The consultation on retaining the domiciliary care workforce in Wales closed on April 6.

This is CFW’s response in full (below) as the main professional, representative organisation for the independent health and social care sector in Wales. CFW has more than 480 members who provide services to all age groups across all settings, including domiciliary care.

Your views on recruitment and retention

1. Why do you think it might be difficult to recruit domiciliary care workers?
2. Why do you think it might be difficult to retain domiciliary care workers?
3. What do you think we can we do to improve the recruitment of domiciliary care workers?
4. What do you think we can we do to improve the retention of domiciliary care workers?
This response covers questions 1-4 collectively.
As stated in the Minister’s foreword, this is not a simple issue – it is certainly not as simple as enhancing terms and conditions, although this is a major contributory factor. Nor is it simply the responsibility of employers and we would like to have seen far greater emphasis on commissioning throughout the consultation document given the raft of issues with current practice. Instead the consultation places a disproportionate emphasis on the responsibility of the provider, which is especially disappointing given the findings of Manchester Metropolitan University in their final report commissioned by Welsh Government, which says “our findings support Philpott (2014) who argues changes to current commissioning processes and higher levels of funding are required”.

Of course terms and conditions are highly significant in recruiting and retaining a high quality workforce and Care Forum Wales welcomes the introduction of the National Living Wage from April 2016. Most of our members would like to be able to offer additional enhancements to be able to recognise the significance and professionalism of the workforce and attract the best candidates. However, the ability to pay NLW is dependent on the level of fees commissioned. Our colleagues in UKHCA have calculated that commissioners would need to pay £16.70 per hour to enable domiciliary care providers to pay NLW and remain sustainable. Yet most Local Authorities pay considerably less than this. Indeed, members in one locality report that the Local Authority pays a flat rate for an 8 hour sleep in shift which is less than national minimum wage and forces the provider to operate at a loss. In such cases the provider has to subsidise the care as the only alternative is putting themselves at risk of an employment tribunal which is unacceptable. The level of fee paid will also impact on the provider’s ability to pay for travel time, maintain pay differentials for advanced practitioners, organise training, reduce workloads, increase the length of visits and, in future, pay for registration of the workforce. Commissioners need to be held to account and we continue to argue that commissioning practices should be inspected and regulated in the same way as service delivery.

There is a very real danger that if commissioners increase hourly rates, they will offset the cost by reducing the length of commissioned visits. Short visits may be appropriate in some instances, but we would expect the use of shorter visits to reduce considerably if we are to realise the ambitions of the Social Services and Wellbeing (Wales) Act to move away from transaction based care towards personal outcomes. Short visits used inappropriately can place care practitioners under more pressure, engender feelings of guilt and reduce job satisfaction. We would argue that guidance to commissioners is insufficient without accountability.
We would like to see commissioning rates that enable providers to recruit sufficient numbers of staff at sufficient wages that will enable them to provide fully relationship based care. Domiciliary care workers often have to display initiative, but we would like to see them empowered to take more control of their work and plan around the needs of their clients. This has worked well with the Raglan project where care practitioners now feel a much greater sense of ownership and fulfilment. Yet this required both a culture change and a move to permanent contracts by Monmouthshire County Council. The independent sector would not be able to compete on this basis unless local authorities commission permanent minimum amounts – in fact, the majority of providers cite the lack of assured work as being the main reason that they rely on zero hour contracts. While care continues to be commissioned by the public sector on what are effectively zero hours contracts, they will continue to be used by providers.

We agree that there needs to be a national approach to establish a career path that will make the sector more attractive. We support activities that upskill and professionalises the occupation, including registration of the workforce, but reiterate that such activities need to be funded. We also need to bear in mind that the additional requirements and scrutiny placed on domiciliary care practitioners could result in numbers of domiciliary care practitioners leaving to become personal assistants instead. Some members who have dismissed staff as being unsuitable have learned that they have gone on to become PAs.

It is too often the case that staff join the care sector as domiciliary care workers, are trained, and then move to work in care homes for the guaranteed hours. This seems upside down. If we look at nursing and midwifery for example, workers start in an institution and gain experience before working on their own in the community. This can only be changed through changing commissioning practices and planning from the commissioning sector.

The reputation of the care sector is a major hindrance to the recruitment and retention of good staff and we know that many care practitioners are embarrassed to tell their friends and neighbours what they do for a living. There is a major role for Welsh Government to help promote the image of care as a worthwhile profession. We would also suggest that practical steps could be taken to help identify and spread best practice, for instance through extending the remit of the Care Homes Steering Group. Unfortunately the poor public perception of care is perpetuated by an institutional prejudice against the private sector in particular and a misunderstanding of the nature of sustainable business, which to some extent appears to be demonstrated through the overwhelming emphasis place by this consultation on the responsibility of providers rather than commissioners.

We have also argued that the care sector as a whole needs to be treated as an issue of national strategic significance. This would help to enhance the reputation of the sector, improving recruitment of domiciliary care practitioners. It would also help increase investment in the workforce to help retention and improve professionalism. The removal of Welsh Government funding for apprenticeships for practitioners aged 25 sends the opposite message.

Your views on our ideas to limit the use of zero hours contracts

5. Which, if any, of our ideas below do you think would work in reducing the negative impacts of zero hours contracts on the quality of domiciliary care
Yes/no
i. Making domiciliary care providers publish the number of hours of care delivered by care workers on zero hours contractsii. Giving all domiciliary care workers the choice about whether they are employed on a zero hours contract or a contract with guaranteed hours

OR iii. Converting all zero hour contracts to guaranteed hours contracts after a domiciliary care worker has been employed for a specific period of time.

What period of time? ……………………………..

OR

iv. Restricting the number of care hours or the percentage of care hours which domiciliary care providers can deliver by zero hours contracts.

What you do think should be the maximum number of hours or maximum percentage of care hours? ………….

6. Which, if any, of the following ways could be used to make sure the changes set out above happen?
Yes/no
i. As part of the inspection process, the Care and Social Services Inspectorate Wales will make sure domiciliary care providers are keeping to the rules about the maximum use of zero hours contracts
ii. As part of the inspection process, the Care and Social Services Inspectorate Wales will make sure domiciliary care providers are not using exclusivity clauses in zero hours contracts.

7. What do you think would be the impact of restricting the use of zero hours contracts?

Please include any views you have on how restricting zero hours contracts may have a good or bad effect on the quality of care for service users

The proposals around zero hours at 5 – 6 are vastly over simplified and assume that providers almost universally opt to impose contracts on an unwilling workforce. It also needs to be recognised that contracts between providers and staff reflect the terms and conditions of contracts between commissioners and providers.

We agree that there is a need to look at the governance of zero hours’ contracts to ensure that there is protection for employees. However, zero hours’ contracts can be a valid choice for both employee and employer and should form part of a mixed offer. Zero hours’ contracts offer great flexibility for people who cannot commit to regular hours, such as working parents and students. We believe this may be supported by the findings of CSSIW’s review into domiciliary care which is not due to be published until May 2016.

Zero hours’ contracts can also offer more flexibility to employers, but can be equally problematic for them in planning resources to be able to guarantee visits. The underlying reason for the prevalence of zero hours’ contracts is therefore less about convenience than commissioning. Whilst commissioners only pay for contact time and give an average of just 24 hours’ notice of cancellation, there is no possibility of providers being able to guarantee work and to offer permanent, fixed hour contracts. Any imposition of zero hours contracts would destabilise the whole domiciliary care sector. Any governance or regulation of providers would need to apply equally to commissioning functions.

Zero hours’ contracts have little to do with quality of care. Indeed a more flexible package may offer more flexibility to the client whose needs vary. Quality of care if far more predicated upon the client having a co-produced care plan in place that focusses on their personal outcomes and allows the care practitioner adequate time – in other words, we need Local Authorities to commission for longer visits.

In terms of the individual proposals 5i would be unlikely to lead to any change but might make it harder to recruit into the sector by further adversely affecting its reputation. 5ii would only be possible if commissioning were to guarantee hours to the provider on a more permanent basis but anecdotal evidence suggests that many members of the current workforce who have been offered regular hours contracts have not taken them. 5iii would not be welcomed by some of the staff covered and would make some providers unviable without a change in commissioning practice. 5iv could only be delivered if the same were to apply to commissioning.

8. If you have any other ideas on how we can reduce zero hour contracts having a negative impact on the quality of care please let us know in the box below

See response to question 7.

Your views on National Minimum Wage and travelling time

9. Which, if any, of our ideas below do you think would work in making sure employers pay domiciliary care workers National Minimum Wage?

Yes/no
i. Provide information to employers and workers on how National Minimum Wage works in practice.
Yes
ii. Make employers keep records on rates of pay, hours worked (including travelling, training and sleepovers) and deductions (including uniforms).
See 11
iii. Local authority contracts with domiciliary care service providers should have a requirement for providers to show how they make sure they pay National Minimum Wage.
See 11
iv. Local authority contracts should be clear about the time allowed for being with the client and the time allowed for travelling.
Yes

10. Which, if any, of our ideas below do you think would work to check employers pay domiciliary care workers National Minimum Wage?
Yes/no
i. Make the Care and Social Services Inspectorate Wales include payment of National Minimum Wage as part of the inspection process
ii. Make the Care and Social Services Inspectorate Wales inform HMRC where domiciliary care providers are not, or they suspect they are not, paying National Minimum Wage
iii. As part of contract monitoring processes, local authorities should make providers demonstrate ongoing compliance with National Minimum Wage

11. Which, if any, of our ideas below do you think would work to check domiciliary care providers are giving, and paying for, enough time for domiciliary care workers to travel between calls?
Yes/no
i. Local authorities should check domiciliary care providers are allowing, and paying for, sufficient time for care workers to travel between calls
ii. The inspector – CSSIW – should include time allowed for travelling as part of the inspection process.

12. Please use the box below to let us know about any other ideas or comments on National Minimum Wage or travelling time:

Again, the suggestions are over-simplified and based on the premise that the solution and the problem are vested solely in the provider, rather than acknowledging problems within commissioning.

The calculations of the interaction between working time, travel time and holiday pay can make calculation of payment of the national minimum wage can be very complex and we would support the suggestion of providing more support and information to employers to help them understand their responsibilities. We would also welcome more transparency in commissioning to define exactly what is being purchased. Sadly, though, we know that many commissioners do not pay for travel time and only pay for contact time. Strengthening commissioning guidance is unlikely to change this as guidance can be (and is) ignored. Commissioners need to be accountable for what they purchase and should be subject to the same level of scrutiny and regulation, including inspection, as providers.

On that basis, it would then seem reasonable to expect greater transparency from providers and the requirement to pay national minimum wage could be written into contracts but commissioning practice must reflect this.

Your views on call clipping

13. Which, if any, of the ideas set out below do you think will help prevent call clipping?

Yes/no
i. Introduce clarity into the system by making it clear to providers, care workers and clients how much time should be spent travelling to a client and how much should be spent with the client

ii. Make sure domiciliary care workers rotas allow enough time to travel to each call and complete each call

iii. Make sure domiciliary care providers pay domiciliary care workers for the time spent travelling to the client and the time spent with the client

14. Which, if any, of the ideas below do you think would work to check call clipping does not happen and calls under 30 minutes do not take place unless they meet conditions set out in the Regulation and Inspections of Social Care (Wales) Act 2016

Yes/no
i. Make providers keep a record of how long care workers are with clients and how much time is spent travelling so they know if enough time has been allocated for the call and enough time has been allocated for travelling between calls.

ii. As part of the inspection process, check the time given for calls is enough for care workers to provide the required care and the travel time is long enough to allow the domiciliary care worker to travel between calls.

iii. As part of the inspection process check any calls which last less than 30 minutes meet the conditions set out in the act.

15. Please use the box below to tell us about call clipping and about any ideas you may have to prevent it from happening

Again this is a simplistic assumption that fails to take account of the commissioning process. Providers should undoubtedly take responsibility for planning rotas and monitoring attendance to prevent call clipping. However, they need to be commissioned realistically for longer visits where necessary and for travel time in order to make this work. They also need to have an adequate staffing level, which as we know if problematic given the turnaround in staff.

Your views on career structure and development and training

16. Which, if any, of the ideas set out below do you think will offer domiciliary care workers more opportunities for training, development and progression?

Yes/no
i. As part of the registration process, require all domiciliary care workers to achieve a qualification such as a Level 2 or Level 3 Diploma in Health and Social Care and require domiciliary care workers to demonstrate they have taken part in ongoing training and development.

Perhaps in the future
ii. Develop a ‘career pathway’ for domiciliary care workers. This would be similar to the career pathway for social workers. The career pathway would support the development of domiciliary care workers throughout their careers.
Yes
iii. Introduce diversity and specialisms into the role of domiciliary care work through providing training and development to care workers to enable them to specialise in working with, for example, people with dementia, to take on appropriate health tasks or support roles for adults with drug and alcohol dependency.

Yes

17. Please use the box below to leave your views about training, development and progression within domiciliary care

Access to training is very important to staff and we would support the need for ongoing training and development. However, this needs to be paid for and reflected in the fees paid by Local Authorities. Providers need to be able to maintain an adequate pool of staff to provide cover for training which will also have to be reflected in fees.

Many current care practitioners are from poor academic backgrounds and have struggled with formal learning. A requirement to hold a qualification might therefore prove a disincentive to many to join the domiciliary care sector and could cause practitioners to move into the care home sector instead if there is no corresponding requirement for all practitioners to hold a qualification. There are also some issues with the quality of training and assessment of qualifications that need to be addressed, not least the lack of suitably qualified assessors and funding for lower level NVQs which is an increasing problem since welsh government withdrew apprenticeship funding for over 25s. The vast majority of those entering the domiciliary care workforce are over 25 and anecdotal evidence indicates that they are more likely to stay in the sector and in general preferred by those receiving care. But the funding requirements of ensuring they were all able to access NVQ training would push an already unstable sector to breaking point in addition to considerations about whether potential staff would want to undertake such qualifications.

We would welcome the development of a formal career structure. The step into management qualification being piloted by Care Council for Wales is a good start, but there is need for considerably more work to be done overall that needs to include Local Authorities.

It might be at some point down the line we could then look at compulsory qualifications for domiciliary care workers but it is not a position that would be sustainable at the present time with the current workforce.

Whilst we also recognise the desire for specialisation opportunities it also needs to be recognised that this would not work in our more rural communities where care workers will need to remain generic or spend all their time travelling!

Your views on the occupational status of domiciliary care work

18. We are doing a number of things to raise the professional status of domiciliary care workers. Please use the box below to let us know of any other ways we can improve the status of domiciliary care work
We are pleased to see the value of the Wales Care Awards recognised in the consultation. A considerable amount of work is currently being undertaken around the care home sector in response to Dr Flynn’s report on Operation Jasmine and the OPC’s report into residential care. We would suggest there is room for this work to be expanded to include domiciliary care to enable similar sharing of best practice. There is also a role for the SCIPs co-ordinators to take on a higher profile in collating and sharing best practice following the evolution of Care Council Wales into Social Care Wales.

As indicated previously, we would also fully endorse the need to raise the status and reputation of domiciliary care and the occupational status of care practitioners and see Welsh Government and commissioners in having a key role in this.

We also agree with the principle of registering the workforce. However, this is on the proviso that registration needs to be funded. It must also be planned carefully to ensure that it does not act as a disincentive for the workforce and have the unintended consequence of causing people to leave the sector (especially to become Personal Assistants instead). We also need to recognise that the sector will be under additional pressure as a result of having to re-register under the new Regulation and Inspection of Social Care Act, so timing will be important to avoid destabilising the sector.

Your views on the health and safety of domiciliary care workers

19. Which, if any, of our ideas below do you think would work in making sure domiciliary care workers are safe when they work

Yes/no
I. Domiciliary care providers must have policies in place – such as lone worker policies, communication and mobile phone policies, health and safety policies
Yes
II. As part of the inspection process, the inspector will make sure the policies are in place and will check domiciliary care workers are safe when working
Yes

20. Please use the box below to tell us about health and safety issues for domiciliary care workers and any ideas which you think will help keep domiciliary care workers safe at work

It is reasonable for employers to exercise their duty of care by having lone worker policies etc. and these should be set out for providers.