Experiences Of Home Care Services

Published Date: 02 Nov 2017

This proposal outlines a project to explore the experiences of home care services in community care for older people. It will begin by explaining why this group of people is a subject of personal interest and a relevant and required area of investigation for social work practice. The second part of the proposal focuses on a literature review, presenting the terms and parameters of the search, as well as exploring and analysing existing research in Community care for older people. It will then highlight the study’s aims and objectives, outlining its proposed methodology, sampling, data collection and analysis, limitations and ethical issues. Finally, it will conclude by presenting its proposed timetable.

1. Background

I developed an interest in working with older people, mainly throughout my work experience. I have been supporting older people for over five years, and I have developed an understanding of the dilemmas that older people face. I am aware of complex needs of older people, consequences of population ageing but also the need to reframe perspectives through which older people are stereotyped and labelled. I would like to undertake this research to improve services for this group of service users. It is often a case that poor practice and inadequate service delivery, underpinned by inappropriate attitudes and assumptions, are core features of everyday life for older people. As a student social worker, I acknowledged the need to understand the diversity of ageing and to view experiences in old age in a positive manner, rather than treating ageing necessarily as a negative experience. It is important to acknowledge and draw on the strengths that older people have developed and demonstrated throughout life course. I believe that work with older people is a relevant subject to social work practice, because the dilemmas older people face, are immense and force them to seek help from formal sources. This is expressed by physical frailty, bereavement, loss, dementia, depression, hospital discharge or end of life, and may be a subject worthy of investigation. (Ray and Philips, 2012) Over the years social work with older people was the least popular area of practice but has recently moved to one of central importance. (Wilson et al., 2008) This is caused by the remarkable speed of demographical change. What does mark out contemporary societies is increase in both the absolute and the relative numbers of people achieving old age. As a consequence, our population is characterised as ageing. This can be illustrated by two main factors: the downward trend in the birth rate, and improvements in life expectancy. (Phillipson, 2011)

In Scotland, in 2010, there were an estimated 1.047 million older people age over 60, with older people being one fifth of the Scottish population. (Age Scotland, 2012) Figures show that the number of older people is predicted to triple by 2031. (Scottish Government, 2007) Therefore, the issue requires to be deeply examined in terms of how society will be able to respond effectively to the complex needs of older people. This definitely raises new challenges, and increases in the demand for care services for older people.

2. Literature search

The purpose of this review, is to consider literature in the field of community care for older people, and to determine the main themes that occur within this. The literature review will provide the evidence, and support information that strengthens the research study being implemented.

I began the review using the internet search engines Google Scholar, as this is a commonly used search engine, that has access to the greatest amount of information. I also used Glasgow Caledonian University Discovery search engine, and Athens management system, that provides access to a variety of online resources, subscriptions and incorporates hundreds of academic journals. Athens is an access site for several databases such as Social Care Online, Social Science Plus, ASSIA. I searched the Scottish Government website for relevant documentation, as I am aware that older people are being considered as part of a national strategy.

Throughout all the searches for this study, I used a variety of the keywords combinations in order to ensure I accessed the most relevant documents between the years 2004-2013. The keywords used are; "older people", "home care services","Scotland" and "Community Care".

3. Literature review

In Scotland, the policy of free personal and nursing care, is supported through Better Health, Better Care: Action Plan. (Scottish Government, 2007a) In particular, there is support for community care, where individuals are supported and cared for at home, if possible, in order to maintain their independence.

Paradoxically, a new programme for change, Reshaping Care for Older People, revealed that in Scotland in 2007-2008, 4.5 billion of public funding was spent on health and social care for people over 65 years old. Where 60% was spent on providing institutional care in hospitals and care homes, and only 7% on home care, in spite of the vision that older people should be cared for at home. (Scottish Government, 2012)

According to the Community Care and Health (Scotland) Act 2002, people aged 65 and over, irrespective of income and based on the needs identified, have been eligible for free personal care, and are no longer charged by local authorities for such services in their own homes. In this measure, Scotland differs from the rest of the UK, where charging continues to be permitted, which may have an impact on the experiences and views of people. What is more, in Scotland there is joint working between health and social care services. Integrated working between local authorities and the NHS has been advanced by the Joint Future, an initiative to provide faster access to services through joint management, joint governance and joint resources. (JIT, 2005) Taking into account the differences between English and Scottish health and social care services, the study will focus on the Scottish perspective only.

In Scotland an estimated 63,458 people were in receipt of a homecare service, provided or purchased by a local authority in 2011, and 46,530 older people were in receipt of free personal care. On average, households received 10.8 hours of homecare in 2011, whereas in 1999 the average was 5.1 hours. (Scottish Government, 2010) The amount of money spent by Local Authorities on providing personal care services to older people in their own homes has risen steadily each year from £133 million in 2003-04 to £342 million in 2010-11. (Scottish Government, 2012a) There is a debate about the sustainability of the policy, in the long term, and current funding shortfalls have led to some local authorities operating waiting lists for the free services. Argyll and Bute council is the one of the authorities with a lengthy waiting list. (David, 2006) As observed during my placement in Community Care for older people, each council implements the policy differently, especially in terms of management of funds, and in operational level.

According to statistics, about 22,700 people in Scotland aged 66 and over are experiencing mistreatment, this includes home care services. (Age Scotland, 2012) Therefore, the Scottish Human Rights Commission involved in the promotion of human rights in Scotland, explores the report of dignity and care. (SHRC, 2010) They convened a series of small focus groups and in-depth interviews, with a range of Scottish communities, groups and individuals. They seek to empower people to know, and claim their rights on the grounds of the Equality Act 2010 and National Care Standards (NCS) 2004. However, the report revealed a lack of understanding of what NCS means in practice, which requires understanding of the human rights framework. The study also showed unacceptable standards in the provision of care to older people in their own homes, most commonly expressed in the form of neglect and lack of dignity. (SHRC, 2010)

Similarly, there is a study carried out by Bowes and Bell (2007) with reference to personal care in Scotland. They looked at the experiences and views of older people. This was done by conducting 15 focus groups involving 88 people, amongst which, 37 were receiving social services. Likewise, uppermost in people’s concerns, was the quality of services, that in many cases, falls short.

Another study, in particular surveys provided by United Kingdom Home Care Association (2013), identified that more than a third of service providers in Scotland, were concerned about the risk to protecting dignity, or safety of care. They also pointed out that the homecare sector, suffers from a lack of routine data collection. (UKHCA, 2013)

The standards of home care services are verified by the Social Care and Social Work Improvement Scotland (SCSWIS), created in April 2011. Currently, there is no obligation for home care workers to register with Scottish Social Services Council (SSSC). However, SSSC is working towards improving the standards of home care, through registration and increasing the qualifications of the workforce. Traditionally, homecare staff are largely unqualified, but the demands of registration mean, that in many areas of Scotland, an SVQ Level 2 in social care would be a pre-requisite for recruitment of staff.

Barry McLeod and Mari Mair have addressed the issue of perception of reablement services in Edinburgh. (Scottish Government, 2009) They used a mixed methodology of a control group, the evaluation tool, focus groups and interviews with 115 service users, social service workers and managers. Reablement differs from traditional services, by focusing on improving the capacity for self-care, and building up confidence, over a limited time. Demands of reablement, require to employ qualified workers, who assist the individuals to undertake the task rather than doing things for them. The study identified that the majority of participants were positive, and satisfied with the service, that allowed them ‘to get back on their feet’ and was very quick in the response to their needs. (Scottish Government, 2009, pp.8) However, there were concerns related to the quality of care at the end of reablement programme, such as, the lack of information about who is going to provide the package of care.

Dr Gillian MacIntyre and Ailsa Stewart from Glasgow School of Social Work, University of Strathclyde (IRISS, 2011) provide an overview of "what works" in working with people aged 65 and over, with high levels of care needs, who are cared for at home. This included one of the 45 national indicators set by Scottish Government in 2007, that recently was extended to 50 national indicators. (Scottish Government, 2013) The results of the report based on a literature search, highlights that majority of older people wish to remain at home, as this supports their mental wellbeing and can delay onset of illness and dependency. It is also suggests that home care services can reduce the costs of care for older people. (IRISS, 2011) The evidence shows that home care workers, have a crucial role in enabling older people to remain at home. Therefore, the importance to employ a well-trained workforce, should not be overstated. It is understood, from the above study, that home care is crucial in terms of empowering older people. (IRISS, 2011)

Similarly, the study by the Joseph Rowntree Foundation in 2009, launched its five years programme A Better life, to question the assumption of older people, and aim to improve the quality of their life. According to the programme, older people should remain at home as long as possible. It aims to challenge the service led approach, and replace it with rights based approach, which recognises older people as equal citizens, who are part of the solution. (JRF, 2010)

In December 2011, a National Outcome relating to older people was added to the National Performance Framework. Since then, collectively, society need to give priority to ensuring that older people receive the care, compassion, support and dignity that older people need and deserve. According to the Scottish Government, there has been an increase (3%) in the percentage of people receiving personal care at home, rather than in a care home or hospital. (Scottish Government, 2013)

The study of Markus Themessl-Huber, Gill Hubbard and Pat Munro (2007) focused on older people’s experiences of services, in four Scottish Health Boards. In 2004 they conducted 18 semi-structured interviews with 12 women and 6 men, who were over 80 years old, who had been admitted to hospital and had previous services in place. The relevance of this study to the topic, is that currently, services to prevent unscheduled admissions of older people, focus on home care based services. However, the findings claim that services are not responsive to the main concerns, such as, meeting individual needs, maximizing independence and helping to live fulfilled lives. The study indicates a lack of person centred care, and influence in the decision-making. Older people highlighted the importance of flexibility of services, and reluctance of service providers to adopt their priorities. One criticism of the study, in terms of validity and reliability, is that it can be questioned how accurate the study is, when conducted in hospital setting. A hospital environment could exacerbate stress and confusion of older people, as a result of unfamiliarity, lack of sleep, medication or pain. This could affect the findings of the study. It also impeaches the issues of privacy and confidentiality, as interviews took place in the hospital ward.

Bowes and McColgan (2013) carried out a broader study in West Lothian, of how far telecare can support older people’s independence, participation and identity. This is of particular importance, due to ideologies across Scotland, of taking responsibility for own care and support. This can be seen through the government led self-care agenda, personalisation and choosing the management of care by self-directed support. The research indicates that the above policy may be supported through technological methods and telecare, such as, community alarm and detectors. The study seems to be more reliable in terms of methodology from the previously discussed as drawing on a grounded theory approach and continued interviewing of 76 participants. The semi-structured interviews were fully transcribed and analyzed using initial open coding to identify key themes. The findings identified that telecare increases independence, limits risk, intervention and disruption to daily life, but also improve relationships.

A project ran in 2011 in South of Glasgow, aimed to match the future expectation and aspiration of living a good older life, to the available resources. (IRISS, 2012) It is very rare for the older service user to have much of a say in how services are designed or indeed, to choose between services providers. This project provided this opportunity. The scope of the project was rather limited, focussing on South of Glasgow only, but the opportunity was given, over eight weeks of the project, to freely and fully express opinions, through workshops, discussions and exercises. (IRISS, 2012) The project involved students, and 30 older people, with carers, who supported the creation of ideas, and practitioners, who ensured the ideas developed are grounded in reality. The project identified some broken relationships between the health and social work sectors. This was due to the decision of NHS Greater Glasgow and Clyde, to break up the community health and care partnerships CHCPs in 2010, that currently, has been changed to Health and Social Care Partnerships with the budget to be overseen by the Scottish Government. (Scottish Government, 2012b)

Overall, the literature search was reasonably thorough, but did not uncover a large number of relevant studies. It seems like there are gaps in the Scottish home care sector of data collection, implications and impact of social services on service users within a social work context. Those studies, were largely focused on a health board perspective, were limited in geographical scope, and placed little or no emphasis on the social work role and its implications for practice. Recurring themes, were that of, the qualifications of home care workers, and the quality of services could be identified. This suggests either that there is plenty of work that this search has failed to find, or that there is a deficiency of research that this proposal will address.

4. Aim of study

Title;

Experiences of home care services in Community Care for older people. Voices from the field.

This study aims to;

Critically examine how the provision of home care services in community care impact on the experiences of older people.

The research questions which this study seeks to investigate, are as follow;

What are service users’ views of home care delivery?

What are feelings of service users, who receive personal care from a number of carers in a week?

What does it feel like, knowing carers’ have keys to service users’ house?

How does current social policy and legislation, impact on the delivery of home care services for older people?

5. Research Plan

My ontological assumptions embrace the idea of multiple realities, and it refers to how one views the world, leading to social reality, in which actors negotiate the meaning for actions and situations. (Crotty, 1998) My epistemology is based on social constructivism, as I aim to develop subjective meanings of older people experiences. With a view that these subjective meanings are negotiated through interaction with others, historical and cultural norms, that operate in an individuals life. (Creswell, 2007) In other words, I would rely on participants views of a situation, and look for complexity within the meanings. The theoretical perspective I utilise, is informed by interpretivism, as I attempt to uncover the meaning of realty and seek to understand older peoples’ opinions, experiences and emotions. (Carey 2009)

My methodology is advised by the philosophical assumption, that inductively develops a theory, or pattern of meaning, through phenomenological inquiry. Phenomenological study is focused on describing what all participants have in common, as they experience a phenomenon, that is home care services. The purpose of phenomenology is to reduce individual experiences with the phenomenon, to a description of the universal essence. (Creswell, 2007) In other words, this is a process of making an interpretation of the meaning. In this sense, the description consists of what, and how, older people in community care settings, experience home care services. It is acknowledged that my interpretations of any findings, would be shaped by my own experiences and background.

According to Creswell (2007), there is a much narrower range of sampling strategies, characteristic for a phenomenological study. For the purpose of this study criterion sampling will be utilised, all participants must be over 65, experience phenomenon such as Cordia home care services and carers must be in possession of service users house keys.

The access to participants would be through my employment, as I am employed by Cordia Home Care Services. This has been agreed with the area operational manager, and my line manager. Therefore, ethical approval for this research will be sought from Cordia and Glasgow Caledonian University School of Health and Social Care Ethics Committee.

It is essential to consider the ethical dimensions of the research question from the beginning, as this will inform the ethical obligations and procedures throughout the research project as a whole. (Alston & Bowles, 2013) The study’s ethical stance will be guided by the Code of Ethics for Social Work and Social Care Research (Butler, 2002), and the Code of Practice for Social Service Workers (SSSC, 2007). Butler (2002) suggested there are four principles to the code of ethics, respect for autonomy, beneficence, non-maleficence and justice. This research, will respect participants autonomy, by ensuring confidentiality, and by seeking informed consent. In respect of confidentiality, recognition of my role and responsibilities as an employee of Cordia is important. It will be made clear that confidentiality would be a priority, unless, disclosure of information has significant implications for others.

Further ethical consideration must be given, as participants are older people, who may experience physical, biological and psychological effects of the ageing. (Wilson et al., 2008) Therefore, they may need time to fully understand the process and research questions. Throughout the study, participants would have opportunity to familiarise themselves with the questions, before the actual interview. They would have time to ask questions and the right to withdraw at any stage of research.

I would like to conduct semi-structured interview, with 4-6 participants, to describe the essence of the older peoples experiences of home care services. A semi-structured interview is the best method of data collection when working with older people, because it is sensitive to the processes of ageing, such as, physical, visual, hearing and cognitive difficulties that older people may experience. A semi-structured interview allows repetition, and for misunderstandings to be clarified. The interviewer can prompt the responder, probe for more information and clarify what the questions mean. It gives the responder time to answer and familiarise themself with the questions. The interview will be conducted in the friendly environment of service users home. This will be done to support openness, honesty, and due to possible difficulties in mobility, that many older people may experience.

I would like to conduct a qualitative research, because, it captures the complex issues within the contexts. Simple interactions between people are difficult to measure, and these measures may not be sensitive to issues such as gender differences, race, economic status or individual differences. I chose this methodology and methods, because, to view individuals as a statistic, means overlooking the uniqueness of individuals. With this in mind, I will use a methodology, incorporating qualitative methods. A qualitative method, meanwhile, will allow me to fully explore the depth and breadth of people`s experiences, rejecting a removed objectivity to interact with participants and draw out detail. (Alston & Bowles, 2013)

Qualitative analysis involves systematic consideration of the data, to identify themes and concepts that will contribute to the understanding, and extraction of a meaning, of a phenomenon for older people. For the purpose of the study, thematic analysis will be used. The thematic analysis is utilised in empirical research that seeks to combine and catalogue patterns of experience or attitudes to create themes. (Carey, 2012) This is to support inductive reasoning, as themes are to be collected and used as evidence to support or adapt thesis. The data will be collected through a semi-structured interview, then conversations will be transcribed and significant statements highlighted, to identify themes from patterns. These will then be used, to bound together to write a brief statement, identify the story, and apply findings to practice. (Carey, 2012)

Limitations of the method: I am not skilled in interviewing techniques. However, Alston and Bowles (2013), state that skilled interviewers are needed for semi-structured interviews. This is because so much depends on the interviewer’s ability to pick up, explore, and accurately record additional information. What is more, my gender, age, class and ethnicity will influence how the respondent answers the questions. Other limitations can be seen in the ability to maintain objectivity and neutrality, as it is possible that I have, or have developed, my own hypotheses about the topic, which may be suggested to responders.

The study will focus on a small geographic area, recruiting participants who live in Glasgow and on only a small sample. Therefore, a significant weakness is that sample size is too small to be truly representative of the population. However, the study will focus is on exploring perspective for depth rather than breath and its place under Scottish law, and this will increase its usefulness in a limited research base.

In order to work realistically and manage the project, I have outlined a possible time line based on a timed road map. (Davies, 2007) The literature review will take place from June to August 2013. This will be a time, when I focus on developing my IT skills, in order to be able to fully access a wide range of local studies. During the period of the summer break, I would like to use this time to work on the methodology chapter, and thus, finalise in September, with the interview scheduled in November. Ethical approval is scheduled for November, with December left clear as contingency. Fieldwork will run from January to February 2014, and data analysis will be in March. The final write up will be completed in April 2014.