The High Road To Better Home Care

Blog 3. Homecare

In my last blog I talked a lot about why social care was not what it could be, and I majored on the negative impact of policies based on a competitive marketplace. However, in the spirit of You Never Know!, I finished on an upbeat note, saying that our new Welsh laws and policies had created the roadmap for achieving brilliant care services. Services which talk to people and are connected up within local communities. Services which value frontline workers and dare to trust their intelligence and good will. Services which pursue long-term goals and set aside short-term self-interest for the widest and most enduring public benefit.

And I promised to describe a home care service in Arfon which was already making strides down the right road. So here goes…

Go back a year or two and the Arfon Home Care service was a daily trauma. 25 staff trying to carry out 723 calls a week to about 40 people, between 6.45am and 10.15 at night, 7 days a week, over a mountainous area of about 200 square miles.   The rounds were changing constantly, as they do, because people die or go into residential care or are newly assessed and referred. Sorting out the ever-changing rounds was a nightmare, compounded (for an ethical employer) by the realities of staff having variable contracts, family demands, holidays and sick leave. The managers spent nearly all their time nursing the rota and doing masses of paperwork to satisfy finance departments that the staff hours were correct for payment and contract monitoring departments that 723 tasks a week had been carried out at the specified times. They made a record of all the demands on their time over a week. There were 306 demands. Only 14 related to the people being supported, with only one direct call from a service user. Traditional home care admin is a nightmare, and nearly all of it is a waste of time caused by requirements that are not related to doing what matters to the people receiving care.

Looking back, it was no fun for the staff chasing about the hills. No fun for the managers with their calculators and ever-changing spreadsheets. And no fun for social workers, with their own huge caseloads and mountainous patches, having to gate-keep the whole system, and sign off every variation of care – because the system didn’t allow them to trust a care provider or a home-care worker to talk with people and make sensible decisions about more or less support. The system required care workers to be trained, vetted, supervised and, if necessary, disciplined, but it didn’t allow them to do anything other than follow a rota and implement tasks prescribed in static care plans from a narrow checklist of fundable activities.

It’s worth pausing to say thank you to everyone who works in the frontline of home care under these circumstances. I’ve no sympathy for those at the top of agencies squeezing private profit out of a cash-strapped care industry. But frontline workers in every sector of home care are invariably decent ordinary people doing their best, and they all deserve better from the care system. Better pay, definitely. But also greater fulfilment and self-esteem. Like we are seeing in Arfon.

Homecare 2a

In Arfon now, the 200 miles and 720+ calls have been broken down into five geographically sensible rounds. The 25 staff have been divided into five teams, one per round. Each team draws up its own rota, and then makes collectively agreed adjustments to the rota whenever required, quickly and with minimum hassle, by communicating directly with each other via Whats App on their mobile phones.  The number of staff potentially visiting each person is reduced, and consequently families and individuals are consistently seeing a familiar face, someone who knows them well, and with whom they can have important conversations about care arrangements or maybe just how they are feeling that morning. Relationships and trust have been strengthened so that staff can ring Mr E to explain if they need to stay longer with Mrs J. They know which calls are time critical and which are flexible.

They are also becoming aware of the scope for reducing people’s dependence, for example when they routinely find someone has cooked the care-plan-prescribed lunch for themselves and is waiting for them just to have a chat. If a chat is what someone needs, there are other ways to help them, building community connections rather than bringing in a paid worker every lunch-time. Many home care workers will be aware of such situations, but the traditional home care system encourages them to keep quiet about it, for fear that their hours and pay will be cut. The Arfon system is based on developing trust between funder and care provider, so that perverse disincentives for doing the right thing are removed.

Crucially, the workers have been given the authority to use their knowledge and good judgment. They are trusted to do what matters, not just by managers and social workers, but by each other. In fact, they are increasingly becoming self-managing teams. Instead of a frazzled manager at the centre of every demand and decision, six or seven workers share out tasks amongst themselves and organise their own solutions to the ordinary problems that pop up each day on their round of calls.

Taking on the management of the rota within the team was just the first step. Each team also now takes responsibility for keeping an accurate record of the calls they make. One of them has taken on the task of managing the team’s timesheets and payroll submission. The intention is for them to use this information to issue invoicing information directly to the local authority finance department, removing the need for an administrator and manager to gather and check the detail and then submit it to head office for further checking and submission – a nightmare of waste. The truth of it is that the office-based staff have no way of knowing if it is accurate, and consequently it can be sent back and forth umpteen times. The care staff get the information right first time.

This doesn’t mean that the teams are unmanaged and unsupported though. When teams develop greater autonomy, the role of the manager changes. What they do each day moves away from rota management, and command and control approaches, to working supportively with the staff team. Their focus has shifted towards mentoring, nurturing an environment of co-operation within each team, and being in the work, shadowing the staff to see how they are doing what matters, and to better understand what might be getting in the way of their being able to do that.

I attended a home care team meeting recently and was struck by the confidence, honesty and insight on display. And I went out on a morning round with one of the team, and was not only impressed with the level of complex and risk-infused care being delivered professionally and sensitively (by workers on the Minimum Wage, for goodness sake!). My companion loved his job, and not just because of the rewards of working with people and being a care giver. He loved his job because it was not just about following a script and obeying orders. All his talents were being valued and given the opportunity to flourish, and his role was rich with responsibility and impact.

A big thank you to the officers of Gwynedd County Council for their courage and commitment to this co-operative experiment. In a world dominated by ideas of competition, it takes courage to put the tendering machine on hold and invest your time in re-designing the system. It takes courage to invite outsiders (from system consultants and third sector managers to frontline care workers) into the usually closed arena of statutory professional discussions. It takes courage to be open, to let go, and to trust.

The story so far is encouraging. I hope everyone involved will stay the course, build momentum, and help trust and co-operation flourish at the heart of care services everywhere.



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