This highly topical report provides practical guidance on how to ensure that older people's views are heard and acted on, and their views monitored, in relation to service quality. Quality at home for older people:
- provides new information on the definition of quality in home care services by service users under and over 80 years of age;
- identifies users' priorities for the first time;
- shows the differences and similarities in the perceptions of quality between white and minority ethnic service users;
- compares different methods of obtaining service users' views;
- makes recommendations for ways of ensuring that listening to older people's views on quality becomes part of the mainstream process of purchasing and providing quality home care services.
This study explored older people's ideas about what a quality home care service should look like and how their views about this can be regularly heard. The researchers saw 143 older people - living in Manchester - in focus groups or their own homes. Older people valued home care services highly and had clear views about what characterises quality in these services. The study found that for people over and under the age of 80:
Older people defined 'quality' in terms of seven key attributes:
- Provision of help to keep your home clean and with small tasks like changing light bulbs.
- Regular carers, so that trust can be built up and time saved.
- Notification of what tasks older people can expect carers to undertake.
- Notification of any changes in carers or carers' activities, so that older people are not opening their doors to a stranger.
- Flexible services which can reflect older people's current needs.
- Carers trained in the tasks they have to do and trained to listen to clients.
- Aids and adaptations to promote independence.
- Services to enable older people to get out of their homes.
- Older people saw good, safe transport and better health care services as important. Both of these promoted their independence and affected their attitudes to their lives in their own homes.
- Additionally, people under 80 saw the provision of company as part of a quality service. For those over 80, a quality service would enable them to occupy their minds, encourage 'good neighbours' and provide robots to do domestic tasks from cleaning to gardening.
- Older people from black and minority groups saw culturally specific languages, foods and activities as additional characteristics of quality services.
- Older people suggested that, to enable their views to be heard on matters of quality, three meetings a year with providers, purchasers, elected members and older people be held in each area of the city. In addition, a daily auditing of a sample of service users' experience of the services delivered should be routinely undertaken and the information reported to the senior manager responsible for adult services.
The starting point for this study was that older people's definitions of what makes for a quality service could and should be heard in their own words. For this reason, the study did not examine what older people thought of existing services but what they defined as a quality home care service. This would enable them to contribute to the national debate about what the standards for home care services should be and inform the quality of provision in the services in Manchester where the study took place.
Quality in home care services
The researchers drew a random sample of those receiving home care services purchased on their behalf by the city of Manchester social services department. Study participants were very grateful for what they currently received. This included a variety of different kinds of services. They valued the carers without whose help many could not continue to live at home.
"You are grateful for what you get and you don't want to ask for anything else."
This said, older people had clear views about what contributed to quality in these services. What carers did and how they did it were both significant and older people did not see these as separate issues. They were very clear that they needed services that helped them maintain their home. Thus they wanted:
"A little help with housework, hoovering especially would help", since
"If you haven't got a family, who is going to do the windows, the surfaces dusting and polishing if you can't?"
They found looking at the dirty curtains and windows very depressing but were unable themselves to do anything about these.
Changes in carers arriving to provide help are common. Older people recognised that these are sometimes inevitable. In a quality home care service, however, older people said they would know if someone other than their regular carer were coming. Regular carers were thought to assist trust building and save time since they don't need to be shown how to do things or where things are. Additionally:
"It is frightening to open your door to someone you don't know and whom you can't see. Couldn't someone phone me to say there's going to be a different person today?"
Most older people currently have no way of knowing what their carer can do for them. Knowing this would remove some uncertainty for them. Equally there seems to be little opportunity to negotiate changes needed in the help they want as their needs change. Older people felt a quality service would ensure that a list of tasks that can be done by home carers is provided annually and that carers are flexible enough to address particular short-term needs and reflect longer-term changes in the help that is needed.
How carers do their tasks was felt to be important in promoting a quality home care service. This requires that carers be trained both in what they do and how they do it.
"You can't expect people to know how to make beds just because they are adult."
"They only hoover around the furniture, the dust accumulates and affects my asthma."
"I want to be treated with respect and listened to; not just 'I'll pop you into bed'."
Older people highly valued aids and adaptations of all kinds as promoting a quality service. Those mentioned ranged from the provision of showers, seats in showers, stairlifts, door intercoms to panic buttons and pendants as well as modified taps for arthritic hands and the 'third hand' (a stick with a claw grabber) which is deftly used by many people. Beyond the home, the provision of seats in and outside shops was seen as contributing to older people's quality of life and their independence.
Getting out of their house could be difficult for people without assistance. Having help to "Get away from the four walls" was seen as an important attribute of a quality service. Amongst other things, older people suggested that having someone to go for a walk with or take them to the shops would help address this.
Neither transport nor health care are currently defined as home care services. However, older people raised them in their discussions of what they defined as quality home care. They valued accessible and affordable transport, designed so that they could get out and back to their homes safely without being physically "shaken up". They also felt that the following health care services contributed to the quality of home care as they experienced it: services which helped them get treatment at home when they were ill; more regular check-ups for those over 75; and the regular review of repeat prescriptions. They also identified the availability of a GP chemist prescription pick-up and delivery service for those who wanted it, as a means of contributing to the quality of their home care service.
Additional quality attributes
For people under the age of 80 having someone to do things with, some company, was an attribute of a quality service. This included the provision of places to go to meet people and people to talk to on a regular basis. Those over the age of 80 did not mention this in their discussions of quality. They saw the provision of things to keep their minds occupied and good neighbours as contributing to quality services at home. They also identified robots as potential assistants with domestic tasks in quality home care services.
Older people from minority ethnic groups
People from Chinese and Asian communities taking part in the study knew little about the availability of home care services. They felt that language as well as cultural norms about this kind of care were important barriers preventing them from accessing services: having information in their own language about what is available and knowing where to get it from would be helpful. They suggested putting such information in locally accessible places in their own communities. Clearly, quality services needed to be delivered by people who speak a language an older person can understand. Services also needed to be sensitive to the dietary requirements and the activities engaged in by older people from minority ethnic communities.
Hearing service users' views
The researchers held a round-table meeting of the participants in the study, service managers, purchasers, providers and elected members to explore how service users' views could regularly contribute to the development and maintenance of quality in home care services. Participants came up with two ways in which this could occur. These were:
- Daily contact by a service care manager with one service user to audit his or her experience of the quality of that day's home care service. This was to be fed back into the local authority and into the provider's monitoring systems. Ways to ensure that this happened would need to be developed.
- A meeting held three times per year in each of the 9 areas into which the city of Manchester is divided. At these meetings, older people receiving home care services, service purchasers and providers and elected members would come together to hear older people's views on the quality of the service provided and suggestions for improvement. These would be noted and reviewed at subsequent meetings of these groups, enabling the older people to say what had improved and service managers to explain why changes had not been made if this was the case.
The researchers concluded that the current emphasis on the provision of personal social care in home care services needs to be balanced by addressing the characteristics of quality home care services as defined by older people. It also suggests the need for health, social care and transport providers to work together to improve the lives of older people.
About the study
The researchers drew a 10 per cent random sample of the 3,000 people over the age of 65 receiving home care services purchased on their behalf by the local authority social services department. They also contacted three groups from local minority ethnic communities, one from the Chinese community and two from the Asian community, to get their views on the quality of the home care services. The researchers used three open questions to collect data:
- What home care services are you currently receiving from any source?
- What makes a quality home care service to enable you to stay at home?
- In an imaginary world, what would make a quality home care service?
People were asked to rank the attributes of quality they came up with, having been taught the technique of paired comparisons.
Initially, the researchers planned to use focus groups to get all the information, with sixth-formers to help run these. However, in the pilot study many people did not want to come to these. So home-based interviews were offered, using the same questions as those used in the focus groups. Interviewees were asked to rank the quality attributes generated in the focus group held in their part of the city. The researchers were able to compare these two methods of obtaining older people's views and see if there was any difference in the information they provided. Interviewees came up with fewer ideas about quality than did focus group participants but their ideas overlapped. Focus groups were an efficient and sociable way of collecting older people's views and did not appear to generate different ideas from those provided by people who chose to be interviewed at home. The focus groups also appeared to be capacity building, promoting confidence in the older people to participate and share their views on quality with others who have the ability to improve services.