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22nd August 2011

Fifteen Minutes of Care

There has been a lot in the news recently about the state of residential care homes, with some appalling stories of abuse and neglect, and yet most of the focus in adult health and social care policy is about encouraging care at home, not in a home. So how do we monitor what is happening when vulnerable people receive care at home? Not very well at all if you listen to a rather tense exchange between MPs on the Health Committee and the care industry regulator the Care Quality Commission (CQC). This follows on from disturbing findings from the Equality and Human Rights Commission who are conducting a major inquiry into care at home for older people which is due to report in November.

Health Select Committee

So back to the questioning of the Care Quality Commission on the 28th June by the Parliamentary health committee who were taking evidence from a number of health and social care regulators. To get the full flavour of the cross-questioning it is worth looking at the video(1) of the committee proceedings. What is reproduced here is some of the transcript of the exchanges. The full transcript can be found on the UK Parliament website(2).

During the committee hearing Rosie Cooper MP for West Lancashire asked the CQC representatives Dame Jo Williams (CQC Chair) and Amanda Sherlock (Director of Operations Delivery) if they regulate care companies that provide domiciliary care , which indeed they do. Rosie Cooper then said:

Those organisations are famed for - we have seen it in the press - the 15 minute call where the patient or the resident gets only five minutes because five minutes is spent arriving, making the call to tell people they are there, people then get almost a choice of what they want doing and then the carer has to register the fact that they are about to leave, and they are gone. They are invariably late.

Rosie Cooper then asked “How would you regulate those companies providing care at home? You only have their documentation to deal with it, unless you go and visit individuals in their home. Do you do that?” To which Amanda Sherlock replied: “It is a very difficult area that the chair and the board have asked us to look at.” “But that is why they are getting away with it,” Cooper commented.

It is not clear why visiting individuals in their own home to monitor how care was being provided was a ‘difficult issue’ but later responses in the exchange suggested that the CQC would only go and knock on doors where there had been a specific complaint. Rosie Cooper MP asked the CQC to write to the committee on what basis the regulator visited individuals at home to see how domiciliary care was being provided. We await their response which will be published when the Committee reports later in the year.

It is fairly obvious that an older person may be reluctant to make a complaint about a care provider for fear of losing the service altogether. Indeed the Equality and Human Rights Commission inquiry(3) has found that one in five of their respondents to a survey said they would not complain about a service. This is probably why Rosie Cooper summed up this particular discussion by saying that that from the comments made by the CQC, people receiving care at home do not get much protection at all.


Equality and Human Rights Commission Inquiry

Reports of the ‘15 minute’ visit also appear in information released by the Equality and Human Rights Commission who are conducting a substantial inquiry into care at home. The inquiry commenced last November and is due to report in November this year. The terms of reference of the inquiry include ‘To inquire into the extent to which the human rights of older people who require or receive home-based care and support, however funded, are promoted and protected by public authorities’. So what do we know of the inquiry already? The EHRC have taken evidence from older people and their families, care workers, and third sector organisations and advice bodies. They have compiled evidence from completion of questionnaires, including asking service users about the length of home care visits. Though the Commission has not reported in full, they did release some interim findings in a press release of 20 June which highlighted major problems in the home care system including inadequate time to deliver care. Their press release which attracted a lot of media attention stated ‘The very brief time allocated to homecare visits — just 15 minutes in a number of cases — does not allow even basic essential tasks to be done properly. As a result people sometimes have to choose between having a cooked meal or a wash. The short visits also mean that staff have to rush tasks like washing and dressing.’

In what way does this become a Human Rights Act issue? The rights contained in the Human Rights Act are all extracted from the European Convention on Human Rights.(4) Duties to safeguard human rights under the Act fall to public authorities. It may well be that private and independent sector organizations are the major providers of home care, but commonly this is provided as part of a contract with the local authority who are obliged to assess and make provision to meet that assessed need according to certain eligibility criteria.(5) The human rights that are jeopardised by poor care at home are fairly easy to locate within the Act:

  • Article 2: the right to life itself, which might be at risk if someone is not able to eat, or offered fluids, or ensure medication is available because of the absence of care
  • Article 3: promotes the right not to be subject to inhuman and degrading treatment, and the ECHR inquiry has already found instances of people being left in soiled clothing for long periods
  • Article 8: allows for the right to respect for a private and family life. Could this be compromised by what the EHRC inquiry has found of older people being put to bed by carers as early as 5 p.m.?


Inadequate time to deliver care

And why does this sorry state of affairs occur? There appear to be a number of factors:

  • The care at home industry is often characterized by a poorly paid workforce, and with recruitment difficulties. The EHRC report suggests the high turnover of care workers contributes to lack of consistent care, and they will be investigating the reasons for this.
  • The questioning in the health committee focused on the motives of private home care operators where the drive to make profit means pressure on staff costs.
  • The current climate of local authority financial restrictions is surely having an effect. A number of commentators fear reductions in care packages following an important case in the Supreme Court in June which found in favour of an extensive care package being reduced. The case concerned former ballerina Elaine McDonald whose care package that included night support to allow her to use a commode was being withdrawn by Kensington and Chelsea Council after a review of the case. In a BBC news item(6) reported on the 6th July, John Wadham, group director at the Equality and Human Rights Commission, said the ruling was a “significant setback for people who receive care in their home. Local authorities will now have greater discretion in deciding how to meet a person’s home care needs and will find it easier to justify withdrawing care.” He highlighted this as a human rights issue.
  • Dame Jo Williams, Chair of the CQC, in her health committee appearance suggested these flying visits are a consequence of the ways local authorities commission care at home, that is by agreeing block contracts with private and independent care providers.


Self-directed support

Surely there is a better way to give service users and their families more time, better care, choice of when they want it and the same carer most of the time. These are all things we would want if we were choosing our own or our parents’ care at home. The idea of changing the home care ‘market’ to meet individual choice has been around for sometime. The Government’s Putting People First (7) policy document put targets in place for achieving personalisation and choice in the provision of care for older people and others, including that service users are offered personal budgets as a means of arranging care.

The move from a traditional care managed service to one of self directed support should in theory put an end to home care visits that suit the provider and not the user. A personal budget is the amount of money that a council decides is necessary to spend in order to meet an individual’s assessed needs. The budget can be allocated as a direct payment or the council can retain direct control of the budget. Very briefly when an older person has received an assessment of their need, this would be translated into an indicative amount of resources which can be spent arranging a support plan of care which as well as meeting the persons daily living needs, could be provided in the way the person wants because they would be directing the care.

The idea is widely supported but implementation is patchy for a number of reasons. It requires a shift in thinking amongst local authorities and their workers, and frankly amongst service users and their families, for whom managing their own budget and package of care may seem daunting. For older people who lack capacity, they may be putting more reliance on relatives to do the decision making. The idea of the local authority deciding when and in what way the home carers work may seem a more straightforward option.


Future monitoring

There is always a danger with stories like this that the public get a one-sided picture. Much home care is being delivered by dedicated staff offering good quality care and this should not be forgotten. However we must be vigilant to ensure that effective monitoring ensures high standards of care for all. The overwhelming majority care for older people is undertaken in their own homes, and yet recent news stories have focused so much on care in residential homes. Let us hope that the publication of EHRC report in November puts care at home back under the spotlight once again.






(4) Making sense of human rights Department of Constitutional Affairs 2006

(5) Guidance on Eligibility Criteria for Adult Social Care Department of Health 2010


(7) Putting People First HM Government 2007


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