Commissioning home care for older people
Practice example 1: St Monica Trust, BristolOpen
St Monica Trust is a Bristol charity for older people funded by a combination of income from residents and a well-established endowment fund. This allows the trust to make its high-quality services available to a wide range of older people, regardless of their financial background.
The trust’s Care at Home service works in a range of domestic settings with people who have highly complex needs. The creative and flexible care it offers has allowed it to help people whose needs have proven too complex for other agencies.
One of its staff has recently worked with Mr A, a paranoid schizophrenic who has lived in supported housing for the last six years. Mr A, who had a history of violence and spent time in mental health institutions throughout his adult life, had developed penile cancer but was refusing all treatment. He had not bathed or received any personal care since arriving, and this, along with his social problems, was making it difficult for him to stay in his home.
A carer from St Monica Trust, who had experience in mental health, gradually built up a relationship with Mr A. The carer got to know him at his own pace and found out that he was interested in crystal therapy and spirituality. The carer read up on the topic and worked with Mr A to choose the right crystal to help him sleep. Mr A is now receiving regular care for his tumour and personal care. He uses a bed rather than an upright chair and will accept other care staff to provide end-of-life care for him.
The commissioning authority highly recommends this service, which relies on well-trained carers who understand the importance of flexibility and creativity in care provision. A Citizens Advice Bureau case worker is also employed by St Monica Trust who can provide free and impartial advice on how people can fund their care.
Practice example 2: Maximising MobilityOpen
Maximising Mobility is a reablement project with a difference. It is delivered by the carers of users with limited mobility after the intensive work of the hospital physiotherapy home team has come to an end.
Double-up teams – carers who work exclusively with people who use equipment to get around – are given training by physiotherapists to continue mobility exercises with their users.
For example, Mr P had received intensive support from the hospital physiotherapy at-home team but continued to need practical support if he was to regain his independence. His carers helped him to carry on with the walking and stair-climbing exercises (home care providers are not usually expected to offer help on stairs) so that he was able to work towards using his shower rather than having to wash from a bowl in the living room.
The benefits of this project have been felt by users and carers:
- in many cases, users have been able to reach parts of their homes they had been cut off from
- staff have developed the confidence and skills to provide the support they know their users need
- physiotherapists know that exercises are being done regularly and in an appropriately supervised way.
There have been some practical problems getting people reassessed for equipment or physiotherapy due to waiting lists, which have delayed progress and reduced motivation of both the user and staff. Finding the right training has been difficult and costly.
Where the scheme has been incorporated into a user’s existing commissioned package of care, it has been shown to reduce the amount of care needed – if not the number of visits, definitely the length of them – and long-term savings have good potential.
Most users of home care services want to return to have as much independence as possible – Maximising Mobility helps them to achieve that outcome.
Practice example 3: The Raglan Project – Monmouthshire County CouncilOpen
The Raglan Project is a pilot project looking at how to deliver a high standard of relationship-based home care to people with dementia. It is replacing task-based care with flexible care that is focused on the social and emotional needs as well as the physical needs of the person being supported.
Five full-time salaried staff work on a fixed rota with 12 to 15 people with dementia. Before the care begins, staff members establish a relationship with the person receiving care. Staff are then given the freedom to decide for themselves how the relationship and care should be managed – and their decisions are supported rather than controlled by management.
Feedback from interviews, care management reviews and the journals that each staff member completes provides evidence that the project is consistently successful.
It has been possible for people with complex care needs to stay at home rather than moving to permanent residential care or hospital. People who had disengaged from their local community and were neglecting themselves have been supported back to independence and re-engagement with their local community. Community-based social events that were established for all sections of the community are now independent and self-sustaining.
There is also is clear evidence that staff have better morale, health, wellbeing and job satisfaction. Sickness has remained at 0 per cent for 18 months.
Practice example 4: Helping a dying centenarian man achieve a ‘good death’ at homeOpen
Most older people die in hospital, many alone. When asked where they would like to be when they die, most say at home, with their family around them. This practice example shows what quality of life at home means for a dying older person.
When Mr S was consulted on where he wanted to be cared for and where he wanted to die, he was in a care home to give respite to his carer. He stated that he wanted to be at home ‘as long as my wife can cope’. He subsequently went home where he was bedbound for two years.
A care package involving five care agencies was put in place and the case was managed by a community matron. General practitioners (GPs) visited when requested.
An advocate supported Mr S and his carer and helped to improve their quality of life as much as possible throughout the two years, for example by fighting for a wheelchair and ramps to allow Mr S to get outside.
The advocate stepped in again to get Mr S back home after a hospital admission for a chest infection after a GP, who didn’t know him and without consultation, instructed that he was ‘too ill to go home’.
During Mr S’s two years at home, he celebrated his 100th birthday and 65th wedding anniversary with a party organised in his bedroom. He enjoyed watching the Olympics and Wimbledon and saw Andy Murray win. He saw family and friends, stayed close to his home and life and was well-looked after.
Mr S eventually died what his family all felt was a ‘good’ death. His wife feels fulfilled knowing she carried out his wishes and does not suffer the typical guilt of many former carers. The rest of the family have become more emotionally connected with each other, having been able to connect with Mr S during his end-of-life journey.
Could Mr S’s experience be replicated for other older people? A ‘good death’ should be the norm instead of the exception as it is now. But it will only become so if attitudes change to value older people and home care properly and help them to have more control over their lives. Cases like this need to be properly led by a GP and managed by a case manager to make sure that all the relevant services work together to achieve this.
Practice example 5: Learning for the Fourth AgeOpen
Learning for the Fourth Age (L4A) provides learning opportunities to older people receiving care.
Older people receiving care are rarely viewed as able to progress, develop and learn. And yet learning in the later stages of life can boost confidence, give people a more positive outlook on life and delay the onset of dementia.
L4A older people receiving care are matched up one to one with volunteers who they share an interest with, for example learning to paint, local history or information technology. The volunteers visit weekly and together they work on shared learning and development projects. The volunteer works at the user’s pace and is sympathetic to the user’s wants, needs and personality.
Mr H is in his eighties and has recently lost his wife. With reduced mobility, he needs some help with his shopping. He is grateful for his family’s help and support but wanted to stay as independent as possible for as long as possible. Specifically, he wanted to learn to use email so he could order his supermarket shopping online. Having gained confidence with email and shopping online, Mr H is exploring other possibilities such as writing documents and finding information on the web.
An independent evaluation by researchers from NIACE (the National Institute of Adult Continuing Education) and Middlesex University have reported a range of different benefits, including:
- less use of medication
- improved attention span and remembering
- the inclusion of a wider range of different people within a care home
- more people taking part in activities
- partners being more included
- more mutual support.
For staff and relatives, benefits have included:
- new skills and knowledge
- misconceptions being dispelled
- new experiences for all participants, including younger volunteers
- immense satisfaction for everyone taking part.
Staff, relatives and other stakeholders have found themselves more able to see older people as individual people and understand them better.
Practice example 6: Transforming home care: seeking quality of life in care at home in Southwark with stakeholdersOpen
How do you achieve quality of life through home care and raise its value and status? That is a question Southwark Council asked itself in the light of the publication of ‘UNISON’s Ethical Care Charter’  and a slew of press coverage of zero-hours contracts, 15-minute care visits and a lack of pay for travelling time that typify the jobs of many home care workers in Britain.
In summer 2013, Southwark Council explored ways to transform home care and improve users’ experiences. It started by convening a series of stakeholder/user meetings to create a vision of what quality of life in home care looks like, what the values are that underpin this and what the ideal behaviours should be. The discussions started with the views of users and their carers, and continued around the themes from ‘My Home Life’  and ‘The Senses Framework’ , which underpin ‘relationship-centred’ care and were shown to work in home care.
From the discussions it was identified that home care providers are crucial in fostering the right conditions for a relationship-centred approach to the delivery of care alongside better working conditions. Both of these are necessary to deliver improvements in the quality of care. To achieve this, the council recognised that it would have to change its commissioning practice to support the providers to change, as well as try to influence a change of attitude towards home care workers.
One of the other conclusions of the ‘visioning’ work was that home care services as they currently exist and are commissioned need to be valued as part of a wider system. So the relationship that home care has to wider community health services, and activity in general practice and hospitals, is crucial to consider. These relationships are an important part in valuing home care and its workforce. As a result, Southwark has changed the language it uses to describe home care and now calls it ‘integrated community support’.
The vision and values that emerged from the discussions were put to Cabinet, who agreed that they should drive a new commissioning strategy for home care in Southwark that would honour the Ethical Care Charter and raise the bar for home care.
The exercise showed that by using existing models and work already done by other organisations as a starting point, it is possible not to reinvent the wheel. The work done in Southwark is the foundation for a wider culture change programme and a new way of commissioning home care.
Practice example 7: Joint working between health and social care in BristolOpen
For the last two years, Bristol City Council has been looking at how to improve its home care services, through closer working with partners such as the National Health Service (NHS) Continuing Healthcare team and providers. The council’s new Home Care Commissioning Plan  redefines home care services: they are no longer divided into ‘personal care that includes physical contact and domestic care that does not’. A broader description of care now defines it as ‘help to live in a safe and dignified way, and support that helps users maintain or improve their independence’.
Notable elements of the new partnership working include the following:
- There is a meeting every two months called the ‘provider forum’, which is an opportunity for providers to meet together and for them all to meet with health and social care commissioners. Commissioners use the meeting to give providers feedback from users, talk about gaps in the market and changing demands.
- A pilot project has been set up in which the NHS commissions support from the local authority’s integrated carers team to support the carers of users of NHS Continuing Healthcare. Carers are now referred for assessment to the team who use NHS resources to commission respite care.
- Joint health and social care quality assurance monitoring has been developed. Two members of the Continuing HealthCare team have been appointed to join the local authority’s monitoring teams, so that providers are under greater scrutiny in all areas of their provision.
- A joint commissioning contract for health and social care has been developed, so that providers, who often supply both services, are asked to deliver to the same requirements, no matter who is commissioning the services.
- With the introduction of personal health budgets, Continuing Healthcare is hoping to benefit from the authority’s experience of direct payments. The aim is to join up processes involved and support for those in receipt of the payments.
Practice example 8: Wiltshire Council’s Help to Live at Home serviceOpen
Wiltshire Council developed its Help to Live at Home service for older people and others who require help to remain at home. The approach focuses on the outcomes that the older people wish to gain from social care. It involved a complete overhaul of the social care system from the role of the social worker working alongside the customer to determine the required outcomes to the role of the providers of the service who must deliver these outcomes and receive payment based on that delivery.
A case study report on the approach was completed by Professor John Bolton of the Institute of Public Care at Oxford Brookes University based on a series of interviews with stakeholders in February 2012. It comprises a short summary of work completed and progress made, and is intended to encourage further discussion about how outcomes-based, personalised support can best work in social care in England in the future. 
Practice example 9: Promoting assistive technologiesOpen
In the London Borough of Hammersmith and Fulham, the role of technology in keeping people at home and out of hospital is taken so seriously that in January 2013 it created a dedicated Assistive Technology Coordinator post. The aim of the post is to raise the profile of assistive technology and engage partners across a three-borough partnership: Hammersmith and Fulham; Westminster; and Kensington and Chelsea.
Time has been invested in building relationships with health and social care colleagues throughout the three boroughs, including those in hospital occupational therapy, mental health services, district nursing, learning disability services and care management teams. Carers’ groups and voluntary organisations such as Age UK and the Alzheimer’s Society have also been targeted.
Before this dedicated coordinator post was established, the occupational therapy team was dealing with all assistive technology enquiries and referrals but did not have the necessary time to keep up with the latest products, research or policy. Having a designated coordinator means that stakeholders have access to up-to-date information as well as support for complex cases. Support includes a Telecare Prescribers Guide, a formal assistive technology induction programme as well as an online resource site.
The service can reach and benefit a greater number of users and carers as more professionals have the knowledge and skills to prescribe assistive technology solutions.
With this model, assistive technology becomes everybody’s business. It also becomes the default option for helping people to stay in their own home and prevents or delays unnecessary admissions to hospital or care homes. The number of referrals for assistive technologies has doubled in the lifetime of the post and the coordinator role has a good reputation.
Practice example 10: Caring Support, CroydonOpen
Caring Support in Croydon is a community cooperative and charity that provides bespoke personalised care in an innovative way through well-trained and empathetic staff working with users in their own home.
The idea behind it is for care to be provided in clusters – matching up users to home care workers and volunteers living locally. This creates formal and informal levels of support in users’ local areas.
An integral part of its ethos is to help those who do not want to die in a hospice to stay in their own home. Here they can be supported by family and nursed by dedicated carers who they know well, who can call on other professionals for support at critical times.
The end-of-life service aims to provide care and companionship for those approaching the end of their lives and their families, matching care to the person and to family support needs through a flexible and personalised staff culture.
It does this by liaising with the user, the family and the professionals involved via meetings at the user’s home and by phone and text, to make for a seamless service. It can provide 24-hour care if needed and signposts the family to information such as:
- carers’ information services
- training for unpaid carers so they can support their relative
- advice about claiming Attendance Allowance
- advice about Continuing Healthcare funding.
What makes this approach work is that Caring Support:
- offers both pastoral and social care
- is flexible
- has an ethos of care and good training
- has the support of local people and health and social care colleagues
- gives staff training about the end-of-life stage, so that they understand the need to give care that is focused on the person and do not panic when faced with someone who is dying
- makes sure that trained volunteers are on hand to provide practical support.
Practice example 11: The Debenham ProjectOpen
The Debenham Project, which started in 2009, is an innovative community-based approach to supporting those caring for someone with dementia in the rural village of Debenham and its surrounding area in Suffolk.
The aim of the project is to make sure that those living with dementia can be supported locally, instead of having to travel miles for local authority or NHS-funded care services. Volunteers are recruited locally to lead a comprehensive range of activities that support people with dementia and their unpaid carers. Professional support is drawn in where required from health and social care services and charities.
The project provides the following:
- signposting and information services
- lunch clubs
- an exercise club
- a carers’ club
- an information cafe
- activity sessions
- confidential telephone support
- emergency care
- respite support
- professional care
- volunteer transport
- dementia awareness
- clinical services.
The project places a big emphasis on supporting the carer and cared-for together, and on recognising that quality of life comes mainly from maintaining family, social and community relationships – ‘Interaction is the chemotherapy of dementia’ (Henry Simmons, Alzheimer’s Scotland).
The project has had positive results, including the following. It has:
- increased people’s understanding of dementia in the community
- reduced stress
- helped carers to cope
- reduced isolation
- reduced the number of crises and, with that, potential hospital/residential care admissions
- meant that more people with dementia can continue to be cared for in their own homes and community.
The project is a model that can be directly applied in most rural and semi-urban communities and adapted for use in more urban environments.
Debenham has been accepted as one of the first ‘dementia-friendly communities’ as part of the Prime Minister’s Challenge on Dementia.www.the-debenham-project.org.uk