Continuity of care

Complaint highlights the need for personal care plans to be agreed and followed

Care at home services are a crucial way to help people live independently at home, but a small minority of people are being affected by late or missed calls, lack of continuity of care workers, and poor care planning.

One complaint investigated by the Care Inspectorate showed the importance of developing a personalised care plan and agreeing the times of visits, and the need to inform people if there is any delay.

A detailed care plan is essential for care at home services

A detailed care plan is essential for care at home services

The individual had a number of complaints that included not knowing when his carers would turn up because the service would not provide him with a rota; that sometimes only one person turned up rather that two; and that the carers have insufficient travelling time between visits. He also said the service failed to implement its complaints procedure to address his concerns.

The team from the Care Inspectorate visited the service and spoke with managers and staff and checked documents. It upheld a number of the complaints about the service.

The inspectors upheld the complaint about the service not providing rotas, as the service confirmed that rotas had not always been sent to the complainant because they are “fluid”, and sometimes required to be changed on a daily basis in accordance with other people’s needs and unplanned staff absences.

The inspectors found there was no formal signed written agreement in place between the complainant and the service detailing the level of support required, but did uphold the complaint about not always providing two carers. The personal plan documents lacked detail, particularly around moving and handling, so it was not clear how many staff were required to support him.

The inspectors also upheld the complaint about the carers having insufficient travelling time between their visits. They reached this conclusion because it was very unclear what times had been agreed for visits at the weekend, because the timings of visits on the client visit sheets differed from the times recorded in the personal plan and written agreement.

Furthermore, the complainant’s care plan had not been reviewed to take account of the changes in the times of visits. The service said that it did not give people who use the service a copy of the written agreement, which was held in the office.

Furthermore, the written agreement/personal plan did not reflect the times of current visits or limitations of the service.

Although the care staff said that they always contacted people if they were going to be late for visits, the inspectors found evidence that the service was not consistent and reliable.

The inspectors found that there were limitations in the service provision and the service could not always accommodate the complainant’s request to change the times of his support.

The recommendations from this investigation were:

  • That the service must consult with the person using the service, or their representatives, and develop a personal plan, which sets out how all their needs will be met. This must be reviewed at least every six months.
  • The provider should inform people who use the service of the times of their visits and who will be supporting them, in accordance with their written agreement and personal plan.
  • The provider should provide people who use the service with a written agreement, which clearly defines how the service will meet their needs. They should be fully involved in the development of the detailed agreement and any reviews of the agreement and any limitations to the service fully explained.
  • The service provider should implement a system to formally monitor and analyse the frequency and reasons for staff running late on their schedules. This should include what action is being taken to address the gaps in service delivery.