Creating person-centred culture in homecare

Community social care services are under increasing pressure to support people with diverse needs against a backdrop of financial constraints. Nearly 500,000 older people receive local authority funded or arranged domiciliary care. These people are often the oldest and frailest members of our society.

For many, this care doesn’t always support their dignity, autonomy and family life (Koehler 2014). However, good quality care and support is invaluable in providing older people with the help they need to remain independent.

Outcome-focused quality care that enables people to be independent and have control over their lives (Compassion in Care DH 2012) requires human rights, empathy, collaboration, co-ordination and organisational commitment to a person-centred culture. It also requires all practitioners to have the necessary levels of knowledge, skills and behaviours to deliver person-centred outcomes (Nuffield Trust 2016).

Frontline nursing and social care workers are well-placed to deliver such care if they feel valued, well-equipped to do the job, that their job is worthwhile and that they have enough time. However, the current financial climate has led to a squeeze on funds, which affects a provider’s ability to offer staff continuous professional development, explore quality improvement and best practice. Added to this, the current high levels of staff attrition and need to increase the social care workforce by 1 million by 2025 (ILC Anchor 2014) means that the sector also needs innovative practice, effective collaboration and a whole systems approach to staff retention.

What does person-centred homecare look like?

Most people receiving homecare want similar things:

To have their needs met to enable them to continue to live their lives with dignity, respect and kindness.
To make the most of their strengths and compensate for their difficulties.
To engage in meaningful relationships as valued members of the community.
To receive good quality, person-centred support.
That the people providing their care and support have the attitudes, knowledge and skills to help them to live well.

To meet these aims, providers need positive, relationship-centred cultures in their organisations, as well as effective collaboration between professionals (Duff, Hurtley 2011). Such ways of working lead to clients experiencing good care and support, family members feeling supported and being confident in the quality of care provided and staff finding the work fulfilling.

A person-centred management approach is essential to achieving this and includes:

An open, facilitative and developmental management style at all levels.
A pivotal role in managing change, involving the client, family carers and staff.
Integrating quality improvement with operational and business plans and staff development programmes.
Supporting staff through continuous coaching, supervision, mentoring and team-building.
Approving priorities, resources and structures for creating and maintaining a person-centred culture and evaluating outcomes (Duff, Hurtley 2011).

Person-centred standards of excellence should be explicit across the organisation, with all team members striving to meet them. Person-centred approaches should be embedded in:

The organisation’s philosophy, values and residents’ rights.
Management from strategic level to operational and supervisory functions.
The knowledge, skills and attitudes of all staff, including their development and training.
Staff support and equipment.
A dynamic quality improvement system.

Person-centred care planning

Person-centred care needs to be specifically detailed within care plans.

As such, care planning and the plans themselves need to reflect the main aims and service delivery, as well as have regard to the wishes and views of clients, their carers and relatives.

These should include:

Protecting the client’s and their relative’s involvement in decision-making.
Giving clients control over decisions about personal care, including discussing and agreeing the support the client needs, consenting to care and treatment and to have it delivered in an acceptable manner to acceptable standards.
Giving clients control over decisions around meals, food and drinks, including being able to influence the variety of food and drink, and choose from a regularly changing menu as well as receiving assistance with eating and drinking consistent with support needs.
Enabling clients to take part in meaningful occupational opportunities inside and outside their home that are compatible with their personal lifestyle, interests, preferences, enjoyment and capabilities, within the agreed care package.
Enabling the client to meet their spiritual needs, follow their religious practices, talk to someone about what is important in their life in an acceptable manner and with a person of their choosing.
Incorporating the client’s wishes and those of their family/carer around end of life, so that they feel confident about receiving the best end of life care in accordance with their own wishes.
Allowing time for staff to engage with the client outside the delivery of physical care.
Recording key issues and outcomes discussed with the client and relatives.
Ensuring there are agreed instructions for consulting the client and relatives on making changes to care and support, or when the client’s health is causing concern.
Ensuring there is sufficient advice on raising concerns and complaints with the relevant person, how to involve an independent advocate, and that their concerns are taken seriously and responded to appropriately.

Preparing the home care workforce

The ability of staff to deliver a person centred approach to care in the community and promote independence for people ‘behind doors’ is closely bound to the quality of relationships and how they can work collaboratively across the system to put the person at the centre of care. This includes how records are shared in timely ways with those who need them.

Although with the right skills, practices, training and sufficient time, existing care staff can and do deliver person-centred care, given the workforce requirements of the sector, there is a place for upskilling a new generation of workers.

A new expert gerontological care worker role could be developed and would require a broad range of cross-cutting, multi-disciplinary knowledge and skills. There is a pressing need to develop expertise that takes account of the diversity, multiplicity and complexity of chronic illness; a focus on enablement and re-enablement as people ‘live with’ rather than ‘die from’ chronic conditions.

Key considerations in developing new workers include:

Experiential learning methods for ongoing learning on the job to embed and sustain good practice.
Integrated, shared multi-disciplinary learning across the system to equip workers with enhanced knowledge, behaviour and skills and develop a more flexible practitioner.
Specialists need to integrate their contribution to the client’s care plan and ‘skill up’ the care team.
A degree of autonomy, supported by good communication loops, coaching and feedback to develop a learning culture.
Ensuring those responsible for evaluating the quality of care assessments, determining needs and how they will be met have enhanced knowledge to help people to be as independent as possible, preventing falls and hospital admissions.

Specific learning topics would include:

Quality improvement and assessment.
Dignity and wellbeing.
Discrimination, eg ageism, disability.
Institutionalisation.
Community and relationships.
Language, cultural and intergenerational differences.
Interpersonal communication and relationships.

There are also considerations for joint-working to include:

Collaboration with colleagues, addressing competency, consistency, continuity and involvement.
Empowerment of the service user and their family/carers in decision-making.
The adoption of models that deliver these outcomes.
Documentation of responsibilities and procedures.

Strategic changes

We are all aware of the tight financial constraints in which social care services, and especially home care providers, are operating. Despite the hard work of thousands of care workers and providers to deliver person-centred care, there are a number of strategic changes that could help embed person-centred care to provide public confidence and create a sustainable sector.

We should start with education and training. We need a government commitment to enable and support a diamond status education in collaboration with Higher and Further Education and training providers. We must come up with an integrated, strategic approach to practice, management and leadership development. This should create an integrated industry-wide strategy for excellence and delivery across the fragmented sector.

A nationally-available Further Education course could also provide a common language across health and social care and would help with integration and consistency of approach. This should complement adult learning and evaluative teaching methods with on-the-job support for staff. Experiential learning methods are crucial to good practice.

Commissioning should enable person-centred cultures within a whole-person, multi-disciplinary approach, to prevent service delivery in silos. Communication systems should also be improved, between all agencies, to enable co-ordination of flexible, person-centred services. This includes improving clarification of responsibilities between commissioner and provider.

Operational procedures between social services departments, primary care services and liaisons with NHS services should also be improved, along with shared communication of essential information. Finally, case management systems should ensure continuity and consistency of assessment monitoring around care planning and delivery.

Everyone’s responsibility

Embedding person-centred care into domiciliary care is the responsibility of everyone, from policymakers to commissioners, providers, managers and frontline care staff themselves. If all aspects of the process have the person and their wishes at the heart, then person-centred care has to follow. It’s important to note that people will judge their experience of a service more positively if the providers, managers and staff are person-centred in both attitude and behaviour towards them.

In our work developing the 360 Standard Framework® (Community Care and Support), I see time and again that commitment to person-centred outcomes develops healthy cultures within organisations and providers achieve good reputations for excellence in person-centred care and practice among clients, patients and families.

Not only this, there are also value added business benefits to creating a learning culture that is continuously striving to improve, sustaining improvements and involving people.

Rosemary Hurtley MSc Dip COT FRSA is the co-developer of the 360 Standard Framework® and Chief Executive of 360 Forward Ltd and a Consultant Occupational Therapist. Email: [email protected] Twitter: @360Fwd

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