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Improving care in the home: Standardisation, compliance and domiciliary care quality

Standardising compliant practice in domiciliary care at the point of delivery in England, Scotland, Wales and Northern Ireland

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Introduction

As a function carried out by a widely dispersed workforce remote from close supervision, domiciliary care has always harboured the potential for inconsistent standards and practice. Over recent years central policy has placed an emphasis on domiciliary care and has been promoted partly on the premise that care delivered at home is a lower cost alternative to care provided in a home.

There can be little doubt that in the age of austerity, domiciliary care allows cash strapped LAs (local authorities) to provide care services to growing numbers of service users, and brings to life what is often a vacuous phrase of politicians and spin doctors - ‘do more with less’.

However, such is the scale of budget reduction that LAs are seeking to provide domiciliary care with an efficiency that seems little short of ruthless. BBC 1 South regional news magazine, ‘Inside Out’, broadcast on 7th January 2013 provided an insight into how budgetary considerations are reducing the time allowed for domiciliary care.

The programme evidenced that some domiciliary care workers are now paid by the minute and risk not being paid unless providing explanations for discrepancies of 2 minutes. Increasing use is made of 15 minute visits, offering a limited window in which to provide quite personal care.

It also acknowledged the emotional dimension of the relationship between carer and service user, the support that comes from human contact and communication. The harsh reality for LAs funding domiciliary care services during these lean times was expressed by Sarah Pickup of the Association of Directors of Adult Services: “If you want to give people social interaction, home care agencies are not the way to do that.”

With the time allowed for care under such pressure, the potential for inconsistent standards and practice is increased yet further; well intentioned domiciliary carers may be tempted to cut corners in order to meet the needs of service users’ within the time allowed.

In other sectors, ensuring consistency of services supplied in people’s homes is a business issue; however, in domiciliary care it is much more than that - it is an essential matter of compliance.

So, how do domiciliary care organisations ensure quality standards are consistently applied at the point of delivery to service users? In this guide we discuss how every UK domiciliary care organisation can take control of the quality standards of service delivery and effectively manage its compliance obligations.

The problems of ensuring consistency of service delivery

Irrespective of whether service quality standards are customer generated, arise from Best Practice or as in the case of health and social care , externally specified by the regulator, standardisation of practice is a critical element in ensuring consistency and compliance.

There are a number of barriers that stand in the way of standardising practice. The majority of these stem from operational factors which impact the ability to manage, communicate and train domiciliary carers. The key distinction here is the setting between residential care and domiciliary care. In the former the point of delivery is a single geographic location while in the latter it is multiple remote points in the homes of service users.

Domiciliary care is a business and this demands an emphasis on efficiency. Any time not spent face to face with service users is clearly an ‘overhead’ that is not paid for directly by the commissioning authority. In response to time or financial pressures there is a tendency to reduce or eliminate activities which contribute to this overhead. The most prominent factors impacting the ability of domiciliary care providers to standardise practice include:

  • Geographical dispersion: By definition, in domiciliary care, workers are physically scattered; a large UK county requires many hundreds of carers dispersed over an operational territory covering several thousand square kilometres
  • Seldom under close supervision: In the context of social care, supervision is observation of each worker’s practice, comparing it with the standard practice, and taking action if it varies from the standard
  • Close supervision is identifiable as an overhead because observation cannot take place informally as supervisors circulate around an institution, but has to be scheduled to coincide with care worker visits to service user homes; this creates a significant supervisory time and travel overhead
  • Communication is often not face to face: Frequently time has to be taken out of providing care to undertake the communication process and this has time and cost overheads
  • Have only remote access to advice and support: In the event of emergencies or unexpected events 1st line support is via telephone
  • Training and development: Training is a clearly identifiable overhead because it only takes place face to face by employees attending a central location, or remotely by distributing printed resources or electronic publishing. Continuous training and development is more problematic; it either takes place inefficiently as a one to one, or centrally in groups outside of working hours, or by postal distribution of printed resources
  • Coaching and mentoring: Institutional carers work in teams with a multitude of interpersonal contacts while carrying out service user support activity; domiciliary  carers generally work in isolation, with little contact with anyone else in the organisation; mobile phones may provide quick access to advice, but fall a long way short in providing a structured approach to coaching and mentoring

Domiciliary care suffers in comparison to institutional care because it is much more difficult in the domiciliary care setting to efficiently use the skills of more experienced and capable staff to informally disseminate standard practice through informal coaching and advice

The implications for quality assurance

To some, the need to closely control detailed aspects of domiciliary care activity may be perceived as a pre-occupation with micro-management. However, quality assurance is about recording, review and change.

In a setting such as the military, action produces results which can be analysed for effect and changed if necessary. On the flip side, if you do not act there are no results to analyse in order to determine any changes that may be required. Ironically, this doesn’t just hold for the business of putting holes in people. It holds equally well in a care setting that demands service consistency, quality assurance and CQC compliance. In both spheres, taking no action invites high risk.

In the absence of an established standard it is enormously difficult to review and meaningfully compare the practice of individual carers. Even if it is possible to extract some useful information, who do you inform of the ‘change’ when there is no universally applied standard practice to change?

This is the basis of the Deming cycle, the four step management methodology of PDCA (plan-do-check-act), which is used to control and continually improve the quality assurance process. Essentially, it is impossible to establish quality assurance in domiciliary care when there is no established baseline from which to evaluate the variability of service delivery.

Ensuring consistency of service delivery with a QCS compliance management system

QCS compliance management systems enable health and social care providers to fulfil the regulatory obligations laid down by The Care Quality Commission (CQC) in England; the Regulation and Quality Improvement Authority (RQIA) in Northern Ireland; the Scottish Care Commission (SCSWIS) and the Care and Social Services Inspectorate Wales (CSSIW). The system provides policies and procedures customised to meet the needs of each individual service provider.

System content is originated and continuously maintained in step with regulatory change by QCS compliance experts and takes the form of printed manuals combined with an online equivalent. This provides care organisations with ready reference to a comprehensive set of resources, placing a complete toolbox of policies and procedures at the fingertips of registered managers, supervisors and care workers.

Particularly suited to standardising practice

The QCS system is particularly suited to overcoming many of the issues that impact the ability of domiciliary care organisations to achieve standardisation of practice of all workers at the point of care delivery to each service user.

Printed polices and procedures may be circulated as required, allowing the dissemination of information and instruction on any specified practice area. Online versions of documentation may be accessed from home computers enabling care workers’ to reference policies at their own convenience. Smartphones and tablets enable further efficiency by enabling access on demand from the service delivery point, if required.

Expertly written to provide compliance with all UK regulatory bodies

With access to one single set of customised, expertly written policies and procedures, domiciliary care organisations have a tool which sets out how each process of every service user’s care plan needs to be carried out in order to be complaint with the regulatory requirements.

By providing a baseline of practice, QCS compliance management systems enable changes to the processes that govern service user care to be determined and allow any changes to be easily communicated across a distributed team of carers.

Standardised practice enables more effective use of the time overhead that needs to be invested in training and development. The start point for training sessions can assume that all care workers are on the same page - quite literally - despite spending the vast majority of their working time providing care in isolation.

Summary

Ensuring the consistency of service delivery across mobile workforces where it is unrealistic to provide close management supervision is a problem for providers of domiciliary care services.

Standardising, disseminating and changing practice to improve service delivery is particularly problematic. This stems from the operational differences that exist between delivering care in institutional settings and delivering care in service user homes.

QCS compliance management systems enable health and social care organisations to take control of the obligations set out by all of the UK’s health and social care regulators.

By helping to address unique factors such as geographical dispersion, supervision and communication; remote advice and support; training and development; and coaching and mentoring, QCS compliance management is particularly suited to providers of domiciliary care services.

QCS ensures that processes and procedures are standardised and that standardised practice can be easily disseminated. By establishing a baseline, changes to processes or procedures can be more easily determined and communicated. This enables quality assurance and the consistent delivery of high quality care services in domiciliary care settings.

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