Powerful review takes aim at dysfunctional care work system

Cavendish review recommends change and aims to 'give a voice to frontline workers who have been largely invisible to the public and policymakers'

Social care support workers are increasingly taking on more challenging tasks in care homes and individuals’ homes, yet are often unregulated, untrained and unrewarded, an independent review has found.

The Cavendish Review recognised that by helping people to live independently, social care support “plays an essential role in supporting the vulnerable and reducing the strain on the NHS”.

The range of tasks undertaken by support workers varies, from helping someone get to the shops after an operation; to diabetes management, changing dressings and managing pressure sores. Some support workers are administering medication, taking venous blood samples, and inserting catheters. 

But it said that in order to do this more competently and to protect patients, Britain’s 1.2m unregistered care support workers should be required to obtain a “certificate of fundamental care” before working unsupervised.

Stafford hospital scandal

Set up in the wake of the Francis inquiry into the Stafford hospital scandal, which found as many as 1,200 patients may have died needlessly through routine neglect, the review aims “to give voice to frontline workers who have been largely invisible to the public and policymakers”.

“Helping an elderly person to eat and swallow, bathing someone with dignity and without hurting them, communicating with someone with early onset dementia; doing these things with intelligent kindness, dignity, care and respect requires skill,” the review stated. “Doing so alone in the home of a stranger, when the district nurse has left no notes, and you are only being paid to be there for 30 minutes, requires considerable maturity and resilience.”

The average resident in a care home is now 85 years old and often very frail, the review noted. “The definitions of ‘residential’ and ‘nursing’ care are becoming blurred: residential care homes are no longer hotels with access to nursing support, but places with more and more very frail residents, many with dementia. People who would have been in hospital or a nursing home 10 years ago are increasingly coming into residential homes,” the review stated.

‘Hugely variable training’

It found care support workers are having to look after more frail elderly people, while social care workers were receiving “hugely variable” training. Although some employers are striving to train, retain and motivate staff under considerable financial pressure, some “are not meeting their basic duty to ensure their staff are competent”.

The report’s author, Camilla Cavendish, revealed she spoke to staff who were given a DVD to watch at home before being sent straight out to the frontline, while others were asked to pay for mandatory training out of their own pocket.

The review has called for a rigorous quality assurance mechanism for training courses and vocational qualifications. It also recommended the main trade associations and social care employers lead a process to agree on core national competences that go beyond the minimum. 

Too many workers do not see caring as a career, the review found, and there are little opportunities to progress. “Some care home owners have told us that they are directly competing for staff with local supermarkets and high street shops,” the review stated. “Yet health and social care do not yet offer the kind of clear, simple career ladders available to staff who join Tesco, or Specsavers.”


Because of this, the review recommends that employers be consulted on the possibility of creating a career development framework for health and social care workers, and that Higher Education Institutions give more weight to care experience, so that talented staff can progress into therapy, social work or nursing.

“In domiciliary care, the review says, “a combination of low pay and time pressure has sent attrition rates soaring. It seems doubtful that health and social care can be successfully integrated on the backs of workers whose turnover rates are so high and pay so low. These workforces are set to grow. There is an urgent need to acknowledge them, support them, and plan for them.”

Despite the pressures, the report found charities, hospices and other social care organisations are pioneering some of the most innovative approaches to person-centred care. However, the report warned it is likely the personalisation agenda “will fragment responsibility as the number of personal assistants expands. Social care will become an even more complex landscape: and commissioners and regulators will need to review fundamental questions of accountability.”

In conclusion, Cavendish stated: “I have been struck by how disconnected the systems are which care for the public. The NHS operates in silos, and social care is seen as a distant land occupied by a different tribe. Yet when Mrs Jones leaves hospital for a care home, or to recuperate in her own house, she is still the same person. She wants to be treated as the same person, and to be looked after by staff with the same core knowledge and core values.

“The message from the frontline, and from the best organisations, is that it is time to start seeing these support workers as a strategic resource, to both the NHS and social care. That is what the recommendations in this review are designed to achieve.”

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