Wiltshire Council report on its Help to Live at Home scheme pulls its punches but still poses serious questions
With social care and its impact on health services so much in the news, many people - especially NHS managers - will be watching the meeting on November 17 at County Hall, of Wiltshire Council's Health Select Committee.
The committee will be discussing their report on the Council's scheme to provide care at home for the old and frail and those with long-term conditions or disabilities that limit their ability to live at home without help: the Help to Live at Home (HTLAH) scheme which the Council is very proud of.
The provision of HTLAH has been contracted out to four providers: Leonard Cheshire Disability in the east of the county (including the Marlborough area), Mears Care in the south and Somerset Care (in north and west) and MiHomecare in west Wiltshire.
The Committee's HTLAH task force was set up in July 2014. Its work was held-up and slightly changed by the Care Quality Commission's (CQC) very unfavourable reports on two of HTLAH's four providers.
Mears Care was suspended by the CQC after its service suffered serious failings following its takeover of three smaller care providers. And MiHomecare (part of the huge Mitie Group) was found by the CQC to be not safe, effective or responsive - but was caring.
The report does not refer to the CQC's unfavourable judgment in May 2014 on Wiltshire Care at Home (part of Leonard Cheshire Disability) calling for action to bring it up to standard.
It appears from the appendix to the report that the task force's witnesses included only five HTLAH 'customers' - two each for Leonard Cheshire and Mears and one for Somerset Care.
The report notes that HTLAH is 'a relatively new model for care' but never spells out what exactly that model is. It does state: "The notion of re-enabling individuals is at the heart of HTLAH service by way of getting people into a position that they can more readily look after themselves without relying on services to do things for them."
Although, as one might expect, the report is generally positive and praises the 'model', it does raise some disturbing issues.
The main problem may lie in this statement: "Evidence from the care providers suggested that clients and their families had an expectation that they would receive visits at specific times for specific tasks. As the care provided through HTLAH focuses on outcomes rather than time and task, the customers’ expectations were not always being met."
This appears to mean that visits to the homes of the old and frail are not to help with specific tasks (getting up, getting dressed, washing, meals - all 'timed' needs), but simply to see how the 'customer' was doing. It would have been useful if the task group had spelled out in their report what these 'outcomes' are. The CQC actually mentioned the problems of the outcome-based scheme in its report on Wiltshire Care at Home (mentioned above.)
The report's opening conclusion states: "The [HTLAH] model is not understood well enough by all those involved in the service, and not all stakeholders appear to have bought in to the model. This means that customers’ expectations are not necessarily being managed appropriately." Which seems a very basic criticism.
The report implies that HTLAH is less prescriptive than other councils' services in defining 'health tasks' - even allowing support workers to give medication to a client. Can this really be the case? And how can time sensitive medication be given if visits are not timed?
Some support workers complained that they were told journey times between calls would be 10 minutes and turned out to be 30 minutes. All four care providers were suffering from lack of staff and difficulties in recruitment.
The Council is urged to "...encourage and support HTLAH providers to improve pay and conditions of front line staff..." - something that may not be feasible under the current austerity regime.
One statement in the report should presumably have been sourced as the opinion of managers - as the task group did not talk to 'many' support workers: "Whilst permanent contracts with salaries would suit many support workers, some prefer the flexibility of the 'zero hours' contract."
One of the chief CQC findings on Mears was that they had too many 'missed calls'. But this report states quite openly: "Each provider has a different definition of a 'missed call'. The Council has not imposed a common definition, and it is unclear whether there is a CQC definition." Surely a 'missed call' is a call that was intended/expected and was not made - whether on time or at all.
One of the report's fifteen conclusions poses a serious question about the way HTLAH was designed and acknowledges that based on the CQC inspections of Mears and MiHomecare, 'risk of failure' may be endemic to HTLAH:
"The economies of scale in giving HTLAH contracts to a small number of providers have to be balanced against limiting flexibility and responsiveness in the market."
But the tenor of the report can best be gathered from this conclusion: "The CQC inspection of Mears was more of a reflection on the organisation failure
of Mears than a failure of HTLAH."
It is a conclusion which neatly ignores the fact that Mears had to buy up smaller providers (which the Council no longer wanted to deal with) to fulfill its contract - and that Wiltshire Council had patently not checked whether Mears had the staff and skills to undertake such take overs without harming their service.
Marlborough News Online showed the report to an experienced care worker who has direct experience of HTLAH. His immediate reaction: "You cannot see this as anything other than a whitewash - where is the accountability of Wiltshire Council?" And he gave one clear example of the shortfalls of the scheme in his area: "When you get your monthly sheet with times for visits, if no one is allocated to a visit it simply means no one comes."