Quality statement 5: Reviewing the outcomes of the home care plan

Quality statement

Older people using home care services have a review of the outcomes of their home care plan within 6 weeks of starting to use the service and then at least annually.

Rationale

Assessing whether the home care service is achieving the outcomes described in the home care plan will help identify any changes or improvements that are needed. An early review of outcomes with the older person within the first 6 weeks will ensure any initial problems are identified and addressed quickly. Regular reviews should be carried out in response to any changes in circumstances such as a hospital admission or deterioration in physical health, and at least annually, to check that the home care service is still meeting the person's needs.

Quality measures

Structure

a) Evidence of local processes to ensure that older people using home care services have a review of the outcomes of their home care plan within 6 weeks of starting to use the service.

Data source: Local data collection.

b) Evidence of local processes to ensure that older people using home care services have a review of the outcomes of their home care plan at least annually.

Data source: Local data collection.

Process

a) Proportion of older people using home care services who have a review of the outcomes of their home care plan within 6 weeks of the service starting.

Numerator – the number in the denominator who have a review of the outcomes of their home care plan within 6 weeks of the service starting.

Denominator – the number of older people starting to use home care services.

Data source: Local data collection.

b) Proportion of older people using home care services who have a review of the outcomes of their home care plan within a year of their previous review.

Numerator – the number in the denominator who have a review of the outcomes of their home care plan within a year of their previous review.

Denominator – the number of older people using home care services for more than a year.

Data source: Local data collection.

Outcome

a) Older people's satisfaction with the home care service.

Data source: Local data collection.

b) Health-related quality of life.

Data source: Local data collection.

c) Social care-related quality of life.

Data source: Local data collection. The Health and Social Care Information Centre's Personal social services adult social care survey includes questions on social care-related quality of life.

What the quality statement means for service providers, social care practitioners and commissioners

Service providers (such as independent home care agencies, voluntary sector organisations, and local authorities) ensure that processes are in place for older people using home care services to have a review of the outcomes of their home care plan within 6 weeks of starting to use the service and then at least annually. The frequency of reviews will depend on individual circumstances and should be responsive to any changes in those circumstances. The frequency should be agreed with the older person but they should know who to contact if they want to request a review at a different time.

Social care practitioners (such as home care managers, support workers, and social workers) review the outcomes of the home care plan within 6 weeks of the older person starting to use the service and then at least annually. Social care practitioners should agree the frequency of reviews with the older person but arrange an earlier review if the person's circumstances change.

Commissioners (for example local authorities and clinical commissioning groups) commission services that ensure that older people using home care services have a review of the outcomes of their home care plan within 6 weeks of starting to use the service and then at least annually. Commissioners should ensure there is an agreed approach to identifying the frequency of reviews based on individual circumstances and that there is capacity to undertake more frequent reviews if needed.

What the quality statement means for people using home care services and carers

Older people who use home care services have a discussion with a member of their care team about whether they are happy with their care and if it is helping them in the way that they want. This should happen within 6 weeks of starting to use the service and then at least once a year. Older people can involve a family member or carer in the review of their care if they wish. The home care provider should agree how often a review is needed but the older person and their family member or carer should know who to contact in case they want to arrange a review at a different time.

Source guidance

Definitions of terms used in this quality statement

Home care plan

This is a written plan put together after the local authority assessment of overall need. It sets out the home care support that providers and the person have agreed will be put in place. It includes details of both personal care and practical support.

[Home care: delivering personal care and practical support to older people living in their own homes (NICE guideline NG21)]

Equality and diversity considerations

People with communication difficulties or sensory loss should be offered appropriate support to enable them to participate in a review of their home care plan. Any information provided should be in a format that suits their needs and preferences. In particular, practitioners should identify, record and meet the information and communication needs of people who have hearing loss, sight loss or learning disabilities, as set out in NHS England's Accessible Information Standard.

People with limited independence as a result of a physical disability, mental health problem or cognitive impairment may need additional support, such as an advocate, to identify whether their care is meeting their expectations and aspirations.

People with deteriorating conditions and those who are likely to be approaching the end of life may need reviewing more often.