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CHAPTER FIVE REVIEW

Evaluation Objectives

• Evaluate the processes in place to monitor and review individuals' needs.
• Evaluate the methods used by local authorities to monitor and evaluate uptake and expenditure on FPC.

Monitoring and Reviewing Individuals' Need

5.1 The Guidance on Free Personal and Nursing Care ³⁵ states that:

" Formal monitoring and review systems and time-scales should be in place to respond to the changing needs of individuals. For those in care homes, these systems should be in line with the national care standards for care homes for older people. Protocols should be clear to staff who are responsible for responding to individual circumstances where the person's needs have suddenly changed due to a crisis in their situation."

5.2 All local authorities have policies in place for monitoring and reviewing the needs of clients who receive FPC as part of the overall operation of community care. However, whilst local authorities and Joint Future Partnerships report on various indicators related to Single Shared Assessment ( SSA) via the Joint Future Performance Information Framework ( JPIAF), they do not report on their performance in relation to undertaking reviews.

5.3 Local authorities typically have targets for reviewing home care plans within four to six weeks of a home care package being set up and then on a six monthly and / or annual basis depending on the level of risk. However, they will review a case and a client's needs before these set dates if the client's circumstances change to such a degree that a change in the care package may be required.

5.4 New residents in care homes will generally have their case reviewed six weeks after they enter the home in order to assess whether their needs are being met. Most local authorities have a target of reviewing cases of care home residents on an annual basis, although at least six local authorities have a six monthly review target.

Monitoring and reviewing home care packages

5.5 Monitoring of home care packages is carried out through the process of home care workers recording the tasks they have carried out at the end of each visit on a daily or weekly diary sheet. The daily or weekly diary sheet lists all the personal care and other care tasks included in the care plan and the frequency and timing at which the tasks are to be undertaken. Care workers use the diary sheet to note any changes in circumstances that might affect the level of care required. Care workers notify their supervisors or the care co-ordinator/ care manager of any significant changes in their clients' circumstances (e.g. increase in frailty that inhibits their capacity to look after themselves in any way) that might necessitate a change in the care package.

5.6 The completion of the record of care is essential to ensure that the level of care provided is monitored. However, some users and carers interviewed during the course of the evaluation complained that care workers appear to spend time filling in paperwork that could be better spent providing more care and support.

5.7 Care workers in the case study local authorities reported that they are consulted by care co-ordinators or care managers during the review process in order for their views about the situation of the person being cared for to be taken into account. In some circumstances care workers are also present at the review.

5.8 Local authorities reported that the procedure for reviewing cases is as follows. In preparation for the review the care manager contacts the user, carer, service provider(s) and other relevant agencies and if necessary will ask them to attend the review meeting. The review uses the same assessment tool as was used for the assessment and considers the effectiveness of the current care plan, any changes in circumstances that may increase or decrease the client's need for care services and the views of the client and carer as to how care is currently provided (e.g. do care workers arrive on time, stay for the time they should, attend to their client's needs) and if the care plan should be amended. If the recommendation of the review is that the care plan should be amended then, as with the original care plan, the client's agreement will be sought on the revised care plan and the timing and frequency of the revised service.

Monitoring and reviewing clients' needs in care homes

5.9 New residents in care homes have their initial review carried out by the social worker responsible for the original assessment. Thereafter, in most local authorities, for residents of local authority care homes, the Care Home Manager takes over the case management and responsibility for undertaking future reviews. For residents of independent sector care homes who receive FPC/ FNC, the social worker/ care manager normally maintains the care management role and undertakes the six monthly or annual review. In these circumstances, the care manager consults with the Care Home Manager and relevant care staff. Care home staff have a key role to play in monitoring the needs of residents and reporting on changes in circumstances that may lead to a change in the resident's care regime. The resident and, if requested, his/ her relative(s) or advocate, will also be consulted to ensure that the resident's needs and views are taken into account in the review.

5.10 Angus Council has established a specialist Review Team to undertake reviews of cases in care homes. The review officer attends the initial six-weekly review in the home and then takes on responsibility for the care plan / client. The review team also reviews contracts for clients who have been placed in homes outwith the council area. The council believes that one of the benefits of the specialist review team is that the review officers have been able to develop closer links with care homes through more regular contact with care homes than care managers would have.

Delays in reviews

5.11 Four of the six case study local authorities (Argyll and Bute, Dumfries and Galloway, City of Edinburgh and Stirling) reported that they are not always able to meet their targets for regular scheduled reviews. They reported that the volume of case workload carried by care managers has meant that some reviews are delayed beyond the target date. Assessments of new cases will be prioritised over non-urgent reviews of old cases.

5.12 If reviews are delayed, this increases the possibility that a client's needs may have changed and are no longer being met. However, each of the case study local authorities reported that they will prioritise emergency reviews of cases where a significant change in circumstances has been reported; for example, an unpaid carer no longer being able to provide the expected level of care or if the client's health deteriorates.

The views of services users and carers

5.13 Interviews with users and carers in the six case study areas found mixed views about whether local authorities are meeting their responsibilities to undertake regular reviews and consider the views and needs of service users and carers. The evaluation spoke to people in all six case study areas who felt their cases and care packages were reviewed regularly and expressed confidence they could ask for, and receive, more help if they wanted it.

Mr H (Angus) is elderly and cares for his wife who has Alzheimers. He had been able to look after her on his own until he collapsed from exhaustion in early 2006. Mrs H attends Day Care twice a week and now receives a package of personal care. Mr H is confident that he would be able to get more help at any time if he needed it. He reported that his and his wife's needs are reviewed regularly by the social worker and their GP: "They check up with me regularly…. the Care Manager phoned me yesterday to see if I was managing….. All the carers are so nice. They ask if we are struggling with anything and if so, they'll do it - like making the bed."

5.14 However, some users and carers felt that their needs were not monitored or reviewed regularly enough, or that their changing needs were not being met by the provision of increased levels of care. In all but one of the six areas, users and carers were interviewed who reported that they had not had a review of their needs as scheduled and/ or felt that their changing needs were not being met.

Mrs G (Stirling) lives with her mother who has dementia. Her mother has day care and respite care which allows Mrs G to work part-time. Mrs G reported that the Social Work Department does not monitor her or her mother's support needs. For example, she is very concerned about her mother's refusal to wash and has tried unsuccessfully to contact the Social Work Department for help. She reported that the social worker who visited two years ago went on long-term sick leave and since then there has been no contact.

Monitoring and Evaluation of Free Personal Care

5.15 The Care Development Group ( CDG) recognised the importance of monitoring and evaluating the impact of FPC. Four of its recommendations related directly to the need to ensure the new policy was monitored and its impact evaluated:

• That monitoring arrangements should be quickly agreed and established, covering provision by all sectors. This should include establishing clearly what levels and volume of services are provided by care providers at the moment and monitoring how that changes after the introduction of the new policy, in terms of meeting unmet need and any shift from informal care
• In view of the importance of ensuring that the new resources are being used specifically for the care of older people, they should be ringfenced until robust outcome agreements are fully in place
• All the money for older people's services distributed to local authorities should be the subject of clear outcome agreements that are closely monitored and that measures to deal with delayed discharges should be a priority for agreement
• In revising planning requirements the Scottish Executive should examine how arrangements for monitoring performance of services for older people could be brought together. ³⁶

5.16 The Scottish Parliament Audit Committee's Community Care Inquiry (2005) ³⁷ criticised the failure to properly implement these recommendations through establishing agreed procedures and frameworks for monitoring the cost of implementing FPC and assessing the impact of the policy.

5.17 The Baseline Study considered the issue of the costs and finance of FPC in some detail. It concluded that there are gaps and weaknesses in the data on costs and finance and recommended that "It is essential that there is a clear and unambiguous definition of what the costs of the policy of free personal and nursing care comprise." ³⁸ It further recommended that the initiative for ensuring that local authorities have a common framework for recording social care data should be pushed forward.

5.18 Local authorities provide substantial amounts of information on a monthly, quarterly and annual basis to the Scottish Executive on several aspects of the uptake of FPC. These have been brought together in the Scottish Executive's Statistical Release 'Free Personal and Nursing Care 2002-2005' ³⁹, which includes information on:

• the number of care home residents supported by local authorities and the numbers of self funders receiving FPC and FNC
• the number of older people receiving home care services, the number receiving personal care services at home and hours of personal care
• expenditure on care homes and FPNC in care homes and expenditure on home care and FPC at home
• Grant-aided expenditure ( GAE) on home based care and personal and nursing care for older people in care homes.

5.19 However, these statistics provide only a partial picture of the implementation of FPC. They do not include information such as the number of people who have had to wait for FPC/ FNC payments in care homes or for FPC services at home, or the level of unmet need (defined as care needs for which people have been assessed but which are not being provided for). There is little evidence of the strategic monitoring of performance and outcomes as envisaged by the CDG.

5.20 The evaluation's survey of local authorities found that very few local authorities produce monitoring reports on the implementation, impact or cost of FPC. Only eight local authorities reported that they produce monthly budget reports showing their FPC expenditure commitment. For example, Aberdeen City Council produces a fortnightly commitment monitoring report and gross expenditure monitoring report for senior management to review the uptake and commitment of all social work services including FPC commitments. Only seven local authorities reported producing monthly monitoring statements of waiting times for FPC services.

5.21 Systematic analysis of information on unmet need gathered from clients' assessments would allow local authorities to better predict and plan to meet these needs in particular areas or in relation to specific services. However, few local authorities collate or analyse data on unmet need as recorded in SSA. Local authorities do not collect information on the impact of FPC on the level and type of care provided by unpaid carers and how this might impact on current and future demand for personal care.

5.22 The lack of robust data on these and other aspects of the delivery of FPC has been highlighted at several points of this evaluation. Requests for information made during the course of 2006 variously by the Scottish Executive, the Scottish Parliament Health Committee and this study were hampered by the problems which some local authorities have with data recording and reporting. For example, some local authorities have to undertake manual trawls of assessment records at a local level to provide information about the number of people waiting for personal care services or FPC/ FNC payments rather than being able to provide this information from a central database.

5.23 There are also some concerns about the consistency of the data supplied by local authorities and about the actual data that is collected, in particular in relation to Home Care. A survey of local authorities conducted in February 2006 by the Social Work Statistics Liaison Group Home Care Review Group and Health Department: Analytical Services Division confirmed that there is a lack of consistency in what data is collected and how it is collected across local authorities.

5.24 Local authorities currently use a wide range of different systems to store home care data ranging from paper records to purpose built databases. For example:

• manual returns reported specifically for the statistical returns
• paper care plans or other paper sources
• computer records from a client care plan/ service requirement record
• electronic schedule of service provision.

5.25 The lack of robustness in the methods used for recording care packages and actual care tasks carried out by care workers means that it is difficult to undertake accurate analysis of levels of service and comparisons across local authorities. For example, it is very difficult to extract from the home care statistics the level of personal care services as opposed to non personal care services provided for older people. The local authority survey carried out for the evaluation attempted to do this, but with only limited success, as less than half of local authorities were able to extract personal care services from the total home care services statistics provided.

5.26 FPC cannot easily be separated from Community Care and the problems associated with recording and analysing data on FPC affect all community care services. Developments in monitoring FPC specifically will be bound up with changes in evaluating and monitoring the performance of community care overall.

5.27 JPIAF and Local Improvement Targets ( LITs), which are used to monitor Joint Future Partnerships' progress across a number of performance indicators, are the primary means by which the Scottish Executive currently monitors how Community Care is being implemented by local authorities and their NHS partners. The development of performance monitoring information for FPC will have to be linked to developments in JPIAF and LITs and the move towards more outcome based measures.

5.28 The evaluations of JPIAF to date have shown that, although the development of LITs has driven significant progress towards an outcomes focus in Community Care, there continues to be wide disparity of performance across Joint Future Partnerships. In order to build upon the experience of JPIAF, the Joint Future Implementation Advisory Group has established a National Outcomes Group to examine the reporting, monitoring and evaluation of joint working. The Group aims to:

• Achieve consistency of understanding of the outcomes agenda across partnerships
• Reduce the burden of scrutiny for Community Care as much as possible
• Identify a small number of key national outcome indicators
• Identify the information needed to performance manage this agenda locally and nationally
• Propose a performance management system against these new targets.

5.29 This group has been concerned more with outcomes, such as social integration and community health and well being, than with the specific means of achieving those outcomes, such as through the provision of FPC. The work of this group should offer an opportunity for partnerships to identify specific performance measures in relation to FPC if that is seen as a priority within the wider agenda of monitoring outcomes and performance for care overall.

5.30 The monitoring of FPC has to be linked to agreement over the outcomes the policy is expected to deliver. Without a clear statement of the outcomes that FPC is meant to deliver it is not possible to establish a set of performance indicators to monitor how local authorities are delivering FPC beyond current measures based on outputs (i.e number of self funders receiving FPC payments and number of people receiving FPC at home).

Summary and Recommendations

Monitoring and Reviewing Individuals' Needs

5.31 In line with guidance on community care assessments, all local authorities have policies in place for monitoring and reviewing individuals' needs and target times for undertaking scheduled formal reviews. However, there is no national monitoring of whether reviews are carried out as scheduled within the target times. Home care workers and staff in care homes have a key role to play in monitoring the needs of individuals who receive personal care. (5.1 - 5.10)

5.32 Where local authorities may be experiencing problems undertaking assessments they also reported delaying 'non-urgent' reviews. Users and carers reported varying experiences. Some were happy that their case was reviewed as required. Others reported long periods without review. (5.11 - 5.12)

5.33 The evaluation found mixed views from users and carers about whether their needs are being reviewed regularly enough and whether the monitoring and review process was an effective process for identifying and meeting additional needs. (5.13 - 5.14)

Monitoring and Evaluating Free Personal Care

5.34 Despite the recommendations of the Care Development Group and the concerns expressed by the Scottish Parliament Audit Committee, few local authorities have developed a systematic approach to reporting and monitoring the implementation, impact and cost of FPC. Whilst local authorities do produce substantial amounts of statistics for the Scottish Executive on some aspects of home care, these statistics provide only a partial picture of the implementation, operation and impact of FPC. (5.15 - 5.22)

5.35 A large number of local authorities still lack the community care information systems to readily produce robust statistical information on key aspects of the implementation and operation of FPC. There is limited collection and analysis of information about key issues such as numbers of people waiting for FPC payments or services, unmet need, and the level and type of support provided by unpaid carers. (5.23 - 5.26)

5.36 Although the development of Local Improvement Targets has driven significant progress towards an outcomes focus in Community Care, there continues to be wide disparity of performance across Joint Future Partnerships. On-going work on improving the reporting of performance in relation to SSA and other aspects of joint working in Community Care has not, to date, specifically considered FPC. (5.27 - 5.30)

Recommendations

R5.1 Local authorities should report on their performance in undertaking reviews of cases. This could be done via the same arrangements that are in place for reporting on progress in implementing SSA through JPIAF and Local Improvement Targets.

R5.2 The Scottish Executive should be clear about the outcomes it expects to monitor in relation to FPC and these should be used as the basis for a set of performance indicators which local authorities should report on.

R5.3 The development of a common framework for recording social care data and the implementation of systems to allow for the collection and analysis of information through the full implementation and operation of e-care should be a national and local priority and should be implemented without delay.

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