public on this live and crucial issue.

First, I congratulate the hon. Member for Teignbridge (Richard Younger-Ross) on securing the debate. I thank him for raising a very important issue and for putting it on record at the beginning of his speech that external bodies have recognised that the Government are pressing forward with improvements across the board on support and the quality of care. I shall say more about that in a moment. I also thank hon. Members on both sides of the Chamber who have contributed to the debate. Hon. Members come to these debates with a lot of passion, because the subject often affects them, their families and, of course, their constituents. Those experiences inform our desire to do more and go further.

I shall take this opportunity to applaud the great efforts by regulators, such as CSCI, by care home providers, by nursing home providers, by people who provide domiciliary care and by staff, who have done a huge amount to raise standards in social care. I agree that there are still areas that are in need of improvement, but there has been continuous improvement in the quality of care since we introduced new regulatory arrangements in 2002.

By the way, today is world social work day. I mention that in case hon. Members were not aware of it. It is a good opportunity for all of us to recognise the central role that social workers play in supporting individuals, families and communities. They do a very difficult job. The values that underpin the role of social work are central to the values that underpin our society. That applies not least to our desire to pursue personalisation—ensuring that services, whether in a care home, nursing home or out in the community, are tailored to meet the needs of individuals.

This issue applies to adults of working age as well as older people. Sometimes debates about care focus only on older people. We know the pressures in that respect, and the demographics and so on, but I want also to emphasise—this relates particularly to the social care Green Paper—that we need a social care system for the 21st century that meets the care needs of working age adults with learning disabilities, physical disabilities and so on, as well as of older people who have retired.

Those challenges will not arise at some distant point in the future; they are with us now. The ageing population is one of the most profound social changes of our time. It is fantastic that we are all living longer—11 years longer on average than we were many years ago—but that makes demands of and puts pressure on our system, not least in respect of funding and quality of care. Building a consensus about the future of the care and support system presents a significant policy challenge not only for the UK Government but for every nation in the world that is grappling with it.

I agree with the hon. Member for Sutton and Cheam (Mr. Burstow) that an ageing society is not a decaying society. He is right to emphasise the positive aspects of becoming older. The fact that we are living healthier and more active lives, as well as longer lives, should be celebrated. I am talking about older people as active citizens, having more choice and control. However, when care needs arise, care has to be provided in a way that supports people to maintain that independence and to have that choice and control.

Before I talk about the detail, I want to emphasise, in relation to the social care Green Paper, that because of the pressures, the changing expectations and the transformation of social care that is going on today, we need a radical rethink of the care and support system. The Green Paper is the vehicle for that debate, and it will be published soon. That will be an opportunity for us to have these debates in the way in which the hon. Member for Eddisbury (Mr. O’Brien) has requested.

I want to put on record again the deferred payment scheme. People can go to their council and ask that they do not have to sell their home in their lifetime to pay for their residential care. They can defer that payment, if they approach their local authorities. That is an important point that the hon. Gentleman often misses out in his contributions.

Standards have been a key theme throughout the debate. The hon. Member for Leeds, North-West (Greg Mulholland) reminded us of the 169 homes that failed the inspection by CSCI. No one should have to experience what was described in a home. I agree with him about that. I will add, though, that although those 169 homes failing the inspection is unacceptable, it is good that 10,208 other care homes are not providing a service of that kind; they are providing a service that does meet the standard that we would expect.

The performance of care homes measured against all national minimum standards has shown improvements each year since those standards were introduced. In 2007-08, care homes for older people met on average 82 per cent. of the standards, compared with 72 per cent. in 2004-05, which is a big improvement. Care homes for younger adults met on average 85 per cent. of the national minimum standards, compared with 76 per cent. in 2004-05. We all recognise the work of CSCI and providers in bringing about those improvements. I am confident that the new Care Quality Commission, which the hon. Member for Teignbridge mentioned, will continue where CSCI left off.

I understood the point that my hon. Friend the Member for Stroud (Mr. Drew) made about inspection and the inspection process, but it is vital that we continue to drive forward and improve standards in our care system. In 2008, 82 per cent. of homes for older people met or exceeded the national minimum standard for hygiene and infection control, compared with 77 per cent. in 2006 and 66 per cent. in 2004, so work is going on and improvements are being made.

Current regulations require care homes to ensure that staff are adequately trained. Hon. Members have mentioned the key issue of training. The regulations and the registration requirements being prepared now will include similar provisions. The CQC, as a regulator, will have a role in inspecting against those, as well as enforcing compliance.

The hon. Member for Sutton and Cheam has mentioned the nutrition action plan. Nutrition is another element of care quality in homes. I have seen examples of excellent practice on nutrition, such as printing menus with pictures so that people can easily identify the food and then want to eat the food that they can see, but clearly more needs to be done. The nutrition action plan delivery board was launched by my predecessor, my hon. Friend the Member for Bury, South (Mr. Lewis). Its chair is Gordon Lishman. It has been meeting for the past year, and it is due to give me a full report in about a month’s time. I shall examine the report and make decisions on its findings.

Staffing issues have been raised. I appreciate the concerns about immigration, but I do not think that the new points-based system will mean that care home providers cannot recruit enough care workers. Our policy objective is to be more reliant on the domestic labour market.

I do not have time to give way; I apologise to the hon. Gentleman.

It will take time to improve local supply, so we are planning to produce a work force strategy for adult social care this spring. Part of the remit of that strategy will be to set out what the sector needs to do to attract, develop and retain a suitably shaped, skilled and qualified work force to fulfil our policy objectives on delivering personalised care. Much of that will mean recruiting from relatively untapped employment markets across existing communities. Delivery depends on activity at the local employer level, which will take time to work through the sector, but I assure the hon. Gentleman that we are on the case. As he will know, most care homes are private businesses, and they agree their terms and conditions of service with their staff, subject to national employment legislation. Of course, it was the current Government who introduced some of those national minimum standards, including the minimum wage and working time directives.

The hon. Member for Sutton and Cheam raised the question of the personal expenses allowance, which was a difficult decision. The question was where we should put our resources. The estimated cost of raising the allowance to £40 a week is £250 million a year. We chose to put £520 million a year into local authorities over the next three years. If we had reduced that by £250 million, it would have meant less money for local authorities to improve the quality of care in their areas, and they would not have had the resources to undertake the essential transformation of social care. The allowance is increased in line with average earnings, but that issue will form part of the debate on the social care Green Paper, because it is a fundamental part of the system that is in place to provide financial care and support for people in our communities.

The dementia strategy was mentioned. I do not have time to—