Factsheet D - Domiciliary care

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The term domiciliary care is used to describe services which may be provided to enable you to live comfortably and safely in your own home. These services include:

• Domestic tasks - housework, shopping etc
• Personal care - bathing, washing, assistance with getting in/out of bed
• Meals on wheels
• Respite care - to enable your carer to have a break
• Day care - transport to day care centres may also be arranged
• Night Sitting Services
• Provision of aids/adaptations to assist with daily living

If you are having difficulty in coping at home you should contact your local Social Services office, and ask to have your care needs assessed. If you have sufficient financial assets you could make arrangements directly with a private agency without involving Social Services. However, it is advisable to seek a Social Services assessment as this will help you in describing your requirements and possibly in finding an agency.

Assessment of care needs

The first step will be for a person to have their care needs identified by their Local Authority Social Services Department. An assessment may be simple or complex, depending on the individual’s circumstances. The Community Care Assessment Directions 2004 makes it clear that:

• Joint assessments with the Health Service should be carried out where necessary.
• Carers should be involved in the assessment and care planning process.
• Assessments for all adults with complex needs should take account of physical, cognitive, behavioural and social participation needs.
• The Local Authority must provide information to the person (and if appropriate their carer) of any payments the person will be liable to make for services they are considering to provide

Once a person’s needs have been identified, the Care Manager will decide which eligibility criteria the needs fall into. All Social Services should apply the following four bands of eligibility laid down in the Government’s Fair Access To Care Services guidance.

Critical – when one or more of the following apply

• Life is, or will be, threatened;
• Significant health problems have developed or will develop;
• There is, or will be, little or no choice over vital aspects of the immediate environment;
• There is, or will be, an inability to carry out vital personal care or domestic routines;
• Vital social support systems and relationships cannot or will not be sustained;
• Vital family and other social roles and responsibilities cannot or will not be undertaken

Substantial – when one or more of the following apply

• There is, or will be, only partial choice and control over the immediate environment;
• Abuse or neglect has occurred or will occur;
• There is, or will be, an inability to carry out the majority of personal care or domestic routines;
• Involvement in many aspects of work, education or learning cannot or will not be sustained;
• The majority of social support systems and relationships cannot or will not be sustained;
• The majority of family and other social roles and responsibilities cannot or will not be undertaken

Moderate – when one or more of the following apply

• There is, or will be, an inability to carry out several personal care or domestic routines;
• Involvement in several aspects of work, education or learning cannot or will not be sustained;
• Several support systems and relationships cannot or will not be sustained;
• Several family and other social roles and responsibilities cannot or will not be undertaken

Low – when one or more of the following apply

• There is, or will be, an inability to carry out one or two personal care or domestic routines;
• Involvement in one or two aspects of work, education or learning cannot or will not be sustained;
• One or two social support systems and relationships cannot or will not be sustained;
• one or two family and other social roles and responsibilities cannot or will not be undertaken.

Where Social Services have limited budgets they can decide not to offer care in the low, moderate or substantial bands of eligibility. However, this decision must be clearly stated in their Better Care Higher Standards Charter – this charter should be readily available from the Local Authority. A person will have to make their own arrangements for any care needs in the eligibility bands excluded by Social Services (see useful organisations below). All care needs in the eligibility bands not excluded by Social Services are considered as "eligible needs."

Once the assessment has been completed a care plan should follow without delay. It is unlawful for a local authority not to meet eligible needs because of budgetary difficulties. If the eligible needs cannot be met immediately (because for instance there are no suitable services available) the care plan should explain how these services will be identified and arranged. Written details of the local authority’s complaints procedure must be provided to enable an appeal to be lodged against the assessment and care plan if is felt necessary.

Older people should be assessed using the Single Assessment Process which emphasizes a person-centred approach. The key attributes of the Single Assessment Process are:

• An older person only has to give information about their needs once, no matter how many different professionals or agencies are involved in planning and providing the care
• Professionals should work together in the best interests of the older person (as defined by the older person or those close to them).
• The older person's views and wishes are central to the assessment process, and the assessment takes account of the strengths the older person can bring to bear on their needs, and external or environmental factors that are causing or exacerbating needs;
• Assessment builds a rounded picture of older people’s needs and circumstances, including not only health and social care issues but also relevant housing, benefits, transport and other issues;
• The depth and detail of the assessment is proportionate to an individual’s needs;
• Each older person is informed of, and consents to, information about their needs and circumstances being collected and shared; and
• Key decisions and issues are copied in writing, or other appropriate formats, to the older person.

If an individual has a carer the latter is entitled (under the Carer’s Recognition and Services Act) to have an assessment of their needs. This could be carried out during the "service user’s" assessment but can also be carried out separately if the service user does not wish to have an assessment. A carer’s assessment may increase the services provided to the individual being cared for but could also provide assistance directly for the carer. The types of help that can be given will be very wide-ranging and not limited to community care services. For example, if the person cared-for refuses to accept help from anyone but a relative, the local authority might provide the relative with help with housework so that they had free time to assist the person who needed help. If a carer’s health deteriorates to the point they themselves require services, they should ask for an assessment as a "service user" rather than as a carer.

Once the assessment has been completed Social Services should provide written details along with their proposed care plan. Additionally written details of the local authority’s complaints procedure must be provided to enable an appeal to be lodged against the assessment if is felt necessary.

If you have problems getting an assessment it might be worth asking your Doctor to refer you. Your Doctor might also be able to arrange some services directly for you. A local authority cannot refuse to assess an individual because they can afford private care - the need for care must be assessed before any financial assessment is made. If an individual appears to be "at risk" without domiciliary care, they should ask for a "fast track" assessment.

Services to be provided by community care services

If an individual’s assessed needs meet the Local Authority's priority criteria the Social Services must provide the care - they cannot refuse to provide the care because of a lack of resources. The Local Government Ombudsman (case no. 00/5/00599) has ruled that once Social Services accept they are responsible for providing a service the refusal to provide that service solely because of a lack of resources is maladministration.

Social Services should issue a care plan giving the following information:

1. A precise description of each service required by the service user (ie; the type of service, the day(s), times and duration of each service delivery).
2. Who will provide the service (ie which statutory agencies have agreed to do what, and which independent providers have been retained to do what);
3. Who will be responsible for co-ordinating and monitoring the service delivery
4. The frequency and nature of reviews
5. The procedures for complaints (particularly if any independent provider is involved)

Direct payments

Local authorities now have the power to allow direct payments to people over 65, as well as those under 65. This means that local authorities are able to make cash payments for community care direct to individuals where a person would like to manage their own care. Payments will only be given for care that comes within the local authority criteria, but this option could be explored where a person wishes to make private arrangements. Payments are not usually allowed to be made to a spouse or close family member who lives with you. Carers may also request direct payments to meet their needs as a carer. A guide to receiving direct payments is available in the publications section of the Department of Health website (www.doh.gov.uk).

Services not provided by community care services

If an individual is assessed as needing care which is not within the priority criteria, the individual will be left to make his/her own arrangements with either a voluntary agency or a private agency.

Voluntary organisations

Libraries usually have details of voluntary groups, ie; church groups, or community groups who may be able to provide help in the home. Local Age Concern branches may also have details of services run in the area such as shopping, home care schemes or schemes to help people with heavy household tasks. The National numbers for Age Concern are listed on Appendix A and the local branch number should be in the local telephone directory.

The British Red Cross Society provide transport for the housebound, loan of medical equipment to the sick and injured and give assistance to those leaving hospital. Their details are on Appendix B.

The Disabled Living Foundation has a helpline which offers advice on useful gadgets and adaptations, self-help groups, equipment suppliers, charities etc. Details on Appendix A.

Private agencies

The number of private care agencies is increasing; they provide nursing care, live-in companions, personal care and domestic help. They charge for services provided, and the amount you pay will depend on the type of help you receive and how long you need help. All domiciliary care agencies which provide personal care must be registered with the Care Quality Commission (CQC). Search engines on the CQC website (www.cqc.org.uk) or the Elderly Accommodation Counsel website (www.eac.org.uk) can locate agencies in any given area.

Anchor Housing, Vitalise, Age Concern and the WRVS are charities which provide domiciliary care in some areas – contact details are shown on Appendix A. Although the RAF Benevolent Fund cannot recommend any care agencies, we are aware of a few that operate nationally and details of these are also given at Appendix A.

When trying to decide which agency to use, you should ask the following questions:

1. Are all staff interviewed before appointment? Are references taken up before they are allowed to start work?
2. Are staff required to maintain confidentiality about the needs and personal circumstances of people whose homes they visit?
3. How are staff supervised by their managers, and at what frequency does this occur?
4. Is there a published tariff of charges? Do the prices vary dependent on the day of the week, or time of day? Is staff travel time included in the price? Will you be expected to provide and pay for all equipment and materials used? Will the charge be subject to VAT? (Not all agencies are VAT registered.)
5. Does the agency have appropriate insurance cover for all eventualities?
6. Does the agency automatically provide cover when the employee is sick, on holiday or attending a training course?
7. Does the agency actively encourage its staff to handle users’ money, by shopping or collecting pensions - or does it have a policy of avoiding difficulties by refusing such tasks? (Even the best of friends fall out over money.) Make sure the agency has thought about that eventuality and that you are satisfied with the systems in place to protect your interests.
8. Does the agency have a complaints procedure? Is the procedure written down and made available to all users?
9. Is the agency a member of any recognised association of home care providers, either locally or nationally (ie; The United Kingdom Home Care Association (UKHCA) which requires members to operate within a code of practice)?
10. Does the agency employ qualified nurses, care assistants and domestics? (Make sure the agency has a policy of replacing like for like, otherwise you could find yourself paying for a nurse to undertake more routine work, or receive "nursing care" from an unqualified person).

Paying for services provided under Community Care Services

The local authority can ask the service user to pay for community care services it provides (not all local authorities charge for domiciliary care, but most do). However, any charges must be in line with the Fairer Charging Policy. Social Services must take disability-related expenditure into account if they wish to include Attendance Allowance, Disability Living Allowance or the Severe Disability Premium as income.

Social Services are only allowed to carry out a financial assessment of the service user - they cannot base their charges on the income of a carer or other family members.

If you cannot afford the charges made, you should make a complaint, as laid out in the appeals procedure. The local authority must continue to provide the services laid out in the care plan whilst an appeal against the charges is made, even if the user is paying a lower amount than has been assessed.

Details of the Fairer Charging Policy are given at Appendix C.

Paying for privately arranged services

If an individual makes private arrangements for their care needs then they are responsible for the cost of this care. However, an individual may be entitled to State benefits such as Attendance Allowance (see Appendix B), which would could be used to offset the cost of the domiciliary care. The local Citizens Advice Bureau or Age Concern group should be able to carry out a ‘benefits check’ to see if the correct benefits are being claimed.

In some cases, charities or trade benevolent funds may be able to help. Charities may be able to help with various costs such as respite care, home improvements, wheelchairs, furniture, alarm installation etc. Counsel & Care can assist you in finding sources of financial help from charities and their details are on Appendix A.

Homeshare

There are currently 7 Homeshare projects run by the charities NAAPS and Vitalise whereby volunteers provide live-in support in return for free accommodation. The volunteers are usually occupied with work or study during the day but are available to offer domestic assistance during evenings and weekends. They generally undertake to be present in the home overnight, every night. Homeshare recruit, interview, take up references and monitor the arrangement; providing training where necessary. For further details contact:

NAAPS
6 The Cotton Exchange
Old Hall Street
Liverpool
L3 9LQ

t: 0151 227 3499
w: www.naaps.co.uk

Community equipment

All Councils are expected to have an integrated Community Equipment Service to prevent the delay caused by applications being passed around from one department to another. The Department of Health Guide to Integrating Community Equipment Services gives the following definition of community equipment:

"Community equipment enables children and adults who require assistance to perform essential activities of daily living to maintain their health and autonomy and to live as full a life as possible. This equipment includes, but is not limited to":

• Home nursing equipment such as pressure relief mattresses and commodes.
• ‘Equipment for daily living’ such as shower chairs, raised toilet seats, teapot tippers and liquid level indicators.
• Minor adaptations such as grab rails, lever taps, improved domestic lighting, and improving the use of contrasting colours
• Ancillary equipment for people with sensory impairments such as flashing doorbells, low vision optical aids, textphones and assistive listening devices.
• Equipment for short-term loan including wheelchairs but not those for permanent wheelchair users as these are prescribed and funded by different NHS services.
• Communication aids for people who are speech-impaired
• Telecare equipment such as fall alarms, gas escape alarms, health state monitoring and "wandering detectors" for people who are vulnerable.

The guidance states:

• Equipment provision for people with rapidly progressing degenerative conditions or terminal illness must be "fast-tracked" to avoid unnecessary distress.
• Health & Social Services must have a single point of contact for equipment services.
• If a person (or their carer) is assessed as being eligible for any equipment to meet a community care need, Social Services must provide the equipment free of charge.
• All minor adaptations (ie grab rails) costing less than £1,000 (which includes the cost of buying and fitting the adaptation) must be provided free of charge. Councils may still make a charge in relation to minor adaptations that exceed £1,000.
• Where Social Services have agreed to provide the equipment, items costing less than £1,000 should in most cases be provided within three weeks.

Hiring equipment

If you only need equipment on a short-term basis it may be available as part of an intermediate care plan (see page 7). If not, it is worth considering the possibility of hiring:

Your local British Red Cross Centre may hire or lend wheelchairs and other items. Their address will be in the phone book or ask at your local library.

You may be able to hire a range of equipment from specialist hire companies and from some manufacturers and suppliers. Ask the Disabled Living Foundation or your nearest disabled living centre for details.

Age Concern publishes a helpful fact sheet Disability equipment and how to get it. For a free copy send a large stamped addressed envelope (23x16cms) to

Age Concern
Freepost
Ashburton
Devon
TQ13 7ZZ

t: 0800 009966 (freephone)
w: www.ageconcern.org.uk

Intermediate Care

Intermediate care is designed to provide high-quality pre-admission and rehabilitation care to older people to help them live as independently as possible by reducing preventable hospitalisation and to prevent delays in moving people over 75 on from hospital.

Intermediate care should

• Be targeted at people who would otherwise face unnecessarily prolonged hospital stays or inappropriate admission to acute in-patient care, long term residential care or continuing NHS in-patient care
• Be provided on the basis of a comprehensive assessment, resulting in a structured individual care plan that involves active therapy, treatment or the opportunity for recovery
• Have a planned outcome of maximising independence and typically enabling patients/users to resume living at home
• Be time-limited, normally no longer than six weeks and frequently as little as 1-2 weeks or less
• Involve cross-professional working, with single professional records and shared protocols.

Intermediate care does not include

• Transitional care that does not involve active therapy or other interventions to maximise independence ie; for patients who are ready to leave hospital but are simply waiting for longer-term packages of care to be arranged.
• Longer-term rehabilitation or support services
• Rehabilitation that forms part of acute hospital care
• It is not suitable for people with unstable acute medical conditions.

Intermediate care services should generally be provided in community-based settings or in the patient/user’s own home, but it may be provided in discrete step-down facilities on acute hospital sites. The most common intermediate care services will be:

• Rapid Response
  A service designed to prevent avoidable hospital admission. Patients can be referred by GP’s, Accident & Emergency Departments, NHS Direct or Social Services for short-term 24hr nursing/therapy support and personal care in their own home.
• Hospital at Home
  Intensive support in the patient’s own home, including investigations and treatment which are above the level normally provided at home but do not necessarily require the patient to be in a hospital. This may be used either to avoid admission to hospital or to enable earlier discharge from hospital.
• Residential Rehabilitation
  A short-term programme of therapy and enablement for people who are medically stable but need a short period of rehabilitation to enable them to re-gain sufficient physical functioning and confidence to return safely to their own home. Stays will range from 1-2 weeks to 4-6 weeks, depending on the individual circumstances. Residential rehabilitation may be offered following a stay in hospital or by a GP, Social Services or Rapid Response Team following a full assessment to prevent unnecessary admission to hospital.

Paying for Intermediate Care

All intermediate care packages are to be provided free of charge to the user, whether they have been arranged by the Health Authority or Social Services. The Government has allocated funds to the NHS which should be deployed from the pooled budgets they hold with Social Services. Even if Social Services instigate the intermediate care package (which should not be put in place without a medical assessment), they cannot charge the service user.

Emergency alarms

The National Benevolent Fund for the Aged (NBFA) has a scheme to provide free emergency alarms to those aged over 60, living on a low income and unable to get an alarm through their housing advisor. Installation, rental and maintenance is free but a £1.50 per week monitoring charge is payable quarterly or annually. For details contact:

National Benevolent Fund for the Aged
32 Buckingham Palace Road
London
SW1W 0RE

t: 0207 828 0200
f: 0207 828 0200
e: info@nbfa.org.uk
w: www.nbfa.org.uk

Appendix A – useful addresses

Age Concern

Provides advice & information for elderly people, their families and carers. They also hold details of "sitting" schemes where arrangements are made for a person to ‘sit in’ the older person’s home to allow the carer to take a break.

Appendix C - Fairer charging policies for home care and other non-residential social services

• Councils should ensure that service users and carers on the basic levels of income support, or whose income is equal to basic income support plus a buffer of 25% are not charged for services (ie £165.75 for a single person and £253.00 for a couple with effect from April 2009).
• Users who receive more than 10 hours care weekly and whose DLA, AA, SDP (Severe Disability Premium) is included as income in their assessment should also have an individual assessment of their disability-related expenditure. As a transitional measure those receiving less than 10 hours care per week can remain on existing charging policies.
• Earnings should be disregarded as part of income
• Councils will have to ensure charges do not bring a service user’s net income below the basic income support level +25% buffer. The calculation should therefore be:

• Only income left after the above calculation can be used towards services provided by the Council.

  Savings credit is completely disregarded so should not be included in the total income figure.

• £10 of the War Disability Pension (unless a higher percentage is disregarded under a local scheme) and all of a War Widow’s Supplementary Pension should be disregarded as income
• If Attendance Allowance or Disabled Living Allowance is being paid because of a need for night care and the Council is not providing night care, then this benefit cannot be included in income.
• Councils will have a duty to maximise the income of users and should ensure comprehensive benefits advice is provided at the time of a charge assessment. This should include help with completion of forms and follow-up if the user so wishes.
• Capital should be disregarded at the same levels for residential care ie; £14,000 disregarded completely and tariff income can be applied between £14,000 and £23,000. Users with capital above £23,000 may be subject to the maximum charge.
• Where the user has a partner and the assessment takes them below the couple’s income support level + buffer of 25%, the assessment should be based on the household. The partner’s earnings should always be disregarded.
• Working families tax credit and disabled persons tax credit should be disregarded
• Carers can only be charged for services they are receiving under the Carer’s Act. The carer’s premium should not be included as income and costs incurred in caring should be included in expenditure. These would include the purchase of private care to allow respite, additional cleaning & laundry costs, transport costs if the need to return quickly prevents public transport being used.
• If disability benefits are included as income, the council must include disability-related expenditure. Examples of such expenditure which must be necessitated by the user’s disability are:

- Payment for any community alarm system

- Costs of any privately arranged care services required, including respite care

- Costs of specialist items cause by disability eg;

- Specialist washing powders or laundry

- Special dietary needs (this may need to be confirmed by GP)

- Specially made clothing, or required because of additional wear and tear

- Additional costs of bedding for example because of incontinence

- Above average heating costs

- Reasonable cost of basic gardening, cleaning or domestic help

- Purchase, maintenance & repair of disability related equipment, including equipment or transport needed to enter or remain in work; this may include computer costs; reasonable hire costs of equipment may be included if waiting for supply of equipment from the local council

- Personal assistance costs, including any household or other necessary costs arising for the user

- Note: The Council may refuse to allow certain costs where a reasonable alternative is available at a lower cost ie; if a council can provide transport to day centre instead of a taxi or if continence pads are purchased privately even though they are available from the NHS.

Note: The user/carer has the right to ask for a review/re-assessment if they feel they cannot afford to pay the assessed charge.

Full details of the Fairer Charging Policies are available on the Department of Health Website: www.doh.gov.uk in the publications section.