On the record

Home carers need detailed knowledge of clients’ needs and
vulnerabilities if they are to provide a quality service. In
Bradford, home care workers are looking to improve teamworking, and
involve clients, through record books, writes Charles Patmore.

How can home care staff come to know everyone they visit well
enough to give good service? Increasingly, home care serves
dependent older people who need multiple daily visits and can be
visited by several different staff. The teamwork needed may mean
staff visiting so many different clients that they cannot easily
know everyone’s circumstances by heart.

One means of tackling this problem is a new home care record
book that Bradford social services’ home care service is placing in
clients’ homes. This combines care plan details with information
for monitoring clients’ health vulnerabilities, plus each client’s
views on how their service could be given added quality.
Encouraging results came from a survey of the record book,
conducted jointly by the social policy research unit
(SPRU)¹ and Bradford social services.

One reason for the venture was social services’ fears that, as
home care teams became larger to incorporate more flexible
services, it became harder to monitor clients’ needs and
vulnerabilities. A second reason was given by staff: that it was
especially difficult for home care to monitor the progress of an
important minority of clients. These are older people who may be
able to resume certain self-care roles if given some rehabilitation
help, such as people recovering following discharge from hospital.
This issue is central to the government’s emphasis on promoting
independence among older people.

A third aspect of the record book was inspired by SPRU
interviews with older home care clients themselves. Some clients,
though certainly not all, named one or two burning issues when
asked about what constituted good quality service for them. These
issues were individual and there was clearly a case for systems to
remind the service about any strong individual preferences.

For example, Mr A lived alone and his health problems meant he
went out rarely. He enjoyed conversation with certain home care
staff. His preference was to receive service from the same three
home care assistants. Also, if he did not want lunch, he wished
home care assistants to be allowed to spend their allotted time
talking with him.

Mr B’s severe mobility difficulties entailed 18 hours’ home care
per week. However, he attended events outside his home on seven
days a week, often in connection with his local church or voluntary
sector activities. He named one crucial personal priority, which
was that home care should help him get up at 8am punctually
everyday, so that he could get to his meetings. No other issues
seemed important to him. He was content with a service from 10
different staff and was very satisfied with home care because it
ensured the early first visit on which his lifestyle depended.

Such individual preferences raise questions about quality
standards that are intended to apply to all home care clients. Many
councils have devised such standards. Often they have drawn on
studies of service users’ values, such as the Nuffield Institute’s
research.² This cites staff reliability, service through
a few familiar workers, punctuality and staff willingness to
provide small extra services. SPRU obtained a similar picture from
group interviews with home care clients. But, when Bradford
interviewed SPRU’s interviewees, some revealed contrasting
individual preferences, such as Mr A and Mr B (see below for
examples).

Uniform standards, focused on commonly named areas like
punctuality or continuity among staff, may fail to satisfy service
users in the precise areas that matter most to them.

So the home care record book also sought to explore service
quality on an individual level by identifying each client’s
personal quality preferences as a possible complement to the local
authority’s conventional quality standards. Staff were encouraged
to devise compromises concerning any difficult requests.

A home care record book was tested for two months in the homes
of 27 Bradford home care clients. After evaluation, it was modified
and is now being introduced district-wide to an enthusiastic
reception. Alongside an attached care plan, which carries
instructions on the basic home care tasks needed, it includes the
following:

• Two sets of tick-box lists that show the client’s expected
  level of self-care and mobility. This seeks to improve home care
  teams’ abilities to monitor quite subtle changes over long spans of
  time.
• A box for instructing staff to watch out for specific
  changes.
• Another box for listing any specific changes that home care
  should try to bring about. During the test, this box was twice used
  to prompt staff to assist physiotherapists by encouraging
  rehabilitative exercises and daily living activities. Another
  example was to instruct staff to keep reminding a family carer
  about opportunities for regular carer relief.
• Another box carries instructions on any important client
  preferences which staff should try to observe. Preferences that
  cannot be fulfilled can be recorded and placed on the service’s
  agenda for development.
• A daily record whereby every home care visit is entered and
  timed, together with a space for staff to record tasks or
  observations or leave messages for the next worker. This component
  had already been introduced by certain Bradford home care
  organisers years earlier and had become a valued tool for
  co-ordinating team working.

Instructions can be entered or changed by the leader of a home
care team. Information on health and social circumstances,
rehabilitation needs and client preferences requires regular
updating, since these all can change quickly. The daily record of
visits can be studied to monitor fulfilment of certain client
preferences or progress concerning rehabilitation goals. The home
care record book can offer much information additional to the care
plan and should be simpler to update.

As a result of testing the home care record book, improvements
were made to some clients’ services. Also two clients had an
improvement in service, achieved through the section that names
specific short-term changes for the service to aim at.

The home care assistants were surveyed by questionnaire. They
generally wanted the home care record book to become used more
widely. Many thought the information was especially useful with new
clients, new staff, temporary staff, staff from independent sector
agencies or when staff came back from holiday or illness. It could
also be especially useful with clients with communication or
cognitive difficulties. They did not find it time-consuming to
read.

What did prove time-consuming during the test was collecting the
information about clients’ needs, vulnerabilities and preferences.
Where new clients are concerned, this seemed easily combined with
the assessment process being undertaken anyway. But collating such
information for established clients also needs visits and
discussion. Care is needed not to overburden leaders of home care
teams through too fast a pace with this extra task.

Possibly the most innovative aspect of this system may be the
collection of quality preferences from clients. But this may create
some dilemmas. For instance, how far should a service go in
fulfilling client requests that are at the limits of the
established home care role? Should a controversial request be
fulfilled, dusting ornaments for instance, if you can do this
without disrupting the service? Debate may well become heightened
concerning what the home care service should or should not provide.
But debate is a normal, constructive process through which services
evolve. Whether through identifying clients’ preferences, through
identifying rehabilitation goals, or through focused monitoring of
individuals’ welfare, this record system promotes a service that is
more centred on individuals. And that can only be to the good.

¹ Social Policy Research Unit, Briefing Home Care
Staff about older people’s individual needs, SPRU Research
Works series, from 01904 433608.

² Melanie Henwood, Helen Lewis and Eileen Waddington.
Listening to Users of Domiciliary Care Services, Nuffield
Institute for Health, University of Leeds, 1998.

Copies of Bradford Social Services’ Home Care Record
Book can be obtained from: Home Care Manager, Bradford Social
Services (North), 438 Killinghall Road, Bradford BD2 4SL. Tel:
01274-435100

Charles Patmore is a research fellow at the social
policy research unit, University of York. The views expressed are
those of the author and not necessarily those of the Department of
Health.

Clients’ preferences or requests

• Five requests concerned the timing of home care visits. Two
  sought early first visits, one a late first visit, one simply a
  regular time for first visit. One sought a later lunch.
• Four people sought the same home care assistants for a week or
  a month at a time.
• Three people wished staff to spend more time with them during a
  visit.
• Two people sought that their shopping or pension collection be
  done on different days.

Other requests, named only by single
clients:

• Help to find honestly priced gardening, electrical and plumbing
  services.
• More help whenever family are on holiday.
• One extra daily visit from home care.
• Temporary extra help, since she has just left hospital. Would
  like cooker always wiped after use.

Examples of messages entered in Home Care Record
Book

“If this client is not sitting on the side of the bed when Home
Care are ready to leave, then she may well be ill”

“Ear infections affect this client’s balance”

“Miss M is 95 per cent blind, lives alone and has no next of
kin…. Any suspicion of total loss of sight to be reported and
input increased”

“Client is very hard of hearing. Any phone-calls which client
needs making, Home Care please make for client”