CQC finds common issues undermining majority of good home care

13 February 2013

The findings of a report into home care launched today, Wednesday 13 February, by the Care Quality Commission, show that people want to be listened to, respected and able to exercise choice. The report entitled, ‘Not just a number’, will be launched at a Parliamentary breakfast hosted by Rosie Cooper MP, member of the House of Commons Health Select Committee.

Overall CQC found most providers were delivering a good service, but a minority of people are affected by late or missed calls, lack of continuity of care workers, unsupported staff; poor care planning, and failures of providers to listen to people using services and their families and carers.

The report captures the findings from a programme of themed inspections covering 250 domiciliary care (home care) agencies providing at-home support and care to around 26,500 people. The inspections checked the quality of home care provision for people aged 65 and over across England.

David Behan, Chief Executive of the CQC said: “People have a right to expect to be treated as an individual, to be able to exercise choice, and to make sure their carers are aware of their specific care needs. We found plenty of evidence of this however we also found elements of poor care which happen too often.”

The report indentifies levels of compliance against five of CQC’s national standards:

Respecting and involving people who use services

The overwhelming majority of providers were respecting and involving people (97% or 241 providers). Where providers were failing to meet an element of the standard, we found people did not feel valued because their visits were often delayed or sometimes cancelled. This was made worse if people were not kept informed if their care worker was going to be late. It sometimes appeared that people were resigned to accepting a level of unreliability within the service.

The care and welfare of people who use services

The majority of providers were promoting the care and welfare of people using this service (85% or 212 providers). Thirty-eight providers were not meeting this standard, with just under a third of these located in London. We found a number of occasions when risks associated with a person’s care or medical conditions, such as diabetes or catheter care, had not been assessed, and care plans had not been updated for several years.

Safeguarding people who use services from abuse

The overwhelming majority of providers were safeguarding people from abuse (96% or 240 providers). Many providers had processes that detailed the action that staff and managers had to take if they suspected any abuse and all agencies had a whistleblowing procedure. Of the ten who failed to meet this standard five were found to have a moderate impact and CQC took enforcement action against one provider.

How providers support their staff

The majority of providers were supporting their staff (88% or 221 providers). People who receive care in their own home, and their relatives, value care workers who are knowledgeable and understand their or their relative’s condition. Twenty nine providers were failing to meet this CQC national standard, of these, three were judged to be of moderate impact on patients and one service was judged to be major.

How providers assess and monitor the quality of the services they deliver

The majority of providers demonstrated an ability to monitor and assess their services (85% or 212 providers). CQC inspectors saw a range of effective methods of monitoring quality including: agencies that made weekly phone calls to people using services to check that the care was meeting their needs; and annual quality audits. Of the 38 agencies who failed to meet this standard 15 agencies were judged to have a moderate impact and two had a major impact on people.

Overall, our inspections have revealed that many agencies are providing a service to people in their own homes which they value and are content with. But we have also seen that some areas need improvement and action from those who commission and provide home care.

Overall the report makes 15 recommendations aimed at driving improvement across the sector. Providers need to work more closely with local authority commissioners to improve care and find solutions to these common problems, and put systems in place to monitor the impact of missed or late visits on people receiving care. Where providers are failing to meet CQC national standards they must learn from the good practice that exists across the sector.

The report has identified a reluctance to complain, some people are worried about getting their regular care workers into trouble and others may be worried about reprisals if they complain. The CQC wants to use this report to inform people of what good home care and poor home care look like.

Ends

For media enquiries call the CQC press office on 0207 448 9401 during office hours or out of hours on 07917 232 143. For general enquiries call 03000 616161.

What does good care look like?

CQC inspectors found a lot of good practice that could be reflected in all home care. The following were many of the characteristics of good care people and carers should look out for:

• Continuity of care workers was one of the most important aspects of personalised care – the best agencies maintained a familiar roster of care workers for each person, with any changes notified in advance where possible. 
• Care workers showing kindness, friendliness and gentleness with respect for a person’s property and belongings.
• Detailed care plans at home are kept up to date, with care workers accurately completing the daily logs. Regular reviews and risk assessments to adjust care plans responding to changing needs and preferences.
• Care workers introduced to the person before they started regularly attending.
• Care workers routinely knocking and announcing their arrival before coming in. The best care workers wear Staff ID badges to confirm their identity and are aware of any security requirements. 
• Encouragement and support for people to express their views and detailed records noting people’s preferences and choice.  
• People’s views are gathered in a variety of ways and fed back to improve the services provided. Personal contact from the management team shows good practice
• Face-to-face explanation of the choices available to the patient from their domiciliary care service as well as clearly written information the patient can refer to.
• High levels of involvement of relatives and carers in decisions about a person’s care.
• Staff understand the illnesses that people have, so are better able to provide the right amount of support when needed. A good understanding of dementia is important where a patient is suffering from dementia.
• People using services are aware of who to contact at the agency if they have concerns. People are given information about the types and signs of abuse. 
• All staff undergo a Criminal Records Bureau (CRB) check before the provider offers a position and asks for references.Care workers introduced to the person before they started regularly attending.

What does poor care look like?

Where poor care exists, our concerns relating to home care servicesincluded the lack of continuity of care workers, missed or late visits, failures to keep people informed about changes to their visits and other areas.

• Lack of consistency of care workers.Many comments were received about the number of unfamiliar care workers. In one instance a person had received 13 different care workers over 35 visits.
• Missed or late visits.Some staff told us it wasn’t unusual for them to be asked to cover an additional visit in their schedule for the day, which could mean they had to cut short other visits. There were numerous examples of rotas that did not allow time for staff to travel between visits. Weekends are a particular cause for concern.
• Lack of coordination of visits requiring two care workers.The report found a negative impact on care when a person required two care workers but one was either late or did not turn up. This means the time allocated to specific two-person tasks can be significantly reduced, resulting in people not getting the care they should.
• Failures to keep people informed about changes to their visits. Being dependent and having to wait for a visit from their care workers leaves people feeling vulnerable and undervalued.
• Inadequate systems to report abuse. In one isolated instance staff had raised concerns about missed visits where people were left without meals, medicines, or assistance, but did not feel management had listened and taken action. As a result, CQC issued the provider with a warning notice, which included a timescale for improvement.
• Lack of detailed care plans,staff knowledge and skill, particularly with regard to dementia. There were isolated instances where the care recorded in a person’s daily log did not reflect the care they actually received. The report notes inspectors saw many staff files that were incomplete and did not include records of supervision or performance appraisal meetings. 79% of the services questioned, where the information was available, care for people with dementia.

Notes to editors

The number of home care services registered with the Care Quality Commission (CQC) increased by 16% in 2011/12, and a further 6% in the first six months of 2012/13. CQC inspects at location level rather than at provider level - there were 7,227 locations registered in 2013.

Although home care is not just for older people, older people over 65 form the majority of those who use home care, accounting for 77% of all state-funded home care services.

The domiciliary care inspections took place between April and November 2012 measuring against five of CQC’s national standards of quality and safety. These were:

• Respecting and involving people who use services(Regulation 17 Respecting and Involving service users)
• The care and welfare of people who use services(Regulation 9 – Care and welfare of service users)
• Safeguarding people who use services from abuse(Regulation 11 – Safeguarding service users from abuse)
• How providers support their staff (Regulation 23 – Supporting workers)
• How providers assess and monitor the quality of the services they deliver(Regulation 10- Assessing and monitoring the quality of service provision)

1. In total, CQC received the views of more than 3,700 people.

CQC inspectors visited some 738 people in their own homes

2,742 people discussed their views with us over the telephone

274 relatives gave us their views during visits or through discussions with Experts by Experience.

2. CQC also analysed over 1,000 responses to our questionnaires. We took into account all these contributions, together with information from our inspections, when making judgements about a provider’s compliance with the regulations.

3. Due to the high percentage (76%) of older people receiving home care we focused on those aged 65 and over.

4. An advisory board was appointed to help us shape the content of the report and our approach to the inspections, with members drawn from a range of organisations Association of Directors of Adult Social Services (ADASS)

• Age UK
• CERETAS
• Community Options
• Equality and Human Rights Commission (EHRC)
• Experts by Experience
• Individual/carer
• Mencap
• National Care Forum (NCF)
• Royal College of Nursing (RCN)
• Social Care Institute for Excellence (SCIE)
• Shared Lives Plus
• Skills for Care
• Standing Commission on Carers
• United Kingdom Homecare Association (UKHCA)
• Local involvement networks (LINKs)

5. CQC inspected 250 home care agencies consisting of:

• 208 privately owned agency services
• 22 council owned, and
• 20 owned by voluntary organisations.
• The number of people cared for in each of the services varied from the ‘micro’ providers
• providing services to fewer than five people to the large providers, caring for more than 200 people. The largest service was caring for 700 people.