At home with quality

The number of people older than 60 keeps rising: there were 12
million in 2000; there will be more than 14 million in 2020; and
more than 18 million in 2030.

Since the early 1990s, governments have pursued policies to enable
older people to stay at home. At the same time, the number of
residential and nursing home beds available has

Despite attempts to listen to what older people have to say about
home care services,2 recent research indicates that
older people question “whether the people who make the decisions
really listen”; and are “frequently marginalised and overlooked in
initiatives for participation”.3

Older people are the biggest consumers of home care services,
costing local authorities £1.2bn a year. Local authorities
purchase these services for older people in a mixed economy of
care, with the independent sector the major provider.

A small number of studies of the views of older people on the
quality of home care services were carried out in the 1990s in the
US, Sweden and England. These showed that what older people define
as quality in services are: reliability, continuity and
flexibility; cheerfulness of staff; more help with housework; clear
information about the services to which they are entitled; and
competence of the staff providing the care.

In a study carried out last year with the help of Manchester social
services department, researchers sought the views of older people
on their definition of quality in home care services. They also
explored how the knowledge gained from older people could be used
to influence commissioning, contracting and monitoring of home care

The key results of this investigation revealed the following.

The top 10 characteristics of a quality home care service common to
people both under and over the age of 80 were:

  • Help to keep the house clean.
  • Regular care workers.
  • Being notified of any changes.
  • A flexible response to current needs.
  • Equipment and adaptations.
  • Knowing what services to expect.
  • Services to get out of one’s home.
  • Accessible cheap and safe transport.
  • Better health services.
  • Good health.

People under the age of 80 identified three additional
characteristics of a quality home care service. These were
companionship, safety and having enough money.

However, people older than 80 did not refer to these additional
qualities. Instead, they wanted activities to keep their minds
active and the provision of help to deal with everyday domestic

Further issues emerged from the work carried out with older people
from ethnic minorities. They said that home care services are not
well known. They also said that a quality service would be provided
by people who speak their language and be culturally based. For
example, food would be bought in appropriate shops.

A round-table meeting involving councillors, commissioners, and
providers of services as well as service users followed. They were
tasked with establishing how older people’s views on quality could
be incorporated into the setting of standards, and monitoring how
the quality requested was being implemented.

It recommended that round-table discussions for older people should
take place twice a year to question commissioners and providers of
services about quality and improvements. A progress report would be
given on what had improved in the service since the last meeting.
Exactly the same could be done in home-based interviews.

The round table suggested that home care organisers should ring one
person each day to check that the service was providing the quality
people wanted and how it could be improved. This information could
then be fed into the council’s own monitoring system.

In addition, a list of services should be sent out each year to
service users, giving the telephone number of the senior manager
involved in commissioning these services.

For these recommendations to be implemented political will is
needed at every level. In addition, personal contact is important,
as are good transport and the use of suitable venues, plus
sufficient resources and training for both staff and service

When older people talk about quality they do not differentiate
between the “what” and the “how” of services. Both of those aspects
of service delivery are equally important to them in ensuring
quality of home care; consequently they think of services truly in
a joined-up way.

If we are to take older people’s views seriously in planning and
delivering quality home care services we need to engage in
listening, learning and doing, over and again. If we do this, when
an older person asks, “do you know what I mean by a quality home
care service?”, we will be able to say “yes we do know, and we have
evidence to prove it”.

Professor Norma Raynes is director of the Institute for
Health and Social Care Research, at the University of


Care of Elderly People, Market Report, Laing
& Buisson, 2002

2 P Thornton and R Tozer, Having a Say in Change –
Older People in Community Care
, Social Policy Research Unit,
University of York, 1994

3 C Hayden and A Boaz, Better Government for Older
People Programme Evaluation Report: Making a Differen
Warwick University, 2000; and T Carter and P Beresford, Age and
, Joseph Rowntree Foundation, 2001

4 N Raynes, B Temple, C Glenister and L Coulthard,
Quality at Home for Older People, Policy Press,


For this research, a random sample of older people who were in
receipt of home care services were selected to participate. All
were invited to come to focus groups. In stage one of these they
were asked to discuss three questions: 

  • What services are you getting now? 
  • What makes for good quality services at home? 
  • In an imaginary world, where we could have anything we wanted
    and not pay for it, what would make for quality services at

In stage two the people in the focus groups determined their
priorities for a quality service. In addition, responses to this
broad question were sought via home-based interviews for those who
wished to participate in the study but who did not wish to come to
a focus group. The same methods were used in the third stage of the
study, in which additional samples were selected from ethnic
minority communities. Finally, stage four involved a round-table

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