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25th November 2011

What is Wrong with Home Care?

This morning’s news is dominated by the news that a home care review by the Equality and Human Rights Commission has highlighted shortcomings in some care at home services. According to the EHRC, some of the abuses are so bad that they breach the human rights of the service user. They quote in particular article eight, which guarantees respect for dignity and personal autonomy, article three, which covers the prohibition of inhuman and degrading treatment, and article two, governing the right to life.

The report states the startlingly low figure of “about half” of the 1200 survey respondents reported general satisfaction with the services which they received.  Amongst the half which reported problems, some problems were widespread. These included:

  • Lack of support for feeding and drinking.  Some carers used the common excuse of Health and Safety to avoid their responsibilities;
  • General neglect caused by carers sticking too rigidly to the tasks set for them.  An example is given of a female service user who, because the staff thought they were too busy, was left stuck on a toilet;
  • Money and property being stolen, sometimes systematically over extended periods;
  • Widespread lack of privacy and dignity, for instance putting people to bed too early to fit in with working patterns, even as early as the afternoon.  And leaving people inadequately washed, or even not washed at all;
  • Carers being patronising, such as talking to friends on their mobile phones at the same time as carrying out care tasks;
  • Physical abuse, such as rough handling, including sheer cruelty such as placing a meal out of reach of a service user.

Those unfortunate enough to have personal experience of care at home can add a few more common problems, including:

  • Missed visits;
  • Late arrivals, early leaving;
  • Changes of staff without prior notice;
  • Short visits; that is, shorter than scheduled, especially if booked and charged as full visits;
  • Short scheduled visits – so short in many instances that they can only be regarded as “are they still alive” calls, with no capacity to actually do anything;
  • Constant moans and groans by the carers in earshot of, or even to, the service user about their own personal or work circumstances;
  • Lack of flexibility – carrying out the scheduled task list rigidly, and ignoring other or changing needs.

Overall the report and personal experience indicate a system which is sometimes minimalist in its vision of what is required of it, poorly managed, staffed by people with less than optimal skills and attitudes, and only tolerated by its customers, who have no real choice in the matter.

What has gone wrong with an idea which was supposed to supplant and improve on the dreaded care home , and offer so much more freedom and independence and, that holy grail of modern political solutions, be cheaper?

Let us deal with “cheaper” first.  Any system of care which demands a minimum 1 to 1 staffing ratio, and throws in travel time and cost between visits is mathematically incapable of being cheaper than institutional care unless, and this is what actually happens, the contact time is reduced compared to a care home by a factor of 5, 10, or even more.

Therefore the benefits of home care are not financial; they are psychological, and tied directly to the service user’s human rights.  Staying in your own home should, on the face of it, make preserving privacy, dignity, independence, personal control, preservation of social networks, and a feeling of living rather than existing, so much easier than is easily possible in institutional care.  It is the ambition of the overwhelming majority of us all to live and die in our own homes, and most of us would be happy to trade off some security and contact time in order to make it happen.  The EHRC report suggests that in the trade-off, up to half of the service users do not receive the benefits they thought they might receive by staying on at home and being supported there.

So how can the problem be fixed, or at least alleviated?

Begin with inspections by the statutory bodies.  CQC have recently announced that they will begin additional inspections of home care providers from April 2012.  Given the length of time that the CQC have been regulating home care, preceded presumably by a research and planning period which should have identified at least the potential problem areas and causes, this announcement does sound rather reactive, when proactive action is required.

Local Authority contracting models have to take some of the blame.  In fact, given that the contract regime under which the providers operate must set the tone and context of the service as it is perceived by the service user, that regime must take the lion’s share of the blame for any problems.  There is a need for a strategic approach to contracting in order to maximise the opportunity for achieving the best services possible, but what is often found is a low level tactical approach.  By this we mean that contracts are often a knitted together patchwork of quick answers to individual service problems, actual or perceived, with no overall logic.  There may be some words about “Partnership Working”, “Shared Objectives”, and “Quality Outcomes” headlining the preamble to the contract, but all too often the structure and content of the contract says something quite different, sometimes even building in certain failure.  One issue which the EHRC report highlights, and which clearly indicates the lack of strategic thinking, is the fact that often the amount paid by councils for care of the elderly is less than that paid for younger people.  How can a council expect the providers and staff providing care for the elderly to respect those clients if the council’s own actions indicate a fundamental discrimination against older people?  The service has fallen at the first hurdle.

Contracts also sometimes build in reasons to fail.  One of these is the issue of travel time between visits.  Most home care is delivered by a carer who has to make multiple visits, with travel time between those visits.  This matter is one of the fundamental financial dis-benefits of using home care, and is therefore sometimes swept under the carpet in order to improve how the service appears.  Some contracts ignore the issue altogether; some contracts have been seen where visits are expected to take place carrying on from each other, for instance visit 1 is 4pm to 4.30pm, and visit 2, to another client, is from 4.30pm to 5pm.  This is a convenient way of shifting the cost of the travel time on to the person least able to and least likely to complain – the service user, who experiences a short visit while the carer and their employer juggle to carry out the service.  If the service user does complain, as the author has done in the past on behalf of service users, then it is certain that the service provider gets the blame, and not the council or the contract.  Other councils try to dodge the issue by recognising travel time but not paying for it.  With spot contracting rife, this policy allows unscrupulous or ill-informed employers to pass on the non-payment to the care staff, and only pay them for contact time.  The more enlightened and legal services have to fall into line if they are to match prices and stay in business.  It’s hoped that the recent Employment Tribunal case which clearly identified travel-between time as part of working time under the directive, and therefore counting towards calculation of minimum wage, will force councils to confront and normalise the matter.

Not only do these policies cause significant day to day management problems for service providers and their staff, but it also indicates to all concerned that the offending council places financial expediency above moral and cultural obligations.  Those councils in turn should not then be surprised when they find that their service providers are staffed by people who see no indication of being valued by the system, and therefore may be tempted to pass on that feeling to their service users by not valuing them.

A fundamental problem with some contracts is the level of task orientation.  Many contract administration systems are based on lists of tasks to be performed with or for service users.  Even a cursory review of research going back many years will clearly indicate that task oriented services do nothing for the feelings of well-being and satisfaction felt by the service user.  Task orientation is the enemy of personalised care.  The individual social worker will probably argue that the task list arises from their expert review of the needs of the service user, but that congruence lasts about one day given the variations in environment, physical and mental health and other changes experienced by every service user.  The list does not allow the only person able to see those changes and do anything about it - the carer on the day – any flexibility to react appropriately.

This brings us to the crux of the contracting problem.  Some councils seem to be unable to recognise that the structure and effect of their contract has a strong effect on the culture that their service providers are able to generate.  Most other businesses appear to understand that achieving excellence as perceived by the customer, the only true measure of excellence, requires that the whole pyramid of structures which deploy to deliver that service must experience the same level of excellence and esteem.  A workforce which feels itself to be part of a system to produce the minimum of help in the cheapest way possible is not likely to feel part of an excellent service, and will perform accordingly.

The employers cannot escape criticism.  Listening in to the management of home care services, one characteristic often comes across, and that is stress and crisis management. Some managers spend their working time reacting to and dealing with a never ending stream of internal crises - staff not reporting for duty, transport delays, car breakdowns, traffic jams, meeting situations they do not feel able to deal with; the list is endless.  The stress level is high, and it often shows to other members of the team, so it is again hardly surprising that the team are concentrating more on surviving the day without the service collapsing around them (as it appears to them), than providing a service to individual service users which they see as meeting their needs.

Recruitment strategies are sometimes not at all connected to service quality development.  In place of the strategic views and planning carried out by successful industries elsewhere in the economy, the poorer care companies recruit according to short term needs, with no overall quality management objectives for the process.  Those companies are seen generally to employ groups of individuals, each working for their own personal ends, with no encouragement to strive for excellence because no-one showed any indication of quality during their recruitment.

If the EHRC report, as they do, that some staff quote Health and Safety as a reason not to carry out household tasks, this points in turn to the lack of skill of the managers and staff in this area.  Health and Safety calls for reasonable actions in the face of risk, and over-reaction is usually an effect of ignorance of risk identification and management.  This is a training issue for the person with primary training responsibility, the manager, and then the staff themselves.

The problems of abuse, in its various forms, as identified by the EHRC report and listed above, are often the end result of an inadequate management culture in the employing organisation, coupled with a lack of quality awareness and management and quality focused training.  This lack of a performing culture stems from a woeful lack of leadership skills and understanding of strategic quality management in some parts the care sector, both on the commissioning and the provider side.  Until that leadership gap is bridged by adequate selection, training and education, and commissioners commission in accordance with good strategic understanding of the service needs, resulting in providers operating within a management system which is fit for purpose, then no amount of surveying, reporting, increased inspection and sanctions will overcome the problems.

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