Home Care Workers

Andrew George Excerpts

Wednesday 6th March 2013 Westminster Hall

[Mr Andrew Smith (Oxford East) (Lab)]

It is good to serve under your chairmanship, Mr Turner. I am pleased to have the chance to discuss home care and home care workers, because it is an incredibly and increasingly important area of service and policy touching nearly every family in the land. As the number of elderly and frail people increases, many of them with some degree of dementia, and as more people stay in their own homes, it is vital that we as a Parliament and the Government take action to ensure that standards of care are what they should be and meet the needs of older people with the dignity and quality of service that they have a right to expect, and that I am sure we all want for ourselves when the time comes.

I appreciate that there are big funding questions. I certainly want social care to be a priority for resources. Under the present austerity regime, social services departments and care providers are struggling to meet the pressures that we discussing. I also favour the full implementation of the Dilnot proposals. However, it is my intention to focus not on finance but on care and care workers and what we can do to address the present shortcomings, which must be evident to Members from all parties.

Let me make it clear at the outset that we should praise the good job that so many care workers and care providers do, often—I shall say more about this—in difficult circumstances. However, there are far too many shortcomings, as described in the recent Care Quality Commission report and the Unison report “Time to care”. We need an across-the-board drive to raise the standards, training, working conditions, terms of employment and professional standing of this most vital group of workers. It is especially important because they are on the front line. They are the first point of care and contact for hundreds of thousands of elderly people and are responsible for helping with their intimate personal needs and medication as well as day-to-day living.

On standards, the Care Quality Commission found a quarter of services to be substandard. Both the Unison report and the survey last autumn by the consumers association Which? found too many instances of rushed and poor care, as well as evidence of good and excellent care. I have been surveying constituents on the issue and have seen the same mixed picture. One daughter in the Which? survey found her mother having her face washed with a flannel with faeces on it and being dressed in the previous day’s soiled clothes. Others spoke of relatives going all day without food or drink, untrained staff using lifting equipment, muddled medication and forgotten alarm pendants. It is clear that standards must be raised to a consistent and higher level.

Training must be an important part of that. We need to listen to people like the worker in the Unison report who said:

“Three half-days’ irrelevant training was given. Then I was on my own. I had never bathed, dressed or cared for anyone before. I had to empty urine bags, colostomy bags etc. with no training. I felt very scared and was left to struggle as best I could.”

The consequences of mistakes involving such vulnerable people do not bear thinking about. We can well understand how workers in that position are being let down by those in charge of home care provision across the country.

I argue, as Unison does, for standardised levels of training and detailed minimum standards on employers to provide practical training to that level, without making the requirements excessively academic, so that we do not exclude people who are good at caring but bad at passing exams. Requirements should include communication, though, especially given the number of people whose first language is not English working as carers. Someone in Oxford told me that her mother was in a care home where just three out of 60 staff had English as their first language.

I also argue for a professional register of accredited carers, just as we have for nurses. People would qualify to get on it and gain the status that it involves, but they could also be struck off if incompetence or negligence warranted it.

[Andrew George (St Ives) (LD)]

The right hon. Gentleman makes an interesting case. How long did it take him this morning, from the moment he got out of bed, to wash, clothe himself, have breakfast and get out the door? Although I appreciate that standards for care workers must be concentrated on, does he not agree that many of them are asked not just to undertake their work on the minimum wage but to complete their tasks in an unfeasibly short time?

[Mr Smith]

Absolutely, and I am coming to that point. I could not get myself completely ready in the limited time that some care workers have; some are allocated 15-minute slots for visits.

When things go wrong, it is vital that staff speak out, yet too often care workers feel vulnerable and not in a position to do so. I note that last month, the Secretary of State for Health said that he was “very sympathetic” to extending to home care workers the duty to whistleblow that the Government are thinking of applying to nurses. I urge the Minister to do so.

It is crucial that inspection is extensive, robust and effective. It is all the more so given the importance of care and the fact that it takes place in people’s homes, away from immediate supervision. There are concerns about that in Oxfordshire right now. Our local paper, the Oxford Mail—I am sure you will remember it well, Mr Turner, from your time in Oxford—has highlighted concerns raised by our local patient voice and county councillors about the adequacy of local CQC inspection arrangements. In November, there were just two inspectors for Oxfordshire, and even now there are only five, who between them are responsible for inspecting 447 health and social care institutions and thousands of home care visits.

There is all-party concern. Conservative councillor Jim Couchman, who chairs the county’s adult services scrutiny committee as well as being a member of the health overview and scrutiny committee, said after meeting the CQC:

“We did get pretty worried by what we saw as an extremely ill-equipped organisation to deal with the responsibility accrued to it…The CQC is not a proper inspection team in any way, shape or form.”

Councillor Couchman has also told me since that apart from the enormity of the task required of such a small staff, the most surprising fact was that recruits did not need any experience or knowledge of the NHS, health care or social services. The CQC seemed more concerned about whether new staff had a background in regulation.

I was also concerned that when asked to talk to the Oxford Mail, the Care Quality Commission declined. When such worries are being voiced, it is all the more important for a body such as the CQC to come forward and answer questions as a basic responsibility of public accountability, as well as to take the chance to build public confidence rather than undermining it, as the CQC ended up doing. Will the Minister look into the position on care quality inspection in Oxfordshire? More generally, will he ensure that the commission has sufficient inspectors across the country with the right experience to do the job?

Feedback from users and their families is another important yardstick by which to lever up care standards. Our county council uses individual visits and client satisfaction surveys to inform contract monitoring. However, a wider public satisfaction rating is needed for the plethora of care agencies. One of the paradoxes of modern life is that, if advice is wanted on the standards of service providers such as restaurants, hotels and garages, or of products such as cars and electrical goods, there is no end of reviews out there to guide people, but for something as important as helping someone to find a good care provider, there seems to be nowhere to look for advice. In theory there is competition for provision, but in reality all the customers are groping around in the dark. That is a good reason not to emulate in mainstream NHS provision the privatisation that has already happened in care services.

Underpinning all that, action is desperately needed on the terms and conditions of care workers. They are doing a demanding job, often on the lowest wages and with minimal security. According to the Unison “Time to care” survey, more than half of home care workers overall and more than 80% in the private sector are not paid for travel time or costs; it has been estimated that between 150,000 and 200,000 home care workers are in effect paid less than the national minimum wage as a result. To make matters worse, more than half of private sector home care workers have a zero-hours contract with no guaranteed pay, and more than half of all home care workers reported that in the past year things have got worse for them on pay, working time and the duties expected of them.

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[Andrew George (St Ives) (LD)]

I congratulate the right hon. Member for Oxford East (Mr Smith) not only on securing the debate but on covering such fundamentally important ground on matters that clearly need to be addressed. From the litany of issues that need to be dealt with seriously by not only the two parties in government but all parties, it is clear that if we were to construct the circumstances for a catastrophe to happen on our watch, all the ingredients are being prepared in the services being provided to people in their homes.

The right hon. Gentleman described many symptoms, and at present the health system is under extreme pressure. The last Labour Government established the £20 billion efficiency gain, now colloquially known as the Nicholson challenge. All parties know that the pressure for efficiency gain inevitably resulted in an attempt throughout the system to push costs down to the least expensive care models, which means out of hospital, into the home and care by the lowest paid people. In addition, a whole heap of management babble obscures the way in which the trend is being catapulted. The health system depends on a group of workers in people’s private homes, but we should not ignore the fact that many people work in similar conditions in residential homes for people who cannot be catered for in their own home. There is a parallel situation in nursing homes.

With pressure on the system, there will be increasing attempts to ensure that patients are discharged from hospital much earlier than in the past. Part of the management mantra is that the worst place for an elderly person is an acute hospital and that unnecessary admissions should be avoided. That is self-evidently unarguable, but is often asserted. However, at the margin an assessment must be made before making that decision. There is a feeling that older people are being denied admission to hospital because of age discrimination in the system, and that because they are older they should be kept at home when, if they were 20, 30 or 40 years younger with the same condition, they would be admitted to hospital. Many of us know that that pattern exists.

MPs have many examples in their casework, and I am sure I am not unique in this: inadequate care is provided in the home for older people who must endure unacceptably poor standards of care and circumstances. The response is often pontification from the political classes, but the care workers are voiceless. Whenever the “Today” programme runs a story about poor care, which it often does when a shocking story of poor care is revealed or a report by the Care Quality Commission is published, some of our own classes are wheeled on to morning media slots and often denigrate the character of the people who provide care, as though a failing in the carers caused the problem. They say that we must address problems with carers’ characters rather than the unfeasible circumstances in which so many of them must operate.

I intervened on the right hon. Member for Oxford East to ask how long it takes him to get out of bed in the morning and to get ready to go out of the door. All of us in the Chamber are able-bodied and do not need a hoist to get out of bed or to use the toilet. We do not need to be assisted in every way, and we are not on a cocktail of medicines—perhaps some of us are. An hour is probably a reasonable time for most able-bodied people, yet we often hear that care workers must undertake those functions for other people in less than half an hour. That is simply not feasible. People may say that carers cut corners, take risks and do not complete the job, but they are asked to undertake an impossible task.

Many carers are on the minimum wage, and in areas such as mine in west Cornwall and the Isles of Scilly the travel time between visits is often significant. If the agency employing care workers is not prepared to cover properly travel times or costs, it may take the worker below the minimum wage, as my right hon. Friend the Member for Bermondsey and Old Southwark (Simon Hughes) said.

We must address the issues that the right hon. Member for Oxford East has properly listed. All the ingredients are there. As we go forward, the pressure will continue. Bed reviews will be undertaken as the new clinical commissioning groups swing into action in the next month. They will look at how many community beds there are in their area, assess whether they are affordable, and look for new ways of working and new pathways. They will use the usual language to argue that there are better ways of providing the care that is currently provided in community hospitals, that local communities should not be obsessed with bricks and mortar, that they can provide better care in the home, and that people should relax and understand that the number of beds can be reduced even when the population is ageing and the number of people needing care is increasing. Reducing the number of beds will increase the pressure on remaining beds. People will be discharged much earlier to their homes with assurances that adequate care packages are in place when we all know that those care packages are marginal and that the people providing the care will be asked to undertake work that is often unfeasible.

I often resist calls for diminution in the number of community hospital beds in my constituency, and I am sure that other hon. Members do the same. We used to know the number of beds in our local hospitals, but the service that used to be provided is becoming increasingly invisible. The problem is that the service can then be cut, denuded and reduced over time in ways that are very difficult for us all to properly assess, because people will not able to see or understand how it operates. Parts of the service will be shaved off in the same way that local authorities have redefined access to support from moderate to critical, and so on—as I know that many local authorities have done.

I have visited a number of agencies in my constituency. I am really pleased that we have some excellent agencies working in west Cornwall. Many of them are impressive agencies, but of course they are all competing, and there is a risk of a race to the bottom. Local authorities are commissioning on the basis of price, and the fear is that they are not necessarily looking at quality as much as they should be when they make assessments.

[Mr Andrew Smith]

I made the point about competition in my remarks. Does the hon. Gentleman agree that a very important dimension is that a lot of clients are paying for care themselves, and they have very inadequate information on which to judge one agency or provider against another?

[Andrew George]

Absolutely. Minimum standards and agreements across agencies—or if the Government will not establish minimum standards, baseline standards—would give people reassurance. What we understand is happening, as part of achieving the efficiency gain that all parties want, is that not only is there an attempt at constructing a clinical and patient interest argument that patients are better off being discharged to their home, which is better for them, because it is where they want to be—the mantra that is often used; but there is cost-shunting as well. Obviously, if a patient is in hospital, the state is paying for them. There is an increasingly harsh attempt at identifying what continuing care is and is not—in other words, the state continues to pay for that patient in their home—but what ultimately happens is that the sooner the hospitals can get patients out to their home, it is the individual, if they have any assets at all, who meets the bill.

In terms of standards, in my view, we should be encouraging agencies that are providing care to offer at least a living wage for workers—£7.20 per hour and, I think, £8.30 in the London area. Travel time between visits should be part of salaried time. A mileage rate should be set and understood, and everyone should share a mileage rate; in my area, the rate paid to travelling care workers varies between 35p and 40p a mile. There should be a minimum visit time of 45 minutes in very exceptional cases, and at least an hour for most visits, especially if it involves at least two of the following procedures for non-ambulant or semi-ambulant clients: getting out of bed; dressing or undressing; toileting; feeding; washing and mobility support.

An efficient and effective arrival and departure reporting and recording system should be introduced, because there is some dispute between agencies and local authorities on that issue. Registration of care workers is very important, and I hope there will be cross-party support for it. The Select Committee on Health, of which I am a member, has been pushing for it for some time. It would ensure that there is adequate training, proper registration and recognition of the significant job that home care workers do. With that kind of support, I believe that we can give home care workers the proper status and support that they richly deserve.

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[Andrew George]

The hon. Lady makes an excellent point about recording arrival and departure times. Often the system simply fails, not only in rural areas, where mobile coverage is poor, but when using the cared for person’s telephone. Carers often cannot get through and calling becomes a greater obsession than providing the care itself.

[Lilian Greenwood]

The hon. Gentleman is absolutely right. I remember well the representative from the High Peak area constantly making that exact point, which was that there was poor mobile phone coverage. They talked about how much of their time would be spent dealing with the telephone instead of focusing on the person who required their assistance. There were also worries about travel time.

I particularly remember the concerns of people who worked alongside private sector care providers where, they reported, staff training was often inadequate and there was often a high turnover of staff. They also reported that the care providers frequently did not provide personal protective equipment; they talked about the lack of rubber gloves and the like. We often had discussions about which tasks home helps were given time to carry out. They often pointed out that their service users wanted and needed things that might not be what the carers were commissioned to provide.

Unison’s “Time to Care” report and the Care Quality Commission’s “Not Just a Number” inspection programme made me wonder whether we should have listened more closely to the concerns and issues raised by those Derbyshire home helps 20 years ago, particularly when, in describing the current context, the CQC talked about the

“increasing pressure on social care budgets and the rise in the number of people with complex care needs and dementia.”

In describing its key findings—as my right hon. Friend the Member for Oxford East said, a quarter of services fell below the standards expected—the CQC said:

“What is concerning is that our findings come as no surprise to people, their families and carers, care workers and providers themselves.”

The findings really do not come as a surprise, because they are exactly the issues that have been raised over many years.

The CQC highlighted several problems, including service users

“not being kept informed about late arrivals, different care workers from one visit to another, not having their preferences clearly documented, a lack of support for care staff to carry out their work, and failure to address the ongoing issues around travel time.”

Those are responsibilities of not just this Government but the previous Government, but the pressure on social services that are commissioning care services is even greater now, and we need to look again at what is required.

There is great similarity between the findings of the CQC and Unison’s “Time to Care” report. Although the care and welfare of service users is the most important focus, the CQC found that staff felt

“unsupported by their management teams and not…able to deliver care in the right way because they are too rushed, with no travel time and unscheduled visits added to their day.”

It also reported a lack of planning and supervision for staff. Training needs were not identified, staff were not confident in using their equipment, and inductions were not always completed following recognised standards.

As the hon. Member for St Ives (Andrew George) said, the voices of care workers are often not heard in debates such as this one. We ought to address that today. I was pleased to see that Unison’s report included many quotes from individual home care workers. It provided an opportunity for them to have a say and to talk about their experiences. My hon. Friend the Member for Wirral South (Alison McGovern) has already quoted one of the home care workers who contributed to the report, saying they did not have time to spend with their service users and they had to rush between calls.

One of the most important issues is about older people. I imagine that many hon. Members have this experience when they are out canvassing in their communities: they knock on the door of an older person, and perhaps the Member is the only person they have spoken to that day. Their priority is to talk to someone who is willing to listen. That was well recognised by one of the care workers who contributed to the report, who said that

“care is not just about duties but communication and many providers do not allow for this…How can half an hour be enough to get someone up, dressed, meds given and have a chat? People are being failed by a system which does not recognise importance of person-centred care.”

There are many quotes in the “Time to Care” report, which I am sure the Minister has read. I hope that he listens to the voices of home care workers and the issues that they raise.

It is vital that, like the director of social services in Derbyshire back in the 1990s, we listen to the voice of home care workers, because they meet service users every day. Most of them are incredibly committed to providing a good-quality service and ensuring that people receive the support that they need. It is also vital that we do not simply listen to them, but act. Will the Minister meet home care workers and their representatives to discuss the findings of Unison’s “Time to Care” and the CQC report? Will he set out today how he intends to respond to the findings of those reports?

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[Liz Kendall]

Care and communication is vital for people with all sorts of frailties and conditions, but particularly for those with dementia, as carers try to keep their memories and brains going. Those people often feel lost in a fog, and having some kind of contact is vital to keeping them going, so it is important.

We have heard about the problems of call cramming, with carers being rushed, getting late to one client and leaving early for the next. Older people are worried when they are left waiting on their own, and staff are frustrated that they have to rush in and out.

The third issue that has been raised is zero-hours contracts. As hon. Members have said, such contracts are very bad for workers, because they find it difficult to budget and plan their lives. Zero-hours contracts make it hard to attract people to the sector. They are also terrible for the users—older and disabled people who do not get continuity of care. I cannot imagine someone coming round to get me out of my bed and take me to the shower. I would be naked and they would be washing me, but I would not know who they were, because they would often be different people each time. We would not put up with that for ourselves, and we should not expect it for older people either.

The fourth issue is the lack of training, which is a real problem in dementia care. It is only since having known people with dementia that I have fully understood why they are seen to get aggressive: they do not, but they are frustrated because they cannot remember things. Carers need detailed training for that.

The fifth issue is the vicious downward spiral or vicious circle that leads to poor care for users of services and real problems for staff. The last UK Homecare Association report states that vacancy rates are at 21%, so we are simply repeating the problems.

In my remaining time, I want to make three comments about why that is all happening and what we need to do. Clearly, demand has increased in recent years. However, as my hon. Friend the Member for Wirral South (Alison McGovern) said, when local councils’ budgets are being cut by a third, when adult social care is 40% of their budget on average and their biggest discretionary spend, and when the money that the Government say they have transferred from the NHS has not been ring-fenced, it is inevitable that care budgets are being cut. Figures from the Department for Communities and Local Government—the Government’s own figures—show that more than £1.3 billion has been cut from older people’s social care budgets since the coalition came to power.

There are a few deeper things going on. First, the caring profession is mostly delivered by women and is low-skilled. Such professions have always been neglected in the past, so that is a concern. Secondly, the problem is invisible: it concerns isolated staff and isolated, frail older people who do not have a voice. In talking about the care crisis, I always tell people that I have received five letters about the care crisis in my constituency and 99 about saving forests. I am passionate about forests, but getting only five letters on the care crisis shows that this is an issue of isolation and we should stand up about it.

[Andrew George]

Like the hon. Lady, I have shadowed care workers in my constituency. One point that often comes across is that when I ask those who pontificate from on high—criticising poor care standards and implying that it relates to the character of the people providing the service—whether they would be prepared to do this job, no one wants to do it, even at twice the salary.

[Liz Kendall]

I completely agree. That is why Unison’s report, “Time to Care”, which has given people a voice, is important.

The third fundamental issue is that our NHS and care system have not kept pace with changing demographics—people living longer—and changing needs and expectations. Families cannot always cope with caring for elderly relatives, and older people want to stay in their homes for longer. In the past, it was not the business of the NHS and social care to think about the home; its business was always about sending people to institutions.

What should be done? I want to raise four matters with the Minister. First, I know that the Low Pay Commission has looked at the minimum wage. Will he confirm, however, that as my right hon. Friend the Member for Oxford East said, Her Majesty’s Revenue and Customs has ruled that it is not legal to pay for travel time? If that is the case, what is being done about that? What action has been taken? In any other area, there would be legal action to enforce the minimum wage, so what is being done?

Secondly, I know that the Minister wants a shift to commissioning for outcomes, rather than by the minute. That is the Government’s policy, but how will he make that work in action? What are his levers over local councils? Thirdly, it is time to have a national strategy for improving training for home care workers. What are the Government’s plans?

Finally, although the announcement on the Dilnot cap is a step forward, Dilnot has always said, as the Minister will know, that proper funding is needed in the current system, which this Government have not produced. I know that he will be in intense conversations with the Treasury over the future budget. If, following the Budget, the Government decide to pull over more money from the NHS to social care, will he ring-fence that money this time?