Part 4: Quality of home-based support services

Home-based support services for older people.

4.1
In this Part, we look at whether the quality of home-based support services is appropriate. We discuss:

Summary of our findings

4.2
Although the Ministry has set standards for timeliness and the range of home-based support services, there are no mandatory standards about quality or the level of services. Without standards on the quality of services expected, it is difficult for DHBs to implement a nationally consistent and equitable approach to service delivery.

4.3
Our limited examination of the results of audits that DHBs have carried out, and their reviews of providers' services, indicate that services delivered are broadly in keeping with contractual requirements. Our review of a sample of older people's files and our interviews with older people also indicate that services are broadly meeting people's needs. However, the Ministry does not collect complete, comparable, and reliable data to provide information on the quality of services nationally. The Ministry is aware of this and is in the early stages of developing a process to get better quality performance information.

Specifying the quality of services to be delivered

There are no mandatory standards for the quality of home-based support services.

4.4
Unlike the provision of residential care for older people, there are no mandatory standards requiring DHBs to deliver home-based support services of a specified quality. There are very broad aspirational standards in the Ministry's Operational Policy Framework 2010/11. They include that DHBs must ensure that they can provide home-based support services and specify the range of services that must be available. However, a DHB can decide how it delivers its services and carries out assessments, and decide on the quality of those services. This can lead to differences in how services are delivered by different DHBs, and differences in their quality.

4.5
The Ministry told us that it is considering how to preserve local flexibility and innovation while increasing consistency between DHBs. DHBs are increasingly working within four regional groups, and the Ministry expects that this will reduce service differences between DHBs.

4.6
Standards New Zealand produced a Standard in 2003 that can be applied to home-based support services (NZS 8158:2003 Home and Community Support Sector Standard).5 Ten DHBs make compliance with this Standard a requirement of their contracts with providers, but the other DHBs do not. The Ministry told us that it is working with DHBs to consider the implications of requiring all providers to comply with the Standard.

4.7
The quality of services is managed through contracts between DHBs and providers of home-based support services. DHBs have specific contracts with providers for the delivery of services, and most DHBs have had these contracts for several years. The contracts largely follow a similar model, based on guidance from the Ministry. Contracts typically include service specifications, sector and employee standards, quality plans, management of risks, and contract reporting.

4.8
DHBs will negotiate contracts with providers based on market forces and specific requirements from the provider. DHBs can pay different amounts to different providers to carry out similar services. In our view, there could be good reasons for paying different amounts to providers for similar services – but this could lead to differences in the level and quality of services provided.

Recommendation 3
We recommend that the Ministry of Health consider making NZS 8158:2003 Home and Community Support Sector Standard mandatory for the provision of home-based support services to older people.

Information about the quality of services that are delivered

Information about the quality of services is patchy and incomplete. Providers seem to be meeting their contractual obligations, service coverage appears adequate, and older people make few complaints.

4.9
A wide range of providers deliver home-based support services to older people. There are about 50 providers, ranging from large national organisations to smaller providers operating locally. Some of these providers are profit-making organisations, and others are non-profit organisations. The number and range of providers means that services are available in all parts of New Zealand.

4.10
The Ministry and DHBs collect some information on the quality of services in the form of reports from providers, direct contact with providers, and audits of providers carried out by, or on behalf of, DHBs. However, different data requirements and different contracts mean that it is difficult to compare providers and DHBs. More data is needed to give DHBs and the Ministry certainty that services consistently meet requirements.

4.11
We were able to:

  • examine a small sample of reports from audits of providers, which look mainly at contract compliance;
  • examine a small sample of reports from service reviews and other reviews commissioned by DHBs, which look at whether home-based support services are operating as intended and delivering the expected outcomes;
  • review 100 files about older people who receive home-based support services, selected at random from providers contracted by three DHBs, to examine how well home-based support services were delivered to older people;
  • interview a small number of older people; and
  • examine the process for older people to make complaints, and the number and types of complaints received by several DHBs.

What audits of providers find about the quality of services

4.12
We reviewed four audit reports from one audit agency that audits the providers contracted to several DHBs. The audit report summarised in Figure 2 presented findings that are typical of the reports produced by this agency. The audit checked compliance with 185 criteria and found a high level of compliance, with no instances of non-compliance.

Figure 2 Compliance with criteria for services

Figure 2: Compliance with criteria for services.

Source: Audit agency's report.

4.13
Another audit identified several matters that the provider needed to improve, including that the provider's reporting to the DHB did not include information on how effective the service had been in achieving the goals set out in older people's support plans. The audit report said that:

… the omission of this information prevents analysis of whether the needs are being met and whether the organisation delivers a client focused service.

4.14
A further audit report checked a sample of the provider's staff files, which showed that only half of the files indicated that Police checks of support workers had been carried out. Only half of the files had documented reference checks. The auditors considered that the failure to carry out such checks exposed older people and the provider to risk.

4.15
We reviewed the audit reports of another audit agency that had audited home-based support services provided to older people. The provider was audited against the requirements in its contract with the DHB, the Home and Community Support Sector Standard, and against good practice models. The Home and Community Support Sector Standard is not mandatory but does ensure that some aspects of the quality of services are checked. These audits found a high level of compliance.

4.16
For each provider audit, the auditors survey the recipients of the service to obtain their views on the service provided to them. Over a two-year period, one audit agency had surveyed people receiving services from seven home-based support service providers in six DHBs. The audit agency amalgamated the results of these surveys to produce regional results. The survey questionnaire had been sent to 571 people and there was a 52% response rate. The survey asked several questions about the service, including the person's views of their support worker. Figure 3 sets out the results of the question about support workers.

Figure 3 Results of question about older people's views of their support workers

Figure 3: Results of question about older people’s views of their support workers.

Source: Audit agency's survey.

4.17
These results for the six DHBs and seven providers indicate a competent and caring workforce. The negative responses were almost all about one provider. The DHB concerned has started a process with that provider to improve their performance. Based on the results of the surveys, the auditors concluded that:

In an industry dominated by high staff turnover, low wages, and a lack of career advancement opportunities, providers should be commended on the positive responses by the majority of respondents, indicating that the support workers employed by these agencies are providing services that meet client expectations.

What service reviews and other reviews find about the quality of services

4.18
DHBs use service reviews and other reviews to try to ensure that services are operating as intended and delivering expected outcomes. These reviews do not specifically look at the quality of services. For example, one review commissioned by two DHBs found there were significant differences in the average hours of service allocated to people receiving home-based support services. In one DHB, the hours allocated were almost double the number allocated in another DHB, even though the people receiving the home-based support services had been assessed as having the same level of need. Reviews like this provide useful information to help DHBs identify where improvements need to be made.

4.19
Regular service reports from providers to DHBs show that there are sometimes delays with services provided to older people once an assessment has been made. However, based on the information we have analysed, we consider that, overall, assessment services are provided in a timely way and that support services start soon after an assessment is made.

What our files review showed about service quality

4.20
We reviewed 100 files, selected at random from providers contracted by three DHBs, to examine how well home-based support services were delivered to older people. We were able to form a view about whether timely and appropriate processes were followed but were unable to assess the quality of a service or whether it met the needs of the older person.

4.21
Our observations from the review of these files include:

  • Generally, there was an attentive relationship between care managers, support workers, older people, and their families.
  • Services appeared to be family-orientated and flexible.
  • Generally, there was a reasonable level of contact and consultation with the older people and family members in delivering care.
  • There were examples where support workers initiated a review of the older person's needs because they were concerned about how well the person was coping.
  • Although we noted some instances where services were less responsive, or where a person was not happy with their support worker, these instances were rare.

4.22
Some of the files we reviewed included service evaluations. Through these, many older people said that they were happy with the services provided and that the services were a valuable form of support for them.

What complaints show about the quality of services

4.23
Providers and DHBs receive very few direct complaints about home-based support services. The number of recorded complaints ranged from 11 in one year for one DHB to one over a four-year period for another DHB. Given that there are about 75,000 people receiving home-based support services through DHBs, this number of complaints is lower than expected. We also looked at the number of complaints received by several DHBs through the complaints process that all providers must have. Again, low numbers of complaints are received.

4.24
Most complaints are about support workers not turning up or reductions in the level of service. There are few complaints about abuse, and groups representing older people also told us that cases of abuse or neglect were rare. Overall, when complaints are made, they appear to be acted on.

4.25
Although the low number of complaints could indicate that the quality of services is high, it could also indicate that older people are reluctant or find it difficult to make a complaint. We have seen audit reports of providers that suggest there may be problems with how complaints are reported. We discuss this further in paragraphs 4.38-4.44.

Monitoring the quality of services delivered

No mandatory standards for the quality of services means that information about quality is variable and incomplete. There is little national monitoring, and the patchy information that is available is not routinely shared.

4.26
Overall, there is little national monitoring of home-based support services. What information is collected tends to be self-assessment information from DHBs and providers. There is no data checking, so the information cannot be validated.

4.27
DHBs carry out audits and service reviews, but these look mainly at contract compliance and are more quantitative than qualitative. They provide limited insight into the quality of the services and their effectiveness. Some information about older people's satisfaction with the services they receive is also collected. However, none of this information is shared routinely with the Ministry or other DHBs to help drive improvement or help the Ministry to assess the effectiveness of its policies and strategies.

4.28
Providers and DHBs have complaints processes, but the low number of complaints suggests to us that there could be barriers to older people accessing that complaints system. There is also evidence of under-reporting of complaints by providers.

4.29
The Ministry and DHBs accept that their performance information needs to improve. Once it does, the Ministry and DHBs can start to use the information to manage the performance of providers and deliver improvements.

How well services are monitored through provider audits

4.30
Our review of provider audits established that most DHBs monitor how contracts operate in terms of cost, timeliness of services, risk, and compliance with the conditions specified within the contract. However, although quality requirements are normally specified in contracts, they do not appear to be monitored effectively by DHBs.

4.31
There is no consistent and robust approach from DHBs to manage quality. Some DHBs require providers to report on quality and customer satisfaction but not always. When quality and customer satisfaction information is reported, it is often based on a self-assessment by providers. Some DHBs conduct their own satisfaction and quality checking, which is a more robust approach to checking the quality of home-based support services delivered by providers.

4.32
DHBs can, but are not required to, commission audits of providers. There is inconsistency in what is audited and how often the audits occur. In total, DHBs commissioned or carried out 93 audits in the five years from 2005/06 to 2009/10. Two of the largest DHBs did not commission any audits of providers in those five years, and three other large DHBs commissioned a total of seven audits between them. Some of the smaller DHBs commissioned many audits, with one of the smaller DHBs commissioning 10 audits of providers in the five years.

4.33
Some DHBs told us that they have not audited providers because they already monitor financial and service use data or monitor admissions to residential care. Other DHBs told us that they have regular meetings with NASC staff to "keep on top of problems", and one DHB explained that it could not afford the cost of auditing the providers of home-based support services.

4.34
Provider audits tend to examine the provider against:

  • compliance with the DHB contract;
  • compliance with the sector standards; and
  • compliance with good practice for all aspects of service.

4.35
Some providers provide home-based support services that are funded by the Ministry and the Accident Compensation Corporation, as well as the services funded by DHBs. Each of these funders will audit the provider's contracts, so providers can be audited by each funder within a short time frame. This increases compliance costs for providers. Providers, DHBs, and the Accident Compensation Corporation have so far failed to agree on a common system of auditing to reduce the duplication that currently occurs.

4.36
We reviewed four audit reports from one audit agency that audits home-based support service providers in several DHBs. In our view, the audit reports were thorough and gave the DHB useful information about the strengths and weaknesses of the provider in complying with contract requirements. The audit reports covered the appropriate areas to ensure that services specified within contracts are provided. These audits included:

  • observing the provision or delivery of services;
  • interviews or surveys of service users;
  • interviews or surveys of the provider's staff; and
  • examining the provider's records.

How well services are monitored through service and other reviews

4.37
Service and other reviews differ from audits because the reviews are less prescriptive. Some DHBs use service and other reviews to ensure that home-based support services are operating as intended. This can include DHBs commissioning service reviews to check that the expected outcomes are achieved. Service reviews are not regularly or consistently carried out.

How well services are monitored through the complaints process

4.38
Older people, or their representatives, can complain if they feel that the services they receive are not meeting their needs or if there are issues with the provider or support worker. A provider's complaints procedure must meet the Health and Disability Commissioner's Code requirements.6 In effect, this means that the complaints processes used by all providers are essentially the same. Overall, the few complaints that are made appear to be acted on.

4.39
Although the complaints process itself does not appear to be a barrier to making a complaint, Some stakeholders told us that older people do not like to complain, particularly about a support worker they rely on or may have been seeing for a number of years.

4.40
We have also seen audit reports about providers that suggest there may be problems with how providers report the complaints. In an audit of one provider, the auditors reviewed complaints over a 17-month period. There were five complaints. The audit report said that "This was a lower number of complaints than expected based on the volume of service users and the time period." The complaints were reviewed in detail. Of the five complaints, two were not recorded in the complaints register maintained by the provider. Three complaints were recorded in a different register. Only one complaint had been recorded in keeping with the procedures established for recording a complaint.

4.41
The manager of the service, when interviewed by the auditors, said that there was significant under-reporting of complaints. Problems such as support workers not showing up or a poor standard of work were recorded in the provider's database but were not recorded as a complaint. The provider established a new system for recording complaints.

4.42
The auditors commented on the complaints process:

The evidence would suggest that under-reporting is a wider issue and not restricted to this region. Discussions with staff verified that under-reporting is a wider issue, with one of the main barriers being defining a complaint. Further training on what constitutes a complaint is required to ensure that reporting accurately reflects complaints volumes.

4.43
The Strategy recommended that the Ministry and DHBs work collaboratively with elder abuse and prevention services to strengthen the community support available to older people at risk of abuse. This action was recommended in 2002. By 2010, the Elder Abuse and Neglect Prevention Services (EANP) co-ordinators within Age Concern had worked with 11 DHBs, but nine had yet to involve the EANP co-ordinators.

4.44
It will be important for all DHBs to work with agencies that support older people to make complaints to ensure that DHBs operate a system that empowers the elderly to complain in confidence should they feel they need to do so. DHBs also need to ensure that providers have systems that ensure that their staff understand how complaints are defined and how they should be recorded.

Recommendation 4
We recommend that district health boards work collaboratively with others in the aged care sector to develop a complaints system that enables older people to confidently raise any concerns about their home-based support services.

5: This Standard "establishes the minimum requirements that should be attained by providers. It is limited to health and disability services provided in the environment of a person's home or in their community, by individuals working as support workers accountable to a home and/ or community support service provider." An updated version of this Standard is expected to be released in March 2012.

6: The code includes provisions such as who to complain to, and the need for the provider to facilitate a fair, simple, and speedy resolution of the complaint.

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