That little bit extra

What enables some home care providers to supply flexible, comprehensive, person-centred help to older people when others cannot? Our research explored how certain home care providers could, for instance, take housebound customers out shopping, console customers in distress, or replace a broken refrigerator for a customer with no relatives to help them.(1).

The first article in this series presented one part of the explanation. For independent providers, it depends on whether social services purchasers support person-centred help through commissioning and the priorities that they give to providers. If encouraged, care staff will use opportunities to help regular customers in a holistic, person-centred way. But a sharp cultural divide was found among councils. Some purchasers had a holistic attitude to older people’s care and encouraged providers to improve morale and quality of life. Others had narrower goals of physical well-being and safety and discouraged extra help from providers, even when there was no extra cost.

A secondary influence is that certain providers have particular strengths that help flexible, person-centred care – if purchasers permit them to use these strengths. At two providers, which excelled at this type of care, the managers’ philosophy played an important part. Both managers held a clear, practical vision of caring for the whole person and encouraged care staff to apply this. They also encouraged staff to seek solutions to whatever problems a customer was facing – to become as one manager put it “not just a home carer but a person who is looking out for the whole person”.

One manager, at a social services provider, used team discussions of customers’ needs, while the other, at an independent agency, used individual supervision meetings. Staff were encouraged to view care situations in terms of how they would wish themselves, their parents or their grandparents to be treated. Both managers sought to always be available by phone to give staff guidance or direct help with the diverse tasks that staff were encouraged to address.

They had a pragmatic approach to decisions and avoided rigid rules. Rather than create rules about escorting customers or changing light bulbs, these managers looked at each situation. They safely provided help that was routinely banned by some providers.

Social services providers had some major advantages over independent agencies for flexible, comprehensive roles – but their use depended on the provider manager. Sometimes their managers could assign extra care time flexibly because they had ready access to social services systems. Thus one in-house provider’s care staff directly bought customers’ disability aids, such as a special shoehorn or a urine bottle, when they recognised a need. It was easier for them to buy costly items for customers, such as a new cooker, since they had social services procedures for witnessing bank withdrawals of customers’ money or for loans from petty cash. Their staff could sometimes supply privately paid extra help at much more affordable prices than independent agencies, since no overhead charges were levied. But use of these advantages required a manager who promoted holistic comprehensive care.

Another area where some providers showed strengths was the presence of management assistants or supervisors alongside the manager. Some providers had four such staff, whereas at others the manager worked alone. Assistant management staff could make it easier to troubleshoot emergencies such as discovering a sick customer. They could also take on occasional tasks that were time-consuming or involved responsibility – such as sorting out a customer’s household bills, replacing a refrigerator or getting keys cut. This is especially helpful at independent providers where using a care worker could involve delay while seeking social services funding for the extra time.

One issue emerged about how providers assign regular staff to customers. As described in the first article, a pre-condition for person-centred care was that each customer was served by regular staff who came to understand and care about them.

All providers in our study supplied this – it has become common good practice. But some used one regular worker, who gave most of the care, and changed back-up staff when the main worker was unavailable. Others however would serve a customer through two, three or even four regular care workers.

One advantage of the latter is that care staff differed in what they could offer customers: some were empathic conversationalists; some offered high standards of cleaning; some were knowledgeable about disability aids or reliable local tradesmen. Good providers would ensure that no worker who was short on relevant general skills or life experience would exclusively serve a customer.

Relationships between customers and familiar, regular care staff are central to person-centred home care. Hence factors that retain staff, like satisfying roles and reasonable pay and conditions, are vital.

At independent agencies, the latter could be seriously discouraging – for instance non-payment of travel costs. Also important is management understanding of the emotional costs for care staff from regularly having relationships with a customer that end in decline or death. “There are no happy endings,” said one supervisor. Yet, if they were supported, care staff could accept this aspect of a job that is based on relationships.

The talents of providers including those of care staff and managers were vital for flexible person-centred care.

But these talents emerged only rarely without the blessing of purchasers, which call the tune and ensured that providers played the favoured tune to their liking. 

  • The research was undertaken at the Social Policy Research Unit, which receives support from the Department of Health. The views expressed in this article are those of the authors and not necessarily those of the DH.

    Charles Patmore devised and led this research project. He worked for eight years on the Department of Health research programme on outcomes of social care for older people, based at the Social Policy Research Unit, University of York. He is now an independent consultant  for community services for older people.

    Alison McNulty was a researcher on the in-depth phase of this research project. She is now research associate at the School of Nursing, Midwifery and Social Work, University of Manchester.

    Training and learning
    The author has provided questions about this article to guide discussion in teams. These can be viewed at and individuals’ learning from the discussion can be registered on a free, password-protected training log held on the site. This is a service from Community Care for all GSCC-registered professionals.

    This final article, in a two-part series, presents new research findings on what helps a home care provider to provide flexible, holistic, person-centred service for older people. Topics include: the philosophy of the provider manager, size of management team, policies on staff rotas, and advantages for in-house social services providers.

    (1) C Patmore and A McNulty, Making Home Care for Older People More Flexible and Person-centred: Factors which Promote This, Social Policy Research Unit, University of York, 2005.

    Further information
    A comprehensive set of publications, both long reports, summaries and articles covering each stage of this research, is available free on the website This website launches a major new publication, Caring for the Whole Person, which presents detailed findings from the project’s final stage plus overall conclusions.

    Contact the authors


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