Identificar las áreas de oportunidad y mejora en la planta de compostaje

Overall sample

A significant minority of interviewed users had previously expressed dissatisfaction with the tasks that agency carers had not carried out when on LA-managed care (see section 6.3.1).

Once on DPs, however, the negotiation of tasks with paid carers (whether PAs or agency carers) was not an issue of discontent or perceived conflict. Interviewed users felt as a whole that they had more control over what care they received and how they received it.

Interviewed users were able to determine what care they received and this sometimes included tasks that were not initially foreseen in the care plan or funded by the LA, for example, housework or social outings, but which users felt they had a need for. In some cases, users had not been wholly satisfied with their care plan and the DPs gave them more leeway in determining what needs they wanted to be addressed by enabling them to directly negotiate this with their PAs or agencies. This was often achieved in conjugation with the ability to bank hours, as previously stated. Narratives around the ability to get housework help (e.g. cleaning) – which had not been covered by care plans – also abounded among the sampled users, often in opposition with previous experiences where they had been refused this type of support while on LA-managed care. Interviewees mentioned no case of refusal to carry out tasks with their current PAs or home care agencies. Sure enough, even when on DPs, some interviewees had come across refusals or less accommodating PAs or carers from home care agencies. However in those cases they had been able to change PAs, agency carers or agencies themselves.

This ability to determine one’s own care needs (or those of relatives in the case of proxy respondents) was important, as dissatisfaction with the assessment of needs were, together with those linked with budgetary constraints and how to use DPs, among the most frequent complaints regarding the process of receiving a DP. For a number of users that had used DPs as an opt-out of what they considered to be unresponsive or inadequate LA-managed care, this ability to determine what exact care to receive was very much appreciated:

For me the care package was to one side and I was sure it wasn't what my mum needed. My mum needs to make sure that she has nutritional meals, and regular drinks, and that she socialises, very much. And then I looked at what I thought she needed and the difference [in the care plan] was this thing about getting dressed and I didn't think that was necessary. The carers always wrote that they didn't

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have any involvement in that, she was always resisting that. And then I thought that the [name of provider omitted due to confidentiality] is actually what she needs and family filled up the other gap [LA#3 012, female, purchaser, aged 81, proxy without user].

The interviewees were also able to better tailor the tasks to their changing needs and routines. This could include determining how their medicines were taken or apparently more trivial things, such as determining how often they wanted to take a bath, but that users felt were important to their perceived quality of life or to maintain decisional autonomy. This was another aspect of the extra flexibility that interviewed users attached to DPs: the ability to more easily and quickly change tasks to better fit their needs. Before, it was not uncommon for even small changes to care tasks to require approval from LA staff. These changes could now be negotiated and settled directly with home care agencies or PAs. In the latter case at least, there seemed to be a fair degree of informality in the negotiation of tasks:

Well, it's actually not too bad under the DPs. Before you used to have to call social services, social services to approve and then change and they would have to contact the agency and the agency would get in touch with us. (…) So we can contact the new carer [name omitted due to confidentiality] directly and she is very flexible. You just let her know and then she can come in a bit earlier in the evening or stay a bit longer to do things that are needed. And she always does the things that are needed [LA#1 001, female, employer, aged 72, proxy with user].

Beyond the greater leeway in defining their care needs and adapt tasks to those same needs, the narratives of interviewees presented also examples of how the relational aspects of care influenced the care they received. Firstly, continuity of paid carers allowed them to gain knowledge of the user’s care needs and personal preferences (see section 6.4.1). There were a number of narratives where users mentioned the often disturbing need to teach each new paid carer how to do things the way they wanted or preferred, or how, on the contrary, they valued PAs or agency carers that took the trouble of learning one’s preferences:

The first people I was with, they sent different people on different days and they weren’t used to things in the flat and I had to show them everything [LA#2 002, female, purchaser, aged 81].

[Interviewer]: It’s a relationship you’ve built with time or…?

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[Proxy respondent]: You build, or mum has new carers come in and they shadow the old carers and then they realise “Oh this is the way she does it” [LA#3 004, female, purchaser, aged 74, proxy with user].

The rapport established with paid carers (whether PAs or agency carers) was also important in two other ways: to ease negotiations with paid carers and to improve the experience of receiving personal care. A number of interviewed users found it easier to negotiate care tasks or to get paid carers to do tasks that were “perhaps not entirely in her remits” [LA#2 008, female, relational, aged 75] once they had gotten to know them a little better. The rapport established with the paid carer more often facilitated the negotiation of tasks – for example, when users were not too self-confident, or felt unsure of how to handle these negotiations – than acted as an obstacle. One instance could be because the user and paid carer could become too close. Again, these negotiations could be imbedded in strong reciprocal relationships:

Well it started off with just doing the… helping me wash and preparing some breakfast and as we got to know each other and I gave him advice on certain things that he needed to sort out in his life, and he had problems with his house and building and that, and he used my knowledge to meet the right people in order to get it sorted. Our relationship grew and obviously the more we helped each other the more he’s helped me. If I said to him now, “Will you clean that mirror for me?” he’d do it. He’ll go down to the shops, do the shopping, come back, put it in the freezer, whatever needs to be done he’ll do it [LA#2 005, male, relational, aged 61].

As mentioned earlier, the intimacy of personal care could be a powerful issue in determining who was best suited to carry out these tasks (see 6.4.3). On this issue, there were again consistent narratives about how the quality of personal care, as perceived by the users, had improved significantly when receiving care from someone they trusted or personally liked, or that knew how to deliver personal care according to the preferences of the user:

(…) when you’re disabled as much as I am, you need to build up a relationship with your carer and then your carer gets to know you and what your needs are, and where he needs to help you, and where you can do it, it’s easier to do it yourself. And of course in the manner and the way you like them done [LA#2 005, male, relational, aged 61].

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Before addressing the issue of potential differences in the definition of tasks between the different types of DP users interviewed, this section already illustrated some salient findings in the context of the research question of this study. The rapport established with the paid carer (particularly PAs) had allowed users to improve the breadth of care tasks that they could receive with DPs – i.e. users could receive care beyond the usual “remits” as the above-quoted user said – and in this sense they could better match the tasks to their needs.

Beyond extending breadth, however, relationships could also fundamentally contribute to improving the quality of care as perceived by the user, of which personal care was the most compelling example.

Differences and similarities between different groups

In the narratives of purchaser-type users, there were noticeably less references to some tasks that were often detailed in the narratives of the other types of users, such as housework help.

There were also occasional references to the perceived lesser flexibility in using DPs for certain tasks when receiving care from agencies, for example, there were no references to social outings as part of the care received by purchaser-type users.

Despite this, the ability to determine tasks, to receive care that might not be explicitly covered in the care plan, and to feel that the agency carer was knowledgeable of one’s needs and preferences, definitely improved as interviewees spent more time with agency carers. In this respect, purchaser-type users came to resemble more the other type of interviewees:

“But I do say for them to do more set of things now than I did at first perhaps. With experience, you know how often... but that's about it” [LA#2 001, male, purchaser, aged 71].

Among employer and relational-type users interviewed, there were more often references to tasks such as domestic chores, particularly more heavy tasks, and when relationships with PAs were closer, also social outings. There were cases of interviewees explicitly mentioning that their PAs were willing to do tasks that previous agency carers had refused to carry out, but these refusals had often taken place while they were still in LA-managed care, so the comparison is somewhat different.

While purchaser-type interviewees generally settled care tasks (as well as schedules) directly and verbally with home care agency managers, the negotiation of care tasks between employer and relational-type-users and their PAs was even more informal. As mentioned before, agreement on the setting of tasks often involved reciprocity or gift exchanges that were not present in the narratives of purchaser-type interviewees. The relational proximity

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often helped to determine tasks without conflicts. Defining the boundaries of relationships while defining care tasks could, nonetheless, sometimes be an issue for some relational-type interviewees and employers with closer relationships. For instance, one relational interviewee who had employed a neighbour as the paid carer expressed doubt about what was done under the remits of “neighbourly help” and what fell under the paid caring relationship.

Across the sample, proximity also helped to improve the perceived quality of care received, namely when paid carers were able to understand the preferences of users regarding how care was to be delivered. There was, however, one exception: personal care of an intimate nature. For those employing close relatives there could be an issue with too much proximity in the delivery of personal care (see section 6.4.3). Kinship relationships, and in some cases gender, could be a barrier to the provision of care of an intimate nature, for example, by sons to fathers or mothers. Some purchaser-type interviewees also expressed strong preferences regarding the gender of their agency carer when it came to the delivery of personal care. This was not portrayed as an issue however, as home care agencies – limited as they were in the leeway afforded to users in the choice of their paid carers – often accommodated users’

requests regarding the gender of their paid carers.

The findings of this section therefore provide some support to the hypothesis that employer and relational-type users had some more leeway in the definition of what care to receive and how. This was particularly evident regarding some types of care such as social outings. To some extent, this reflected the fact that as direct employers of their PAs, employer and relational users faced fewer constraints and had more power to determine the content of care. Relationships, however, also played a role in this. The leeway to define care and to get paid carers to provide other tasks expanded with time, and with it the strengthening of the relationship. Moreover, purchasers also made reference to this in their narratives, whenever continuity of agency carers existed, which strengthens the evidence that relationships can contribute to increased leeway in the defining of care tasks.

Possible confounding factors behind the definition of tasks

Besides continuity, i.e. the tenure of the paid carer, other factors, mainly related to the characteristics of users, were also systematically explored in order to explain differences in the definition of tasks. Chiefly among these factors were place of residency (in which LA was the interviewee residing), living arrangements and social networks, health condition and age of the interviewee. The first sought to explore possible differences arising from the fact that

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one LA had not yet implemented PBs, which could have implications in terms of the leeway in defining tasks (see section 3.2.2). As for the other factors, they mostly referred to the possibility that interviewees with better health, who were younger, with stronger social networks or living with their spouses or children could better negotiate tasks with their paid carer, either because they were not as frail, or because they could rely on their spouse or wider social networks to negotiate on their behalf.

LA#2 had not yet implemented PBs at the time of the interviews, which could mean that interviewees from this LA could potentially have less leeway in receiving care other than personal care. However, the narratives of interviewees (or their proxies) from the different types of groups of users residing in LA#2 did not show significant differences from their counterparts in the other LAs. For example, PAs employed by users in LA#2 also regularly performed household tasks and/or tasks that clearly went beyond personal care:

[User]: So, what I'll be doing, when the time comes, I will just say "Finish the things half an hour earlier every day, collect the hours and on the Sunday take us to Southampton then." You're with me? This is the beauty of DPs!

[Wife]: As long as they are doing their job…

[User]: You don't do that if you were with an agency. And we are not cheating anybody. We are not doing anything wrong. Because I told the social worker and he said to me "This would enable you to use your hours how you see fit". [LA#2 010, male, employer, aged 71]

As exemplified by the above quote, this was explained by the fact that restrictions imposed on the possibility to accumulate DPs in LA#2 – a key factor, together with relationships, in allowing for tasks beyond personal care to be delivered – did not seem to be particularly more stringent that those enacted in the other LAs.

In the narratives of users it was not evident that co-residing with the spouse or having a larger social network had a significant impact on the ability to negotiate tasks. There was no explicit reference to spouses or children mediating the negotiation of tasks with paid carers.

The exception was those with advanced stages of dementia, where the negotiation of tasks was undertaken directly by their proxy respondents (an issue further discussed in section 6.6). As mentioned earlier (see section 6.2), employer-type users were in general younger than the users sampled in the other groups, namely purchasers. This could have constituted an advantage in the negotiation of tasks with their paid carers as it could mean less frail and more articulated users.

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