Hello Mollie!
Ah, hello.
How are you today?
I'm not too bad, thank you.
Wonderful.
Nice to see you.
Oh, Really good to see you as well.
There are many instances of good home care being provided in the UK.
However, with an aging population and continuing economic pressures, the
commissioning of home care that provides what older people with complex needs say
they want is a challenge.
There is evidence that some people and their families are dissatisfied with what they
receive, as well as public perception that home care provision can be poor.
I think some of the commissioning of home care that gets bad press is the stuff that is
kind of time and task based in which purchases, often very small blocks of time for
home care, in particular the 15 minute contracting of home care that's had a lot of
negative coverage in the press over the last period is an example of that.
In Bristol, St Monica Trust has a reputation for providing good residential care and
sheltered housing.
In 2012 the Trust launched a home care service for older people - which provides
support for individuals funded from a variety of sources including self-funders and
continuing health care.
We felt that there was a need for a service to maybe challenge some of the current
models of working.
One of our key models at the St Monica Trust is about well being of the individual and
it's something that's, you know, at the centre of our work, like dignity, respect, overall well
being and that's our primary aim.
But we're very different in the sense that all our staff are salaried.
We pay travel time, we put emphasis on staff training, we put emphasis on personal
qualities, skills, competence, and our relationship with the customer is one based on
how our customer and our carer form a relationship together to meet the needs of
the customer.
So that's been our primary aim.
So we have supported people with end of life, we've supported people obviously with end
stage cancer, we've supported people with COPD, long term problems of COPD
and then we've also supported people who are not at end of life
but are living with complex illnesses day to day and maybe have other, you know
clinical needs for instance colostomies, catheter care a wide variety.
What I do need to stress is they're not nurses, so they're not actually undertaking what would
be seen as a nursing duty.
So, for instance, if we are supporting a customer there is a need to engage with the
local GP practice, the district nurses or the hospice so that we've got this care plan that
we're all working towards and we support each other to work towards that care plan.
Everything should be put in that care plan and we build on that care plan as often
as needs be.
It gets reviewed so that that person's care, they feel, is personal to them and their
needs are being met.
Are there additional considerations a care worker has to give when somebody has
complex needs?
Yes, we have lots of different complex needs, we also do end of life, we visit people that
are terminally ill, and you just have to adapt your skills to that person because no two
people are the same, no two cases of dementia are the same.
They affect people in different ways.
They affect the families in different ways and you have to see where their aspect of dementia
is affecting them the most and work with that.
And once you've done that and you've been able to that, you'll find that they will build a wonderful
relationship with you and the families will build a wonderful relationship with you.
The afternoon and Tracy pays a second visit of the day to Beryl, a woman with vascular dementia,
who is cared for at home by her two daughters.
Deliver all of the personal care needs first thing in the morning and then go back later in the evening
to give assistance with helping the customer get ready for bed and make sure they're settled and
positioned comfortably as well.
Beryl's daughters, Sally and Rachael, previously used other home care providers
but didn't feel that the services and support given met Beryl's needs in a
person-centered way.
The sisters agreed to be interviewed, but requested their mother's face not be
shown in full.
Hello Sally, how are you doing?
I'm good thank you. And you?
Yes, good. How's Mum?
Yes, she's good.
Oh wonderful!
She's pleased to see you.
Wonderful.
Beryl.
There's Tracy.
There! That's a lovely surprise.
I know darling?
Ah, you're a little bit sleepy.
Rachael. You've decided to look after your Mum at home. Can you talk about that?
I think it's an understanding that we always had that Mum loved being at home and it
was never really a question for us that we were determined between us that we would
keep Mum at home and care for her in an environment that she was familiar with.
It's marvellous to do what we do. It's hard work but..
It's a privilege.
it's a privilege for sure.
We've had many very special moments.
And what does good home care mean to you, Sally?
It means continuity.
It means a face a friendly face coming in regularly to see Mum.
To come and hold hands, smile, talk quietly to her and build up a rapport, a good
relationship with Mum.
Mum was an incredibly private person and I think from a respect point of view that's an
important thing for the carers coming in to be respectful of this particular situation.
You know, respect, empathy, understanding and to be able to build a rapport with us as
Mum's main carers.
There are so many things to consider.
At St Monica's we have our key liaison person, Tracy, who we know that we can call
at any time of day but there was a few weeks whereby she wasn't able to come in.
And when she came back in again after that break, with Mum's particular condition, it all?
she has no verbal communication it's all non-verbal communication and Tracy came in
on this particular day and Mum looked up at her and said You're back. You've come back?
And it was, it was you know a really a special moment for both, for all of us here?
Very emotional.
Because it's you know, it's very you know don't often hear Mum's voice and to hear her not only
speaking but to be able to say that to Tracy and I think that's an absolutely prime example
of how important it is for a provider to listen to the carers, the family and understand that
particular conditions need particular types of care support.
The St Monica Trust approach to person-centred home care is built on the
recruitment of the right staff - and ongoing support.
This includes training, developing skills of care workers to work with individuals and
their families, taking an integrated approach to meet complex needs.
They're not nurses, they are care workers.
But it's really important that they get a broad spectrum of the different aspects of
work they might get involved in.
So ultimately we have a number of carers who went through some intensive end of
life training to the point where they could be our trainers.
So even within our team two members of our staff actually deliver bespoke end of
life training to our team.
So they've done the work with the customers they've been out there, they've
looked after customers with end of life needs they've engaged with district nurses
they've engaged with St Peter's Hospice.
We've formed those relationships we've learnt from them directly as well as in the classroom
and then those our own carers who are trained in this area do group workshops
for our team.
So we really can actually focus in on the types of specific customers we're supporting with
specific needs and then support them with those needs.
The St Monica Trust is achieving high levels of satisfaction from people who use their services.
Nationally, challenges remain for the commissioners of home care.
I think we need to see a shift towards something that is a bit more nuanced than paying for blocks
of care and especially small 15 minute blocks of care to something that allows providers more
flexibility within the terms of that contract to do what they think is necessary with the expertise
they have to deliver the best outcome and that they can for the money that's available.
What are the kind of arguments that a commissioner needs to make to justify a
contract for high quality home care?
The sorts of arguments that commissioners would need to make the case for investing in
high quality home care and paying perhaps paying a slightly higher rate for that relate to
the important role that community based provision and home care delivered to those people
in their own homes has in keeping people away from more acute services delivered in
institutional settings.
If you are investing creatively in your home care market you would certainly hope that that would
result in fewer people requiring high level intensive support within residential and
nursing settings.
The SCIE guide on commissioning home care for older people with complex needs draws
together the published evidence on the subject.
When you do it and you do it right it is completely rewarding because you leave and
that person is so happy.
They're so happy, you feel, and that's the whole purpose of being a carer is that person enjoys
that visit with you and looks forward to you coming again.