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i The Recruitment and Retention of a Care Workforce for Older People Jill Rubery, Gail Hebson, Damian Grimshaw, Marilyn Carroll, Liz Smith, Lorrie Marchington and Sebastian Ugarte February 2011 European Work and Employment Research Centre (EWERC) University of Manchester Project funded by the Department of Health as part of the Social Care Workforce Initiative Disclaimer This is an independent report commissioned and funded by the Policy Research Programme in the Department of Health. The views expressed are not necessarily those of the Department. EWERC i Acknowledgments This report is based on the final two years of a University of Manchester research project on the recruitment and retention of the social care workforce for older people under the Department of Health‟s Social Care Workforce Initiative undertaken by a team based in the European Work and Employment Research Centre in Manchester Business School. The results of the first year of the project were reported on separately by the Manchester PSSRU unit in 2009. We are grateful to the Department of Heath for funding this project, while the usual disclaimer applies (see above). We would also like to thank the academic coordinator of the initiative, Hazel Qureshi, for her support and guidance over the course of the project. We are extremely grateful for the time taken by the participants in this research project to provide us with the data without which the report could not have been written. The participants ranged from local authority commissioners and contract managers, to independent sector providers (owners and managers), human resource managers of national chains and nearly 100 care workers. The project has also benefitted from the active participation of members of our advisory board, whose names are listed below. We are particularly grateful to Mary Murphy for facilitating the setting up of a focus group of users and to Dan O‟Donoghue for facilitating the piloting of our telephone questionnaire. Over the course of this project a number of researchers have been involved in this project in addition to those named on the report; these include Colette Fagan, Carrie Hunt and Claire Shepherd, and we would like to record our thanks to them. Members of the Project Advisory Board EWERC Name Position/Organisation Ged Taylor Mary Murphy Judy Scott Sharon Brearley Peter Urwin/ Ray Short Michael Wyatt Dan O‟Donoghue Sue George Gillian McCormack Chris Hopwood Consultant Lay Person Lay person Age Concern Unison St Helens Council Home Care Support Skills for Care Skills for Care ACAS ii Table of Contents Part/Section Page I. The study context 1 I.1. The research framework 1 I.2. The impact of external environmental factors on recruitment and retention I.2.1. Policy environment I.2.2. Commissioning and contracting practices of LAs I.2.3. Labour market conditions 4 4 7 15 I.3. Management and organisational factors in the recruitment and retention of a social care workforce I.3.1. Management and human resource practices I.3.2. Reward practices I.3.3. The organisation of care work I.3.4. Training and development 19 I.4. Recruitment and retention from the user and employee perspectives I.4.1.What makes a good care service and what makes a good care worker? I.4.2. Is care work a good job or a bad job? The employee perspective I.4.3. Time and space in the recruitment and retention of a social care workforce 36 36 I.5. Key research questions 42 I.6. Research strategy and methodology I.6.1. The project research stages I.6.2 The first stage survey 45 45 48 I.7. The research methods for stage two I.7.1. The local authorities I.7.2 The telephone survey 49 49 53 I.8 The research methods for stage 3 case studies I.8.1 Rationale for the case study approach I.8.2. Stage three: design of the case studies I.8.3. Stage three: selection, conduct and analysis of the case studies 58 58 58 60 I.9 The plan of the report 64 EWERC 19 22 28 34 38 41 iii II. Commissioning and Contracting in the Selected Local Authorities 65 II.1. Key commissioning and contracting characteristics II.1.1. Extent and form of external commissioning and contracting II.1.2. Provision of fees for externally provided care II.1.3. Role of HR factors in tendering, contracting and monitoring II.1.4. Extent of support for providers through forums and training provision 65 65 72 78 80 II.2. Approaches to commissioning and contracting: the qualitative interview data II.2.1. Making the market II.2.2. Price versus quality. II.2.3. Integration of social care and health II.2.4. User choice 83 84 91 96 98 II.3. Classifying the strategic approach 102 II.3.1. Typologising the local authorities 102 II.3.2.The coherence, stability and sustainability of LAs‟ commissioning 110 and contracting practices II.4 The selected LAs and user satisfaction surveys 113 II.5 Summary and conclusions 116 III. The provider telephone survey: Recruitment, retention and employment conditions 118 III.1. Recruitment and selection III.1.1. Recruitment difficulties III.1.2. Recruitment practices: Attracting a suitable pool of applicants III.1.3. Selection: Choosing the right applicant III.1.4. Selection problems 120 120 124 129 134 III.2. Turnover and retention III.2.1. Staff turnover 138 138 III.3. Pay and rewards III.3.1. Level of pay III.3.2. Pay differentials and pay supplements III.3.3. Pay uprating III.3.4. Payment for travel time, overtime and training time III.3.5. Payment for upfront costs of starting work 143 143 147 150 152 155 III.4. Flexibility, Working Time and Work Organisation III.4.1. Flexibility, working time arrangements and work organisation in domiciliary care. 157 157 EWERC iv III.4.2. Flexibility, working time arrangements and work organisation in care homes 173 III.5. Employee development and training III.5.1. Induction of new staff III.5.2. Training III.5.3. Appraisal and staff development 177 177 178 184 III.6. Performance management, job autonomy and employee voice III.6.1. Performance management III.6.2. Discretion and autonomy III.6.3. Employee voice and communication 186 186 191 193 III.7. Summary 195 IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 199 IV.1. Organisational characteristics and the management of independent sector providers IV.1.1. Organisational characteristics IV.1.2. Management in the independent sector 200 IV.2 HR practices and outcomes by provider characteristics IV.2.1. HR practices and outcomes by provider characteristics IV.2.2. HR outcomes by provider characteristics IV.2.3. HR practices and strategies by individual provider IV.2.4. Employer views on the effectiveness of HR strategies 213 214 223 228 230 IV.3. LA commissioning and contracting and provider HR practices IV.3.1. The influence of LA fee levels on pay IV.3.2. HR practices and outcomes by type of LA 233 233 237 IV.4. Labour market conditions and provider HR practices and outcomes IV.4.1. The influence of local labour market conditions on pay IV.4.2. The influence of local labour market conditions on HR practices and outcomes 246 246 247 IV.5. Internal and external environmental factors associated with good HR practices and HR outcomes IV.5.1. Exploring the factors associated with the adoption of good HR practices IV.5.2. Exploring the factors associated with good HR outcomes 253 IV.6. Providers‟ views on the social care policy and commissioning environment IV.6.1. Providers‟ attitudes towards and experiences of local authorities IV.6.2. Providers‟ attitudes towards and experiences of monitoring systems 267 EWERC 200 205 253 259 267 273 v IV.6.3. Providers‟ attitudes towards, and experiences of, policy developments likely to affect social care IV.7. Summary 280 283 V. Recruitment and Retention in the Care Sector: A Case Study Approach 289 V.1. Case studies in four local authorities: exploring the impact of commissioning and contracting arrangements V.1.1 Introducing the local authorities V.1.2. Pay practices of providers by local authority. V.1.3. Working time practices of providers by local authority V.1.4. Work organisation of providers by local authority V.1.5. Training and development of providers by local authority V.1.6. Comparing national providers in different LA environments. V.1.7. Overview of HR outcomes for providers by local authority 291 V.2. Care workers‟ perspectives on recruitment V.2.1 Factors that influence entry into the care sector V.2.2. Role of employers versus employees in access to information on care job vacancies 300 303 309 V.3. Care workers‟ perspectives on turnover and retention V.3.1. Care workers‟ intentions to stay or to quit. V.3.2. Factors that may contribute to turnover 313 313 318 V.4. Care workers‟ perspective on pay and working time V.4.1 Pay and travel time V.4.2 Working time 321 321 325 V.5. Care workers‟ perspective on work organisation and the quality of care 330 V.6. Care workers‟ perspectives on training and development V.6.1 Experiences of training V.6.2 Development and opportunities training 337 337 340 V.7 Summary and conclusions 344 VI. Research Findings and Conclusions 347 291 293 294 295 297 298 300 VI.1. The local authority commissioning environment 347 VI.2. Explaining the variety of HR policies and HR outcomes of providers 352 VI.3. Recruitment and retention from a care worker and user perspective 362 VI.4. Prospects for recruitment and retention under expanding demand: the policy issues 366 Appendix 376 Bibliography 419 EWERC vi List of abbreviations ADSS CIPD CQC CRB GMB HR IDP KPI LA LADP LPC MaROT R2 Association of the Directors of Social Services Chartered Institute of Personnel and Development Care Quality Commission Criminal Records Bureau GMB Trade Union Human resource Independent sector domiciliary care provider Key performance indicator Local authority Local authority domiciliary care provider Low Pay Commission Management of recruitment and retention, reward policy, organisation of work and training and development National Health Serivce National Minimum Data Set National Vocational Qualification Primary Care Trust The policy environment, commissioning practices of local authorities, and labour supply factors Coefficient of determination of a linear regression R&R Sig. TUPE UKHCA Recruitment and retention Significant ( statistical) Transfer of Undertakings Protection of Employment UK Home Care Association NHS NMDS NVQ PCT PoCLS EWERC vii Notes on coding used through the report We have used a number of coding systems to provide identifier throughout the report. The 14 local authorities have been given a two letter identifier. This has been used as the first part of the identifier for the providers interviewed in the telephone survey. After the LA identifier we use the codes D, H and IH to signify domiciliary, homes or inhouse (LA) provider. The first number indicates whether they are the first, second, etc; domiciliary provider or home interviewed in the LA. Other codes have been added to facilitate identification by the research team of the key characteristics of the provider, but readers may ignore them. In part V we provide a simplified coding structure for the case study providers and the correspondence between the two sets of codes is outlined in appendix table V.A1. Variable codes used in part IV are fully explained in the appendix to part IV. EWERC Part I. The study context 1 I. The Study Context I.1. The research framework The overall aim of the project is to contribute to the debate on how to recruit and retain a social care workforce for older adults to meet current and future needs. The specific focus is on care assistants and on care for older adults. Improvements in recruitment and retention are critical to enhancing the quality and the availability of care staff, an objective which has been a long standing policy concern (Cm 4683 1971, Cm 6233 1975). Its importance for policy has increased as a consequence of the policy emphasis on the provision of care for vulnerable older people both in their own homes and in care homes (Cm 849 1989). The research project also responds to an increasing policy focus on quality in domiciliary and residential care (Department of Health 2000), particularly as perceived by users and carers (Nocon and Qureshi 1996, Department of Health 2009), and on the regulation of these care sectors (Department of Health 2000, 2003a, 2003b). The focus of the research is on the recruitment and retention of care workers in the independent private and voluntary sectors. The shift from local authorities (LAs) to independent providers of care, particularly from 1993 onwards, has diminished our knowledge of the context for recruitment and retention due to the much larger variety of organisations providing care, the diversity of organisational approaches to HR policy and practice and the important new role of LA commissioning arrangements. The starting hypothesis for our project was that the recruitment and retention of the workforce would be influenced by the environment in which the providers operate – namely the policy and commissioning environment and the labour supply conditions – and by the policies and practices of the independent sector providers. Recruitment and retention is also influenced by the experiences and aspirations of the workforce and an additional emphasis in our research is to include employee experiences and voice in understanding the current context. The project design did not allow for extensive engagement with users‟ perceptions of care quality and the links between their perceptions and quality HR polices. However, as chapter two makes clear, we have aimed to include user perspectives in survey design and analysis wherever possible. Also, as the project was designed in 2004, the potential role of personalised budgets in shaping future patterns of recruitment and retention is only considered to a limited extent. However, recent policy favouring the development of individual budget arrangements (Department of Health 2008) makes it even more important to gather information on the problems of sustaining and developing a social care workforce in a context of potentially even more fragmented employment arrangements. EWERC Part I. The study context 2 Figure I.1 sets out the overall framework that we have used for understanding the influences on the recruitment and retention of the social care workforce. The figure depicts first of all the key external environmental factors (PoCLS) including: the Policy environment (central government and devolved government policy); Commissioning practices of local authorities, including inhouse arrangements and purchaser-provider relations; and Labour Supply factors, including local market conditions, changing gender relations and the structure of the care labour market. We have elaborated the central government policy agendas to include not only the direct relationships between central government and LAs in the form of budget setting and policies with respect to care arrangements but also government policy towards the NHS and personal budgets, thereby bringing the users directly into the picture. A second set of influences on recruitment and retention are depicted by the role of independent providers in shaping the conditions of work within the organisation (MaROT), including: Management of recruitment and retention, including the use of „high performance bundles‟ of HR practices, and mechanisms for employee voice; Reward policy, including pay rates, pay premiums and travel pay, and particularly in relation to part-time work and women returners; Organisation of work, including the nature of care work, the pace and timing of work, the skill content and scope for autonomy and discretion; and Training and development, including formal training provision and the effects of regulatory standards. The experiences and aspirations of the care workforce are influenced by the commissioning and provider policies in social care but also by the general labour market conditions and by their own experiences of both work and care, both inside and outside the labour market. The users are shown as having a potentially more active role in the future in both employing the workforce directly and by using brokers or independent sector domiciliary providers, with or without LA involvement to commission services. This figure provides the framework for this review of current literature and knowledge. We start in section I.2 with the external environment factors that impact on the recruitment and retention of social care staff including policy, commissioning and labour supply conditions (PoCLS). This section is informed by government policy documents and academic research literature but also by the results from a survey of all Local Authorities in England involved in commissioning social care (sample number 149, achieved sample of 90) conducted as the first stage of this project but reported separately by the PSSRU research team that had responsibility for this stage (Hughes et al. 2009). Section I.3 discusses the key organisational factors (MaROT) likely to impact on recruitment and retention with sections on the management of provider institutions and approaches to quality care standards, on resourcing and reward policies, and on the organisation of work and the approach to training and development. Section I.4 considers recruitment and retention from users‟ and employees‟ EWERC Part I. The study context 3 perspectives. Here we focus on what we know about user perspectives on care quality, namely what makes both a good care worker and a good care service. We then consider the literature on what makes a good and a bad job from an employee perspective, focusing particularly on the literature on care work and on low paid work. Drawing on this literature review, section I.5 identifies the key research questions for the project and the methods adopted to investigate these questions are outlined in sections I.6 to I.8. Figure I.1. Framework of influences on the recruitment and retention of care workers Policy environment Commissioning practices NHS INDEPENDENTSECTOR PROVIDERS Management,Rewards, Organisation of work, Training ) SOCIAL CARE WORKFORCE Personal budgets EWERC USERS/ QUALITY OF CARE Labour supply Personal and family experience Part I. The study context 4 I.2. The impact of external environmental factors on recruitment and retention Figure I.1 above identifies three key external influences (PoCLS) on the recruitment and retention of the social care workforce for older adults: the Policy environment, the Commissioning practices of local authorities and Labour Supply factors. We review each in turn in the following discussion. I.2.1. Policy environment The policy environment for social care for older adults is first of all informed by social needs. Three main factors are increasing the need for social care: the ageing population and increased life expectancy; the associated need to reduce costs of healthcare for older adults by speeding up hospital discharge; and the decline in availability of unpaid carers due to changes in women‟s roles and the trend towards single independent living for the elderly. This general policy environment which applies across the developed world means that social care is and will remain a critical area for welfare state policy. A fourth key policy issue is the increasing demands from users to have greater control over their care arrangements. This is leading to policies to make care more user-centred and for care commissioning to be assessed not only on cost but also on quality outcomes as perceived by users. While this policy context raises a very wide range of issues, including how care should be funded and the like, our prime concern is with those questions which impact upon the employment environment for the social care workforce. Of particular salience here are policies which have an impact upon who employs the social care workforce, under what conditions and for what types of work. Three main policy developments can be highlighted: the development of commissioning and contracting to the independent sector; the integration of health and social care and the current policy of devolving budgets to care users. Commissioning and contracting to the independent sector: government sets the policy environment The foundations for the current high levels of commissioning and contracting to the independent sector were laid by the 1989 White Paper, Caring for People, which required LAs to promote „the development of a flourishing independent sector alongside good quality public services‟. In 1993 the roles of purchaser/commissioner and providers were formally separated (Department of Health 1990) and the 1998 White Paper required LAs „to plan, commission, purchase and monitor an adequate supply of appropriate, cost effective and safe social care provision for those eligible for local authority support‟ (Cm 4169 1998: 111). Around the same time the Labour government decided to replace compulsory competitive tendering with Best Value (Cm 4014 1998). In doing so it also decreed that it had „no preconception about whether the public or the voluntary or private sector should be the EWERC Part I. The study context 5 preferred providers‟ (Cm 4169 1998: 119). Instead the mix of providers was to be determined by the outcome of Best Value commissioning and contracting. Local Authorities have also been under pressure to increase efficiency in their procurement policies as a consequence of the Gershon (2004) review of public sector efficiency. Further pressure for efficiency in procurement has come from a relatively tight budget settlement for social care, certainly in comparison to health. A recent report from the House of Commons Health Committee notes that overall gross expenditure on adult personal social services increased by 57.4% in real terms between 1997–98 and 2007–08 but spending on the NHS doubled in the same period (House of Commons 2010). Furthermore, central government grants to LAs only increased by 48% in real terms over the same time period. The impact of this environment on the commissioning and contracting practices of LAs is explored further in section I.2.2. Integrating health and social care Coordination and integration of health and social care services to older people became a major element of government policy after new Labour made a manifesto commitment in 1997 to bring down the so-called Berlin wall between health and social care. The range of initiatives since then to promote joint commissioning are outlined in box 1.1. These include the specification under Best Value that there should be an integrated review of health and social care. Nevertheless, it is still the case that in most LAs only a minority of social care services are jointly commissioned. According to this project‟s first stage survey conducted in 2007-8 (Hughes et al. 2009), 77% of LAs were engaged in some joint commissioning and 45% pooled some ring fenced monies but two thirds of LAs said that under 20% of services were jointly commissioned. A small minority of LAs undertake all their commissioning with the NHS (5%) and a similar share (7%) pool all their budgets for adult social care with the NHS. Although integration of health and social care is claimed to have positive benefits for reducing waste and promoting better quality services through joined up government, some research has questioned whether these benefits are automatic. The key concern is that the NHS tends to be the dominant partner and may use integration primarily to reduce pressures on the NHS by facilitating early discharge from hospital. This approach may not serve the interests of those older people who are not recent or prospective admissions to the health service (Glendinning et al. 2002, Lewis 2001). Too great a focus on early discharge may distract attention from the other long term cost reduction strategy - that of keeping more older people in their own homes and reducing admissions to residential homes of people able to live in their own homes or in extra care facilities (see Challis and Hughes (2002) for evidence of „too high‟ admission to residential homes). A further concern is whether re-ablement services will be primarily used to help people return to their own homes after hospital and not be used to help prevent admissions to homes where the person has not been a hospital admission (Glendinning et al. 2002). Moreover, research suggests that integration has so far been rather limited and that without more radical institutional changes such as the integration of the health and social care information systems significant benefits may not be realisable (Brown et al. 2003). Hudson (2002), however, found that even where cooperation across EWERC Part I. The study context 6 boundaries was limited it was yielding positive benefits in collaboration across traditional hierarchical and professional divides. Box 1.1. Initiatives to promote joint commissioning Pooled budgets: where health and social services put a proportion of their funds into a mutually accessible joint budget to enable more integrated care. Lead commissioning: where one authority transfers funds to the other who will then take responsibility for purchasing both health and social care. Integrated provision: where one organisation provides both health and social care. Introduction of practice based commissioning. Creation of Care Trusts: to commission and deliver primary and community health and social care for older people and other user groups. Duty of partnership: local health and social care planners to achieve both national standards and local milestones. Local Strategic Partnerships: councils to work with other local agencies to improve economic, social and environmental well being followed by the introduction of Local Area Agreements to facilitate the work of government, local authority and its partners by agreeing the design and delivery of outcome targets which reflect national and local priorities. The introduction of national service frameworks, in partnership with the NHS: to create a greater level of consistency and fairness in social care. Requirement for Primary Care Trusts and local authorities to produce a joint strategic needs assessment of the health and well being of its local community. Streamline budgets and planning cycles between Primary Care Trusts and local authorities, based on a shared, outcome-based performance framework. Sources: adapted from Hughes et al. (2009: box 1.4). Implementing personal budgets Currently LAs have main responsibility for commissioning social care services for older adults. However, since the 2005 Green Paper, Independence, Well Being and Choice, the government has committed to allow all users to have a personal budget to enable them to commission and organise their own care arrangements. This has coincided with a renewed commitment in the 2006 White Paper, Our Health, Our Care, Our Say (Cm 6737 2006), to increase the use of direct payments to users which started in 1997. These changes introduce considerable uncertainty into the system as they could in principle significantly reduce the role of LAs in managing the social care provision and the social care market. It is not only the likely extent of take-up of personal budgets that is unclear but also their impact on both LAs and current independent sector providers is unknown. The evaluation of pilot programmes for individual budgets did find that older adults were more likely to see the additional responsibilities that come with managing individual budgets as a burden (Glendinning et al. 2008a), suggesting a possible lower take-up than anticipated. These concerns may also suggest a continuing need for LA involvement in brokering services for individual budget holders. Other researchers have raised concerns over potential conflicts, for example between EWERC Part I. The study context 7 the choice policy agenda and the safeguarding of vulnerable adults (Manthorpe et al. 2008) and between choice and the organisation of services to reduce travel times by appointing only one provider to a particular area (Glendinning et al 2008b). The same research also indicates that the independent sector providers are concerned about a number of new risks, such as late or non payment for services and poaching of care staff by users, particularly if they pay higher wages. However, the risk that a user who was also the employer may only be able to offer short and uncertain employment may enable agencies to retain their staff. The independent sector providers also face a further uncertainly that although they need to develop a wider range of services to meet the more diverse priorities of individual budget holders, the new services would not be available to all users if only a minority take up the individual budget option. I.2.2. Commissioning and contracting practices of LAs The change in the primary LA role: from direct providers to commissioners Since the 1989 White Paper, Caring for People (Cm 849 1989), LAs have moved from being the primary providers of social care services to being enablers and commissioners of social care services. This change in role has been progressive but has accelerated at certain key periods. Furthermore the extent and pace of outsourcing has varied between LAs. Withdrawal from residential care came first in most cases. The first stage survey for this project reports that three fifths of LAs had moved the majority of their residential care into the independent sector before 2000, 17% having done so even before 1993 (Hughes et al. 2009). Figure I.2 displays the rapid expansion of private beds in England throughout the 1980s. Total provision plateaued and then declined from the early 1990s, while public sector residential care continued to fall. Figure I.3, also drawing on Knapp et al. (2001), shows that the overall drop in residential places was in part the result of a shift to domiciliary care LA withdrawal from domiciliary care came next. Only a quarter of LAs (26%) in this project‟s first stage survey (Hughes et al. 2009) reported they had moved the majority of their domiciliary care into the independent sector before 1999. But the pace of externalisation accelerated in the 2000s so that by 2004 three quarters (77%) of LAs used the independent sector for the majority of domiciliary care. By 2008 less than one in ten LAs (7%) had 60% or more of domiciliary care provided by inhouse staff. By comparison, close to one fifth of LAs (17%) still retained the majority of residential care inhouse. Overall then, with respect to both types of care services, the majority of LAs by 2008 had become primarily reliant on the independent sector for their social care provision for older adults. EWERC Part I. The study context 8 Figure I.2. Residential care places for elderly people in the public and private/voluntary sectors, England 1980-1998 Source Knapp et al. (2001: figure 3) Figure I.3. Residential and domiciliary care trends, England 1993-1997 Source Knapp et al. (2001: figure 4). EWERC Part I. The study context 9 To explore the impact of these developments we first consider what previous studies have revealed with respect to the role of LAs in developing the independent sector market through commissioning, contracting, monitoring, regulating and other forms of engagement and consultation. These activities in „developing the market‟ have to be understood in the general context of public sector procurement and public sector budgets. Thus the second topic we review is how the general budgeting and commissioning environment, characterised by Best Value principles, on the one hand, and the continuing and intensifying budget pressure, on the other, has influenced the development of commissioning and contracting for social care. Developing the market The making of the market for social care through commissioning, contracting and engagement involves a number of elements or stages. First, there is an evolving division of labour or specialisms between the remaining inhouse and externalised activities. This may be a dynamic relationship as priorities change. In some cases inhouse facilities may be at the forefront of new initiatives and innovation - for example, in extra care or re-ablement - but in other cases LAs may look to the independent sector for new ways of working and innovation. Drake and Davies (2006) in fact identify six different strategies used by LAs, including outsourcing most domiciliary care but providing specialist services inhouse (primarily reablement), providing the full range of services using both inhouse and external providers and using outsourcing only as means of topping up inhouse services.1 Evidence from the first stage survey suggests there is now a high level of specialisation in the inhouse departments. For intermediate care, more than four fifths of LAs use inhouse staff and less than two fifths use independent sector staff. In comparison, for community care nearly all LAs use independent sector staff and less than three fifths use inhouse staff. Mental health care was a more equally shared activity with nearly three fifths of LAs using inhouse staff and four fifths using independent sector staff. Given the increasing focus on re-ablement as the route to long-term policy goals such as reducing the share of older adults who are unable to stay in their own homes, the remaining LA inhouse departments are in an important strategic position to maintain and/or increase their importance within the older adults care services. Indeed Drake and Davies report LAs explaining their decision to keep these skills inhouse in order to retain core skills that are „mission critical‟ (2006: 185). Thus there could even be a reverse dynamic of increasing the role played by the inhouse departments. However, some LAs have already outsourced their re-ablement as well as their community care work. An important issue for research is the extent to which these different governance models promote or hinder the development of a re-ablement service. Drake and Davies (2006) demonstrate that while some LAs may have outsourced specialist care simply because they no longer have inhouse capacities, others exhibit a policy of outsourcing both high and 1 One LA in the Drake and Davies (2006) study that had used the top-up model reported problems that the independent providers were able to push up their prices when they knew the only reason for the outsourcing was the exhaustion of in house capacities. EWERC Part I. The study context 10 low skill activities to independent providers - as well as maintaining some inhouse - in order „to give independent providers the professional integrity to provide specialist services if they can.‟ (Drake and Davies 2006: 185). In some areas of care –for example smart housing and xtra care - there is clearly some reliance on partnerships with private or voluntary sector companies for developing new ways of delivering care. However, there appears to be no research on whether external providers have engaged in innovative activities related to the actual delivery of home care or residential services. As external providers are still infrequently engaged in the assessment and design of care packages (Hughes et al. 2009) it seems unlikely that they have played a major role in innovation in ways of delivering care or new ways of working. A second concern for LAs is to secure an adequate supply of providers; this follows the requirement in the 1989 Act to ensure a flourishing supply, but is of critical concern where LAs dominate the social care market, particularly that for domiciliary care but also for residential care in areas where most beds are funded by the LA. The supply of providers depends on a host of factors, including: the overall price or fee level; the security of work flows and/or fee income; the availability of information; undertakings that enable providers to plan their work loads and their staffing policies; and any hidden or additional costs that are not compensated for (that is the risk involved in contracting at a given price). LAs are also expected to take into account the need to foster local and diverse providers to meet the needs of specific groups and ensure effective choice. This fits with the national procurement strategy for LAs, which requires them to „confidently operate a mixed economy of service provision, with ready access to a diverse, competitive range of suppliers providing quality services, including small firms, social enterprises, minority businesses and voluntary and community sector groups‟ (ODPM/LGA, 2003 quoted in Hughes et al, 2009: Box 1.10). However, there may be conflicts between, on the one hand, the provision of security and planning and the requirement to promote small providers and diverse providers and, on the other, the requirement to use competition between suppliers to increase public services responsiveness and efficiency (Kirkpatrick 1999). Furthermore both the LAs and the Department of Health retain ultimate responsibility for the delivery of care to vulnerable adults and for ensuring its quality. Although to meet these responsibilities a regulatory regime external to both LAs and the independent providers has been set up, LAs still assume some responsibility for ensuring that aspects of the quality agenda can be delivered, ranging from ensuring continuity of care to ensuring that training is available to independent sector staff. With respect to securing an adequate supply of care homes, a number of studies in the 1990s and early 2000s investigated the reasons for home closures. Two studies attribute the closures to a combination of LAs paying low fees or not raising them in line with an increase in high dependency residents, coupled with the costs of complying with new national care standards (Darton et al. 2003, Netten et al. 2003). Most homes closing were small so that overheads EWERC Part I. The study context 11 were high relative to fees but the quality of care provided had been of a high standard. In a subsequent study, Netten et al (2005) report that fear of an undersupply of care beds, with implications for hospital discharges, led the government „to retreat on the standards and to increase funding to local authorities‟ (op.cit: 319). Andrews and Phillips (2000) argue the long-term outcome of the trend towards both higher dependency and lower residential care fees will be increasing concentration in the sector (that is, a smaller number of very large providers) contrary to the apparent policy goal of diversity and choice. With respect to contracting for residential care the Audit Commission (1997 quoted in Kendall 2001) recommended a greater use of longer term contracts to foster better working relations and information flows as well as assisting residential homes providers to engage in longer term planning. Research also emphasises the need for better information flows between LAs and independent care homes (Matosevic et al. 2007, 2008). Relatedly, Knapp et al. (2001) argue that, „Complaints are legion from independent providers about poor matching of users to services, poor signalling of purchasing intentions and priorities‟ (op.cit: 302). Filinson (1998) also found that most residential home providers did not participate in the planning of social care. Changes to contracting arrangements are not necessarily the answer: three quarters of LAs have some block contracting but the share of beds contracted was below 10% in nearly 50% of cases) (Hughes et al. 2009: table 3.39). However this block contracting to larger homes has been identified as a factor in the closure of smaller homes (Netten et al.2003). Moreover, Kendall‟s (2001) research casts doubt on the Audit Commission‟s view that providers of residential care would welcome more block contracting as residential home owners were concerned to maintain a balanced client base between LA contracted and private clients, thereby reducing LA control over their operation. Matosevic et al. (2008) also suggest that LAs tend to ascribe more purely financial motivations to care home providers than the care home providers themselves reveal in parallel questionnaires, suggesting a need for new practices that can develop trusting relations between providers and LAs. Very similar issues emerge in relation to developing the supply of domiciliary care providers, although this market has developed more recently; a survey of providers in 1999 found that two thirds (64%) had been established during or since 1993 (Ware et al. 2001). The same study also found that LAs were at different stages in the development of the market with some still seeking sufficient providers to cover the market while others had already developed a sufficient supply and were now in a position to start to work closely with „selected and proven providers‟(op.cit.: 340). The first stage survey for this project found a relatively high level of satisfaction among LAs with the number of potential providers; three in four LAs reported the number of responses to their tender was „about right‟ and only 17% and 7% stated the number was too few or too many, respectively. With respect to contracting for domiciliary care services, most published research points to the development of larger block contracts that tend to squeeze out the smaller providers (Ware et al. 2001, Drake and Davies 2006). In response, some LAs are reported as willing to pay higher fees to smaller local providers to ensure diversity of supply, despite potential ethical and legal problems of favouring local providers in procurement (Drake and Davies EWERC Part I. The study context 12 2006). Our first stage survey in fact suggests strong polarisation between LAs with two fifths (39%) recording no block contracts and a similar proportion (37%) using block contracts for three fifths or more of their total expenditure on domiciliary care with the independent sector. However, this division between LAs is likely to change. LAs appear to be moving towards an intermediate category of preferred providers, in part in response to the personal care agenda (see section II.2 below). In addition to securing a reliable supply of providers, LAs have a responsibility to promote competition between providers. Several studies test the assumption that greater competition encourages improved responsiveness to user needs. For example, Lewis et al. (1996) find that care services had become more responsive (measured by the likelihood of a user being put to bed at a time they prefer) in several LAs following the purchaser/provider split but that it was too simplistic to attribute this simply to competition. In some LAs it was in fact inhouse provision that had become more responsive, and in at least one case this resulted from devolution of budgets to care managers rather than competition per se (op. cit.). Drake and Davies (2006) comment that block contracting involves fierce competition only at the point of the contract award, whereas spot contracting encourages continuous competition. They also point to the danger that large contracts may lead to concentration and a shift of power back from consumers to independent providers. Nevertheless when LAs seek a step increase in outsourced provision they often resort to block contracting with large providers to achieve cost reductions. Another incentive to contract with a small number of suppliers is to reduce transaction costs (that is, the costs and time of designing and negotiating contracts) particularly if LAs do not fix a standard price for services (op. cit.). Effective competition as described in an economics textbook should involve multiple providers and multiple purchasers. But on the purchasing side, LAs are in fact dominant clients and may fix prices which providers have to accept or else risk losing the majority of their business in the locality (Knapp et al. 2001). Fixed prices may also mean that care services requiring different levels of skill are priced at the same level. Drake and Davies (2006) report that some providers find it fair to have a fixed price but others argue the price should reflect differences in costs such as training costs. Another issue is whether there is only one or more providers for a geographical locality. Drake and Davies (2006) report at least one LA making a decision to select more than one provider per area to prevent the formation of monopolies. Although the issue of quality standards has in part been taken over by national regulatory standards and inspections provided by the Care Quality Commission, LAs still play a role in monitoring and regulating standards in their independent providers and have scope to require particular approaches to both quality of care and to the approach taken to the management of staff in their tenders, contracts and monitoring procedures. The first stage survey found that almost all LAs included some HR requirements in their tenders and contracts for both homes and independent domiciliary providers – particularly related to induction training and training achievements against national standards. Also, all LAs monitored domiciliary providers throughout the contract period, with over four fifths monitoring staff development and training and recruitment practices (Hughes et al. 2009: figure 3.14, tables 3.32-34 and 3.41). EWERC Part I. The study context 13 LAs are also involved in providing support to providers although research suggests there are problems in information sharing (Wistow and Hardy 1999) and in developing long-term trusting relations (Curtice and Fraser 2000, Ware et al. 2001), except with voluntary providers in some areas. Provider forums have become more common (Ware et al. 2001) and although on balance have been welcomed by providers they are also found to be highly controlled with clear limits set to the flow of information. LAs also provide support for training the independent sector workforce, even extending to some higher level skills such as re-ablement when they have outsourced all their own provisions (Drake and Davies 2006). However, there is also evidence that LA provision of training is strongly linked to availability of funds to provide the training (Rainbird et al. 2009). Thus once the ringfenced monies for training ended in 2004 there was a move to mobilise more general funds such as „Train for Gain‟ and European Social Fund related monies. But once these alternative funds became scarce problems of training provision have arisen (Rainbird et al. 2009, Rubery and Urwin 2010). Not all problems of training are attributable to lack of availability of courses or funding for the training. There is evidence of reluctance on the part of independent providers to train their staff (Balloch et al. 2004, Fleming and Taylor 2006), caused by both pressures of workloads and costs. These reasons are in part also the result of the conditions under which providers are contracted by LAs. Price versus quality: an issue of budgets? The increasing budget constraint faced by LAs in relation to social care is illustrated by the growing gap between expenditures and central government funding. During the ten years from 1997-98 and 2007-08, real expenditures on social care increased by 57% and central government funding rose by just 48% (House of Commons 2010). Given the strong pressures on demand for services, the tendency for commissioning strategies to increasingly rely on the independent care sector is underpinned by the strong cost differences between inhouse and external provision. Data from the NHS Information Centre for Health and Social Care show that the average hourly cost of home care services in 2008 was £23.40 when provided inhouse by LAs and only £13.00 when provided by other organisations. 2 Part of the cost differential is accounted for by the more specialised services provided by inhouse LA care workers but this is unlikely to account for the majority of the large cost difference. In fact the cost difference reflects to a large extent the collectively negotiated terms and conditions of employment for LA staff that deliver relatively high basic pay levels (Eborall and Griffiths 2008), as well as more generous benefits and provisions for travel time and unsocial hours payments. Pay and conditions in the private and voluntary sectors tend to be determined unilaterally by management and are characterised by lower basic pay and non-pay benefits typically set at the legal minima. One of the key questions for this research project is to investigate the degree to which these conditions are the outcome of both LA 2 The average hourly cost was £15.20, indicating the dominance of the private sector in delivery. All data accessed from the website http://www.ic.nhs.uk/statistics-and-data-collections/social-care/older-people. EWERC Part I. The study context 14 commissioning policies and the HR policies of provider organisations. We know that many LAs fix the price for the service at tender. Figures vary, including an estimate of around two thirds of LAs in the study by Forder et al. (2004), just over one third (36%) in our first stage survey and around one third (32%) in a UKHCA survey (Mathew 2004: table 10). A fixed price does not necessarily mean a low price; the UKHCA survey idenitifed one LA that moved from variable to fixed prices and this led to considerable increases for providers that had entered the market with low tender prices. Research suggests that LAs also operate with a fixed price system for residential care, although there may be lower prices for block than spot contracts (Forder and Netten 2000). Research suggests that LA fees for both domiciliary and residential care have not always risen in line with costs that providers are unable to avoid. These include: statutory improvements to employment conditions – the National Minimum Wage and the working time directive, including the recent extension of guaranteed holiday entitlements (Andrews and Phillips 2002, Clarkson et al. 2005, Knapp et al. 2001, Netten et al. 2003, Angel 2007); and implementation of the National Minimum Care Standards - especially the additional training costs to meet the 50% NVQ level 2 target and providing higher staffing ratios in response to higher levels of dependency at the same price (Andrews and Phillips 2000, Darton et al. 2003, Forder and Netten 2000, Netten et al. 2005, Ware et al. 2001). This accumulating evidence suggests LAs are requiring providers to do more for the same or even lower prices. The likely outcome is reductions in quality of service or closure of suppliers. Indeed, Netten et al. (2003) report that three quarters of homes that had closed claimed LA fees were insufficient to cover their costs following the introduction of higher care standards. This has particularly affected small homes and small domiciliary care providers – a further factor promoting concentration in the sector. Not all problems relate to basic fee levels. Many of the difficulties in covering costs are associated with the absence of specific fees to cover travel costs or to provide sufficient time for care delivery. In their study of users‟ perceptions of care services, Francis and Netten (2004) point to the practice of not paying for travel between appointments and allowing insufficient time for quality visits as a major perceived barrier to quality of care. Ware et al. (2003) also comment that the increasing emphasis of LAs on procedure-based care management subordinates personal relationships between care worker and user to short-term task delivery, which, in their words, „may threaten patterns of trust and accountability‟ (op. cit.: 411). A UKHCA survey (Mathew 2004: 37) found that while higher paying LAs were the least likely to make any adjustment to their hourly fee to compensate for short visits (thereby providing for more travel time payment), there were also examples of low paying LAs that also failed to provide any enhanced fee for short visits. The Best Value framework for commissioning services, along with the national minimum care standards, are expected to establish a dual focus on quality and price. Drake and Davies (2006) found some authorities that admitted to having been willing to use low quality EWERC Part I. The study context 15 services to meet excess demand before the passage of the Care Standards Act and the Best Value regime. However, research also suggests that the Best Value regime has had less impact on reducing cost pressures on commissioning practices than might be expected, in part because of requirements for continuous improvements in public service efficiency of 2% per annum (Cunningham 2008: 382). Cunningham‟s detailed study of the conditions facing voluntary sector providers of social care suggests Best Value placed additional pressures on providers to meet both higher quality employment standards and higher care standards without any relief in cost pressures. Also, LA commissioning focused on improving quality of care rather than quality of HR practices, with the main HR focus on compliance with statutory regulations (including CRB checks and equal opportunities and disciplinary and grievance practices) rather than developing high performance working (op. cit.). Aside from LA commissioning, other important influences on HR practices in providers derive from the Care Commission and its focus on training standards. There is also no evidence that the Best Value regime has fostered long-term relationships between LAs and independent providers, or contributed to greater stability in employment relationships in the independent sector (Cunningham and James 2009). Kirkpatrick (1999) has indeed questioned the feasibility of partnership arrangements between LAs and independent providers, not only because of the low levels of trust within the sector and the difficult of building trust but also because of the disconnect between a partnership agenda and the requirement to „shop around‟ to achieve best value and continuous performance improvements, and because of the need for probity in the management of public monies, with strong trusting relationships leading to a risk, in the extreme case, of corruption. Overall, the research suggests that Best Value may be seen as an additional requirement for independent providers to meet at the same price. Instead of a move towards a quality approach through partnership, quality has become a requirement of the competitive tendering regime in social care. Furthermore where the quality standards are based primarily on care standards, these may create some problems for HR standards, including the promotion of employee-oriented flexible working. I.2.3. Labour market conditions The adult social care sector now employs around one million workers (Moriaty et al. 2008) with 900,000 located in the private and voluntary sector. According to the Low Pay Commission (2008) it is the third largest low-paying sector in the UK economy, with around one million jobs being paid at or around the level of the minimum wage. Although local labour market conditions vary across the country 2010 data from the National Minimum Data Set (NMDS) for Social Care (see www.nmds-sc-online.org.uk/) show a remarkably narrow range of variation in rates for care workers. EWERC Part I. The study context 16 For example, across the nine English regions, the wage at the 20th percentile3 only varies from £5.73 in the North East (equal to the national minimum wage from October 2008September 2009) to £6.10 in the South East. If London, the South East and the South West the three highest paying regions - are excluded, then the range of variation is only 17p. Likewise the range of median hourly pay rates varies by just 67p from the lowest in the North East at £5.95 to the highest in the South East at £6.25; again, excluding the three highest paying regions leads to a variation of just 50p (see table I.1). Table I.1 Hourly pay for care workers by English region: 20th percentile and median rates. North East North West Yorkshire and Humberside West Midlands East Midlands Eastern South West London South East 20th Percentile £5.73 £5.80 £5.80 £5.80 £5.80 £5.90 £6.00 £6.00 £6.10 Median £5.95 £6.10 £6.15 £6.25 £6.30 £6.45 £6.55 £6.58 £6.62 Source NMDS online data (June 2010). This range of pay rates does not reflect the range of variations in labour demand, as is indicated for example by the strong regional differences in use of migrant workers. A study by Experìan (2007) for Skills for Care found that over two thirds of care staff in London were migrants (defined as „born abroad‟) compared to less than a fifth in seven out of nine regions (figure I.4). Also, the low level of pay has not established a neat equilibrium of supply and demand. For example, turnover rates are very high for care workers, running at around 22% (NMDS 2010). Also, vacancy rates were estimated at over 3% in social care compared to 1.4% for all sectors, with 25% of care providers reporting vacancies compared to 12% for all sectors (2009 National Employer Skills Survey data, cited in Eborall et al. 2010). Although the level of vacancies has declined with the recession the impact on turnover has been less, and the differentially higher rates of vacancies compared to the average position has been maintained. However, high vacancy rates are not attributed so much to actual skills shortages as to high turnover compared to other sectors with high vacancy rates. The evidence therefore suggests that the social care market has tended to adjust to shortage not through pay rates but by use of migrant workers to fill employment gaps in those areas with greatest recruitment problems. Labour shortage is also acute for senior care workers; JobCentre Plus data show that the vacancy-to-unemployment ratio for the period February 3 This is the wage level at which 20% of the category of workers earn less. EWERC Part I. The study context 17 2008 to January 2009 is much higher for this group than the ratio for all occupations (1.88 compared with 0.38) (House of Commons 2009). Figure I.4. Percentage of social workers and care workers born abroad, by region Source : Experìan (2007) for Skills for Care. Although turnover is clearly high, there is as yet no conclusive evidence that social care workers are subject to labour market churning between sectors rather than between different social care providers. The NMDS finds 13% of care workers leaving for other care sectors and only 2%, for example, to the retail sector. However, more than half (55%) of worker departures do not have a recorded destination so these data are not yet reliable. Social care work is still largely women‟s work and women still account for over 85% of care assistants and home carers (Skills for Care 2010). Macro level evidence on women‟s changing employment pattern may therefore provide more solid indicators of future problems for social care. Research suggests that the tendency for women to stay in employment with the same employer over the period of childbirth, now supported by the right to request flexible working, is likely to reduce the number of women trading down the occupation and pay hierarchy in order to find part-time work (Neuburger et al. 2010). This greater continuity of employment should in principle allow women to pursue more upwardly mobile careers which may reduce the labour supply for job sectors with limited opportunities for pay or career advancement. However, the evidence cited here relates to the period before the 2008-9 recession. Increased unemployment and the overall shortage of jobs may lead to a postponement of the upgrading of social care jobs which is indicated as necessary by the employment gaps and the compression of wages at or near to the national minimum wage. EWERC Part I. The study context 18 Beyond these regional and cyclical labour market influences, the locality is likely to have significance for the recruitment and retention of the social care workforce due to both the nature of social care work - particularly domiciliary care - and the primary source of labour supply, mainly mature women. The locality takes on importance because of the delivery of care work in the users‟ own homes and the need for repeated and short visits to these locations and for visits to multiple locations. These characteristics are likely to lead to a labour force drawn primarily from the immediate locality to reduce the costs of travel between home and workplaces, particularly where work is organised on a split shift basis or where the hours of work are variable and may involve short shifts. This pattern of work organisation is likely to reinforce the reliance on female labour, as there is strong evidence that women in all types of jobs (due to both care responsibilities and less access to private transport), as well as part-time workers of both sexes, commute a shorter distance to work and are therefore likely to be attracted by jobs in the immediate locality (Green and Owen 2006, Houston 2005, Yeandle et al. 2006). However, this apparent matching of demand and supply side preferences is both positive and negative for the recruitment and retention of a social care workforce. It is positive in that it may help organisations to recruit workers and also ensure retention, even when wages may be low relative to the nature of the job and to alternative job opportunities involving longer commutes. This could be regarded as also opening up an opportunity for providers to exercise monopsony4 power over the workforce - that is, to rely on their staff‟s commitment to the job due to its convenience with respect to place and time, even when wages and conditions fall below relevant rates (Barth and Dale-Olsen 2009, Hirsch 2010, Manning 2003). However, these work characteristics are also negative for recruiting and retaining a social care workforce if there is a desire or a need to expand the size of the workforce once the supply of those for whom the work is convenient is exhausted. It may be difficult to attract similar workers located in different neighbouring localities as they may also prefer to work in their own locality and to minimise commuting time. Indeed economic theory would suggest that monopsonists would tend to keep employment down to maintain low wages even if some vacancies remain unfilled (Manning 2003). In the UK social care sector, employers do not have a free choice to raise the wages to solve these supply constraints since to a large extent the wage levels are shaped by LA fee levels rather than by their internal HR policies. 4 A monopsony employer is one that controls the market for hiring a particular type of worker, defined by skill, expertise or occupation, for example. EWERC Part I. The study context 19 I.3. Management and organisational factors in the recruitment and retention of a social care workforce In this section we discuss the key organisational factors (MaROT), as described in figure I.1 above, which are likely to shape the recruitment and retention of a social care workforce. These include: first, the formal and informal Management of recruitment and retention, including consideration of so-called „high performance bundles‟ of HR practices and provisions for individual and collective employee voice; second, the Reward practices, particularly in relation to part-time work and women returners; third, the Organisation of care work, including discussion of the nature of care work, scope for worker autonomy and skill content; and fourth, evidence of Training and development practices as a factor in shaping recruitment and retention. I.3.1. Management and human resource practices The management of human resources varies by character of organisation, particularly by size and by ownership. The social care sector is characterised by large numbers of small establishments with over 40,000 local units employing care staff engaged with adult social care belonging to over 17,000 organisations (Eborall et al. 2010). There are now 5,319 domiciliary care providers – an increase of over a quarter between March 2006 and August 2009. In contrast the number of care-only homes has declined by 9% over the same period (although the number of beds increased) and now stands at 14,138 while the number of care homes providing nursing increased by 4% to 4,303. Overall there is a very high share of small establishments with three quarters of the 40,000 total employing fewer than 20 employees. Although the sector is still highly fragmented there is a general trend towards more concentration of ownership. Published data are only available for the care home sector (Eborall et al. 2010). Here the concentration is particularly notable among care homes offering nursing where according to Laing and Buisson‟s definition of a major provider - any company listed on the London Stock Exchange - the major providers‟ share of private sector homes increased from 36% in 2000 to 58% in 2009. For care-only homes the increase was almost as striking but from a lower level – from 8% to 28% over the same period -, while the share of major providers in the voluntary sector (accounting for around 17% of all homes5) is even higher, rising from 64% to 73% over the same period. Overall, despite the trend towards more concentration, the sector is still dominated by small establishments and the practices of the major providers may still be to treat human resource policies as largely a local issue, delegated to local management. There is an extensive literature on differences between large and small firms in recruitment methods, human resource policies and employee voice 5 The 17% figure refers to all care homes while the Laing and Buisson data only refer to homes for the elderly and physically disabled. EWERC Part I. The study context 20 mechanisms. These characteristics of the employers within the social care sector are thus likely to be shaping the recruitment and development of the workforce. Recruitment practices Larger firms are known to make more extensive use of formal recruitment methods than small firms where recruitment is often by word of mouth or informal channels. A range of explanations have been offered for this tendency towards informality. First, there is the obvious incentive to avoid the costs of advertising and formal procedures (Ram et al. 2004), particularly if recruiting in this way may reduce turnover further reducing hiring costs (Carroll et al. 1999). Secondly, small firms and establishments may be more concerned with ensuring a good fit between the new employee and the established team due to the close working environment for all employees (Holliday 1995). However, such considerations may apply less to domiciliary care than to care homes due to the work being undertaken in users‟ homes with staff often working alone. A third explanation is that the use of a network may be a means of hiring staff with already developed tacit understandings and tacit skills related to the area of work. The network through which hiring takes place can thus be considered to be an extended internal labour market (Manwaring 1984). The idea is that employees with the required skill and experience may be found both inside and outside the organisation, where employees outside are connected through informal channels and social and family relations to those inside. Such an approach may suit management‟s need to control the workforce; the informal channels and social networks can diffuse certain attitudes towards work, such as compliance with organisational practices, thereby reducing the need for direct management intervention (Collinson et al. 1990). In many areas of social care, managers are not in a position to directly supervise the work and therefore may be reliant on social networks to spread norms and attitudes towards work discipline among potential future recruits. A key issue is how and when organisations change from informal to formal recruitment methods. Change may occur because the organisation faces rapid expansion, or reaches a critical size beyond which the owner or head manager is unable to devote time to informal methods (Carroll et al. 1999). In social care, there are particular regulatory pressures that promote greater formalisation. These include the monitoring of minimum care standards and the inspection processes of both the CQC and the commissioning LA, as well as the requirement that all social care providers check the references of job applicants and apply for CRB checks. Research suggests there are mixed attitudes towards the effect of regulations on recruitment processes in social care: some employers welcome it as a catalyst to a professionalization process, which should improve the status of care work and, in turn, ease recruitment in the long term, while others see it as adding to bureaucracy and delays (especially the wait for CRB checks) thereby inhibiting recruitment (Edwards et al. 2003). EWERC Part I. The study context 21 Human resource practices Perhaps the most dominant research theme in human resource management over recent years has been the investigation of bundles of HR practices that might be associated with high performance or high commitment work systems, whether measured by productivity, profitability or staff turnover (Appelbaum et al. 2000, Huselid 1995). High performance bundles of HR practices are expected to provide benefits that outweigh the costs of their introduction and maintenance by creating the kind of work culture in which workers are likely to feel both more satisfied and more motivated and committed. Most research applies to large organisations and there is evidence that small organisations are less likely to adopt high performance HR practices (Bryson et al. 2007). Nevertheless, to the extent that small organisations do adopt these practices, there is some evidence that they may be associated with some performance benefits. One UK study shows that the adoption of nine specific HR practices – namely, careful selection, formal performance appraisal, performance related pay, group incentives, multi-skilling, job rotation, quality circles, team working and disclosure of information - is associated with higher profitability, although no impact was found on productivity or staff turnover (Stirpe et al. 2009). Importantly, the simple formula that predicts a positive relationship between a given set of HR practices and organisational performance is contingent upon (and complicated by) the sector. Within social care, there are first of all multiple obstacles to the adoption of certain HR practices. Managers may be unfamiliar with particular HR practices, or sceptical of their assumed benefits, especially where they involve considerable upfront costs. Other HR practices may be difficult to implement within a social care environment. For example, the practice of performance-related pay would raise ethical issues, not to mention the concrete problem of how to assess and measure performance. A fundamental problem with the HR bundles approach is its presumption that organisations already apply certain basic HR practices and provide stability of income and employment. But in the UK social care sector, such basic stability and protection of pay and employment is often lacking (Rubery and Urwin 2011). We may therefore need to consider an alternative bundle of HR practices that differentiates organisational performance in terms of whether employers provide basic employment conditions such as guaranteed working hours, stable weekly income, payment for all time spent at work (including, for example, travel time and training time), a decent level of pay and pay progression in recognition of skill and experience. Employee voice The opportunity for employees to exercise „voice‟ in an organisation rather than „exit‟ is an important factor in improving rates of staff retention. The outsourcing of social care to the independent sector means that the majority of care workers no longer enjoy the opportunity for collective voice through trade union representation and collective bargaining. This is both a result of a shift from the public sector, where collective bargaining is strong, to the independent sector where it is weak, and a shift from large to small organisations, since EWERC Part I. The study context 22 presence of all types of voice mechanisms and communication channels is positively related to firm size. Non union forms of employee voice offer a potential alternative but the evidence suggests that in the absence of strong formal voice mechanisms alternative communication mechanisms tend to be ineffective (Willman et al. 2006). All of this does not augur well for voice and communication systems in social care. In addition the highly fragmented work processes in domiciliary care makes mobilisation and organisation of collective voice especially difficult. Nevertheless, while the circumstances of the sector may present obstacles to the formation of strong collective voice, there are good reasons why social care workers may require a minimum set of standards that ensure individual voice. Marsden (2007) argues that opportunities for informal, one-to-one renegotiation of tasks between employee and employer (or manager) ought to be considered and promoted as a form of employee voice. He makes this argument in relation to work which may change only periodically; in social care, particularly domiciliary work, there are changes on an almost daily basis associated with changing users and user needs, as well as the timing of work, such that there is a need for individual care workers to negotiate with their manager about whether such changes are acceptable. Much depends on how the boundaries of acceptability are defined and whether or not these are mutually accepted be employee and manager - as we learn from the many studies of the employment relationship and the „psychological contract‟ between employer and employee. Some research does suggest that it is individual relationships with managers that matter most and make people feel involved and listened to. McClimont and Grove‟s (2004) survey of the causes of high employee motivation at work identified good managers and access to them as very important. Also, in Eaton‟s (2000) discussion of low quality care jobs some of the most important characteristics of such jobs were a lack of feedback on effects of their work, little or no supervision and, no information about the condition of patients. How managers manage the work allocation among staff and how far they are able to match employees‟ expectations and preferences with respect to the mix of users and tasks, as well as the available working time, is likely to be a very important factor in improving rates of retention of the care workforce I.3.2. Reward practices We turn now to consideration of how reward practices shape the extent to which care organisations enjoy a positive experience in their recruitment and retention of workers in the UK context. We know from general research on pay practices, as well as specific studies of the social care sector in the UK, that pay practices have a significant impact on the ability of organisations to recruit and retain staff. Our discussion distinguishes three issues: the relative level of pay in the social care sector, the influence of upratings in the National Minimum Wage and use of pay enhancements. EWERC Part I. The study context 23 Relative level of pay Higher pay places employers in a stronger position relative to competitors and increases their attractiveness both to prospective employees who are more likely to apply for a job and current employees who are less likely to depart. Such an assertion is confirmed by wellknown economics models – „efficiency-wage‟ models - which argue it may be rational for some employers to pay a wage above that offered by competitor organisations since higher pay can reduce staff turnover and attract a better pool of job applicants (Akerlof and Yellen 1986). Several studies provide an empirical test. Levine‟s (1993) study of a US manufacturing firm, for example, showed that a higher relative wage improved workers‟ job satisfaction, their intentions to stay with the company and their willingness to work harder. Also, Barber and Bretz (2000) demonstrate that higher pay is an effective tool to attract larger pools of interested job applicants (cited in Guthrie 2007). But to what extent is such a strategy applicable in the UK social care sector? Compared to other labour market competitors there is limited evidence of use of higher pay in the social care sector. Table I.2 presents pay data for the residential elderly care sector6 and the retail sector, the sector consistently cited as a key labour market competitor (eg. Yeandle et al. 2006: 24). Pay data are provided for the two dominant groups of care workers, female part-timers and female full-timers, at different points of the pay distribution, along with the pay differential between sectors. Table I.2. Women’s pay in the residential care sector and the retail sector compared, 2009 All sectors D10 All male and female employees 6.19 D20 Residential care for the elderly (SIC 873) Part-time Full-time Retail trade (SIC 47) Part-time Full-time Pay differential between sectors Part-time Full-time 5.73 6.03 5.73 6.00 0.0% 0.5% 7.15 6.00 6.48 5.76 6.32 4.2% 2.5% Median 10.99 6.81 7.96 6.25 7.80 9.0% 2.1% Mean 14.43 7.88 9.32 7.02 9.74 12.3% -4.3% Note: Gross hourly earnings, overtime excluded. Source: Annual Survey of Hours and Earnings, own compilation. The earnings data in table I.2 show that average hourly pay at the bottom decile of the pay distribution7 is similar in the social care sector and the retail sector – equivalent to, or a little above, the national minimum wage of £5.73 that applied in April 2009, the time of data collection. Further up the pay distribution there is some evidence of higher rates paid to 6 Using the industry classification this category gives the most precise estimate of earnings for workers in the sector. No separate industry category exists for the domiciliary care sector. 7 That is, the level at which 10% of the workforce earn less. EWERC Part I. The study context 24 women in part-time jobs, up to a premium of 12% at the average point, but the pattern is reversed among women in full-time jobs where pay is actually 4% lower than the average hourly wage in the retail sector. Overall, the inter-sectoral comparison suggests employers in the care sector are not using pay to address recruitment and retention issues, despite the evident need. Prior to the recession, the low level of pay in the sector was a major reason explaining difficulties in recruitment and retention. Surveys of employees in the care sector suggest that the level of pay falls below expectations, given the required responsibilities, skill and emotional demands of care work. A Unison survey in 2002 reported more than four fifths (82%) of domiciliary workers disagreed with the claim that their pay was fair, a higher proportion than other groups surveyed such as social workers and housing workers (Unison 2003). The detailed study completed by Yeandle and colleagues identifies low pay and the attractiveness of less demanding jobs in other sectors offering similar pay. The following quote from the one of the independent domiciliary providers in their study is illustrative: At the end of the day, [care workers] are going to look at what the salary is, and then they are going to look at Tescos where they can make a hell of a lot of money without the responsibility, without being out in the community themselves, in charge, and having to be the first person in an emergency. It‟s an awful lot of responsibility (Newcastle provider, cited in Yeandle et al. 2006: 25). The issue of low pay and problems of comparability with other sectors such as retail is especially pronounced in the private sector, where pay is lower on average than in the local authority and voluntary sectors. Estimates from the National Minimum Dataset for Social Care (NMDS-SC) suggest median pay for care workers in the private sector in 2009 was just £6.00, compared to £7.03 in the voluntary sector and £7.73 in the LA sector. For senior care workers the differences are even larger – median rates of £6.70, £8.08 and £10.69, respectively (Eborall et al. 2010: 111). If we compare pay data from the different sectors of care work with pay for retail assistants, we see a strikingly divergent pattern of pay premiums and pay penalties for social care work (figure I.5). At the median pay level, care workers in the LA sector earn over 20% more than retail sales assistants, those in the voluntary sector around 10% more but care workers in the private sector 5% less. At the average level of pay, the penalty in the private sector is even higher at 15%, compared to a premium of 13% among LA care workers. Overall, therefore, the evidence on levels of pay suggests the majority of employers are not using pay-setting as a strategy to enlarge the pool of job applicants or to improve staff retention among existing employees. EWERC Part I. The study context 25 Figure I.5. Pay difference with retail sales assistants among care workers in the private, voluntary and LA sectors, 2009 25% 20% 15% 10% 5% 0% median -5% average -10% -15% private voluntary LA -20% Source: Eborall et al. (2010: 111) for care worker earnings data and Annual Survey of Hours and Earnings for retail sales assistants data (SOC code 7111). All earnings data are for all adult employees, gross hourly pay excluding overtime. Regarding oppotunities for pay progression in the sector, the very small differential between pay at the bottom decile for care workers and the median pay suggests limited chance for pay advancement. The median pay for female part-time workers in the residential care sector is only £1 or so above the bottom decile pay (table I.2 above). This might be expected if care workers stay for very short periods in the job, and fail to accumulate the stock of experience and skill that can lead to higher pay. However, estimates from the national minimum dataset for social care (NMDS-SC) suggest two thirds of workers (64%) have more than five years experience in social care, and more than a third (36%) register experience of at least 11 years (Eborall et al. 2010: 93). The influence of the National Minimum Wage In low-paying sectors such as social care a statutory minimum wage can play an important role in shaping pay practices, which in turn influences recruitment and retention. On the one hand, steady uprating of the statutory minimum wage can provide a valuable benchmark for employers (by providing a coordinated wage floor to labour market competition) and employees (by protecting against exploitative wage levels). However, a minimum wage also presents serious challenges to organisations that operate in product markets where there are obstacles to increasing revenue, typically achieved by passing on higher labour costs to clients in the form of higher prices. Grimshaw and Carroll (2006) identify three types of obstacle associated with particular product markets: first, in international markets prices are set through international not domestic competition and are therefore not responsive to trends in national minimum wages; EWERC Part I. The study context 26 second, a product market dominated by one or two client organisations can make negotiation of price rises difficult; and third, where a product market includes firms operating in the informal economy there is a risk that unscrupulous employers undercut organisations that raise prices in line with the minimum wage (op. cit.). The second type of product market constraint prevails in the social care sector. Care providers are strongly reliant on LA fees as a source of revenue. The longstanding disconnect between annual raises in LA fees (adjusted in line with inflation and average earnings growth) and the national minimum wage (which was purposefully adjusted above average earnings growth during 2003-2006) generates a major squeeze on providers‟ income. This, at a time of new regulations to introduce national minimum care standards, has presented care providers with a major challenge. The Low Pay Commission (LPC) has repeatedly recommended that government address this issue (eg. LPC 2009: 73). Also, in light of the third constraint listed above concerning informal activities, the LPC has also raised a new concern that personal payment plans risk problems of non-compliance with minimum wage legislation: In circumstances of individuals purchasing their own care, both the service user and those performing the personal assistant role may not be fully aware of their rights and responsibilities in respect of their employment relationship, including payment of at least the national minimum wage (LPC 2009: 73). Because low-paying sectors in the UK have a high proportion of jobs paid at the adult minimum wage, trends in the minimum wage have a major influence on the setting of pay. According to the Low Pay Commission (LPC 2009), the cleaning sector has the highest incidence of workers paid at the minimum wage (22% in 2008, up from 19% in 2007). In social care, there is a public-private divide; in 2008 nearly one in ten workers (7.8%) were paid a minimum wage in the private sector, compared to around one in a hundred (1.3%) in the public or voluntary sectors (LPC 2009: 71). The difference reflects the influence of collective bargaining and joint agreements for LA employed care workers and their general absence in the private sector. National earnings data for the occupational group of care assistants and home carers demonstrate a very close relationship between nominal pay trends and changes in the minimum wage. For female part-time care workers, figure I.6 shows that the differential in pay at three different points of the pay distribution (the bottom decile, lower quintile and median) has remained very stable since 2005 suggesting a very strong influence of minimum wage rises on pay-setting.8 The influence is most striking at the bottom pay position (D10) where care workers‟ pay has fluctuated around 5% higher than the adult minimum wage. The rising differential from 2002 to 2003 occurred at a time when the minimum wage rise was very low (10p, from £4.10 to £4.20), and preceded a decision by the LPC to increase the minimum wage at a pace above average earnings growth. 8 Earnings data for female full-timers reveal a very similar trend as the one shown in figure I.6 EWERC Part I. The study context 27 Figure I.6. Pay trends of female part-time care workers relative to the national minimum wage, 2002-2009 45% 40% % differential with NMW 35% 30% D10 D20 25% Median 20% 15% 10% 5% 0% 2002 2003 2004 2005 2006 2007 2008 2009 Source: Annual Survey of Hours and Earnings, gross hourly pay excluding overtime, SOC 6115 „Care assistants and home carers‟, own compilation. Pay enhancements Pay enhancements offer an additional tool to address recruitment and retention issues. Theories of compensating differentials maintain that pay supplements for night work or weekend work, for example, are explained by the need for employers to compensate the disutility experienced by employees working during unsocial hours. However, in many 24-7 areas of the UK economy, pay supplements for unsocial hours working have been eliminated or reduced, alongside the decline in trade union influence on wage-setting. The trend appears to have been led by the retail sector. Tesco, for example, abolished a customary 50% pay premium for overtime work, reduced a percentage premium for night work to a fixed sum payment, and reduced the premium for Sunday and public holiday working from 100% to 50%. The representative survey of 502 care workers undertaken by the market research firm, TNS, provides evidence of the use of pay premiums for overtime and unsocial hours working in the social care sector. Regarding overtime, 34% of jobs involved paid overtime compared to 25% with unpaid overtime (TNS 2007: 30). It is notable that those workers with longest experience in care work are most likely to undertake unpaid overtime, suggesting that longserving workers are either more likely to volunteer to cover for absent colleagues without pay, or more likely to be pressured to take on extra work by managers with the knowledge their alternative job opportunities are limited, a problem that will be more pronounced now EWERC Part I. The study context 28 during a period of high unemployment. Overall, while jobs in care homes are more likely to involve overtime work, it is the jobs in domiciliary care that are more likely to demand unpad overtime – 33% of all domiciliary care jobs. Shifts are a major feature of care work but only a third of jobs requiring shiftwork pay a supplement; in private firms this share drops to one fifth (18%) (TNS 2007: 33). Similarly, nightwork is required in around two fifths of care jobs (43%) but most workers (61%) in such jobs do not receive any form of pay enhancement, making them worse off than retail supermarket chains which at least pay a fixed supplement for nightwork. Again, private providers are least likely to pay a nightwork enhancement – only 28% of the surveyed care workers employed in the private sector (op. cit.). Any notion of compensating differentials in the social care sector thus appears to have been abandoned. One pay enhancement peculiar to the social care sector is payment for travel time, given the requirement in around one third of care jobs to travel between users‟ homes. The TNS survey reports that of those care workers in jobs involving travelling, some 37% travel more than 5 hours per week (TNS 2007: 34). Again, around half of workers are neither paid for their travel time (52%) (in contravention of the national minimum wage legislation) nor compensated for travel costs (petrol, etc.) (45%) (op. cit.). The issue is an obstacle to improving recruitment and retention (Yeandle et al. 2006) and recognised as problematic by the industry employer body, the UKHCA. The following quote illustrates the interlinkages with commissioning arrangements that focus on precise units of care time, an issue we explore further in the following section: [Local authority] commissioners will also use other cost saving mechanisms, such as only paying for contact time, sometimes as short as 2 to 10 minutes, or using short care episodes for personal care tasks to reduce costs. As care is generally purchased by reference to “contact time” (ie the time spent in the user‟s home) the rate paid is crucial. Providers must be able to reach National Minimum Wage - which must cover travel time – from increasingly small units of time. In addition, there is an impact on the wellbeing and job satisfaction of the workforce, and the user‟s satisfaction with care received. It also constrains providers‟ ability to pass on wage costs for careworkers undergoing training as they are only able to derive fees for billing for services provided (UKHCA 2009: 9). I.3.3. The organisation of care work In this section we identify the ways recruitment and retention in care work may be affected by the organisation of care work. The nature of care jobs, how these jobs are designed, the pace of work, the skill content of the job and the opportunities for workers to exercise autonomy and discretion when performing the role can all be expected to influence both recruitment and retention. Likewise, how working time is organised, including shift arrangements, the flexibility available to meet workers‟ needs and requirements for travel may be critical to both entry and retention. While low pay exacerbates recruitment and retention difficulties, wider debates relating to job quality indicate that broader measures of job satisfaction are also helpful in understanding labour market behaviour such as turnover EWERC Part I. The study context 29 for example. Indeed, Clark (2005) argues that restricting analyses to wages and hours of work „gives a misleading picture of what makes a good job, and hence of workers behaviour‟ (op cit: 2005: 12). The nature of the job The limited research that has looked at why people choose to work in the care sector reveals that even when there are pragmatic motivations, such as choosing a job that fits with other commitments or fits with a chosen career, „the choice is unlikely to be motivated purely by its extrinsic rewards. Rather, if a care worker feels she has made a choice it will be for reasons that touch upon the work itself‟ (Himmelweit 1999: 34). McClimont and Grove‟s (2004) survey of 3,000 care workers found the three most cited reasons for entering the care sector were enjoying helping others, liking care work and working time flexibility and a survey of 500 workers commissioned by Skills for Care (TNS 2007) found that enjoying working with people and wanting to enter this type of care work were the most important reasons along with the desire to work flexible hours (box 1.2). Case-study research indicates that this predisposition to caring for others is not formed within the workplace (Cunningham 2005: 4) and in domiciliary care the lack of a fixed workplace means that management and colleagues in the workplace are less influential on care workers‟ commitment to care work. However, for recruitment and retention it is important to see if care workers have the opportunity to act on these values once they have entered the sector. The survey results indicate that these pre-entry values, expectations and motivation continue to take precedent in explanations of job satisfaction. Job satisfaction is high in the sector with almost nine in ten (88%) care workers in the Skills for Care survey saying they were happy in their jobs. Box 1.2 presents the main factors underlying this broad finding of job satisfaction, and points to the importance of the nature of care work, including the relationships with users and caring and looking after others. Social care work can therefore be described as „intrinsically satisfying‟ in the sense that workers feel they can, in principle, „make a difference‟ in their job (Eborall 2003: 11). If there are no barriers to care workers making a difference, then „job satisfaction will automatically be high‟ (Eborall 2003: 11). Yet it is important to recognize that the way the work is organized may indeed present barriers to care workers making a difference and that such barriers may impact on care workers‟ propensity to remain in the sector. Likewise, survey research shows the importance of being able to work flexibly and again if this need is not met there may be an adverse effect on recruitment and retention. Therefore, a crucial factor is the way organisations manage and meet expectations in relation to the nature of the work and the flexibility on offer. EWERC Part I. The study context 30 Box 1.2. Reasons for entering care work and for remaining in care work Two surveys provide evidence of the reasons people cite for entering care work: McClimont and Grove‟s (2004) survey reports the following eight most cited reasons: 1. Enjoy helping others 2. Like care work 3. Flexibility to fit around other commitments 4. Easy, quick application process and rapid start to work 5. Pay 6. It was convenient 7. It provides a way into a career into nursing 8. Just needed a job The survey for Skills for Care (TNS, 2007: 59) reports the following commonly cited reasons: 1. Always enjoyed working with people I care for (40%) 2. Always wanted to enter this area of work (25%) 3. Convenient/flexible hours (25%) 4. Knew someone that did it (21%) 5. Just needed a job/ to earn money (19%) 6. Someone recommended it (18%) 7. Was unpaid carer for family member (15%) 8. Was close/ easy to get to (15%) And the same surveys also report evidence about the factors held to be important by care workers already in employment in shaping their satisfaction with the job: McClimont and Grove‟s (2004) survey reports The Skills for Care (TNS 2007: 64) survey 13 factors cited by care workers: identified the following ten „favourite things about work‟: 1. Relationship with clients [users] 1. Job satisfaction (14%) 2. Good managers 2. Chatting with clients [users] (12%) 3. Being able to get hold of managers easily 3. Meeting different people (11%) 4. Training 4. Caring/looking after people (1%) 5. Being trained before starting work 5. Helping people (10%) 6. Flexibility to do what client [user] wants 6. Knowing you are making a difference or needs (10%) 7. Clear and easily understood contract 7. The people I work with (8%) 8. Opportunity to undertake an NVQ/SVQ 8. Keeping clients [users] happy (7%) qualification 9. Flexibility of working hours (3%) 9. Being involved in decisions about clients 10. Building relationships with/gaining the [users] or work trust of clients [users] (3%). 10. Staying with the same clients [users] 11. Being able to say „no‟ to work 12. Opportunity to progress to senior care worker or higher 13. Clearly defined career path EWERC Part I. The study context 31 The organisation of work shapes the nature of care work in three key ways: the degree of standardization of tasks and the amount of time allocated to perform these (pace of work); the job content and specifically the level of skills required to perform the role, including opportunities to exercise autonomy and discretion (control over work); and the opportunities for employee involvement and supervisory support (voice at work). Standardization of care and pace of work A certain amount of standardization of care work is a requirement in the relationships that develop between LAs and providers. LAs purchase from providers a specified period of time to carry out a range of tasks for individual service users (Glendinning et al. 2008b). These tasks are set out in a care plan where the care needs of users are broken down into specific tasks and the time needed to carry out these tasks. Care workers have no involvement in the organisation of care plans and in this sense it mirrors the notion of „service sector Taylorism‟ (Bosch and Lehndorff 2001) characterised by a separation of the planning and execution of tasks. A key issue for care workers is the extent to which they have enough time to do all the tasks allocated within the time frame they are given. In other words, is the volume of work and pace of work acceptable and compatible with care workers‟ expectations and needs about what the job should involve and what they value from it? Research suggests that when this is not the case care workers are dissatisfied with their work and this can adversely impact upon retention. According to McClimont and Grove‟s (2004) survey, commissioning arrangements that facilitate tightly specified time slots lead to short visits that create feelings of being rushed and this is a key factor in retention. Staff shortages may require the existing workforce to accommodate many more visits across a wide area (Francis and Netten 2004). Cunningham‟s (2005) case-study of a not-for-profit care provider reveals pressure on care workers to concentrate on the more basic parts of their work rather than aspects they valued because of limited time. The current move to more outcomes-based care can be interpreted in part as a response to these problems and provides some recognition that this model of standardization and fragmentation of care tasks is „inappropriately rigid when it comes to the needs of people receiving care‟ (Bosch and Lehndorff 2001: 87). Greater control by the user over the care they receive may also give some scope for the care worker to respond flexibly to users‟ needs (Sayer 2005). While the focus has been on what this has meant for users, studies of outcomes-based services have also identified improvements in staff retention. Sayer argues that, „It seems that clarity about the results they are trying to achieve, together with the autonomy to respond flexibly to service users, is making the provision of domiciliary care services much more fulfilling and satisfying to staff‟ (op cit: 2005: 23). EWERC Part I. The study context 32 Job content: skills, autonomy and discretion While care work is low paid and is often categorized alongside other routine service work as a „bad job‟ (Coates and Max 2005) the job of a care worker does not fit a standard classification of routine work (Rubery and Urwin 2010). It shares with other types of frontline work the simultaneity of production and consumption (Korcynski 2002) but management scope for controlling service quality in this sector appears to be more limited than in other frontline service work such as call centres, hospitality and retail because of the amount of discretion the role potentially offers workers (Bolton 2004). For the recruitment and retention of the care workforce a key question is therefore whether the skills and discretion involved in care work can be considered a positive or a negative aspect of the job. Gospel (2008) and Gospel and Lewis (2010) identifies three kinds of skills in care work: technical skills needed to perform physical lifting, bathing, feeding and the administration of medicine; interpersonal skills or social skills required to interact with older people; and administrative skills for record-keeping and administration (2008: 22). Despite the required multiple skills, however, Gospel found that in care homes care workers enjoy limited discretion. Care workers have little input into personal care plans and have to refer to senior care workers if they want to change minor aspects of this (op. cit.). Moreover, Gospel‟s research demonstrates that care workers are keen to take on a wider range of tasks. However unlike similar jobs in the NHS where a national programme of skill development and job redesign has been implemented in part in response to shortages of cleaners and assistant nurses (Cox et al. 2008, Grimshaw and Carroll 2008), there is no such evidence in the care sector, except with regard to specialist services provision in some LA inhouse providers. However, the lack of a sector-wide approach appears to have caused a polarisation of job quality between LA and independent providers. McClimont and Grove (2004) argue the focus of many LA providers on specialist care restricts the range of job opportunities independent providers can offer their staff. Sayer‟s (2005) work on outcome-based care also suggests independent domiciliary providers design jobs that fulfill basic „maintenance outcomes‟, such as meeting basic physical needs, rather than „change outcomes‟. Sayer argues the involvement of all providers in the full range of outcomes „is probably an important step in enabling all providers to build stable, successful workforces‟ (op cit: 23). The specialisation of activities among LA providers and accompanying process of skill enhancement has also involved certain costs for the workforce, including enhanced temporal flexibility (see below). But the general effect, like the pay gap between providers reported above, is a polarization of jobs in terms of the skill and opportunities available between those offered by LA inhouse providers and those by independent providers. Like other types of service work, any depiction of care work that focuses on the more tangible aspects of skill, such as certified knowledge, training, accredited qualifications and career progression, misses the relational, or interpersonal, features of the job which are essential to what constitutes a good care worker and a good care service. The relational aspects of the work create positive opportunities for a worker to exercise discretion and autonomy because of the relationships involved in caring and the absence of direct supervisory control over these. Eaton (2000) cites a range of tasks involved in relational and EWERC Part I. The study context 33 emotional work, and elaborates the types of tacit knowledge required to perform the job well (box 1.3). The challenges of decision-making in a context of intensive relational work are perhaps most evident in the domiciliary care sector. Here, care workers often work alone and have to be able to negotiate with the user all the aspects involved in the delivery of personal care, including both the preset or routine tasks and the idiosyncratic or changed tasks. This feature of their job can be a source of satisfaction, as we described above, but can also be a source of stress. Care workers are expected not only to express empathy with the user but also simultaneously to negotiate and manage boundaries between their commissioned tasks and the user‟s expectations (Rubery and Urwin 2010: 3). Box 1.3. The relational work of care workers A review of studies by Eaton (2000) and Himmelweit (1999) suggest the following characteristics of relational work and tacit knowledge are present in care work: Relational work and emotional labour: - conveying information - providing comfort or companionship - preventing a problem - the „display‟ of a felt state, such as kindness, compassion and cheer - ability to complete tasks patiently and gently with tolerance, even if one is being physically abused or attacked Tacit knowledge: - how to lift and turn patients - how to cheer patients - to know who has grandchildren - to know who prefers warm water for bathing. The extent to which relationship work can be considered a type of skill is disputed (Lloyd and Payne 2008). However, in contrast to other service areas where there is tight managerial control over the formation of customer relationships through scripting and prescriptive modes of behaviour - for example, flight attendants or call centre work - social care workers have relatively high levels of discretion and freedom in their development of relationships. However, there are tensions between discretion and control within care work. On the one hand, managers rely on workers to sort out the changes in care associated with changes in user needs (Francis and Netten 2004) and to establish positive personal relationships with users in order to improve the perceived quality of the care delivered. But on the other hand, managers and LAs seek to increase control over costs by introducing new methods for monitoring care work, such as electronic monitoring where discretion is limited by increased EWERC Part I. The study context 34 pressure on time taken to deliver the care package. Cunningham‟s (2005) case-study research demonstrates that care workers‟ discretionary behaviour and caring values were indeed compromised by the work intensification that resulted from specific commissioning practices. Moreover, the diminished opportunity for care workers to act out their values meant they were more likely to express the desire to quit. However, the resilience of workers‟ commitment to helping and caring for others may still be enough to ensure this discretionary behaviour continues despite the rigid targets in place (Bosch and Lehndorff 2001, Hebson et al. 2003). Research evidence suggests that those individuals who are motivated intrinsically or by a „calling‟ to their work may engage in more expansive „job crafting‟ – that is, the exercise of discretion in defining and extending what the job entails - than individuals who are more extrinsically motivated by financial reward or career advancement (Wrzeniewski and Dutton 2001). I.3.4. Training and development Our fourth organisational factor described by the acronym MaROT (figure I.1 above) is training and development. High quality provision of training and development of the social care workforce is a vital aid to recruitment and retention. It can provide workers with much needed support in their job through expanding their knowledge and skills and also establish opportunities for career development. At the national level, the development of minimum care standards9 and LA commissioning requirements related to induction training and having at least 50% of care workers qualified at NVQ level 2 (including agency staff and excluding managers) was found to be an important driver for professionalization of care work and a boost to recruitment and retention (see Gospel and Thompson 2003: 21-22 for details). In particular induction should ensure that recruits are aware before they start work what a job in the care sector actually entails; this might increase turnover in the very short term, but undoubtedly reduces wasteful investment in new recruits who do not have the appetite for care work. Training requirements can also exacerbate the recruitment and retention difficulties facing independent providers. High turnover means not only that more time has to be spent on training, thereby compromising the ability of providers to deliver services, but also that a provider may fall below the training target, causing problems with both the CQC and the LA. Even from the perspective of future or current employees, training is not always welcome; those already experienced may resent being required to train and those considering entering social care may be apprehensive about their academic ability to complete the training or disillusioned by the lack of financial reward in the form of a pay rise (Gospel and Lewis 2010: 16-18). Yet training and development on its own may not be sufficient to improve either the image or experience of care work particularly if completion of training does not 9 These minimum standards with respect to NVQ training have been discontinued in 2010 EWERC Part I. The study context 35 lead to any advantages in terms of pay or future career opportunities. There is now evidence that the introduction of regulations has stimulated the amount of training in social care (Gospel and Lewis 2010),even if there are differences in the extent to which providers actively engage with the training agenda, linked in part to the availability of support for training from LAs and other agencies (Rainbird et al. 2009). Overall, however, the low pay rates that still prevail suggest that this has not done much if anything to improve the status or rewards of care work. Other countries have higher requirements for training for social care than the UK (Ungerson and Yeandle 2006, Simonazzi 2009, Fagan and Anxo 2005) and these training requirements are often associated with a greater professionalization and higher status attached to social care work (Christopherson 1997). These higher training standards are often implemented in contexts where there are sector-wide pay regulations, often based on collective bargaining so that it is not the training in and of itself that raises status but training combined with more regulated pay setting and the opportunity for social partners to engage in social dialogue. EWERC Part I. The study context 36 I.4. Recruitment and retention from the user and employee perspectives The above discussion has shown how some of the ways care work is organized can shape the quality of the care jobs on offer to a potential and existing care workforce. In this section we assess the potential linkages between the quality of the care job on offer and the quality of the care provided. Through a review of existing research on users‟ views of what constitutes a good quality care service we identify the complementarities between user perspectives and employee perspectives. Thus poor quality care jobs may not only exacerbate recruitment and retention difficulties but also curtail opportunities to provide good quality care. In contrast good quality care jobs have characteristics that improve service quality and job satisfaction, which is pivotal to improving recruitment and retention. A key issue then is whether there are complementarities or contradictions between user-centred services and employee-centred work organisation (Kirkpatrick and Martinez Lucio 1995). The review below suggests a greater presence of complementarities than contradictions, although only if the interests of both the workforce and users are taken into account in the design and organisation of service delivery. A final section considers the importance of time and space in shaping employee perspectives on care work. I.4.1.What makes a good care service and what makes a good care worker? What makes a good care service? In their summary of Qureshi et al.‟s (1998) research on older people‟s definitions of quality care Glendinning et al. (2008b) suggest the priorities include change outcomes (such as improvements in physical, mental and emotional functioning), maintenance outcomes (prevention of or delay in deterioration in health, wellbeing and quality of life) and process outcomes (such as feeling valued and respected, being treated as an individual, having a say over how and when services are provided, perceived value for money and compatibility with cultural preferences and informal sources of support) (op. cit.: 6-7). In case-study research examining users‟ views on the care they receive and what they value, it is often process outcomes that are emphasized which puts the care workforce, and how they are managed trained and treated, at the centre of explanations of user satisfaction. Francis and Netten‟s (2004) study of user views identified reliability, flexibility, continuity of care, communication and good staff attitudes as the most important dimensions. However, when talking about flexibility, it was flexibility to go beyond the care plan that users valued most - that is, the attitudes of care workers and their willingness to help and undertake jobs beyond those stipulated in the care plan (op. cit.: 295). In particular, users believed a „caring motivation‟ was more important than the skills and knowledge defined in training standards; Francis and Netten put it simply as follows, „if` care workers care they are good carers, if they don‟t they are poor carers‟ (op. cit: 300). Two further reports (Henwood 2001, Sinclair et al. 2000) identify older people‟s dislike of care workers‟ lack of flexibility and autonomy EWERC Part I. The study context 37 to deliver the type of service which users want. Both studies point to the importance of the relationship between user and care worker, the need for user choice and flexibility over tasks undertaken, and the need for users to have more control over the tasks undertaken. Such flexibility may be compromised by organizational and commissioning practices where these lead to fragmentation of tasks and short task-oriented visits (Sayer 2005). Furthermore, problems of recruitment and retention directly impact upon the quality of the service users receive. Users value reliability of care visits because it gives a sense of control over their lives (Francis and Netten 2004: 295). Missed calls and waiting for calls along with rushed visits are often the result of staff shortages and all compromise good quality care standards. However users do not blame care workers for this and understand the pressures they face (op. cit.). Interestingly, the desire for flexibility in service delivery not only concerns temporal flexibility but also involves the desire for care workers to be responsive to individual needs. On the basis of this discussion it is now possible to put forward some tentative ideas about what makes a „good care worker‟ that is sensitive to the way organizational and commissioning environments may shape this. What makes a good care worker? Caring involves caring for and caring about a person (Himmelweit 1999). A good care worker must thus not only be able to care for the person to the best of their ability, putting into practice skills and training they have acquired, but also, and significantly, must care about the person they are caring for, respond flexibly to the user and their needs and ensure process outcomes are achieved, including respect and independence and quality of life outcomes that only come through the relationships that develop between the care worker and user. To do this the onus is on the care worker displaying „citizenship type behaviour‟ (Hodson 2001) and „voluntarily giving extra effort to ensure production takes place efficiently‟ (op. cit.: 68). In short, being a good care worker often involves going beyond what they are expected to do out of commitment to either the user or the service (Cunningham, 2005). Significantly, managers may rely on this discretionary behaviour to deliver quality of care but as we have seen in our discussion about job satisfaction (I.3.3 above), this is also an aspect of the job care workers value. Relationships with users are a key source of job satisfaction and helping and caring for users using tacit skills would appear to be a key component underpinning the pride care workers experience in their job and the dignity they derive from work. However, this discretionary behaviour and flexibility, so clearly valued by users and central to definitions of „good care workers‟, may prevail despite organisational factors rather than because of them. As Bosch and Lehndorff argue, „it is the standards of the employees themselves that ensure such a system can operate irrespective of the targets set‟ (2001: 87). EWERC Part I. The study context 38 I.4.2. Is care work a good job or a bad job? The employee perspective The success of any recruitment and retention strategy for the social care workforce is likely to depend upon whether care work is considered a good or bad job from an employee perspective. Here we first of all review debates on good versus bad jobs before addressing the relationship between care work and attitudes towards women‟s employment and women‟s skills. Care work and job quality: complementarities, trade-offs and contradictions A range of dimensions are used in measurements of job quality including pay and benefits, job security, training and career opportunities, task discretion, job content and pace of work, employee involvement and voice and ,work-life balance (Tilly 1997, Appelbaum et al. 2010). However, because some dimensions such as pay are more easily measured compared to others good and bad jobs are often defined in relation to these (Goos and Manning 2003). Use of pay as a proxy for job quality is of course only valid to the extent that low pay is accompanied by other low quality job dimensions. Some studies confirm such an association, with evidence of „multiple deprivation‟ (Ritter and Anker 2002, Clark 2005) and segmentation of jobs, such that „some groups of workers may have better jobs than others‟ (Clark 2005: 21). Efforts to use HR practices to improve job quality need to recognise the potential for complementarity and positive inter-linkages. Recent comparative research on the hospital sector suggests that redesigned jobs have limited impact on job satisfaction if they are not supported by training and compensated by wage increases (Méhaut et al. 2010: 16-17). This has also been found to be the case in relation to good quality care jobs. Gospel and Lewis‟s (2010) research on the impact of training regulations in the care sector found that this did not have the desired impact on job quality because training initiatives were not complemented by newly designed job roles, the provision of financial reward for qualifications, and opportunities for workers to pursue clearly defined and managed career pathways. Studies by Hunter (2000) and Eaton (2000) also identify a bundle of HR practices that make a positive difference to job quality and quality care. However, this additive approach to job quality does not sit easily with a workforce that appears to have accepted a trade-off between different dimensions of job quality. As suggested above, care work does not fit the picture of routinised, low paid and low status work since the discretionary content and levels of job satisfaction can potentially be quite high. For care workers it would appear that their job is not so much a „good job‟ constituted by a bundle of complementary, „good‟ dimensions, but a job riddled with trade-offs and contradictions reflecting in part the importance of one or other dimension from the perspective of providers and care workers. These trade-offs are found both within a single dimension and between job quality dimensions. For example, with respect to discretion and control we have seen that care work EWERC Part I. The study context 39 provides for a high level of discretion but the value of this discretion is not necessarily recognised even though it is contributing to quality of outcomes. Moreover new electronic monitoring techniques, although introduced by LAs to monitor the provider, are being used to monitor employee behaviour which could reduce employees ability and willingness to engage in discretionary work effort. However, Brown and Korczynski (2010) have shown that while organizational commitment to the employer may decline because of this form of monitoring, it can lead to higher discretionary effort because of the care workers‟ commitment to provide quality care despite the constraints such monitoring can place on achieving this. There also appears to be a trade-off between pay and job satisfaction. A report for the employer body for provider organisations (McClimont and Grove 2004) highlights the problem in assessing how important pay is in workers‟ perceptions of the job since most surveys, including their own, only focus on care workers in employment. These workers ranked pay fifth out of eight in terms of importance, but this may not reflect the importance of pay to those care workers who quit to work elsewhere. Therefore, it may be unwise for policymakers to place too much weight on evidence of high satisfaction and low concerns over pay among existing care workers when seeking to identify means of expanding the workforce. Measures of job dissatisfaction may provide more useful information on where the barriers to recruitment and retention may lie. In the Skills for Care survey (TNS 2007), of the few care workers who said they were unhappy, the most commonly mentioned reasons cited were poor pay, wanting more support from the management, disliking the unsociable or long hours and not liking the particular company they worked for. McClimont and Grove (2004) also show how important managerial support is for job satisfaction and how dissatisfaction tends to relate to the employer rather than the job itself. What becomes clear is that if workers are dissatisfied with the job, and in particular feel they cannot take pride in their work and act upon their values and expectations about caring for users, other dimensions such as pay, that are often cited as relatively unimportant by those working in the sector, become increasingly more important and low pay becomes a reason to quit (Cunningham 2005, Sayer 2005). Issues around working hours also seem to be a dimension of job quality that can determine intentions to enter the occupation or quit (Cunningham 2005). One area where there is evidence of cumulative poor job quality is in relation to both pay and pay promotion prospects. Social care not only offers low initial pay but also poor opportunities for advancement (section I.3.2 above). These combinations of job characteristics may be tolerated by older female care workers who may expect limited chances of advancement wherever they move to in the labour market (Grant et al. 2005) but if new recruits from under-represented groups are to be targeted, for example younger workers and men, their expectations and aspirations for career and pay promotion will be different. EWERC Part I. The study context 40 Care work and women‟s skills Care work is often regarded as low skilled by virtue of its low pay and the lack of formal qualifications required for entry. As we argued above, this latter characteristic is in some sense specific to the UK as other countries require acquisition of more formal qualifications and have gone down the route of professionalising care work. However in all countries there remain residual problems of low pay and status for this kind of work that are associated both with a general tendency for women‟s work and skills to be undervalued in the labour market (Grimshaw and Rubery 2007) and with a specific tendency for care work to be undervalued due to its association with unpaid work undertaken by women in the home. It is this potential for women (and indeed men) to acquire skills through informal experience in domestic environments that in part enables the skills involved in care work to go unrecognised. A third of respondents in McClimont and Grove‟s (2004) survey who were recruited into care work had previous informal care experience. However, skill in care work is not primarily technical but involves emotional labour or emotion work or more specifically described by Bolton (2005) as „philanthropic‟ emotional labour, given as a gift. Moreover, unlike other frontline service work where connections are transitory, care workers form real attachments to users and suffer emotional dissonance if the relationship involves dealing with, for example, abusive service users (Eaton 2000). The outcome is that care workers may prefer to remain with users even if it is not convenient (Himmelweit 1999: 35) and may become as England (2005) has suggested „prisoners of love‟ where their attachment to the user may lead them into more intensive or more extensive work than they have been commissioned to undertake or are rewarded for. However, it is open to debate whether the relational and emotional content of this care work should be emphasised over that of improving technical skills and training and encouraging the professionalization of care work. The latter approach may make care work more appealing to a wider range of groups including some men as they are reluctant to enter work that stresses the need to have communication and social skills (Lindsay 2005). Furthermore, although generic skills such as social skills and communication are emphasised as important by employers when recruiting the relational aspects of work are not rewarded financially (Hebson and Grugulis 2005). In other caring occupations it has been found that care work is „contaminated‟ by the skill of caring, leading to undervaluation. Findlay et al. (2009) argue that nursery nurses have much to gain from focusing on the educational element of their role and a parallel strategy for care workers could be to focus on the emphasis on quality of life and dignity that is crucial in good quality care. However, as we have seen, care workers and users prioritise this relational aspect of care. If this aspect of the job is underplayed then there is a danger of deterring the very people who users want to have care for them, as well as exacerbating retention difficulties. Fagan and Anxo (2005) show that job satisfaction and service quality are both adversely affected where staff have insufficient time, training and other resources to meet the demands of emotional labour. EWERC Part I. The study context 41 I.4.3. Time and space in the recruitment and retention of a social care workforce Time and space factors are important positive and negative factors in the recruitment and retention of the social care workforce, particularly in domiciliary care where work is carried out in a range of locations through repeat visits at key points in the daily and evening cycle. The workforce is thus likely to be recruited from a localised pool of labour and this tendency is reinforced by the use of informal methods of recruitment by employers and by the relatively high job satisfaction found among care staff. In the Skills for Care survey, three fifths of care workers (59%) said they definitely would recommend their job to a friend, and a further one in four workers (24%) said they possibly would, meaning more than four in five workers (83%) overall would recommend care work to a friend. The mobilisation of local networks for recruitment does not necessarily mean people enter the profession by chance as Lee-Treweek (1997) suggests. Rather, new entrants may feel they know more about the job than if they had applied through formal channels without the insights provided by the recommendation of a friend. But this form of recruitment may itself set limits to the pool of labour on which the sector can draw. While there may be a general case for those seeking work to expand their spatial horizons and seek work outside their immediate area, this approach does not necessarily follow for domiciliary care work given current patterns of work organisation and employment rewards and guarantees. Travel to work time is always an issue for those in part-time work but where the work is fragmented over the day, not necessarily continuous and involves travel within the work day as well as from home to work the problems of expanding the geographical pool of workers is even greater. While care homes are more able to recruit staff for regular hours and for continuous shifts they also face the problem of operating on a 24 /7 basis and the need for staff to work nights and weekends increases the problems of commuting any distance to work as public transport may not always be available. For such a feminised sector, and one so reliant on more mature women often with caring responsibilities, it is important to recognise that the hours of work do not fit with standard notions of family friendly or employee-flexible working time. Instead the hours of work are set more with respect to user needs and may directly clash with family responsibilities, including early mornings, teatime and evening shifts, weekend work and, in care homes, night shifts. These working time arrangements further increase the likelihood that the work as currently organised would only be considered „convenient‟ for local labour and may only fit with quite specific family arrangements (for example where the partner is able to take the kids to school or make the supper). This fits with early research on working time arrangements in women‟s‟ jobs where what constitutes a convenient working time might be highly family specific and would be reinforced by specific childcare and other arrangements (Horrell and Rubery 1991a, b). However, in domiciliary care and to some extent in care homes the workforce has to cope not only with working time patterns that do not conform to standard family friendly arrangements but also with working time patterns that may be subject to constant flux. EWERC Part I. The study context 42 I.5. Key research questions The above review of literature on social care and the social care workforce has revealed a range of key issues that have been used to inform the design of research questions for this research project. We divide these into questions related to the LA commissioning environment, questions related to the HR policies and practices of providers and questions related to the recruitment and retention of care workers from the perspectives of both users and care workers. Our final research question relates to the underlying policy issue, that is the prospects for recruiting and retaining a larger and higher quality social care workforce to meet increasing demands for social care under current institutional arrangements and employment conditions. LA commissioning environment The LA commissioning environment was explored through an extensive postal survey in the first stage of this project. The research questions identified for the second stage of the project built upon this survey information but focused in particular on the following inter-related issues. 1. How do those in the Local Authorities responsible for commissioning and/or contracting make sense of the multiple, changing and potentially contradictory pressures on commissioning policy? The potential contradictions arise not only because of the need to contain costs while also ensuring quality and adequacy of supply, but also because short term pressures may conflict with longer term or strategic objectives to provide a more integrated service for older people covering social care and health or even housing or to develop more user-centred service delivery including the involvement of users themselves in the commissioning process. 2. What are the variations and trends in the specific characteristics of LA commissioning and contracting practices, from price and contract to quality monitoring and provider relations? For both questions the key issue is the attention paid by LAs to factors that may impinge on the recruitment and retention of the social care workforce. This attention may involve on the one hand LAs monitoring their own commissioning policies to ensure they facilitate rather than prevent providers adopting good HR policies. On the other hand the LAs may use their positions in tendering, commissioning on contract monitoring to require providers to offer good HR practices. EWERC Part I. The study context 43 HR policies and HR outcomes of providers Our analysis of the role of providers in the recruitment and retention of the social care workforce requires an initial mapping of the human resource practices in use within the sector. These practices include: recruitment and retention practices; pay and reward systems; work organisation and working time arrangements; employee development and training; and systems of performance management and employee voice. A related objective is to map the range of approaches to human resource management deployed by individual providers, measured across all these dimensions to HR practices. This then sets the foundations needed for our key research questions as follows. 3. What is the current state of HR practices and outcomes in the sector? What are the current employment practices and employment outcomes in the independent sector and how do they differ between homes and IDPs. 4. What role do provider characteristics play in shaping HR practices? In line with the findings from other studies we can anticipate several provider characteristics to be potentially influential, including ownership (national, local chains, single homes/agencies), sector (public, private, voluntary sector), size of establishment (eg. by numbers employed) and different quality ratings, as determined for example by the CQC star ratings. 5. What is the impact of the external policy and commissioning environment and the local labour market demand factors on HR practices? 6. What is the combined impact of HR practices, environmental conditions, and organisational characteristics on the quality of recruitment and retention outcomes? These fifth and sixth research questions follow the analytical framework set out in figure I.1 by interrogating the inter-related effects of different environmental factors (related to LA commissioning and local labour market conditions) and internal approaches to human resource management on the overall outcomes for recruitment and retention. Recruitment and retention from a care worker and user perspective Due to the design of the project and to ethical issues relating to access to users, the research questions that could be explored empirically within the project related primarily to the experience of work from a care worker‟s perspective, although these were related to the quality of care and the user experience wherever possible. The key research issues EWERC Part I. The study context 44 highlighted by the literature review and explored primarily through the stage three case studies involving interviews with care workers were as follows. 7. What factors shape the recruitment of care workers? 8. What factors influence the retention of care workers? The multiple factors include on the one hand the HR practices of providers and on the other hand the personal motivations, expectations and experiences of the care staff. Both questions, however, need to be set within the wider question of the nature of care work and its impact, both positive and negative, on recruitment and retention, which leads to a further question as follows. 9. Is care workers‟ job commitment influenced by the nature of the job and does it involve trade-offs between „bad‟ and „good‟ aspects of the job? In particular, we aim to identify and explore whether care workers enjoy opportunities to provide good quality care and whether the relationship between „good‟ and „bad‟ aspects of the job are in practice synergistic, with good HR practices potentially offering more job satisfaction and better opportunities for good quality care from the perspectives of users and care workers. In exploring this question we also consider whether the current care staff‟s commitment to their work is linked to their particular interests and circumstances that may not be easily generalised to an expanded labour pool. Prospects for recruitment and retention under expanding demand: the policy issues The final research question relates to the context in which this research was funded, namely the expectation of increased demand for the social care workforce, in relation to both quantity and quality. We draw on the answers to all nine research questions to ask: 10. What are the prospects of meeting current and future increased demands for a social care workforce under present conditions – that is without major changes in commissioning arrangements, the policies of provider organisations and the conditions of employment? EWERC Part I. The study context 45 I.6. Research strategy and methodology I.6.1. The project research stages The project to explore the recruitment and retention of the social care workforce involved three main stages as detailed in table I.3: from local authority commissioning practices to HR practices of providers to the experience of care workers. These are outlined in figure 1.7. Figure I.7. The project stages Survey of 92 LAs Follow up study of 14 LAs Part II Telephone survey 115 provider establishments 10 national provider interviews 20 case studies of providers Part V 98 care staff interviewed Part V Parts III and IV The first stage – a postal survey of LA directors of social services conducted by the PSSRU unit in Manchester- has already been reported on (Hughes et al. 2009) and provided a framework for the first part of stage 2, namely the selection of local authorities for follow up interviews (stage 2a) and as sites for the telephone survey of providers (stage 2b)-. These providers include domiciliary care providers (IDPs), residential and nursing homes in the independent sector (homes) and local authority based domiciliary care providers (LADPs). We also added a third element to stage 2, a survey of national providers (stage 2c).Stage 3 involved the selection of four LAs from our initial sample of 14 for cases studies of providers with particular focus on the experience of care workers employed by these providers. All three stages are described in more detail below. Table I.3 also provides a summary of how and when user views and issue were taken up and explore within the project, with further detail provided in the sections below. The project benefitted from the setting up of a helpful, well informed and active advisory board (see box I.4 for information on the EWERC Part I. The study context 46 composition of the advisory board). This board met annually and an individual member of the board provided valuable assistance at key stages, in particular in setting up a focus group of users to inform the development of the case studies. The results of the project were presented at each meeting and then the board was consulted on issues to bear in mind in developing the next step. Box 1.4: Membership of the Advisory Board Social Care Consultant Representative from Age Concern Full-time Officer from Unison Local Authority Service Director (LA not included in Stage 2) Owner of a domiciliary care agency Representative from Skills for Care Representative from ACAS 2 lay persons EWERC Part I. The study context 47 Table I.3 Summary of project stages Responsibility and project stages PSSRU and EWERC Project development PSSRU Stage 1. January 2008 Dates/ responsibility /sample frame Ethics approval sought from university ethics committee –stage 1 by PSSRU, stages 2 and 3 by EWERC. Agreement form ADASS for stages 1 and 2 secured by PSSRU. Postal survey of LA directors of social services Sample frame and number of responses Inclusion of user perspectives/ user issues Formation of Advisory board including representatives from all key stakeholders including users 92 responses (149 LAs surveyed) Information collected on consultations with users by LAs and on flexibility in service provision at the level of service user - one dimension to typology Advisory board including users consulted on follow-up questions on commissioning. National user attitude surveys used to explore/validate typology of LAs (see part II ). Advisory board including users consulted on most important care standards from a user perspective. Challenges in meeting CQC care standards, importance of continuity of care and attitudes to personal budgets included in questionnaire. Attitudes towards personalisation, care standards etc. EWERC Stages 2 and 3 Stage 2a October 2008 to June 2009 Follow up interview with key actors in LA commissioning and contracting 14 LAs (15 LAs approached) Stage 2b. November 2008 – February 2010 Telephone survey with independent providers and LA inhouse departments in 14 LAs (Targeted sample – 3 to 4 homes /IDPs plus LADP per LA. Achieved in 12LAs, 2 undersampled) 115 (>300 providers approached) Stage 2c. January 2010 - May 2010 Telephone survey with national chains Target 10all to have a branch within telephone survey – 5 IDPs, 5 homes Case studies of providers 10 ( 12 chains approached) Stage 3 June 2009 to March 2010 Target cases studies in 5 providers in each of 4 LAs - 5 care workers per provider EWERC 20 case studies of providers, (30 approached in total ) 98 employee interviews Focus group of care users to inform themes within case studies. Two themes highlighted (see Box 1.6) Part I. The study context 48 I.6.2. The stage one survey Stage one of the project was designed to provide an overview of commissioning and contracting practices in local authorities and to use that information to provide the basis for the systematic selection of sites for stage two of the study. Data was collected from local authorities with responsibility for social services through a postal survey distributed in 2008. It comprised questions relating to the commissioning and contracting arrangements for domiciliary care and care home provision and care management (care coordination) arrangements for older people. The results of the first stage are reported separately in Hughes et al. (2009). Ninety two of a total of 149 local authorities returned completed questionnaires, a response rate of 62%. To identify local authorities using common approaches to commissioning and contracting the PSSRU study identified fourteen indicators relating to three domains of interest: commissioning and contracting arrangements; employment practices; and flexibility in service provision at the level of the service user. A cluster analysis was undertaken which suggested the presence of seven types of local authority (table I.4). These were found to vary in the level of activity in each domain of interest. For example, local authorities in type seven were seeking to develop their commissioning activities, particularly in partnership with health, and the processes associated with contracting; sought to reflect employment practices in this context; and were striving to promote flexibility in service provision. Conversely, the opposite appears to be the case in type four authorities. The remaining two thirds of the sample displayed varying levels of activity in each of the three domains of interest. Table I.4. Typologies of Local Authorities: Stage 1 of the project Type (No. of authorities) 1 (15) 2 (19) 3 (11) 4 (15) 5 (6) 6 (13) 7 (13) Commissioning and contracting arrangements Medium Medium High Low Medium Medium High Source: Hughes et al. (2009: p.9) EWERC Employment practices Medium Medium Medium Low High Low High Flexibility in service provision at the level of the service user Medium Low High Low Medium Medium High Part I. The study context 49 I.7. The research methods for stage two I.7.1. The local authorities The selection of local authorities for the second stage of the research was driven by a range of factors. These included the typology developed in the first stage; geographical spread; local labour market conditions; and types of local authorities. The seven cluster typology of local authorities influenced, first of all, the decision on how many LAs to include in the second stage of the project. As the aim was to include both independent sector domiciliary care providers and independent sector residential homes in the telephone survey in each area, together with, where present, the inhouse domiciliary care provider, 14 was considered the largest number of LAs that would allow for a normal sample of six to eight independent sector providers within our target of around 100 to 120 achieved interviews. Selecting a smaller number of local authorities would have raised two different problems; first as the number of domiciliary care providers in one area was often quite limited, we would not necessarily be able to achieve a sample much greater than four in some cases, particularly if, as could be anticipated given the nature of the industry (see above), we encountered difficulties in securing responses. Furthermore, as the indicated sample frame for selection was the seven clusters of LAs generated by PSSRU‟s first stage survey, it seemed appropriate to select two local authorities from each cluster. We made one variation to this approach, namely we selected three from the largest cluster accounting for 19 local authorities and only one from the smallest which included only six local authorities. Three additional criteria of geographical spread, local labour market conditions and types of local authorities were also taken into account in the selection to ensure that we covered a broad range of types of external conditions and local authority characteristics. We contacted the local authorities in stages as it was thought important to embark as soon as possible on the telephone survey of providers after agreement had been secured from the local authority to support their involvement in the second stage. For practical reasons, therefore, the development of the local authority sample was done on a rolling programme with these criteria in view. Of the 14 initially selected LAs, one did not agree to cooperate so that we were able to achieve our initial selection of LAs with only this one exception. This was an outer London borough and was replaced by another outer London borough in the same cluster. The characteristics of the achieved sample are shown in table I.5. Five local authorities were located in the north, three in the midlands and six in the south including two in outer London. The types of LAs were also spread over the main categories of shire counties (2), shire unitaries (4) principal metropolitan (2) other metropolitan (4) outer London (2) with inner London the main missing category (completion rates for both types of London boroughs were lower at 50-54% compared to the highest rate of 83% for Principal Metropolitan Authorities in the first stage survey). This variety of types of LAs is also reflected in the size of EWERC Part I. The study context 50 population: five had populations of under 250,000, five between 250 and 350 and four over 350,000 with two of these exceeding 600,000. Table I.5. Characteristics of the selected LAs LA Population size a Type of LA Cluster Area Female employment conditionsb Female part-time earningsb Labour demand conditionsc AH small Shire unitary 2 South 5 M Strong ON medium Other metropolitan 7 North 3 L Weak RT medium Outer London 3 South 3 M Medium RN medium Shire unitary 6 South 5 H Strong UY medium Other metropolitan 1 Midlands 4 L Medium AD small Other metropolitan 4 North 3 L Weak AW small Outer London 2 South 3 H Medium IL medium/ large Principal metropolitan 7 North 2 L Weak OM medium Shire unitary 2 Midlands 2 L Weak XD large Shire counties 5 South 6 H Strong HD medium/ large Principal metropolitan 6 North 5 M Strong TE small Shire unitary 1 Midlands 2 L Weak LK large Shire counties 4 South 6 M Strong RD small Other metropolitan 3 North 4 M Medium a Small <250k, medium 250-350k medium/large >350k<600k large > 600k See appendix table I.A1 c See appendix figure I.A1 b The local labour market indicators that we focused on were those related to the potential availability of a labour supply for care work, related to both quantity and wage level. As most care workers are women we decided to look at the local labour market conditions for women as the core indicator. The available labour supply for women is not necessarily fully or appropriately captured by the unemployment rate as many women move directly from inactivity to employment. We therefore took into account the unemployment rate, the share of the working age population who are inactive but want a job and the achieved employment EWERC Part I. The study context 51 rate (see appendix table I.A1). We combined these measures to indicate the strength of demand for female labour in the local labour market. Using a scale of 1 to 6 table I.5 shows that as an average for the period July 2008 to June 2009 (source LFS NOMIS), the 14 local authorities were spread rather evenly with each of the possible points 2 to 6 including at least two of the selected local authorities. We also looked at evidence of pay levels in the LA area, focusing on the median hourly wage for female part-time workers. We combined this information to come up with a classification of local labour demand as strong, medium or weak (see appendix figure I.A1). The two outer London boroughs are located in the medium category: this reflects the polarised nature of London labour markets, with wide wage inequalities even among women (median full-timers‟ pay being much higher relatively than female part-timers‟ pay) and low employment participation by some ethnic groups. Stage two interviews with Local Authorities The local authorities selected for further study and for the telephone survey sites were contacted via a letter to their director of Social Services. The letter drew the LA‟s attention both to the approval of the project by the Association of Directors of Adult Social Services (ADSS) (obtained at stage 1 of the project) and to the LA‟s prior participation in the postal survey. This letter was followed up by a request for an interview with those responsible for commissioning and contracting domiciliary care for older adults and residential and nursing home care for older adults. Due to differences in organisational structures and arrangements for commissioning and contracting, the person or persons interviewed and their responsibilities varied between the LAs. However, in most cases we were able to interview officers with responsibility for both commissioning and contracting - either in the same person or by joint or separate meetings with relevant managers. In most cases only one main interview was undertaken lasting between 90 minutes and two hours in most cases, and with two or more officers in nine of the cases. Some follow up telephone interviews were undertaken where key people – for example on training - were not able to be present. In one case where contract implementation and monitoring was undertaken by a different department from commissioning and outside of social services, the main interview was with the contracting and monitoring group (the staff concerned had previously been located in social care but had been moved to a general contracting department) and a follow up interview by telephone undertaken with the officer with main operational responsibility for commissioning. In one LA (AD) a second visit was made to interview a key actor at a different site and in another (RN) sequential interviews were held with key actors. In all other cases the interviews were joint and no attempt has therefore been made to separate out the views of the different officers concerned. Table I.6 shows the number of interviewees and area of responsibility in each LA. The interviews at the LAs focused on two issues. First of all we asked for support for the research team‟s study of external providers in the area. At a minimum we asked for lists of current contracted providers and key contact names and email addresses if available. Many of the LAs, however, also gave more active support by informing their providers through their EWERC Part I. The study context 52 forum, their newsletters or through emails that we would be contacting them and that the LA was aware of and supportive of the research. In providing this support it was made clear to the LA that they would not be able to have direct feedback on their own providers in order to ensure confidentiality but they would be sent a copy of the report. The second purpose was to follow up on the information already provided in the first stage survey and to explore in more depth the relationship between LA commissioning and contracting and the recruitment and retention practices of their providers. A semi structured interview schedule was used. Table I.6. Local authority managers interviewed in stage two LA Initial interviews and follow up interviews Managers interviewed AH ON 1 1 joint + 1 telephone interview Manager responsible for commissioning Service director Managers responsible for: contracts performance management training RT 1 Managers responsible for: commissioning contracts quality training RN 2 Service Director Manager responsible for contracts UY 1 joint Managers responsible for: business services training commissioning AD 2 Managers responsible for commissioning older people‟s services AW 1 +1 telephone interview Managers responsible for commissioning contracts IL 2 Managers responsible for commissioning contracting OM 1 + 1 telephone interview Manager responsible for commissioning and contracting XD 1 Manager responsible for commissioning and contracting HD 1 joint Managers responsible for: older people‟s services commissioning HR contract TE 1 joint Service Director Manager responsible for commissioning LK 1 joint Managers responsible for contracting quality training (2) care homes RD 1 + 1 telephone interview Service Director Manager responsible for commissioning EWERC Part I. The study context 53 I.7.2. The telephone survey Design of telephone survey For the telephone survey of providers, in each of the 14 LAs we aimed to include three to four care homes, three to four domiciliary care providers and the LA inhouse domiciliary care provider (where applicable). Within this sample we aimed for a mix between star ratings, local and national providers and, in the homes, nursing and residential care. The survey of providers took the form of a questionnaire administered mainly by telephone. The questionnaire was designed for the owner, manager or person responsible for the day-today running of the home or independent domiciliary care provider. Because of the differing nature of work organisation in domiciliary care and care homes separate questionnaires were drawn up for each, but the greater part of the questionnaire was common to both. The questionnaire was primarily aimed at three issues: identifying the current situation with respect to the recruitment and retention of care staff; identifying the range of HR practices used by the providers with potential relevance for recruitment and retention; probing the providers‟ views of the influence of the external commissioning and labour market environment on their HR policies and outcomes. The broad topics covered are: general information on the establishment, recruitment and retention of care workers, pay, organisation of work, training and development, relationship with LA and experience of the policy and regulatory environment. Parts of the questionnaire were designed to be filled in and returned prior to the telephone interview. The rationale for this was twofold; firstly to enable the respondent to gather certain information, particularly on workforce statistics, in advance, and secondly to cut down the length of time managers‟ would need to spend on the telephone. A copy of the questionnaire for IDPs and care homes combined is provided in the appendix to part I. The shaded sections indicate those parts sent in advance. Consultation with the advisory board/ users over inclusion of quality questions During the first meeting of the project Advisory Board held in July 2008 a consultation exercise was held with the members of the Board, including service users, and the members of the research team to consider the care standards and associated indicators of best/quality practice developed by PSSRU. Members each selected the 20 best practice indicators they considered to be the most important determinants of quality in each area of service. Analysis of the documents completed by members of the Advisory Board was undertaken to identify the most frequently reported indicators of quality and best practice. However, this analysis EWERC Part I. The study context 54 suggested that there was no real consensus. A decision was therefore made to include the whole set of CQC standards as the framework for questions on quality standards in the telephone survey questionnaire. Piloting the questionnaire The questionnaire was piloted with the manager of a care home not situated in any of the LA areas chosen for the study. The pilot interview took 35 minutes. Following the pilot interview some minor changes were made to the questionnaire. Further changes were made following suggestions from a local authority contracts manager. Conduct of telephone survey Following each of the local authority interviews we asked for lists of their current providers of domiciliary care and care homes, with contact details where possible. Table I.7 shows the numbers on the lists for each LA. Table I.7. Potential sample of providers for telephone interviews XD Homes 147 IDPs 41 RN 63 10 AH 37 16 UY 62 10 OM 45 9 RD 35 15 HD 95 14 RT 27 7 AW 29 10 AD 51 10 IL 96 8 ON 40 22 TE 36 6 LK 145 80 Some LAs offered to smooth the way for us by informing their providers of our research, and letting them know that they supported our project. The researchers made initial contact with the managers by telephone and/or email to obtain their agreement in principle to take part and, if possible, arrange a time and date for the telephone interview. Those who agreed were sent further information about the project, and a factsheet about the implications of taking part (including issues of confidentiality and anonymity) as agreed by the University of EWERC Part I. The study context 55 Manchester Research Ethics Committee. They were also sent the parts of the questionnaire that had been designed to be completed in advance. The managers were telephoned at the agreed time for the interview. If the manager agreed, then the interview was recorded digitally but the responses to the questions were also noted on the questionnaire as the interview progressed. The recorded interviews were used to check responses and for additional qualitative data. Most of the interviews were between 45 minutes and one hour in length. Composition of the achieved sample In practice the quota was obtained by contacting more than the target number of providers in each LA area and stopping contact once the target number had been achieved. In order to achieve the sample of 105 providers (excluding the inhouse providers) it is estimated that a total of 303 providers were contacted. Furthermore it was often necessary to contact each of these providers on several occasions. Even when an interview had been arranged the researchers often found that the manager was not available at the allotted time, and the interview would have to be re-arranged (several times in some cases). To some extent these difficulties reflect the nature of managerial work in domiciliary care and care homes where diaries tend to be „fluid‟ and managers are often, for example, required at short notice to meet with service users and families, deal with practical problems or cover for absent staff. The composition of the achieved sample is shown in table I.8. Table I.8. Composition of the achieved sample Homes IDPs LADPs Total XD 5 4 1 10 RN 4 4 1 9 AH 4 5 0 9 UY 3 3 1 7 OM 4 3 1 8 RD 4 3 1 8 HD 4 4 1 9 RT 3 4 0 7 AW 2 3 0 5 AD 4 4 1 9 IL 4 4 1 9 ON 4 4 1 9 LK 4 6 1 11 TE 4 1 0 5 Total 53 52 10 115 EWERC Part I. The study context 56 The table shows that the target sample for IDPs and care homes was achieved in 12 of the 14 LAs. In the case of TE it was difficult to achieve the target sample of IDPs because of the limited number contracted by the local authority. On the other hand the target sample was overachieved in three LAs. Two of the LADPs (AW and RT) had no inhouse domiciliary care provision, but ten of the remaining twelve were included in the sample. Additional interviews with national providers Stage two of the project also included interviews with senior managers of national providers of care homes and domiciliary care. We decided to aim to interview five national providers of care homes and five national chains of IDPs. Our priority was to include national providers that were represented in our telephone survey of providers (all of the ten achieved interviews). The response rate was relatively high with twelve national providers contacted to achieve the sample of ten. The interviews were semi-structured; eight of the interviews were conducted over the telephone, and two were face-to-face interviews. One of the telephone interviews was conducted with two managers simultaneously by conference call. The interviewee sample by job title/area of responsibility is shown in box I.5. Box I.5. National Provider Interviewees Homes Recruitment Director HR Director (2) Group HR Director Corporate Services Director IDPs HR Director Commercial Director Managing Director and Head of Recruitment and Retention Managing Director National Recruitment Manager Coding and analysis The responses to the telephone survey were entered into an SPSS data file. Efforts were made to complete missing data, particularly where the respondents had not returned the advance questionnaire but a number of the providers still did not complete the information. For those who did complete the advance questionnaire (96 out of 115) the information was of a higher quality than could have been achieved in one telephone interview. Cross-tabulations were used to produce the descriptive statistical tables in part III of the report to provide an overview of recruitment and retention in the selected providers and to EWERC Part I. The study context 57 document the rage of HR practices in use. To compare the use of HR practices between individual providers and between groups of providers - by organisational and local authority characteristics- the data on HR practices and outcomes were converted first into indicators and then into subindices and indices to represent a range of practices from poor to good with the value 1 for the best practices. Part IV, including the extensive appendix tables, gives more detail on how these were constructed and used, and provides further analysis of the telephone survey data. Multivariate analyses were also carried out using these indicators and indices. EWERC Part I. The study context 58 I.8. The research methods for stage three case studies I.8.1. Rationale for the case-study approach The role of the cases studies in the project design was to provide a more in-depth exploration of how the HR practices of providers influenced recruitment and retention and to do this through exploring the experience of work among the care staff. While the cases studies were designed to explore the care workers‟ experience of the providers‟ HR practices it was also recognised that many factors that shape recruitment and retention may be related to their own personal and social circumstances. While some of these may be influenced by the employer, others may not be. An understanding of some of the personal motivations and expectations of those who enter the sector could help providers to put in place HR practices that can facilitate a smoother entry into the sector and a more long term commitment to stay. The case-study data was thus designed to provide more in-depth data on a range of areas including: firm level practices and their impact on recruitment and retention in the care sector; the characteristics and experiences of care workers including their entry into the sector, their desire to stay or leave, and the levels of satisfaction with key aspects of their employment; the linkages, where they exist, between commissioning practices, employer practices and job quality issues for care workers; differences, where they exist, between the views of established staff and those of new recruits to gauge potential problems in retention in the sector; linkages, where they exist, between the provision of good quality care and good quality care jobs. I.8.2. Design of the case studies Focus group with users Involvement of service users was sought by holding a focus group with users in February 2009 under the auspices of Age Concern. Two researchers from the project and four service users, including one member of the project advisory group, attended. The aim of the focus group was to solicit care users‟ views on the most important issues to follow up on the linkage between recruitment and retention issues and the quality of care. Issues discussed were: the attitudes, attributes and quality of care staff working conditions the organisation of care delivery The views of the focus group on these issues were used to inform the case-study survey design as outlined in Box I.6. EWERC Part I. The study context 59 Box 1.6. Focus group held with care users During the focus group care users identified a number of issues relating to quality of care, the working conditions of care workers and the organisation of care delivery and these themes were integrated into all case study interview schedules. Some of the issues identified relating to low pay and training were anticipated but other themes were unexpected. For example, the focus group revealed that care users often have contradictory expectations of care workers; they expect both the informality of friendship and the formality of a host/guest and employer/employee relationship. To explore this further in the case study interviews we included a section entitled „Relationships with users‟ in the interview schedule. This includes questions that asked care workers whether they find it is easy to meet the expectations of service users and whether they find it difficult to fulfil the different roles of both a care worker providing a service and a friend. This theme is explored in part V which reveals that care workers are constantly having to negotiate this difficult balance and when done well this appears to improve both the working experiences of the care workers and the feedback they receive from the care users. Another important theme that emerged in the focus group with users related to the organisation of care delivery and, in particular, the care users‟ concern about timekeeping, timing of visits and care workers‟ capacity to deal with unanticipated events when timings of visits are tightly defined. These issues were included in a section entitled „Doing the job‟. We asked care staff about the lengths of visits, any difficulties that arise when carrying out tasks in defined times and what happens when unforeseen events mean visiting schedules cannot be met. These are particularly revealing questions as they ensured that care staff gave concrete examples of what they were expected to do in the times they were allotted and the problems that could arise because of the unpredictability of service users‟ needs. Specific stories about the day to day reality of caring may be more informative than generalised views about „being a care worker‟. Some of the difficulties and frustrations of working as a care worker are revealed in responses to these questions as well as the good practice in the sector. We therefore feel involving care users at the preliminary stages proved invaluable in ensuring that the case studies generated meaningful data on the linkages between quality of care and recruiting and retaining a quality workforce. Design of the cases studies In stage three of the project we aimed to interview five staff in five provider organisations (two homes, two IDPs and one LA inhouse provider) in each of four local authority areas. The interviews were semi-structured and separate interview schedules were designed for care workers and supervisors. The interviews with care workers covered background information EWERC Part I. The study context 60 and work history of the employee, recruitment, pay, working time, job content, relationships with service users, communication with management, training and development, career prospects and future plans for working in care or elsewhere. Similar topics were covered in the supervisor interviews, but we also asked additional questions about their supervisory role. I.8.3. Selection, conduct and analysis of the case studies Selection of LA areas for case studies The selection of LA areas for case studies was done on a „rolling‟ basis which started before the completion of the LA interviews in stage two. This was necessary in order to ensure completion of the fieldwork within the project schedule. It was not, therefore, possible to use the analysis of all 14 LAs as a basis for selection from the outset. We did, however, aim for a good contrast between the four areas in terms of high/low wage areas, geographical areas, local labour markets, a variety of LA commissioning approaches and fee levels. The four chosen were IL, ON, XD and RN. IL was identified as a very low fee payer, RN a medium to high payer and XD a high payer. These LAs also provided examples across the range of types of LAs as subsequently classified through our interview material even though this typology was not available at the time of selection of the first two LAs ( see section II. 3): XD and RN feel into the partnership category, IL the cost minimising and ON fell into the mixed category. IL and ON are in the north of England, RN and XD in the more affluent south. IL, ON and RN are urban, or mainly urban, and XD covers a mixed urban and rural area. Parts II and V give more details of the selected LAs. Selection of case study organisations In stage two of the project we asked the managers at the end of the telephone interview whether they would agree to their establishment taking part in the project at a later date as a case study. When selecting the case studies we approached those in the four selected LA areas who had agreed in principle. We approached 30 organisations at this stage in order to achieve the target sample of 20. Selection of staff to be interviewed in each case study The case studies primarily focused on the experiences of care workers within organisations where a large amount of information had been collected through the telephone survey with respect to their working conditions. In each case study we sought to interview two relatively new recruits, and two longer serving, more senior members of staff. We also interviewed someone with supervisory responsibilities, in addition to the four care workers. All the telephone interviews with managers for the case-study organisations were fully transcribed and analysed in detail to provide the organisational context in which to locate the care workers‟ interviews. Nevertheless, the case studies were somewhat more employee-focused EWERC Part I. The study context 61 than was originally planned but the problems experienced in gaining cooperation from managers to give of their own time for the telephone surveys made it very difficult to require further cooperation from management as a condition for participation in the case study stage. The stronger focus on the experiences of care workers themselves could be considered a strength of the case-study data as it was revealing of a range of key issues in recruitment and retention that is not visible from a management perspective. Conduct of the case studies A time and date convenient for the case study interviews was arranged with the manager in each case. The managers were asked to identify five potential interviewees: we informed the manager that the interviewees would be offered £ 15 shopping vouchers as an incentive to take part and this proved very successful in helping to recruit interviewees. One or two researchers travelled to the case study site on the agreed date, and individual interviews took Table I.9. Composition of the achieved case studies ON ON.D.1 DN ON.D.3 DN ON.HN.1 BS ON.H.2.ML ON.DIH.1 DP IL IL.D.1 CN IL.D.2 DL IL.H.3 BN IL.H.4 BS IL.HIH.1 CP XD XD.D.1 CN XD.D.3 CN XD.HN.4 DN XD.H.5 BS XD.DIH.1 DP RN RN.D.1 CN RN.D.2 CN RN.H.1 AL RN.H.3 AN RN.DIH.1 DP EWERC Type CQC Star rating Local/ national Private/public/ voluntary Total no. of staff Established IDP IDP Home with nursing Home LADP 2 star 3 star 2 star National National Local Private Private Private 102 30 24 2005 1983 1979 1 star 3 star Local chain Local authority Private Public 52 128 2001 Registered 2003 IDP IDP Home Home LA Home 2 star 2 star 2 star 2 star 2 star National Local chain National Local Local authority Private Private Private Private Public 70 210 25 30 2008 1995 2004 1998 Registered 2003 IDP IDP Home with nursing Home LADP 3 star 2 star 3 star National National National Private Private Voluntary 50 60 113 2004 Registered 2004 2006 3 star 2 star Local Local Authority Voluntary Public 26 130 1947 1947 IDP IDP Home Home LADP 2 star 2 star 3 star 2 star 3 star National National Local chain National Local Authority Private Private Private Private Public 60 52 23 24 150 Registered 2004 2005 1979 2003 Registered 2004 Part I. The study context 62 place in a location which ensured privacy. Before each interview the interviewee was given printed information about the project, an information sheet on ethical issues approved by the University of Manchester Research Ethics Committee, and asked to sign a form consenting to be interviewed and for the interview to be recorded. The interviews lasted around 30 to 40 minutes. All recorded interviews were fully transcribed. Composition of achieved case studies and staff interviewed In all four of the selected LA areas we achieved the target number of case studies, i.e. two homes, two domiciliary care agencies and one local authority provider. Four of the LA providers were domiciliary care providers and one was a local authority care home. Table I.9 shows the characteristics of the case studies by type, star rating, local/national, public/private/voluntary, total number of staff in the home or branch and date established or registered. Table I.10. Composition of staff interviewed ON ON.D.1 DN ON.D.3 DN ON.HN.1 BS ON.H.2.ML ON.DIH.1 DP IL IL.D.1 CN IL.D.2 DL IL.H.3 BN IL.H.4 BS IL.HIH.1 CP XD XD.D.1 CN XD.D.3 CN XD.HN.4 DN XD.H.5 BS XD.DIH.1 DP RN RN.D.1 CN RN.D.2 CN RN.H.1 AL RN.H.3 AN RN.DIH.1 DP Total Less experienced care workers Experienced care workers Supervisor Total 2 1 2 2 2 2 2 3 2 1 3 1 1 1 5 5 4 6 5 2 2 2 2 2 1 3 2 2 2 2 1 1 1 1 5 6 5 5 5 2 1 2 2 2 2 3 2 2 2 1 1 1 1 1 5 5 5 5 5 2 2 2 2 2 36 1 2 2 1 2 40 1 1 4 5 4 4 5 98 1 1 22 Table I.10 shows the numbers of staff interviewed at each organisation. In most cases the target number was achieved. In two cases we interviewed more than the target number, because more than the requested numbers arrived for interview, and it would have been EWERC Part I. The study context 63 difficult not to interview them all as they had been promised shopping vouchers. In five cases we interviewed fewer staff than we needed, or did not achieve the desired mix of experience. In the IDPs in particular the number and experience mix of interviewees was constrained by the practicality of staff coming in to the office in their spare time to be interviewed. In one home one interviewee was working as a cook, but was interviewed because she had daily contact with residents and had previous experience of care work. This interview is not counted in the total sample. Analysis of the case studies In total we conducted 98 interviewees and the desired split between new recruits and established staff was achieved (see table I.10 and table I.11). Although we tried wherever possible to include a mix of care workers in the sample that are underrepresented in the care workforce, including men, younger workers, care workers from different ethnic background and migrant workers, the sample was predominantly female and white British and over half within the 30-49 age category (see Table I.11). Table I.11. Sample composition by job tenure 1 Sample No. 2 yrs or under (%) 2-5 years (%) 6-10 years (%) Over 10 years (%) IDPs 381 71 21 3 5 Homes 38 50 26 13 11 LAs 20 25 25 20 30 Total 1 53 24 10 12 96 Two IDP care workers- no information Table I.12. Sample composition by age: all and new recruits Under 30 (%) Total New recruits 30-49 (%) Total New recruits 50-59 (%) Total New recruits Sample No. No.new recruits IDPs 40 21 28 33 53 52 18 Homes 38 12 26 42 53 42 LAs 20 10 10 10 60 50 Total 98 43 23 30 54 49 Over 60 (%) Total New recruits 14 3 0 16 8 5 8 30 40 0 0 19 19 3 2 For each organisation we developed a template where relevant extracts and quotations relating to a number of themes were recorded for each interviewee. An inductive approach was adopted: while some themes were determined by the interview schedule and the research questions of the project, others were unanticipated and were generated by the responses of interviewees. For example, we did not anticipate the extent of the use of family and social networks in shaping entry into the sector and when this theme started to arise in many of the EWERC Part I. The study context 64 interviews we ensured all interview data had been analysed with this theme in mind. The template facilitated comparisons between providers within case study local authorities and across local authorities. It also allowed comparisons between new recruits and well established staff as well as staff with supervisory roles and coordinating roles. The templates also allowed us to quantify some of the trends found in the case study data. While the aim of the case study data was to explore the care workers‟ attitudes and experiences using qualitative techniques, the number of interviews also allowed us to identify some general trends. This opportunity was particularly useful because of the limited data on care workers as a group. While the case studies of each organisation were interesting in their own right, for this project the comparisons between cases within and across different local authorities was also significant as this could help tease out any explanatory factors that could account for any similarities or differences across the sector. Of particular interest here were the two case studies of national chains operating branches under two different local authorities as this offered insights into the relative impact of company policy versus commissioning and local labour market conditions on HR practices. I.9. The plan of the report This first part of the project report has described the research framework, reviewed the relevant literature, formulated the key research questions and provided an overview of the methodology adopted and the samples achieved. The organisation of the rest of the report is as follows. Part II describes the commissioning and contracting practices identified in the 14 selected LAs and provides a typology or classification of commissioning practices. Part III provides a mapping of the current HR practices according to the telephone survey of our achieved sample of 115 providers, analysed by IDPs, homes and LADPs. Part IV explores the role of LA commissioning practices, local labour market conditions and characteristics of providers in accounting for variations in HR practices and HR outcomes. It also explores relationships between providers and LAs from the providers perspectives, including those of national chains. Part V also explores the impact of different LA commissioning environments and different provider HR practices but this time from primarily a care worker perspectives. Here the role of work organisation and staff recruitment and retention in providing quality of care is also emphasised. Part VI draws together the different pieces of evidence to address our nine research questions including the pointers for public policy to promote the recruitment and retention of the social care workforce. EWERC Part II. Commissioning and contracting in the selected local authorities 65 II. Commissioning and Contracting in the Selected Local Authorities One of the project‟s key hypotheses is that the commissioning and contracting practices of Local Authorities shape the environment in which private and voluntary sector providers are able to seek to recruit and retain the social care workforce. Here we explore the characteristics of these commissioning and contracting practices in the fourteen LAs that we selected for further study. The chapter is divided into four parts: in II.1 we combine information from the first stage survey of LAs with information from the second stage LA interviews to provide a quantitative analysis of the key characteristics of commissioning and contracting practices. In II.2 we analyse the qualitative material based on the interviews with key actors in commissioning and contracting in stage two of the project to explore the different pressures placed on LAs and to identify the approach taken by our selected LAs. In II.3 we draw together the two sources of information to provide a categorisation of the approaches by the selected LAs to be used to inform our analysis of the telephone survey of providers. Finally in II.4 we use our classification of LAS to explore variations in user satisfaction scores in the home care survey of LAs 2008-9 (NHS Information Centre 2009a). II.1. Key commissioning and contracting characteristics II.1.1. Extent and form of external commissioning and contracting Extent of outsourcing in domiciliary care The fourteen LAs all contracted the majority of their domiciliary care work to independent providers (see table II.1 column 1)10. The shares outsourced varied between 55% and 100%: two outsourced under 60%, five between 60 and 80%, five over 80% but still with some inhouse and two outsourced 100% with no inhouse provision. This level of outsourcing was relatively new in some cases with 6 reporting that the majority was outsourced only after 2005, five between 2000 and 2004 and three before 1999. There is no link between the date of outsourcing and current levels: two that started early have relatively low levels of outsourcing and two that moved late to significant outsourcing have ratios above 80%. There is also a continuing tendency for the LAs to increase the share of work outsourced with 10 This share is higher by contact hours than by price due to higher unit costs for LA provision. Most of the LAs when asked in interview gave the information on an hours basis; this difference in measurement in part explains the higher levels of reliance on external providers in our follow up interviews from the first stage survey. EWERC Part II. Commissioning and contracting in the selected local authorities 66 increases in several between the stage one survey and the stage two interview and six LAs had plans for further increases. Only one anticipated a possible reversal of this trend if more emphasis was placed on re-ablement; this was an LA that currently outsourced over 90% but its inhouse provision, joint with the NHS, was focused on re-ablement. Of the twelve still with some inhouse provision, five were providing both specialised and general domiciliary care from its inhouse provision while seven had already moved towards a specialised focus for inhouse provision (Table II.1 column 3). Two LAs (OM, TE) had changed from more general to more specialised inhouse provision between the first stage survey and the second stage interview. In six LAs only inhouse units were engaged in intermediate and/or mental health elderly care (table II.1. column five). In the remaining eight, six recorded involvement by both inhouse staff and independent provider staff while two, those with no inhouse provision, relied entirely on independent providers. Involvement in unsocial hours working is common across both LADPs and IDPs. All LADPs were involved in daytime, evening and weekend work. Likewise, all independent providers were involved in these forms of work. The majority of evening and weekend work is likely to be carried out by the independent sector given their high share of total care hours and expenditure. The main differences among LAs were found in night work (table II.1. column six). One carried out no night work by either type of staff. A further two had no inhouse facility and five more undertook no night work, leaving six LAPDs that were involved in night work. Three of these six did not involve any IDPs in night work. In the 10 LAs where IDPs were involved, this concerned all providers in five LAs but only some providers in the other five. Overall, there is a strong reliance on the IDPs for the unsocial hours working but as inhouse operations have become more specialised, there is also a high involvement among the remaining inhouse staff. Among our LAs all but three commissioned jointly for intermediate care with the NHS (table II.1. column seven). The three exceptions had either no or very limited inhouse provision. This may suggest that the lower the direct involvement of LAs in service provision, the less likely their involvement in joint commissioning. While the stage one survey found that three LAs did most of their commissioning with the NHS all the rest recorded an involvement of under 20% except for one other at 40-60%. One LA (AH) had become fully integrated with the NHS between the stage one survey and the stage two interview. In several cases there were plans for more involvement, even in one case when currently there was no involvement. Independent care staff were involved in providing jointly commissioned services in half of our LAs (table II.1. column eight). EWERC Part II. Commissioning and contracting in the selected local authorities 67 Table II.1 Key commissioning and contracting characteristics for domiciliary care LA % Outsourced Planned change to outsourcing AH 80%-99% Less Specialised Both LA and IDPs IDPs only High Joint commissioning but no IDP staff involved ON 60%-80% More Specialised LA only IDPs only Low IDP staff involved in more than one area RT 100% No change None IDPs only IDPs only Very low No joint commissioning RN 80%-99% No change Specialised Both LA and IDPs LA only High Joint commissioning but no IDP staff involved UY ≤60% No change Mixed Both LA and IDPs LA only Low IDP staff involved in more than one area AD 60%-80% More Mixed LA only IDPs only Low IDP staff involved in more than one area AW 100% No change None IDPs only IDPs only Very low No joint commissioning IL 60%-80% More Mixed Both LA and IDPs High Joint commissioning but no IDP staff involved OM 80%-99% More Specialised# LA only Both LA IDPs Neither Low IDP staff involved in one area XD ≤60% No change Mixed Both LA and IDPs LA only High IDP staff involved in more than one area HD ≤60% More Specialised LA only IDPs Low IDP staff involved in more than one area TE 80%-99% No change Specialised# LA only and Medium No joint commissioning LK 80%-99% No change Specialised LA only and Low Joint commissioning but no IDP staff involved RD 60%-80% More Specialised Both LA and IDPs Both LA IDPs Both LA IDPs IDPs only Low IDP staff involved in one area *Integration with the NHS: Role of the LADP Involvement in night work High = ≥60% intermediate care joint commissioned Medium = >20%≤60% intermediate care joint commissioned Low = ≤20% intermediate care joint commissioned Very low = no joint commissioning of immediate care # Recent change from general to specialised EWERC Involvement in intermediate and/or mental health care and Integration with the NHS* Independent sector staff involved in joint commissioned intermediate care Part II. Commissioning and contracting in the selected local authorities 68 Number of providers and contract form in domiciliary care The number of domiciliary care providers that the LAs contracted with at the time of the stage 2 interview varied w from five to 35 (table II.2. column two). The extent of additional spot contract arrangements varied between LAs, complicating comparisons of the number of actual providers. For example, one LA (AW) had intended to use almost exclusively two main providers for each of its two main geographical areas but due to major post contract problems with one of the providers, much of the work was being undertaken by providers with only spot contract arrangements with the authority. Table II.2 sets out the different types of contracts and number of providers under each type that were active within the fourteen LAs. One of the major areas of change, both over recent years and planned for the future, was the switch from block contracts to preferred providers. The most common form now of contracting is through selected preferred providers but often contracted under a framework agreement or under a cost and volume contract but with no guaranteed hours. This applied to nine of the LAs. The five other LAs used block instead of preferred providers but only four of these put most of their work though block contracts. The fifth LA had a large rural hinterland served by a large number of spot contract providers. Compared to the stage one survey results for early 2008, the number of our LAs with block contracting had reduced by late2008/2009 from six to four. A further four had also recently moved from block to preferred provider, three of them in 2007/8 (table II.2. column six). Two of the LAs using blocks in 2008/9 had in fact moved to block contracting in the relatively recent past (since 2005), so that the direction of travel was not all in one direction. Furthermore, the move from block to preferred provider was not in all cases associated with an increase in the number of providers. Two LAs had in fact reduced providers while moving from block to preferred provider (AH, AW). One of these LAs (AH) also described the new arrangement as a „new block‟ contract, that is involving similar commitments to block but without minimum guaranteed hours. Overall there is quite a diversity not only in the number of providers contracted with but also the direction of change; eight had explicitly sought to decrease the number of providers it mainly dealt with while four had sought to increase the number (and only two recorded no change). The outcome of these various strategies had also resulted in quite a diversity among the LAs in the extent to which they were primarily reliant on relatively few or quite a large number of domiciliary care providers to deliver the bulk of their domiciliary care. Thus four relied on five or fewer, four on six to ten providers, four on 11 to 20 and two on more than 20. All the LAs had divided up their tenders by geographical areas but still had adopted quite different strategies with respect to the designation of providers by area. In some LAs (at least seven) there was only one provider per area. In others there was a main provider and one or more second tier providers (either spot providers or preferred providers who had a main and one or two more subsidiary areas). Only three had a number of main providers per area (two had three and one five). The characteristics of the areas had an impact on the tender arrangements in some cases. For example, XD required bidders to choose an easy to service EWERC Part II. Commissioning and contracting in the selected local authorities 69 area and a difficult to service area as an explicit means of increasing the supply of services in the more rural areas. Table II.2. Characteristics of LAs’ organisation of domiciliary care contracting. LA Number of external providers of domiciliary care LA contracts with Number of block contracts Number of preferred providers Number of spot providers Recent changes in block contracting Experience of TUPE transfer AH 5 0 5 10 Away from block none ON 17 0 10 7 Away from block none RT 7 1 6 0 LADP to IDP 10 0 10 0 No change some block No change no block RN UY 10 0 6 4 none AD 10 0 4 6 No change some block To block AW 10 0 2 8 Away from block IL 9 0 9 0 Away from block LADP to IDP. IDP to IDP IDP to IDP OM 17 0 17 0 Away from block none XD 35 11 0 24 To block none HD 17 10 0 07 none TE 5 0 5 0 LK 30 30 0 50 No change some block No change some block Away from block RD 14 0 6 8 Away from block none none none IDP to IDP none In three of the LAs, inhouse staff had been TUPE transferred to external agencies and in one case the same staff had been TUPE transferred a second time to a new agency (Table II.2. column seven). The TUPE regulations protect the terms of employment of transferring staff, resulting in continued LA pay and non-pay conditions which are more generous than in the private sector (see part 1). In all three cases these arrangements were still having a significant impact upon the fees paid to the providers concerned. TUPE arrangements affected not only ex-LA employees, but also cover staff moving from one independent sector provider to another. In at least three LAs there were examples of staff TUPE transferred from one agency to another due to changes in the providers, either because of outcomes of tenders or because of closures of providers. EWERC Part II. Commissioning and contracting in the selected local authorities 70 Commissioning and contracting of care homes Twelve of the fourteen LAs still provided some residential home care inhouse (table II.3. column two). Those without LA provision included one which also had no domiciliary care but the second LA with no domiciliary care was still providing a range of forms of inhouse residential care. The second LA (XD) with no inhouse provision had transferred its homes to one specific provider. Ten of the LAs provided short term intermediate care and ten dementia-specific short term care (though not the same ten as two provided intermediate and not dementia and two vice versa). Four of the twelve with some inhouse provision only provided short term care of some kind (including short term care in a resource centre although this was always combined with either intermediate or dementia short term care or both) (table II.3 column three). The remaining eight were involved in some forms of long term care: all eight provided dementia long term care and three provided resource centre based long term care but none provided short or long term care under the heading of other, suggesting all had withdrawn from standard residential care provision. Ten LAs have some block purchase contracts with independent providers for residential care of various kinds (Table II.3 column four). While the purposes of the block purchases are spread across dementia, respite and intermediate care- with only two mentioning other purposes (non specific and carer support respectively), the proportion of the residential care accounted for by block purchases was most commonly under 10% ( six LAs). Two LAs (IL and XD) had shares above 40% while two (AW and LK) had shares at 20-29% and 10-19% respectively. The high share at XD was due to the transfer of its homes to a specific provider. In IL intermediate care is contracted out through a block contract although consideration is being given to changing the inhouse provision form long term care to short term care which might reduce the use of block contracting. With these exceptions, contracting was thus mostly on a spot basis, usually according to the preferences of the user. LAs usually had a list of homes that they were prepared to place users in; in some cases they had a policy of only placing users in homes above a minimum CQC star rating (either one or two star) but sometimes they would still make exceptions if there was either a shortage of beds or a strong reason why the user preferred the home even though it had a poor quality rating. Under this spot contract policy the number of homes that the LA was currently contracting with was normally quite large although the numbers quoted varied from 30 or so to 400. Where the area bordered other residential areas- for example in the outer London boroughs- there was more use of homes outside the area. In some cases (RD) this was a planned strategy as labour costs were lower across the border so that those not able to pay top up fees were encouraged to choose a home outside RD. EWERC Part II. Commissioning and contracting in the selected local authorities 71 Table II.3 Commissioning and contracting of residential care LA Local authority is a provider of residential home care? Type of residential care provided (all intermediate, dementia or resource centre – no ‘other’) LA has any block purchase arrangements with residential or nursing homes Estimate of block contracting as share of total beds by external providers, Residential care price per week for older people provided by others. PSS EX1 Return for 2007-081 Higher fees for higher quality homes AH Yes Long and short term Yes 1-9% High >£460 No ON Yes Long and short term Yes 1-9% Low £350-£390 No RT Yes Long and short term Yes 1-9% Medium £390-£460 No RN Yes Short term only Yes 1-9% High >£460 Yes UY Yes Long and short term No N/A Medium £390-£460 Yes AD Yes Long and short term Yes 1-9% Medium £390-£460 Yes AW No None Yes 20-29% High >£460 No IL Yes Short term only Yes 40-49% Very Low <£340 No OM Yes Long and short term No N/A Very Low <£340 Yes XD No None Yes 50% or more High >£460 No HD Yes Short term only Yes 1-9% Low £340- £390 No TE Yes Short term only No N/A Low £340- £390 Yes LK Yes Long and short term Yes 10-19% High >£460 No RD Yes Long and short term No N/A Low £340- £390 No 1 Definition- based on unit costs residential care for older people provisions by others Unit Costs Summary Sheet PSS EX1 return 2007-8 annex council tables. http://www.ic.nhs.uk/statistics-and-data-collections/social-care/adult-social-care-information/personal-social-services-expenditure-and-unit-costs:-england-2007-08 EWERC Part II. Commissioning and contracting in the selected local authorities 72 II.1.2. Provision of fees for externally provided care Fees for domiciliary care Six of the LAs set a fixed fee per hour when they published the tender for IDPs and all providers were contracted at that rate11 (table II.4. column two). In the remaining eight cases fees varied across providers according to the price at which different providers tendered to provide services. Those paying fees according to tender price were much more likely to ask for the wage element to be separated out at tender: this applied to seven of our LAs and an eighth that asked for it at short list stage. Only one of these eight (LK) paid a standardised fee. The practice thus seems to be more about the LAs wanting additional information if it were to pay above a standard rate than a policy to select on the basis of fair treatment of staff. Only two of the LAs specified a minimum wage to be paid (TE that did not ask for the wage elements to be spelled out and XD that did). In practice even if the fees were fixed according to the IDPs‟ tender price, the variation within an LA was quite low, that is at £2 to £3.50 except for one LA (XD) where the range was £12 between the lowest and the highest fee (table II.4, column four). The LA (LK) that had different prices by area had a differential of £4 between the most difficult and the easiest to service and it is likely that some of the variations in the other LAs reflected differences by geographical area. The three LAs which contracted with agencies where TUPE transferred inhouse staff were employed paid these agencies a fee that exceeded the median rate for the other IDPs by between £4 and £7.50 per hour12. The average fee paid to IDPs (excluding these TUPE related fees 13) ranged from £10.45 to £14.50 for 13 LAs. XD was again an exception with a higher implied average fee as well as large range of £16 to £28; we have classified the average fee for XD as £20. To classify the LAs by fee level we paid attention to both the lowest fee and the midpoint or modal fee level (where this was indicated to us). Two paid a fixed fee to all below £11 and we classified these as very low payers. Two more had average fees below £12 and we classified these as low payers (one paid a fixed fee14 and the other had variable fees). Those paying between £12 and £14 – both minimum and average fee levels were classified as medium fee payers and those paying above £14 on average and above £13 as a minimum were classified as high fee payers (table II.4 column three). 11 In the case of LK there were three fixed prices related to the nature of the geographical area- easy to service, medium and hard to service. 12 No precise information for RT but a significant differential was paid 13 The fees rates reported for agencies with LA TUPE transferred staff were £22 compared to an average of £14.50 to other providers (AH) and £16 to £19 compared to an average of £13 to other providers (AW) (table II.4. columns 2 and 3) 14 In the case of ON there was a move from a fixed flat rate of £11.17 per hour with a higher price for half an hour contact visit to a fee of £1 per hour plus a proportion of £12.15 per hour depending on the actual recorded minutes of the visit. The flat rate element was to be reduced in 2010 to 60p. EWERC Part II. Commissioning and contracting in the selected local authorities 73 Table II.4 Fee levels and fee setting for domiciliary care LA Standard price or contract price AH Varies by tender offer ON RT RN UY AD AW IL OM XD HD TE LK RD Standard price or midpoint of price range 14.50 Range of price variations - maximum minus minimum 1 £3 £9 including TUPE Price set by LA 11.17 £0 Source of variations across providers Tender offer, preferred/spot, TUPE None Varies by tender offer Price set by LA Price set by LA Price set by LA Varies by tender offer Price set by LA Varies by tender offer Varies by tender offer Varies by tender offer Varies by tender offer Price set by LA Varies by tender offer 13.00 10.78 12.53 £2 (estimate) TUPE price not known £0 £0 £0 £2 £7 including TUPE £0 £3.49 Tender offer TUPE HR performance None None Tender offer TUPE Urban/rural Tender offer 20.004 £12 11.74 £1.93 13.08 £2.60 14.25 12.5 £4 £3 Tender offer Urban/rural Tender offer Urban/rural Tender offer Performance Urban/rural Tender offer Urban/rural 1 13.10 13.16 10.45 13.00 Additional payments for unsocial hours Bank holidays Weekends or nights Travel costs Bank holidays3 Higher price for 30 minute visit. Require payment in contract Higher price for 30 minute visit Low+3 Higher price for 30 minute visit Monitor for gaps No specific provision No specific provision Medium+ Medium+ Very low Medium No specific provision No specific provision Very low Medium Rural price High+ Rural price Low No specific provision Medium Rural price Rural price High+ Medium+ Weekends or nights Weekends or nights No specific provision Classificati on of LA by fee level High + Medium+ These ranges exclude fees paid to IDPs with TUPE transferred staff + indicates either some provision for unsocial hours payments, for travel time or for performance bonus 3 These were withdrawn between our LA interview and our survey of providers 4 This LA had a range of £12- the norm was estimated on the basis of the interview to be closer to the bottom of the range- we thus took the point one third of the way up the range rather than the midpoint. 2 EWERC Part II. Commissioning and contracting in the selected local authorities 74 The fee paid per contact hour may not, however, capture all the dimensions of the generosity of fee provisions. In particular it does not provide us with information on how contact hours are calculated. Such information is difficult to collect in detail in a comparable form and was beyond the scope of this project. However, some information was collected on additional aspects of fee provision, particularly with respect to issues such as type of care, the treatment of travel time, unsocial hours, etc. The first point to note is that the fee paid for domiciliary care was a flat rate fee, not normally differentiated by level of care provided, except in some cases where the LA was commissioning intermediate care in conjunction with the NHS. This pattern for our selected LAs complied with that found in the stage 1 survey. For the 90 responding LAs over one third, 36%, had a standard price for domiciliary care. Of the remaining 64%, only 10% of LAs, just over 6% of the total sample, reported variations in fee by individual user and this did not include any of our LAs. The implication of this policy is that there are no gains for providers in relation to the fee paid if they have more skilled staff able to undertake care work for those with a higher level of dependency, unless this work falls under a different commissioning process. Very few LAs also provide for travel time explicitly in their pricing and fee policy. Of the fourteen in our survey only three paid more for short hours visits (usually a higher rate for 30 minutes) and two of these were phasing this practice out (ON, RN). A number of other LAs said they had paid higher rates in the past but had already phased them out in the interests of administrative simplicity. One other LA (UY) said it paid for travel time in calculating contact hours. Four had an explicit policy of paying extra for rural domiciliary visits but this was normally built into the standard price for the provider who covered the rural area. This information was confirmed at the stage two interview but also matched answers to the first stage survey with respect to variations by ease of travel, except for one LA (LK) that responded to the stage one questionnaire that it had a standard price for domiciliary care but in practice it had recently introduced three standard prices which varied according to the travel issues in the area. As eight of the fourteen LAs did pay different rates to providers there may be more allowances for travel issues than perhaps is captured by these measures. One LA (TE) paid a higher fee not on the basis of travel time per se but if the provider agreed to take on a case that was outside their specified geographical area. This may reflect a tendency to only allow one fee per provider under the contract, unless something unusual outside the standard terms occurs. Another factor affecting payment for travel time is whether or not electronic monitoring is used. One LA (ON) moved to payment by minutes based on electronic monitoring during the period of our telephone survey of independent providers and this was changing how providers compensated staff for travel time (see part III and part V below). There was even less evidence of additional payments for unsocial hours in the fees paid by our fourteen LAs. Two (ON, AH) paid extra fees for bank holidays but one was considering phasing this out (ON). Only three paid extra for nights or weekend work (AH, RN, XD). This low incidence of additional payments is similar to the overall results for the stage one survey where only just over 20% of the LAs without a standard price said they paid extra for travel time. Two LAs, both medium fee payers (RN and TE) provided some additional fee for EWERC Part II. Commissioning and contracting in the selected local authorities 75 providers who met performance targets, with RN specifically setting HR performance targets and requiring providers to spend the additional fee on their staff. If we include additional payments for unsocial hours or travel time into the analysis (table II.5 column five) we find that these additional payments on the whole reinforced divisions between LAs rather than compensated for low basic fees. The one low payer that was making additional payments was withdrawing from these as it moved to payment by minutes recorded by a new electronic monitoring system (although it was also raising the fee level, potentially pushing it into the medium category). However, the greater incidence of additional fees for travel among the high payers reflected the rural nature of the areas covered in the two cases concerned. Fee levels are related to geographical location: Table II.5 shows that all the very low and low fee payers are located in the north and all the high payers in the south. Among the medium fee payers three are southern LAs, three in the midlands and one a northern LA. All the high fee payers were in areas of high female labour demand (see section I.7 and appendix table I.A1). Local labour market conditions may explain the positioning of two southern LAs (the two outer London boroughs) within the median fee category as they scored only three for female labour demand but the final southern LA had a score of five for female labour demand. Another outlier is the northern LA that is a low fee payer but has a five score for female labour demand. The other three low or very low payers were in areas of low or medium female labour demand. Fee levels in the majority of the LAs thus bear some relation to geographical position and local labour market conditions but the relationship is not fully consistent. Table II.5. LA fees for domiciliary care by geographical area and local labour market conditions Total Geographical area Local labour market conditions: Additional payments for unsocial hours, travel or performance Number of LAs given + in table II.4 column 8 Low and very low fee payer 4 4 north 1 strong, 3 weak 1+* Medium fee payer 7 1 north, 3 midlands, 3 south 1 strong, 4 medium, 2 weak 4+ High fee payer 3 3 south 3 strong 3+ Note: *These were withdrawn between our LA interview and our survey of providers Fees for residential care Table II.3 column six classifies the LAs by the average cost of their residential care for older people (without nursing or dementia) according to the data provided by the LAs themselves EWERC Part II. Commissioning and contracting in the selected local authorities 76 in their PSS EX1 Return for 2007-08. We have used these data in preference to that provided by the LAs in our survey as it became apparent that there were inconsistencies in how these fees were reported to us. However, the published data corresponds to our information in most cases, except where we were doubtful of its accuracy. One- that for OM- appears rather low but there have been changes in its system since 2007-8 including quality uplifts which may account for this divergence. Only broad categories have been used here to preserve the anonymity of the LAs. There are major problems in classifying the LAs according to fee levels as it is clear that the variations in fee levels are very large and reflect differences in property markets more than in labour markets. For example, the two outer London LAs are classified here as high and medium payers but both pay below average for outer London. While this could be an alternative way to classify the LAs for the two cases, there is a very wide variation in property and labour markets in for example unitary authorities, metropolitan areas and shire counties so that these average fee data are less helpful for the purpose. The information that we did gain from our interviews is that many LAs have introduced quality enhancements. Five of the LAs are currently paying higher fees to higher quality homes (table II.3. column seven) and ON pays an additional fee for Investors in People award and is considering a more fully developed quality framework. As we discuss further below, there are differences in the strategies used by LAs with respect to setting their fee level; some aim to minimise any pressure for those placed in homes to pay top up fees, while others expect most to have pay an additional fee or even seek to place those unable to pay additional fees in homes located in cheaper property areas outside their own boundaries. Classifying the LAs by fee level: domiciliary and residential combined To put all this pricing information together we have combined information on domiciliary and residential care. In Figure 3.1a.we classify the LAs on the basis of average fee for domiciliary (table II.3. column 8) and the average cost of residential care (table II.3 column six). We allocate a score of 1 to 4 for very low to high for each category and for overall categorisations we take high payers as having a score of eight, medium six or seven, low five and very low four or less. On this basis we have five very low fee payers (IL, HD, AD, OM, ON ) two low fee payers (TE, RD) four medium (AW, RN, RT, UY) and three high (AH, LK, XD) (note the squares are shaded from light to dark as one moves from very low to low, medium and high fees). In Figure 3.1b to capture the extent to which LAs provide additional payments for quality in the cases of homes we add 0.5 to every LA that has a quality uplift and for LAs that pay for either unsocial hours and travel to IDPs we add a 0.5 to the score for domiciliary fees (table II.4 column seven). We then adjust our scoring categories with very low still 1 to 4, low 4.5 to 5.5, medium 6 to 7 and high 7.5 to 9. On this basis three move from very low to low (AD, OM, ON) and one (RN) moves from medium to high. Indeed all but IL, HD and AW increase their scores by 0.5 points. EWERC Part II. Commissioning and contracting in the selected local authorities 77 Figure II.1a. Categorising the LAs by standard fee levels- domiciliary and residential Domiciliary care fee Very Low Very Low Residential home fee Medium IL Low Medium Low High OM ON TE HD RD AD RT UY High AW AH RN XD LK Figure II.1b. Categorising the LAs by standard fee levels and quality enhancements domiciliary and residential Domiciliary care fee Very Low Very Low Very Low+ Low Low+ Medium HD Low+ ON RD TE Medium Residential home fee High+ OM Low High High IL Very Low+ Medium+ Medium+ RT AD UY AW AH,XD LK High+ EWERC RN Part II. Commissioning and contracting in the selected local authorities 78 II.1.3. Role of HR factors in tendering, contracting and monitoring The stage 1 survey asked whether LAs required providers to conform to up to ten HR policies in either the tender or their contracts for IDPs. In practice most LAs included the same number of policies at tender as at contract15. In practice only three LAs (AH, IL, RD see Table II.6 column 3) included most or all of the ten policies, at nine or ten policies each. The majority of LAs (six at tender, five at contract) included six to eight policies while four at tender, five at contract included fewer than six. (One LA (XD) had missing data). Three policies were categorised as concerned with pay (pay for training, travel or mileage) and five with training and development16 (staff development and appraisal, management training, induction and training, specialist dementia training and training achievement against national targets). More LAs (11) scored high on training and development (with at least four out of the five policies) compared to only four LAs who included at least two out of three pay policies. Only three LAs required payment for training time (AH, ON, IL) and only five for travel time (AH, ON, RN, IL, RD). 15 One LA (ON) included more policies at contract stage and one (OM) at the tender stage The two excluded were payment for sick pay as it was not clear if this referred to more than statutory sick pay and supervision of staff as all but one LA included this in their requirements. 16 EWERC Part II. Commissioning and contracting in the selected local authorities 79 Table II.6 LAs’ monitoring and quality frameworks LA Domiciliary care providers Number of policies Quality monitoring by LA In tender/In contract training pay HR policies Own framework Use of electronic policies policies Maximum without/ with financial monitoring Maximum Maximum 103 incentives 51 32 Residential homes Number of policies Quality monitoring by In tender/In contract LA training pay HR Own framework with/ policies policies policies without financial Maximum Maximum Maximum incentives 51 12 83 AH 4/4 3/3 9/9 Yes None 4/5 1/1 7/8 None ON 0/2 0/2 0/5 Yes Planned* m m m RT 5/5 0/0 6/6 No All 5/ 5 0/0 6/6 Yes with financial incentives None RN 4/5 2/2 7/7 None 5/ 5 0/0 6/6 UY 4/4 0/0 5/5 Yes with financial incentives Yes Some 0 0 0/n,a, AD 5/5 0/0 6/6 Yes Planned 5/ 5 0/0 6/6 AW 0/3 3/0 4/4 No All 0/3 0/0 0/4 Yes with financial incentives Yes with financial incentives Yes with financial incentives None IL 5/5 3/3 10/10 Yes All 5/5 1/1 8/8 Yes OM 5/3 2/0 8/4 No Some 0 n/a 0/n.a. XD m m m Yes All 4/0 0/0 5/0 Yes with financial incentives Yes HD 5/4 0/0 6/6 Yes Planned 4/n/a 0/n/a 4/0 Yes TE 4/4 0/0 4/4 All 4/n/a 0/n/a 4/0 LK 5/5 0/0 6/6 Yes with financial incentives Yes None 5/5 0/0 6/6 Yes with financial incentives Yes RD 5/5 2/2 8/8 Yes None 3/n.a. 0/n/a 4/n.a Yes EWERC Part II. Commissioning and contracting in the selected local authorities 80 In relation to tenders with care homes LAs were only asked about eight HR practices as travel time and payment for mileage were much less relevant. Three LAs specified no policies in their tenders and for another data were missing. Of the remaining ten, six specified six or more policies and four between four and five. However, only two specified payment for training, the only pay policy apart from the ambiguous sick pay question. Most policies were related to training with nine LAs specifying at least four training policies, not including the pay for training policy. The question about contracting referred only to block contracting which only applied to ten LAs. Of these, two did not provide for any HR policies in their contracts and one had missing data while six specified six policies or more and only one had a low score at four. Only two LAs specified pay for training while six had at least five other training policies in their contracts. The majority of the LAs were also actively involved in monitoring the provider with respect to HR practices and many were active in developing their own quality framework: only twothe two outer London boroughs- relied entirely on external monitoring by CQC and one was planning to introduce its own framework. Of the remaining 12, all but one had a quality framework for IDPs and nine for homes. Two LAs (TE and RN) offered financial incentives to IDPs for meeting quality targets, with the target explicitly related to HR issues in one case (RN). Although quality frameworks were somewhat less common for homes, they had potentially more impact on providers as they were associated in six LAs with a quality-based pricing framework. Five however had their own quality framework for monitoring (RD, IL, HD, XD, LK) without any financial incentives. Another mechanism for monitoring IDPs was electronic monitoring. This was another area of rapid change. At the time of the stage two interviews five LAs had already introduced electronic monitoring for all17 (table II.6 column six) and two were using it with some providers In almost all cases this was a very recent development and another LA (ON) introduced it over the period of the survey with a further two having active plans to introduce it. This left four with no current use or plans for its use. II.1.4. Extent of support for providers through forums and training provision Local authorities provide additional support to independent providers in two main ways: first by providing or organising training for independent sector staff; second by consulting with providers through forums and in relation to commissioning strategies. 17 AW said it had a mix as not all spot contractors had introduced it but further probing revealed that it was only those with electronic monitoring that were being actively commissioned. EWERC Part II. Commissioning and contracting in the selected local authorities 81 Table II.7 LAs’ support for providers through training and provider forums 1 LA Frequency of forum meetings per annum High- 6+ M-3 -5 L-1 or2 Organisation of forums for domiciliary and residential homes providers Training partnership with independent providers 1st stage survey/ 2nd stage interview Number of types of training1 provided by LA to Independent sector Stage 2 interview Assessment of training activity by LA alone or in partnership Involvement in commissioning : Providers of social care services AH M Combined No/No Low Low Yes ON M D and H separately No/Yes Low High Yes RT M D only No/No Low Low Yes RN H D only Yes/No Medium High Yes UY H D and H separately Yes/Yes High High No AD H Combined Yes/Yes Zero High Yes AW M D and H separately Yes/No Zero Low Yes IL H D and H separately Yes/Yes Medium High Yes OM M D and H separately Yes/yes Medium High Yes XD L Combined No/No Zero None Yes HD M D and H separately No/Yes Zero High No TE M D and H separately No/Yes Medium High Yes LK H D only Yes/yes Medium High No RD H D and H separately Yes/Yes High High Yes Coding Zero-none Low up to 4 Medium 5- 9 High 10 + more Training support may be provided through training partnerships; in the stage one survey eight of the LAs said they had formed training partnerships with independent providers but information from the stage two interviews suggests that this should be nine. In fact three more said they had partnerships while another two did not currently have a partnership (table II.7 column four). Of the two who said they had a partnership at stage one but not at stage two one (AW) did not provide any training themselves, probably because it had no inhouse staff, while RN did not have a training partnership but was nevertheless very active in the provision of training for independent staff. Table II.7 column five shows that the formation of a training partnership was associated with higher levels of support for the training of independent staff but not in all situations. All who provided medium or high levels of training to independent sector staff had a partnership according to our stage two interviews – except for RN that opened up its own LA training to independent staff. Some that recorded a low or zero incidence of training on the stage one survey were found in the stage two interview to have high levels of activity (for example ON, HD, AD). In each case the training was provided by a partnership and the respondent may therefore have decided to answer no with respect to LA provision. Column six of table II.7 provides an overall assessment of activity of the LA in training provision based on the stage two interview supplemented with the stage one information and finds: one LA (XD) not involved currently in training provision due to EWERC Part II. Commissioning and contracting in the selected local authorities 82 the collapse of a previous partnership when funding sources dried up, three LAs (AH, RT, AW) with either no or very limited inhouse provision recording low involvement; all remaining ten have been classified as having a high level of involvement. With respect to consultative arrangements, all but two LAs involved the providers in consultation over commissioning (the exceptions were HD and LK table 3.7 column seven). All also held provider forums for care providers according to the stage one survey. In one case these forums met only once a year but for the others the frequency was three to four times a year for seven LAs and up to six times for six LAs. Through the stage two interviews we gained more information about these forums; in all cases there were forums held for domiciliary care providers and in three cases these were joint with providers of residential homes. In seven LAs separate forums were held for domiciliary care and residential care providers and in three LAs no forums were organised for the residential home providers. In six LAs the interviews with the LAs suggested that these were not very active bodies, whether for domiciliary or residential. One of these had only recently re-established the forum18. In another (AD) in principle the forum met six times a year but in practice attendance was low so meetings were often cancelled. A particular problem here was that many providers worked for more than one LA so that they felt they had too many meetings to attend (see part IV for providers views in the telephone survey with respect to the usefulness of the forums). 18 Under the stage 1 survey this was the LA- XD where the forum met only once a year but there were plans for it to be more active. EWERC Part II. Commissioning and contracting in the selected local authorities 83 II.2. Approaches to commissioning and contracting: the qualitative interview data The qualitative interviews with key actors responsible for commissioning and contracting in the 14 selected LAs revealed the multiple and potentially conflicting influences on commissioning practices19. Not only is social care commissioning taking place within the wider local authority and is thereby subject to specific local organisational and political environment but there are also multiple and often competing longer term policy agendas for the development of social care. In respect of policies towards independent providers there are competing agendas between the need to support providers and develop the supply base against the need to take costs out and control price while improving quality. Further competing agendas stem from the issues of whether LAs should continue to be the drivers in commissioning or whether this should be developed jointly with the NHS or devolved to users. The issues of direct concern for this project were how LAs made sense of and prioritised the various influences on their commissioning and contracting strategies. The two main current conflicting pressures were the pressure on budgets and costs on the one hand and the need to develop capacity in the market on the other hand if both quantity and quality targets in delivery were to be met. Linked to these cost versus capacity issues was a parallel potential conflict between pressure to respond to short term factors versus the need for more strategic longer term changes to the approach to social care provision. Cutting across the traditional conflicts over cost and quality and the short and the medium term came the new policy agendas of integrated health and social care provision on the one hand and personal budgets on the other. These new policy agendas were adding to some of the conflicts between short term concerns and long term strategic directions, in part because they provided potentially alternative long term strategic visions of the future of social care and the role of LAs within that provision. To explore further the nature of these conflicts and how they were being resolved within our selected LAs we follow the same four themes as identified in the literature review, namely: o making the market o price versus quality o integrating health and social care, and o the personal choice agenda 19 Note in this section we attribute quotes to the LA commissioners in general not to specific interviewees. This is done because most of the interviews involved multiple participants and to preserve the anonymity of the official concerned. In one LA- IL- we interviewed the contracting and commissioning departments separately and as they had very different and distinctive positions on the polices pursued we have made an exception and linked the quotes to either the contracting or the commissioning branches. In other cases we use commissioners to denote interviewees in contracting and commissioning. For further information on whom we interviewed at the LA level see section I.7. EWERC Part II. Commissioning and contracting in the selected local authorities 84 II.2.1. Making the market The need to develop the supply of independent providers, both to secure an adequate supply of care hours and to promote the quality of the independent sector, emerged as a repeated theme within our interviews on commissioning approaches and strategies. The diversity of issues that came up under this general heading was large and we discuss them below under three main subthemes: capacity development and managing the spatial market; purchaserprovider relationships; and interventions on quality. Capacity development and managing the spatial market The first concern with respect to capacity related to overall supply. Many of our selected LAs had been expanding the share of their social care hours that were outsourced and several were also planning further expansion. However, some LA commissioners were concerned about the capacity of the independent sector to supply the desired number of hours. For the contracting department managers in one LA (IL), the problem in their view lay in the fact that there was a fixed pool of staff and offering more hours to one provider, as the commissioners suggested as a solution to capacity, just increased labour market churning. In another LA (AD) interviewees reported that they had expended a lot of effort in encouraging its existing suppliers to make a step change in their contracting hours from around 400 or 600 to 2000 hours a week. This was to enable the LA to provide better and more guaranteed geographical coverage and to increase the share of work outsourced. In another LA (TE) commissioners spoke of the dual problems of both getting existing suppliers to cooperate in delivering according to their service needs and also in judging just from a tender what a new supplier would be able to deliver in practice. The providers are a mix of small local providers and national providers. There is one charity and one very small local company that the council has had to offer a great deal of support to to enable them to deliver what the council wanted. ….Some of it was dire, really! TE While the need to develop supply was a key part of the LA commissioners‟ concerns, these questions were primarily considered at a local rather than a national level. Thus, for example, the concerns of UKHCA that a focus on large volume contracts may ultimately reduce supply nationally by squeezing out the middle level supplier was not an issue that came up in our interviews. More concern was expressed about the actions of national providers in „asset stripping‟ the residential homes that they took over, but here the strategies of the national providers were seen as independent of any specific policy initiatives by the LA. A second set of capacity concerns related to geographical coverage. These included the need to ensure an adequacy of supply, particularly in those LAs with a large rural area, the need to to develop the spatial coverage to reduce travel time and the need to use allocation by geographical areas to reduce uncertainty over likely volume of demand for contracted providers. EWERC Part II. Commissioning and contracting in the selected local authorities 85 Different solutions were used in the two LAs with sizeable rural areas- XD and LK- to ensure supply. In XD providers were required to bid for a city and a rural area at the tender stage; in LK where most of the area was rural the tactic adopted was to offer a guaranteed stepped higher price for difficult to reach and very difficult to reach areas. It was a real challenge providing service in rural areas as workers don‟t want to travel. So they have linked urban with rural so providers work in both difficult and easy areas. XD These rates were agreed with the providers on a parish by parish basis, and will be reviewed periodically. The result of this has been that recruitment has improved in the agencies – it was good to acknowledge that providers need extra cash as encouragement. UK In less rural areas the main concern around geography was to minimise travel time and reduce inefficiencies (for example IL, HD, TE, RN). For one LA (HD) the move towards one local provider was said to be part of a wider strategy to „rebalance the market „by establishing a clearer division of labour between the inhouse re-ablement function and the transfer of cases to the independent provider selected on the basis of the LA‟s geographical mapping of the city: We have mapped every home care client across the city where they live in terms of the street and which provider, and so from there you can spot a couple of providers who are going to the same street which kind of doesn‟t make any sense. It adds additional challenges for the providers. HD Another LA (TE) had also undertaken a major reorganisation of its supplier network around a new five area geographical division, with one provider per area. This was partly related to issues of travel time but more importantly was a response to a user survey indicating problems of time keeping, rushed visits and inconsistency of care workers, all issues indirectly linked to operating a city wide rather than a geographically specific service. For at least two LAs (AD, AW), organisation by geographical area was said to be part of a wider strategy to guarantee higher volumes of hours to providers. A third set of capacity issues related to ability to meet specific needs such as care during unsocial hours or care for diverse client groups. Some LA commissioners were aware that in order to be able to outsource their social care work, independent providers needed to be in a position to provide flexible and unsocial hours services. In the case of one LA (AD) the solution seemed to be one of encouraging cooperation rather than competition between providers. This illustrates the potentially conflicting motivations in commissioning when LAs may also be concerned to encourage competition in the interests of keeping costs down. I said really you need to establish a framework for an evening service. If you are recruiting people in cars you can work across boundaries. You can come to some agreement with each other. And really what I was trying to sell them was the whole idea that this does not need to be businesses in competition. This actually could be businesses working in consensus and supporting each other. AD EWERC Part II. Commissioning and contracting in the selected local authorities 86 Promoting a diversity of supply was a major concern of the employers‟ association in this sector (UKHCA) and a principle of both the best value regime and the personal choice agenda is that there should be a range of suppliers available in the sector to provide for choice and to reflect diversity of the population. Some of the commissioners in the selected LAs were also conscious of these issues- for example, as discussed above, those in TE had provided support to a small organisation to enable it to fit with its reorganisation. However, it was one of the outer London boroughs with a diverse population where there was most recognition of the diversity of supply agenda. Because we have such a diverse community, and we tend to have more smaller voluntary organizations rather than great big national ones….I think in terms of working with the voluntary sector to provide these services if anything we‟re very slightly ahead of the curve, certainly compared to other boroughs I‟ve worked in. RT Some LA commissioners did express concern at the increasing role of national chains in the residential homes sector and the long term impact on both diversity and quality of supply: The hugely big providers just asset strip, not to put too fine a word on it. So they move in, they strip the food budget, they strip the training budget, the decorating budget, they cut down people‟s wages, you know, they do the whole bit really, as their first act, and it never gets reinstated. RT Purchaser - provider relationships The need to develop the market had led commissioners in a number of LAs to make a strategic decision to change their relationships with their providers. One LA (AH) had entered into longer term strategic relationships with a smaller number of preferred providers. A key advantage was said to be benefits in improving access and reducing processing of people coming into the system. The LA commissioners felt the smaller number of providers meant that uncertainty over volume of business would be reduced, allowing them to refer to these new preferred contracting arrangements as the „new block‟ contracts. The whole idea was that we wanted to create strategic partnership and therefore we would work with fewer partners and we knew that unless we gave them a reasonable amount of work they wouldn‟t want to go with it AH Other LA interviewees also talked about actions to change relationships into more partnerships. Our commissioning practices have changed and I very much base this on the relational aspect of commissioning. ..it‟s about the relationship with providers which is important – sharing our values, and looking to achieve a principled outcome. Win win for us all.. UY However, in some LAs the motivation for changing the relationship with providers was more to reassert LA control over the relationship. Commissioners at XD sought to reduce the power that spot contract providers had in a context of constrained supply. EWERC Part II. Commissioning and contracting in the selected local authorities 87 What we were faced with in terms of home support was a position where the balance of risk and the balance of power firmly rested with the current in county providers. We were starting to get demands - for 3 successive years we had demands for increases of 10%.... Prior to 2006 we worked purely on the basis of spot contracts, so no guarantee of incomes for them, no guarantee of service,... The strategy adopted was one of expanding the number of contractors but then moving to block contracts and consolidated pricing to include mileage. The idea behind the block contracts was that providers had told us that they couldn‟t recruit and retain staff because they hadn‟t got the guaranteed income and they didn‟t have a block contract like the internal service, so we tried to replicate that [the internal service] …around salary levels, then our internal service was on a basic of around £7.24 per hour weekdays and so the bids we generally accepted were those who pitched at around £7 per hour. Previously it had been around £6 per hour so we knew we were going to take a financial hit but we compensated for that by looking at how we might address some of the weaknesses around invoicing by bringing in electronic timed monitoring system and paying from this system. So this was the whole strategy. XD However, the ability of the LA to use its provider relationship depended upon their own power within the market. LAs could face particular problems of limited leverage on care home providers in more affluent areas due to the rather low share of LA funded clients in the total client population. If you have 128 providers with 30 beds and only 5 of those beds are local authority funded, it‟s very difficult to engage with them as they don‟t necessarily need to engage with the LA. RN Quality interventions As a key aim of „making the market‟ was to improve and to guarantee quality standards, one way of addressing the issue was to intervene directly in the development of quality standards. Most of the LAs in our sample had in fact developed their own quality framework for monitoring both domiciliary and care home providers there were some exceptions. LK which had a large number of providers on its books because of its highly spread out population. had adopted a policy of leaving it primarily to CQC to establish standards. Any provider can go through the accreditation process with the LA, and the LA then decides whether or not to take them on. …They are registered with CQC, and they agree to work to our terms, conditions, and service specifications. For a dom care agency we require them to have either been through 1st key inspection so we have evidence of type of service they deliver, or they have undertaken a customer survey with at least 6 current customers and analyzed that. However, we mainly rely on CQC accreditation.LK Where LAs had their own monitoring, this was often linked for care homes to quality uplifts on LA fees. Examples of how these quality uplifts worked were provided by three LAs (UY, OM and AD). EWERC Part II. Commissioning and contracting in the selected local authorities 88 We have incentivized our contract now with care homes we want to rid ourselves of poor homes, ….We pay an additional amount of money for excellent care homes if they are excellent they have had 2.5 % uplift plus the inflation, if good they get 1% plus inflation, and if adequate they get inflation uplift, if poor they get nothing. This is with national minimum standards, but we like to think our contract takes this further as we are outcome focused we have gone way from days of what we want them to do to specifying what we expect the outcomes to be as a consequence of that engagement.UY What we now have is a banding arrangement applying to our older persons care homes, and there‟s a quality banding and there‟s quality uplift and you can sit within one of four or five bands. …what we have done is we have dedicated £800,000 to the city residential care homes and our service users within that, and we have said that for every banding uplift that you achieve, as determined through our quality monitoring, ….you will receive an uplift of X. So you can lift your unit cost for each …city resident by an appreciable sum. And we‟re not talking about two percent, we‟re talking about somewhere in the region of twenty percent in some cases (OM) Fifty percent of the quality framework will be based upon the quality of the care delivered, thirty percent of the framework is delivered upon the environmental … arrangements, ten percent will be based around their CSCI star rating and ten percent will be based upon the views of carers and service users who use those services. So that‟s the way we‟re doing our split.AD Only a small number of LAs provided such uplifts for domiciliary care. In fact only TE provides a quality uplift in relation to care standards, as explained below. Our service users told us that there were three things wrong with it. One was that people didn‟t turn up on time, that they didn‟t stay the allocated time and there was inconsistency of carers. So using the feedback from our customers we developed contracts aligned to that, and we put three key performance indicators in it, so that ninety percent of the contract value would be paid as normal, but they would only get the extra ten percent if they could demonstrate that the KPIs had been met, which was very painful for them and us... which were also tortuous! Just so that we could demonstrate to our customers that the service was being delivered in the way that they wanted it to be, that we were getting value for money. TE In contrast one LA (IL) had discontinued its quality premium on the grounds that it had served its purpose in raising the minimum quality threshold so that it was no longer necessary to reward the good performers. We used to pay a premium for quality service, but not all organizations met the quality standards. Presumably, this was to bring up quality, because it was very low. Over time, the quality of all services improved, so we were paying for quality when we didn‟t need to. ..so, it was almost a unanimous decision – about one fee and we expect quality to be in there for the price. IL In some cases the moves towards improving quality standards through commissioning were currently aspirational due to a shortage of supply of providers that reached the desired quality standards as the contracting manager at RN explained. EWERC Part II. Commissioning and contracting in the selected local authorities 89 For care homes we have just recently introduced a process called fairer contracting and that‟s about actively encouraging higher quality and we want to work towards only contracting with good and excellent care homes but if we did that at the moment there wouldn‟t be enough care homes! RN Some LA commissioners (for example RT) stated that they were committed to working with providers to improve their star ratings so that they saw themselves a playing an active role in developing as well as monitoring standards. Another way of managing capacity was to intervene in the development of the workforce. Most of the LAs are engaged in providing training for the independent sector staff whether through partnerships or other routes. We‟ve put a lot of time and effort into improving the quality of the product, if you want, and that includes the staff. So for example, I say we‟ve invested heavily in the training partnership, which has really been very successful. RD I think the issue of how people are treated and how they are employed and whether they are invested in and developed in the independent sector is a concern that we have. [UY area] partnership forum that we have is about encouraging employers to invest in their staff and provide leadership training for managers. UY. A particular attraction in providing training for one LA (ON) was that they had control over its quality. I mean I‟m quite interested in that wider debate we‟re having about cost and fees, is there other things we could deliver that adds value to them that (…) necessarily tied up with what we pay them for an hourly rate. And training is definitely one of them, cos then we can quality assure the training that they receive, i.e. we will have delivered it.ON For another LA (OM) the advantage of involvement was said to be the opportunity to undertake better planning of training provisions than was possible if it was left up to individual small providers. Rather than them saying yes that looks like a good course we can actually evidence base it through the workforce planning, not got to that stage yet but we are looking to it (OM). One LA had set a target of 70% NVQ level 2 for its providers compared to the national standard of 50%. We target 70% of care workforce to have NVQ. One group of 16 workers, all over 50 had no qualifications and no learning since leaving school. All reluctant learners – anxiety and stress of embarking on that as well as a full time job. All got a lot out of it. LK Beyond interventions on training we found isolated examples of LAs intervening to improve employment quality along other dimensions. At one LA (AD) commissioners had tried to get providers to agree to offer guaranteed hours contracts to staff, now that they were in receipt of block contracts but one national provider had refused, leading to the overall scheme being EWERC Part II. Commissioning and contracting in the selected local authorities 90 abandoned. In another LA (ON) there was concern to ensure that providers did pay for travel time and training time. However, although the commissioners said they specified payment for travel and training time in the tender they felt themselves to be still primarily reliant on good relations with providers to ensure compliance. We‟re trying to monitor it to see there is some degree of travel time. So it‟s not just what we say it‟s what they plan. I mean we don‟t do it in a very precise sense but there is some gap between the ordered period of time and the next. I suppose … we‟re morally trying to … take the moral high ground. Obviously we can‟t instruct people to pay…. ON Another LA, RN, built in differential payments to reflect the type of care and the time dimension to care but was moving away from this system by the time we undertook interviews in the area. The price levels vary by standard/special care (i.e. needing 2 carers, medication, colostomy etc) by weekday/weekend and length of visit (60, 45, 30 and 15 mins) and then they have waking nights (though not many of them) Some LAs such as XD had used its tendering process to identify in detail the HR policies of the providers and were using this information as a key element in selection and in the price paid to providers which was highly variable. So they tried to build provisions within their contracts to meet these challenges. Also when they assessed tenders they asked providers to give them a build up of their unit costs as they knew recruitment and retention was a big issue and they wanted to make sure providers were pitching their salaries at a level were they could recruit, and they also wanted to know that tenders were viable for the future. So they had a pre-tender conference for providers where they explained to them what they would be asking for and that the purpose of it was recruitment around business continuity and viability. XD Only one LA (RN) was directly rewarding HR performance during the course of the contract. RN had a policy of monitoring its domiciliary providers against national turnover rates and rewarding those whose performance was better than the national average but only if the additional money was used to improve staff conditions. One of the evaluation criteria is staff turnover, we said the national average is 17.5% we got that of the DoH website and so we look for anything under that, that would go some way, though we have to look at size of provider as well …..They have incentive payments: 4/5 different ones! Continuity of care; take up of work; NVQ training and whether they‟ve met the 50%; and staff turnover. What they get depends on these criteria and the amount of work they provide as a company. Each quarter they send performance indicators and a formula is used to calculate the incentive payment which they will get each quarter – that‟s paid separately. They have to prove that they use the incentive money on training, staff bonuses, staff incentives and team building to encourage low staff turnover. RN EWERC Part II. Commissioning and contracting in the selected local authorities 91 One particular concern expressed by a manager at AD was that the capacity of LAs to intervene on quality standards in general might diminish if LAs continued to withdraw from being providers themselves as much of the monitoring was dependent upon the current managers‟ knowledge of the sector in operational as well as contracting terms. I actually think that if we pushed all our work out now there‟s a generation of managers who all of a sudden are late forties, early fifties, who will be gone within ten plus years time. Now if we‟ve stopped providing during that time you do have this sort of notion that, actually, we won‟t have any expertise any more. And if we don‟t have any expertise then, as I say, I have a real concern about, well, then who will develop that market. AD II.2.2. Price versus quality. The outsourcing decision The explicit reason for increasing outsourcing of domiciliary care in many of our LA cases was to reduce costs. However, those LAs that had outsourced all their services had found themselves with a high cost legacy due to the transfer of staff under TUPE to IDPs who charged a higher fee to cover the protected conditions. Interviewees at these LAs now regretted the total outsourcing decision, made in haste and no other LAs, according to our interviews, were planning any TUPE transfers even if planning further shrinkage of the internal capacity to reduce costs. Differences in the proportion of domiciliary care outsourced in part reflected both political decisions and the strategy of the LA with respect to re-ablement. Political decision was also important in residential care. One LA, LK, had quite a high proportion of inhouse residential provision and commissioners explained this practice by reference to the fact that there had always been cross-party support for inhouse provision in the council. In residential care it is clear that factors other than wage costs influence decisions to maintain or close inhouse provision; for example in one LA (RT) it was said that said that reducing inhouse provision was not „a result of overall policy decision. It‟s much more about the fact that we simply can‟t afford to maintain the buildings.‟ RT. Commissioning and contracting for low prices Although all the LAs were outsourcing to reduce costs, the importance attached to cost reduction nevertheless varied. For example many appeared to value continuity in their relations with providers but one LA (AW) made wholesale changes in their preferred providers at their most recent tender as new providers had come in at lower tender prices. This complete change of providers also involved a second TUPE transfer of former inhouse staff to two new agencies. Another LA (IL) had also pursued a strong policy on keeping rates EWERC Part II. Commissioning and contracting in the selected local authorities 92 low, including removing the quality premium. It pursued a policy of paying at the bottom of fee levels across the country. The officer responsible for commissioning justified this on market grounds, even though she recognised that the market may be undervaluing the skills required for the work. We have benchmarking information and understand that we‟re not the highest payer, but we feel it‟s reasonable. The problem with Dom Care is it is a minimum wage skills set, or perceived to be. I personally don‟t think it is, but that‟s what the market is currently paying. Because of that, they often lose staff‟. IL commissioning Several examples demonstrated that LA commissioners were aware of their position as dominant clients and pursued strategic objectives to achieve lower average cost levels. One LA (RD) had used the strategy of moving to a single price for all providers to reduce the average price level, an approach also found in AD. I think there‟s a standard price now, but we‟ve been through a whole series of getting the prices down through the tendering process, and we have tried to move to a much clearer pricing structure. We have moved to a much better, more competitive pricing structure that is a reasonable one for[our area], and that‟s, you know, the whole tendering process has been around delivering that.RD So you really had an absurd situation where some providers were getting £2 an hour more than other ones, purely and simply because that‟s what they‟d asked for. So we used the opportunity to consolidate and have one price. And we also wanted to get a way where all the things like evenings and weekends were just paid an hourly rate, and that‟s it. AD In one LA (OM) commissioners were concerned that LAs would lose their ability to „keep the lid‟ on the price level if the personalisation of budgets was widely implemented. So what we will have is a position where we do not lift the lid off the role of competitive tendering, and tendering and procurement as a principle for ensuring quality at a good price, which is the role of the local authority as a procuring body. But if you just suddenly lift the lid off and go for spot contracts then what are you gonna base your price on,…. you will find then the providers have a more robust position to just put their prices up irrespective of what the care needs are and the intensity of the care needs.OM Even under current conditions commissioners in some LAs – for example RD and IL – felt it was important to ensure sufficient competition in the market to keep costs down. In one LA (RD) commissioners were wary of reducing their number of suppliers too far in case this changed the balance of power within the commissioning environment, again leading to higher prices. „from our point of view we get the service at a lower rate because of competition‟. IL You need, I would say, at least six decent sized providers, otherwise you‟re at the mercy of the market. There is value for the local authority in having both small and large players in the market, plus new players …. A really good balance RD EWERC Part II. Commissioning and contracting in the selected local authorities 93 In another LA (ON) interviewees justified a move to a uniform price from a different block/spot price system as a way of reducing wasteful competition between providers for staff. We used to have a range of prices and that, if nothing else, encouraged the 5, 10, 20p an hour more which encouraged the movement between agencies. …. It‟s not identical, but I think it‟s closer. ON While LAs‟ fee policies varied, commissioners in some higher paying LAs (such as AH) were worried that they may have pitched their contract at too high a price, given likely future budgetary constraints. But in terms of the way the contracts have been set up has restricted us some ways – for example tied into inflationary uplifts – which are a lot more than other providers might expect to receive. AH In one LA fees for residential homes were pitched at a level where top up fees would almost always be payable. The availability of places in an adjacent lower priced area provided a rationale for keeping fees below actual residential home care prices in RD. Quite a lot of people are placed outside the borough where there is available space so RD would pay their rates under a reciprocal deal. Within the borough many establishments charge top-ups, so if people want to go into those homes there has to be a third party agreement. RD Commissioning and contracting strategies to take cost out In addition to these pricing strategies there were three commissioning strategies to take cost out of social care that emerged out of our interviews. The first involved tightening up on the time paid for through electronic monitoring and other strategies; the second involved moving from block to spot or call off contracts; and the third involved minimising the skill requirements of specific services. The rather rapid spread of electronic monitoring was being used not only to provide more accurate information on lengths of visits but also to tie payments more closely to time spent. In practice this also involved removing premia for short visits in several LAs where they had traditionally paid more for half hour than thirty minute visits. Thus as commissioners in one LA (OM) explained, the outcome is much tighter costs control over. We commission to the provider, half hour slots, pay for half hour slots, but.. some of those care packages are no more than fifteen minutes….. But new care agreements will be -You‟ll be getting fifteen minute payment for fifteen minute care package.OM Another LA, HD, had also used retendering to simplify fee systems to one flat rate, removing block and spot differences for the individual providers (although providers only doing spot may have different rates) and removing additional payments for short visits. Another LA EWERC Part II. Commissioning and contracting in the selected local authorities 94 (ON) introduced in the period covered by our survey a move to payment by the minute as registered by electronic monitoring. Not only did this replace the higher premium per half hour visit that was in place when we visited the LA but it also introduced penalties for short visits. As we explore in our case studies (see part V), some providers responded by giving an incentive bonus to staff who stayed at least 25 minutes for a half hour visits. In the interim period a flat rate £1 per hour fee was paid in addition to the timed minutes but this flat rate fee was to be reduced in 2010 to only 60 pence. At XD electronic monitoring was explicitly used to recoup some of the costs incurred by its policy of raising prices to allow for higher basic wages among the domiciliary care providers. At IL the tightening of control over visits was said to have arisen out of the change from block to spot contracting. Travel time is not included in the price. It was „sort of‟ included in block which was taskbased so they did the jobs and then left to travel. The new tenders show times, for example 15 minutes, so there is no leeway for travel time. Service users are charged for 30 minutes, but carers HAVE to leave to get to the next call on the rota and there is no time. On the schedule, one call ends at 10 am and the next one starts at 10 am. Some calls are time critical e.g. where there are medical needs. All of this is in the care plan, but if you leave a few minutes early, we get complaints. The new charging went ahead without consulting us….the complaint is not about the care, but about the charge. IL contracting The commissioning department thought that travel time should have been factored into the fee at which organisations tendered for work so that it was not the responsibility of the LA to be concerned with travel time costs. I think people should be paid for travel but I think that should be worked out when organizations are bidding for work – how much they can do their business for per hour – they should factor in that travel time. I think it should be included in the overall cost – when they say we can do that for £10 70 an hour, they will factor in say, 70p for travel time. IL commissioning A number of LAs had moved away from block to spot or call off contracting in order to improve the efficiency of use of providers as they were not able to make full use of all the guaranteed hours ( for example AW, ON). The development of the personalisation agenda was also increasing concerns among LA commissioners about being tied long term into block contracts in case they would not have this volume of work commissioned through LAs in the future. Commissioners at one LA (IL) justified the move from block to spot as giving the providers an opportunity to prepare for the uncertainties under the personalisation agenda. In another LA (ON) the move from block to spot was justified as a means of increasing flexibility and reducing overhead costs but also the change was reinforced by awareness of the personalisation agenda. [It‟s] quite expensive to manage the blocks, because with home care people are absent in hospital, respite, whatever, and you either accept there‟s a higher cost or you manage it at a cost to make sure you‟re maximising the use, and with spot buying you pay for what you get. And it used to be an argument, it always was argued that ... dom-care moved to blocks to give stability and security, but in fact the good providers have either grown or stayed very stable EWERC Part II. Commissioning and contracting in the selected local authorities 95 since we moved to this, and we haven‟t had providers saying, „Oh, we do need blocks to give us security.‟ And so on. So it‟s not proved to be a problem. And then with the personalisation agenda anyway …ON For the most part LAs did not pay extra for cases requiring more intensive care or more skill on the part of the workforce. This tended to be different when there was joint commissioning with the NHS for intermediate care where in principle care staff should be trained to NVQ level 3 in order that they can carry out instructions from professional (nurses etc) staff. In one LA (IL) these staff were notably higher paid and at a domiciliary care providers forum attended by one of the project researchers the possibility of only using NVQ level 2 staff on lower pay for those cases which were deemed not complex, said to be the majority of cases, was to be explored by the LA. Contingent commitments to provider support Another dimension to the price versus quality trade off was the tendency for support to providers through training provision to be in some cases contingent on the availability of external funds to the LA. In one extreme case –XD- the training partnerships had been entirely closed down due to a drying up of funding streams. XD has no training partnership currently with independent providers. They used to have [one]– managed by the LA but a change in funding meant that it collapsed. They are trying to invest some money into the establishment of an employers‟ forum which they say is needed because of the move towards self directed support and perceived demand for personal assistance. XD LAs with no inhouse unit for domiciliary care were also much less likely to be involved in training independent providers. The implication of some comments might be that this joint provision of training would only continue if LA staff still had a significant involvement in the training. we just have a huge demand for the basic training, so health and safety, manual handling, so there‟s just huge demand, and the individual providers find it quite hard to catch up and ….you‟d be running huge programmes wouldn‟t you. Some of them have got 300 carers. We couldn‟t possibly put that many through. RT EWERC Part II. Commissioning and contracting in the selected local authorities 96 II.2.3. Integration of social care and health Perceptions of the need for integration The LAs were found to be pursuing different agendas and strategies with respect to the development of a more integrated or holistic approach to social care provision. Some had moved a long way towards integration with health involving joint commissioning and pooling of budgets- indeed one LA (AH) merged its adult social car and housing function with the PCT- between the stage one survey and the stage two interview. The rationale for this change was explained as: The big two agendas for commissioning are the transformation of social care and transformation of community health services- so we have pulled together our commission intentions for both of those big agendas. AH Some other LAs had not integrated that far with health but were nevertheless said to be attempting to develop an integrated approach across for example social care and housing: We have an approach of promoting universal services, not just about health and social care and this where the link with housing is very important, because a lot of people have other needs other than just health and social care, benefits needs, housing needs, general support needs etc….…. Overall strategic direction is about independence, well being and choice, not promoting institutional care. We have re enablement team (care at home) – 40% of people receive 6 week intense re enablement, generally 40% less need for care packages. UY Whether the integration is with health or with other aspects of social services, one of the underlying motivations for a change of approach is a recognition that too many resources are going in to residential care. We‟re spending about forty percent of our budget on care homes. That‟s too much. It‟s reducing, I mean we‟ve seen fairly dramatic reductions so I think you are beginning to see a shift, but personally, I mean I just think that‟s far too much. But we need to do something that provides a range of stuff at an earlier point. ON At one LA (RT) commissioners expressed more radical views as to what should be happening to social care services: I mean, with residential care, and again, we‟d just stop using it. We‟d close it. It‟s a very unhelpful model of care. And it makes people poor. It strips them of their assets apart from anything else. I wish they‟d stop doing that. Again, this is all magic wand stuff. If you take what we spend on residential care –…it‟s just millions upon millions. Well, if we took it out of there and put it in our community support we could have a brilliant support. ….for example, one of the major reasons that older people in particular lose their independence is an increase in sensory impairment, particularly dual sensory impairment, so you can train a homecare worker who sees them every day to start noticing sudden deterioration in their EWERC Part II. Commissioning and contracting in the selected local authorities 97 hearing or their sight and flag it up earlier. Plus they can do all the early stroke warning stuff. I mean, we could really use this.‟ RT The identification of the causes of this problem varied. For LK, the LA among our selected 14 spending the highest share of its older people‟s social care budget on residential care (NHS Information Centre 2009b), commissioners thought the problem lay in the interface between the hospitals and the care service, a problem in their case exacerbated by the rural nature of much of the county. One of the issues, my personal view, is the hospital system - no valid assessment before they come out of hospital – they will be put into residential because it is hard to get a package for them to stay at home.….There may be a rural aspect to this – complex packages more diff in a rural area. You may need two carers, and this isn‟t happening as the providers can‟t or won‟t provide it. LK For RT, the LA where the commissioner interviewed would in principle like to close residential care, the problem is short termism. Instead all we do is, it‟s just like a sticking plaster job but actually what we could really have is a real network of workers who are experienced and trained and know their area intimately, and know the neighbours, and know what the support system is and they could support people for ages with much better early warning signs of what‟s going on. RT Hospital discharge as the driver of the care system Awareness of the long term need for a more holistic approach to social care did not prevent tensions developing between the social care and the health services. In one case (UY) the performance regimes attached to a foundation trust were said to be stretching the availability of care services which was only resolved by bringing in more suppliers on a spot purchase basis. We have great pressures at the moment, our district general hospital is a foundation trust so they want throughput so it means we have to have services and interventions for people to be discharged so we need to increase our services so we have preferred and then they approved that we spot purchase.UY In another LA (AD) the drive towards consolidation of commissioning around four block contract providers was driven by problems of meeting the demands from the health service. It was about growth. Like everybody else we were having difficulties with hospital discharge…., there was basically just a blockage at the front end. So the idea was very much about trying to create much more fluidity. AD EWERC Part II. Commissioning and contracting in the selected local authorities 98 Harmonising commissioning strategies While in some LAs the key driver towards integration was the need for better services, in other cases the driver was the efficiencies to be gained from joint commissioning and the avoidance of competing approaches to commissioning within the same geographical space. It is pretty joined up in that respect…., rather than us going out to tender for something and them tendering for something similar. HD „You avoid duplication …and the PCT would be commissioning dom care packages from providers we had just decommissioned. LA and PCT pay different fee rates, and PCT pay more than LA, even for cases where there is little health input. IL In the case of one LA (RN) involvement with the PCT in joint commissioning was in fact holding back a strategy of implementing a policy of fair commissioning based on financial incentives for reaching quality standards for residential homes. The NHS staff had had less experience of commissioning in social care and were convinced, on the basis of information on lower prices in other LAs that it may be possible to bring down the costs of social care by more aggressive commissioning strategies. This procurement hub model [with the NHS] is more cost and block focused and less fairer contracting! RN II.2.4. User choice The fourth policy agenda to impinge on LA commissioning and contracting was that of personalisation or user choice. At the time of our interviews its main effect was in the planning of future commissioning rather than on current practice but all LAs were actively involved in considering the implications. Four types of implications were under consideration: for the contracting form; for the organisation of care delivery on a geographical basis; for the inhouse facility; and for the organisation of care assessments and care delivery. Form of contracting The tendency to move away from block contracts that we identified was associated in six cases (ON, RD, IL, OM, LK, AW) with an awareness of the possible incompatibility between block contracting and user choice. Well, there‟s no point signing three or four year contracts at this point, .. because, of course, in terms of home care people may well start to exert their own personal choice. RD We‟re just not gonna go near blocks, thinking about the future ON EWERC Part II. Commissioning and contracting in the selected local authorities 99 We have just tendered for 3 year contract, but built in break clause after 2 years so we can assess where we are with personalisation agenda. UY In two LAs (IL and TE) the changing of contractual relations from block to preferred provider or spot was said to be a means of preparing the providers for the changes, but in one LA (TE) there were concerns about moving too quickly because of the LAs continuing responsibility for ensuring the availability of care. The reason why providers need to build capacity into their organisations, is to prepare for the personalization. In other words, they will be attracting their own customers, so they won‟t need them coming from us anymore. ….and that is one of the reasons we didn‟t want to eat up all their capacity with our own blocks. Apart from the fact that we didn‟t want to pay for stuff we didn‟t want to use.IL However we also need to make them aware about the implications of personalization. And that has massive implications for the domiciliary care market, and particularly block contracts, which we probably wouldn‟t want to have. So we‟ve got personalization events with the independent sector – voluntary sector in April and private sector in May. It‟s about raising awareness of the implications of people having personal budgets, about making sure that people will be able to choose where they go. What we can‟t do is go the whole hog. We can‟t afford to destabilize the market and then find that we can‟t fulfil our statutory function. TE Care delivery by geographical area Considerable concern was expressed by LA commissioners over the implications of personalisation for their contracting by geographical area. These arrangements had been put in place to reduce travel times but were recognised to conflict with the notion of user choice. In two LAs (AD and TE) commissioners were concerned that they would have to undo the recent work they had undertaken to rationalise travel problems. if one provider‟s working in the centre of AD and you live in the far west but that‟s the provider you want to deliver your care, personalisation would say you can go and buy your care from them but that does mean that all the work we did around reducing travel times, which actually has an impact on the cost, starts to shift and change. AD So the pain of splitting into the 5 neighbourhood areas was actually not necessary under the personalization agenda really, because they can go wherever they like. TE Two more LAs (IL and XD) had already however moved towards more than one provider per area in response to the choice agenda We were looking for 10 in order to offer a choice of providers in each geographical area (ward). This is because if there is only one provider, service users don‟t have a choice and it becomes a closed shop. Contracts said they could handle 8-10 providers.IL EWERC Part II. Commissioning and contracting in the selected local authorities 100 Future for inhouse provision Some LA commissioners believed the personalisation agenda would lead to significant changes in the inhouse provision of domiciliary care. In one LA (ON) there were concerns that personal budgets were going to put pressures on the inhouse provision as the key issue would be „whether the public want to buy our inhouse services and what‟s the unit cost gonna be... That could be the big tipping poin‟t. ON In another LA (AD) there were also concerns expressed that the inhouse provision might be priced out by personal budgets but that the consequence would be a loss of skills and capacity of re-ablement that would be difficult to replace in the local area. As a consequence more radical options such a setting up the inhouse facility as a social enterprise were being toyed with. I think the issue is around considering whether... because of the quality of our inhouse service and because of the skill levels of the staff, I think what we feel quite strongly is we would not want to take that out of the marketplace in terms of a choice that the public would want to take. ….our stall would be set out in the same way as all the other providers. We might be more expensive but do we deliver a better quality service? …. it might be that the inhouse service becomes a different kind of business model, I dunno, social enterprise, whatever. AD A quite different approach to the impact of personal budgets on the inhouse facility was being taken by another LA (RD). Here we were told that the change in policy was to be used to legitimize a complete withdrawal from directly provided long term services. We have a different plan. They don‟t know it, this is the problem. … Basically, we‟re gonna allow individual budgets to be a driving force. No need for a workforce. Okay. When people have choices over costs I think it‟s going to have a significant effect, isn‟t it? ….… It‟s going to expose big cost differentials that are unsustainable. … This is not a sentimental authority. There will be no subsidy. RD Changes in care assessment and delivery of care For the most part, at the time of the stage two interviews, few changes had been made in the organisation of care assessments or in the planning and commissioning of care. In two LAs (AD, OM) interviewees spoke of moving towards more responsibility for the provider, either in undertaking assessment or in working out how a total block of hours over a week would be delivered. It‟s meant to actually specify outcome needs, rather than, she needs a wash at three o‟clock on a Tuesday afternoon. There‟s an expectation that once they have those needs the provider goes and works out the detail. I didn‟t want providers having to come back to us because they thought somebody needed an extra twenty minutes... AD Now, what we haven‟t done is to move the providers into a position where they are fundamentally challenged, professionally, to provide assessments, cause the assessment is EWERC Part II. Commissioning and contracting in the selected local authorities 101 always undertaken by the authority as the local commissioner, and that has to change.…. OM A third LA (RN) was engaged in a pilot programme on outcome based care, the principles of which involved moving away from an hours target to outcome based target. We give the providers a care plan, so rather than saying this is 12 hours and we‟ll pay them for 12 hours, we say this is what we want for Mrs Smith and she‟ll be in charge of that and its much more detailed and will be delivered reaching the goals and outcomes of Mrs Smith, rather than us saying that‟s 10 hours Outcome based pilot RN However, as we have seen in our discussion of price and costs based commissioning and contracting above, these developments were very much in the minority of LAs. A stronger trend was towards more detailed control of care delivery through electronic monitoring and tight time specification of visits. EWERC Part II. Commissioning and contracting in the selected local authorities 102 II.3. Classifying the strategic approach II.3.1. Typologising the local authorities The LAs in our sample were clearly engaged in addressing four separate but potentially conflicting agendas. Recognition of the need for provider support and development coincided with strategies to take costs out and increase competition between providers. Likewise there was both awareness of the need for LAs to develop a long term strategic approach towards a more integrated and joined up system of social care provision and a recognition that the personalisation agenda might reduce or weaken the strategic planning role of LAs in social care provision in the future. While all LAs were being pulled in different directions, there were nevertheless differences expressed between the commissioners in the different LAs in their preferred strategic approaches and in what they were doing to implement these approaches. Indeed the starting point for this element of the project was that one might expect to find variations in recruitment and retention of care staff influenced by differences in the approach taken by LAs to commissioning and contracting. This hypothesis is backed to some extent by evidence of divergent practices across LAs as indicated by the stage 1 postal survey and by the stage 2 interview survey. However, as table 3.8 shows the range of approaches pursued by the LAs makes classification into neat and bounded categories somewhat problematic. Thus the classification is based around multiple criteria. First we take into account the pricing strategies of the LAs. Second we summarise in table II.8 the strategic approaches adopted by the LAs focusing on evidence of an approach to partnership with the providers, in the sense policies aimed at developing and stabilising the market, rewarding and promoting quality in care and/or employment. We use these two criteria to classify the fourteen into three categories: o partnership focused; o cost minimisation focused; o or mixed. Clearly all fourteen are „mixed‟ to some degree but we classify those as partnership focused where they are either high payers and have a partnership orientation or medium payers and have specific policies of promoting and rewarding quality. Five LAs fall into the partnership category. This includes three of the four LAs classified as „high‟ fee payers in figures II.1a and II.1b (AH, XD, LK) for both residential and domiciliary care and all of which also face strong demand conditions for women‟s employment in the locality (see section 1.7 and appendix table I.A1). All three combine high fees with either a strategic partnership approach within an integrated NHS/LA unit (AH), a commitment to allow independent providers to match inhouse basic pay levels (XD) or higher pay in rural EWERC Part II. Commissioning and contracting in the selected local authorities 103 areas and maintaining a high share of inhouse residential homes (LK). We also include UY and RN in the partnership category. Both are „medium‟ fee payers when quality is not included (figure 3.1) but RN moves into the high fee paying category when quality enhancements are taken into account. RN also faces strong labour demand conditions while UY is in the medium demand category. They are included here as they also have a forwardthinking approach to their providers. UY has a strategic approach, linked to its integration into housing and has developed its own strong quality monitoring and incentive approach; RN has a commitment to fair contracting and rewards good HR performance with bonuses to be spent on staff. The quotes in box II.1 illustrate that these five „partnership LAs‟ have focused on support, innovation, improving quality and developing the market. Box II.1. The partnership LAs The idea behind the block contracts was that providers had told us that they couldn‟t recruit and retain staff because they hadn‟t got the guaranteed income and they didn‟t have a block contract like the internal service, so we tried to replicate that[the internal service] …around salary levels XD For care homes we have just recently introduced a process called fairer contracting and that‟s about actively encouraging higher quality and we want to work towards only contracting with good and excellent care homes. Each quarter they [domiciliary care providers] send performance indicators and a formula is used to calculate the incentive payment which they will get each quarter – that‟s paid separately. They have to prove that they use the incentive money on training, staff bonuses, staff incentives and team building to encourage low staff turnover.RN We target 70% of care workforce to have NVQ.LK We have an approach of promoting universal services, not just about health and social care and this is where the link with housing is very important UY It‟s about the relationship with providers which is important – sharing our values, and looking to achieve a principled outcome. Win win for us all - we get the services we want UY I think the inflationary uplifts have already been agreed for the full duration of the contract which is 5 years, that differs quite significantly from other areas of commissioning .AH The whole idea was that we wanted to create strategic partnership and therefore we would work with fewer partners AH At the other end of the spectrum four LAs fall into the category of „cost minimising‟. Two (IL and HD) are classified as „very low‟ fee payers (figure II.1a and II.1b) and in fact pay either very low (IL) or low (HD) fees for both domiciliary and residential homes. Moreover, they have no quality uplifts; IL has removed its premium for iDPs and accepts that the EWERC Part II. Commissioning and contracting in the selected local authorities 104 consequence of low fees will be wide use of top up fees for care homes even in a low income area. The third LA in this category, RD, is a low fee paying authority. It pays medium level domiciliary care fees but prices its residential fees such that they require top ups, with low income clients encouraged to use homes out of area that are cheaper. The fourth cost minimising LA , AW, is a medium fee payer (high for residential but lower than the outer London average). It has outsourced 100% of domiciliary care and is prepared to change all suppliers on the basis of costs. Moreover, it has kept residential fees at low or zero uplift for some time. These four LAS have very different local labour demand conditions, with HD recording strong demand, AW and RD medium and IL low demand. Neither RD nor AW commissioners wished to take an interest in the HR policies of providers as this might, they felt, interfere with competition. The examples provided in box II.2 illustrate that interviewees at these four LAs made positive comments about the flexibility and responsiveness of the market, priced residential care at a level that they knew would lead to top up fees being the norm, distanced themselves from responsibility for the HR polices of providers and treated quality as an additional requirement, not something to be paid for. One LA, HD, had previously made an attempt at partnership but had retreated due to conflicts over fees. Box II.2. The cost minimising LAs External providers just recruit people, they‟re very quick, they‟re very slick, very flexible.RD I don‟t think you can be too prescriptive on HR issues [since] it would have a direct impact on the rates we charged.. RD Quite a lot of people are placed outside the borough where there is available space so RD would pay their rates under a reciprocal deal. Within the borough many establishments charge top-ups, so if people want to go into those homes there has to be a third party agreement. RD The council doesn‟t really get involved in providers‟ HR issues In terms of conditions of service, that‟s nothing to do with us in a sense. AW We used to pay a premium for quality service, but not all organizations that met the quality standards. Presumably, this was to bring up quality, because it was very low. Over time, the quality of all services improved, so we were paying for quality when we didn‟t need to.IL Approximately 82% charge top-up, in some cases this is a small amount (£10-15), sometimes it is more, e.g. £355 from us, and the charge is £470. IL The City Council has been committed for some years to working in Partnership. When Building Capacity came out we did try and secure Partnership based on that. This is about six years ago now, and at the time mainly with the residential sector there are big issues about fees and fair fees and stuff, which kind of gets into the way. But we actually do have regular meetings with providers HD EWERC Part II. Commissioning and contracting in the selected local authorities 105 This leaves five LAs (ON, AD, TE, OM, RT) that we categorise as „mixed‟ and in each case there are strong elements of both cost minimisation and partnership. Three of the five are very low payers, as defined in figure II.1a – ON, AD, OM- but move into the low paying category (figure II.1b) if quality uplifts are included. One pays very low domiciliary fees (AD) and one low fees (ON). Four of the five face weak local labour market demand with RT the exception with medium levels of local labour demand. ON commissioners espoused a partnership approach, but in practice have not only set low fee levels but also moved away from their strong commitments to paying for travel time during the course of the project as a consequence of moving to electronic monitoring (which led to the removal of the half hour supplement). The authority did pay extra to homes with Investors in People awards but in general had not progressed very far in thinking about how to promote quality. „I think the thing we‟re beginning to consider… do we begin to link what we pay against some level of quality and is that, you know, the kind of CSCI ratings or something like that. And that‟s only a thought at the moment.‟ ON AD also pays low domiciliary care fees but at present does not require the outsourced providers to undertake complex work or indeed evening work with inhouse covering these areas. Moreover, unlike ON, it pays high residential fees. Commissioners at AD had made efforts to develop the market (through involving providers in person-centred care) and to stabilise the market- for example by offering block contracts and then encouraging block providers to offer guaranteed hours contracts- which were rebuffed. Interviewees at both ON and AD in fact seemed to be expressing a desire to move to a high trust approach but in practice were torn between that and ensuring value for money through for example introducing electronic monitoring. These contradictions are summarised as follows. We‟re the local government who hold the service users and the purse strings, and we recruit these people to do some jobs for us. But we don‟t really trust them. We‟re not really sure they‟re not going to rip us off. And we‟re not really sure about whether we trust them to turn up when they say they will. So it‟s still a very unsure market place to be honest. So the degree to which we actually kind of move away from a task based processes is patchy, I think. AD The other two low fee payers, OM and TE, pay medium domiciliary care fees, but do not offer additional fees (for shorter visits or unsocial hours working). Nevertheless, both have sought to develop a more strategic approach to their providers. OM has been expanding its providers to use greater competition to boost quality and keep down prices but it also has a strategy of its providers playing a greater role in assessments. In residential care it is investing £800,000 in quality uplifts. TE comes closest among this category of mixed LAs to a partnership approach with its focus on partnership and rewards for quality in both homes and domiciliary care. However, interviewees reported that the process of change had been „a very difficult situation, and the providers and the staff here and the service users went through significant pain‟. The reorganisation had required a lot of TUPE transfer of staff EWERC Part II. Commissioning and contracting in the selected local authorities 106 between agencies and although the relations may settle down into a partnership approach a mixed categorisation for the current situation seemed more appropriate. The fifth LA in this mixed category, RT, is medium authority according to our figure II.1a and figure II.1b classification. However, it is an outer London borough and therefore could be considered (along with AW) to be a relatively low fee payer for the area. But it differs from AW in that its commissioners were seeking to develop a partnership approach based on longer term and renewed contracts with the providers and a commitment to working with a wide diversity of organisations reflecting the diversity of the population. On the other hand, however, it had underdeveloped links with the NHS and no retained specialised inhouse services provision. RT managers also acknowledged serious contradictions in their approach towards providers‟ HR practices. In terms of workforce training and development, I mean, it‟s clear that practices that we encourage because we want to keep the prices down, militate against having a properly trained and maintained workforce. RT EWERC Part II. Commissioning and contracting in the selected local authorities 107 Table II.8 LAs’ strategic approach: from partnerships to cost minimisation a. Partnership LAs LA code Fee level AH H/H Without/ with quality Local labour market conditions Strategy towards providers Change within past 3 years plus plans for change Strong 100% joint NHS- integrated health and social care teams for re-ablement. Social services and housing merged with PCT (post PSSRU). Strategic partners in dom care chosen 60/40 quality/cost. High paying but with no variations by time/care. RN M/H Strong NHS joint commissioning/ 90% outsourced- additional support for providers increased outsourcing (e.g. fire officer)- also in response to publicity on poor care Guarantees providers 55% of work in an area. To 5 strategic partners/more outcome based approach. Away form unsocial hours payments Outcome based care pilot. Moving away from additional payment by length of visit. Fair contracting/quality uplift. HR related bonuses/ pay for weekends etc. UY M/M Medium Integrated with housing/ extra care Specialised inhouse provision Quality incentives and partnership approach Quality monitoring now around excellence, previously qualifications- no relation to star rating. XD H/H Strong High and variable prices –costs offset by electronic monitoring and requirement for services in rural areas. Built in continuity standards into contracts and ensure wage levels adequate. High inhouse share due to similarity of prices and problems of supply 2006 introduced block contracts by easy/difficult area to change power balance and provide more equitable conditions between independent sector and inhouse (but end to unsocial hours payments and costs offset by electronic monitoring). LK H/H Strong Fixed but variable price by area reflecting variations in availability across areamaximise recognised suppliers. Specialised inhouse. 70% target NVQ 2. Political commitment to LA homes but high incidence of top up fees. Too much capacity in homes/ too little in domiciliary care. Commitment to own monitoring Introduced fixed but variable price by area EWERC Part II. Commissioning and contracting in the selected local authorities b. 108 Mixed LAs LA code Fee level Without/ with quality Local labour market conditions Strategy towards providers Change within past 3 years plus plans for change To payment by minute/ electronic monitoring away from unsocial hours payments and pay for travel ON VL/L Weak Partnership approach to stabilize the market but combined with value for money. Pay for travel/training but moving to payment by the minute. RT M/M Medium 100% outsourced- strategy to develop the partnership and maintain diversity of supply AD VL/L Weak High/specialised inhouse plus unsocial hours- routine out of house but with person-centred care Quality fees for homes- top ups only out of borough Blocks with few providers since 2006-single price- some personalisation. Plans to transfer evening work. High quality inhouse (3*). OM VL/ L Weak Enhancing role of providers in interests of performance and personalisation. Increased competition through more providers. Specialisation for inhouse. Quality fee uplift for homes. Quality monitoring for both. Increase in providers, from block to framework agreement. Providers to make assessments and more performance/ quality oriented. Paying by minutes not in half hour blocks. Plan to increase quality monitoring with stronger HR focus. TE L/L Weak High share with NHS. Quality strategy- star rating raises home fees10% paid to IDPs if meet KPIs.Response to user survey through enforced geographical reorganisation Geographical reorganisation including TUPE transfers. Fee rises to reflect costs but removed higher prices for short visits. Large inhouse redundancies 2006/7- no TUPE transfer as independent sector expanded later EWERC Part II. Commissioning and contracting in the selected local authorities c. 109 Cost minimising LAs LA code Fee level Without/ with quality Local labour market conditions Strategy towards providers Change within past 3 years plus plans for change AW M/M Medium Price focused; prices to reduce over next three years for one IDP; 20 minute time slots and no pay for travel time; sets maximum fees for homes- existing placements kept at lower levels/ zero increase in fees for out of area homes. Requirement to meet user needs with respect to diversity in contract. High number of LA TUPE transferred staff Moved from 4 to 2 block contracts/ change of all main providers. TUPE transferred staff had to change provider. IL VL/VL Weak Price focused. Removed quality premium once threshold met. Monitor but do not pay for quality. Allow wide use of top ups From block to spot. Removed quality premium. Split between contracting and commissioning HD VL/ VL Strong Specialised inhouse plus area block contracts Geographical reorganisation specialisation of inhouse role RD L/L Medium Price focused. Use homes outside area as cheaper; fee set at too low a level for own area . Brought in new providers . Plans to end inhouse for regular care. EWERC and increased Part II. Commissioning and contracting in the selected local authorities 110 II.3.2.The coherence, stability and sustainability of LAs‟ commissioning and contracting practices While we have provided a categorisation of the commissioning and contracting strategies of the LAs, a triangulation of the various sources of information on LA strategies and approaches casts some doubts on the coherence, stability and long term sustainability of some of the apparent differences in commissioning and contracting stances. There was wide recognition of the existence of vicious circles that stood in the way of developing a coherent and sustainable approach. For example in one LA (RT) interviewees felt that the competition requirement for repeat tendering ( to comply with EU law) stood in the way of developing the quality of domiciliary care providers in ways that would enable them to move forward with the longer term objective of reducing reliance on residential care. So instead of kind of focusing on really working with providers to try and develop those kinds of things that we could do, we‟ve suddenly got this dreadful kind of treadmill of block contracts, tenders, problems, you know, cut the price down. …and you just go round and round in this awful circle instead of really focusing on what you should spend your money on to improve the standards.RT At another LA (LK) officers were concerned that those concerned to reduce hospital discharge delays were too ready to move patients into residential care, a problem compounded by the difficulty of putting together care packages in rural areas. At OM the concern was that personalisation would reduce the strategic role of LAs in managing the social care market thereby leading to a major increase in the price of care services. Others such interviewees at TE and AD feared that personalisation would make it more difficult to minimise the problems of travel and create more problems in guaranteeing supply. Other concerns included whether specialist re-ablement services built up by LAs inhouse might not be financially viable under personalisation (AD, ON). Innovative re-ablement services provided by integrated health and social care teams (AH) might be the strategic way forward to reduce residential care but whether further development along these lines might require reducing the share of outsourced work was unclear. At another LA (HD) concerns were raised over how „extra care‟ specialised housing schemes could be managed under personalisation. The model of the extra care scheme is to have the care provider obviously on site and delivering services as a domiciliary care provider in the individual homes. And for that to work as it does as the extra care model there‟s always got to be an element of block within that. But then there could also be an element of people having their own care provider (HD). Some of the contradictions arose simply out of the different regulations and pace of change under different budget headings. For example XD had been forced to withdraw temporarily from supporting providers in their training provision due to the sudden cutting back of government funds under different budgets to support such training. This decision was at odds with their more partnership approach. EWERC Part II. Commissioning and contracting in the selected local authorities 111 In some cases we found examples of incoherence and contradictions in the policy approach that were already calling into question the longevity of current commissioning approaches. For example, at one LA (IL) there was some recognition that their flat rate fee and spot contract system was causing some problems of delivering care for complex cases that they were having to recognise how far the flat rate system could be maintained. So we have hot spots around the city where it is really, really difficult to get care, and if you talk to an agency, they will say it is because we have difficulty recruiting in those particular areas. And because it‟s spot, they say it doesn‟t enable them to plan very well. IL Another challenge to current policies might come from the response by providers. For example one LA (LK) had raised their price significantly for rural providers but commissioners were not convinced that this increase was being passed to care workers in the form of paid travel time. If this proved to be the case then support for the higher prices might wane. In the case of RN the decision to increase joint commissioning with the NHS was directly causing a problem with the implementation of RN‟s fair contracting policy. The NHS was regarded as new to the game and was requiring RN to go through the motions of seeing if they could reduce prices, while the LA officers felt they had already explored that route and knew that they needed to do more to improve the quality rather than going for the lowest priced service. Nevertheless it was unclear whose approach would win out. The interviews with the LAs also brought out the difficulty of classifying commissioning approaches by reference to government policy agendas for in a couple of cases the LAs made it clear that they were openly embracing a particular policy agenda in order to achieve a specific objective which was independent of the policy agenda itself. The clearest example of this was in the case of RD where the personalisation agenda was said to offer a justification for closing down the inhouse social care team for more routine work, a policy which was being pursued primarily as a cost reducing agenda. And at IL we were told by the contracting officers that the decision to end block contracts and move to spot contracts was for cost reason but the commissioning officer legitimised the move as a way of helping IDPs prepare for personalisation. One of the most consistent findings from the second stage interviews was that there was a continuing rapid pace of changes in all aspects. Table 3.8 in its last column summarises the main changes in policy that had been implemented over the three years prior to our interview together with any changes that took place after our interview and before or during the telephone survey and future planned changes. These summarise the high level of change. Some of the frequent changes that had taken place included moving away from block contracts, decreasing or increasing the number of providers, moving away from enhanced payment for short visits to single flat rate minute-based payments through introducing electronic monitoring, introducing more quality monitoring and more fee enhancement related to quality, enhancing re-ablement functions, particularly inhouse, movements towards more user-centred care or more involvement by providers in assessments and stronger EWERC Part II. Commissioning and contracting in the selected local authorities 112 geographical divisions between providers. As we discussed above, many LAs were said to have plans for more outsourcing and some were engaged in plans to develop or expand joint commissioning with the NHS. All were developing some response to the personalisation agenda and many mentioned possible ways in which they may have to reverse their previous changes or at a minimum make adjustments to their policies to fit the personalisation agenda. Examples of significant changes that occurred within the period we were looking at the LA include the change in payment arrangements and electronic monitoring in ON, the merger with the PCT in AH (after the stage 1 survey), moves away from additional payments for half hours at RN, contracting with more providers and moving to payment by minutes rather than enhance pay for short hours at OM. In addition to a fast pace of current change it also become apparent that what had seemed the right strategy in the past had in some circumstances proved to be a disadvantage in the current policy climate. This was particularly the case where LA had outsourced all or almost all of their domiciliary care and to do so had TUPE transferred a large number of staff. Not only was this adding to the cost base for these LAs but the legacy of TUPE transferred staff was causing problems in developing a pricing structure for personalised budgets as individuals were unlikely to wish to pay the higher prices that agencies with TUPE transferred staff typically receive from the LA. With hindsight we‟d have been better doing what some other councils have done, which is to take their inhouse workforce, either retain it inhouse, or put it out to one organization but then to use that for re-ablement AW Where a high share of domiciliary care work had been outsourced, as in AH, there was the possibility that this may not provide the best arrangements for the future when cost savings might in the future come more from specialised re-ablement which may be better developed by LAs directly or in partnership with the NHS. The overall finding is thus of a high rate of changes plus a considerable likelihood of change in different directions over future years. This uncertainty over the future was well captured by the comment by a TE officer that they had started off developing a ten year strategy for health and social care for older people in the city but „we soon discovered that that was completely wrong, that the world was changing too fast for us to have a nice plan for 10 years, so we have reviewed it and we are redoing it.‟ (TE) EWERC Part II. Commissioning and contracting in the selected local authorities 113 II.4. The selected LAs and user satisfaction surveys We complete this investigation of the commissioning practices of our selected LAs and their approach towards the providers of care, whether IDPs or residential homes, by drawing on published evidence of their relative scores in user satisfaction surveys. These satisfaction scores were analysed only after we had undertaken the classification of our LAs. They therefore provide an interesting test as to whether our classifications have any linkage to user satisfaction scores. We have computed average scores for both the overall level of satisfaction with care and for each of a series of eight questions on care quality. The average scores for the overall level of user satisfaction (a scale of 1 to 10) for the 14 LAs do not vary greatly. The range of scores for LAs classified by partnership orientation of the LA is as follows: Partnership (AH, RN, UY, XD, LK): 5.67 – 5.87; Mixed (AD, RT, ON, OM, TE): 5.47 – 5.84; Cost minimising s (RD, AW, IL, HD): 5.44 – 5.52. Further interrogation of the rankings of each LA among the group of 14, however, reveals significant patterns.20 Table II.9 presents the average rank scores for all nine questions for each of our three categories of LAs - partnership, mixed and cost minimising. For the first, overall satisfaction question the data reveal that while the partnership and the mixed categories have quite similar levels of satisfaction, the cost minimising LAs are clustered at the bottom of the distribution. A similar pattern also applies to the averages for the other eight questions as indicated by the very low average ranking for cost minimising LAs, ranging from 8.0 to 12.0. In contrast the average rankings for the partnership LAs were between 5.2 and 8.8 and for the mixed LAs between 4.0 and 7.0. This evidence therefore appears to provide some support for the more partnership oriented LAs generating higher user satisfaction. Table II.10 presents the rank scores for each of the LAs separately for the overall satisfaction question, the average ranking for the other 8 questions and a total rank score. Five LAs stand out as having very consistent high rankings: two are from the partnership category- AH and UY and three from the mixed category – AD, TE and OM. It should be noted that AD had a very large inhouse provision and these ranks relate to the provision by the LADP as well as the IDPs. The five are in the top five rankings on both measures so that their average ranks were 4 or less, while the next in line is LK another partnership at 6.5. 20 Use of ranking scores rather than actual satisfaction scores also preserves anonymity of LAs. Scores for the separate questions were standardised in order to facilitate comparison across answers. This was necessary due to the use of different scales for questions, including a 1-7 scale for question 1, a 1-5 scale for question 6 and a 1-4 scale for questions 2-5 and questions 7-9. The 14 LAs were grouped into the three defined types of partnership, mixed and cost minimising and an average score calculated for each question for each type. EWERC Part II. Commissioning and contracting in the selected local authorities 114 Table II.9. Average ranking of user satisfaction scores by type of LA Partnership (AH, RN, UY, XD, LK) Mixed (AD, RT, ON, OM, TE) Cost minimising (RD, AW, IL, HD) Q.1. Q1: Overall, how satisfied are you with the help from [Social Services] that you receive in your own home? 5.2 6.2 11.8 Q2: Do your care workers come at times that suit you? 7.0 4.4 12.0 Q3: Are you kept informed, by your home care service, about changes in your care? 5.8 5.8 11.8 Q4: Do your care workers do the things that you want done? 5.2 6.6 11.3 Q5: Are your care workers in a rush? 5.8 7.0 10.3 Q6: Do your care workers arrive on time? 8.8 4.0 10.3 Q7: Do your care workers spend less time with you than they are supposed to? 5.6 6.4 11.3 Q8: Do you always see the same care workers? 8.4 6.2 8.0 Q9: Overall, how do you feel about the way your care workers treat you? (e.g. whether they are understanding and treat you with respect for your dignity) 6.0 6.0 11.3 Survey questions. Note: LAs ranked by average scores with highest satisfaction ranked 1 and lowest 14. Source: NHS Information Centre 2009a Home Care Survey 2008-2009, own compilation. Two more partnership LAs - XD and RN - come next at 8.5 followed by ON, a mixed LA, at 9. The lowest satisfaction scores include all four cost minimising LAs along with the mixed LA, RT. The rank scores are 9.5 for AW and 11 for RT, the two outer London boroughs, and 11, 12 and 14 for the other cost minimising LAs. These satisfaction scores thus provide support for the categorisation of the LAs as cost minimising but suggest that there may be some aspects of quality commissioning we are not capturing particularly for the three mixed LAs with high scores – TE, AD and OM. We have already suggested why AD may be in this category and TE is the LA we identified as closest to our partnership category. OM was going through a period of change at interview so it is difficult to know whether the changes will lead to a reinforcement or reversal of these high satisfaction scores, if there is indeed a connection between commissioning and contracting and these user outcomes. EWERC Part II. Commissioning and contracting in the selected local authorities 115 Table II.10. Ranking of user satisfaction scores by individual LA* LA Type of LA Rank for question 1 Rank by average of ranks for questions 2-9 Average of column 2 and 3 UY Partnership 1 1 1 TE Mixed 2 3 2.5 AD Mixed 5 2 3.5 AH Partnership 3 5 4 OM Mixed 4 4 4 LK Partnership 7 6 6.5 XD Partnership 6 11 8.5 RN Partnership 9 8 8.5 ON Mixed 8 10 9 AW Cost minimising 12 7 9.5 RT Mixed 13 9 11 IL Cost minimising 10 12 11 RD Cost minimising 11 13 12 HD Cost minimising 14 14 14 Note: Scores based on responses to 4, 5 or 7 point scale. LAs ranked by average scores with highest satisfaction ranked 1 , lowest 14. Source: NHS Information Centre 2009a Home Care Survey 2008-2009, own compilation EWERC Part II. Commissioning and contracting in the selected local authorities 116 II.5 Summary and conclusions In line with the findings from the first stage survey of LAs, we found significant variation in the specific practices adopted by our selected LAs with respect to commissioning and contracting, particularly in the case of domiciliary care, although some general trends can also be detected. In both domiciliary and the care home sectors the majority of the service had been outsourced to the independent sector and further outsourcing was planned. Nevertheless most interviewees anticipated keeping some inhouse provision, although this would be increasingly focused on specialised re-ablement services and none were planning any TUPE transfers of existing LA staff. Indeed those that had TUPE transferred staff in the past believed this to have been a strategic error. Contracting in domiciliary care had in many cases moved away form block contracting and instead LAs were establishing a set of preferred providers, in part as a cost efficiency measure to reduce risks of unused hours but also in preparation for the personalisation agenda. However, five still used block contracts and two had recently moved to such contracts. In the care home sector the majority of contracting was on a spot basis, following the preferences of the user. Twelve of the 14 LAs did still provide some residential home care inhouse and ten had some block purchase contracts with independent sector homes. Pricing strategies also varied between LAs. In domiciliary care there was a general trend towards simplification of fees around a standard fee with many LAs not making any differences in payments for shorter visits, unsocial hours, higher dependency of users or travel time, although some had introduced more differentiation between rural and urban abased agencies. However, although the trend was towards a single rate, in eight LAs fees still varied by providers according to their tender price. Nevertheless overall the average fees only ranged from £10.45 to £14.50 for 13 LAs and the range among providers within a locality rarely exceed £2 to £3. One LA was an exception on both counts with a range from £16 to £28. The main motivation for the simplification strategy tended to be to reduce both direct costs and transaction costs for the LA. Likewise the move towards use of electronic monitoring was primarily driven by the interest of reducing costs and ensuring clients received their full visits. Only two LAs offered any IDPs any quality enhancement to their fees for meeting quality targets. Variations in fees for residential care were much wider than for domiciliary care between LAs and reflected regional variations in housing costs, not just wage costs. However, the level of fees set did not simply reflect local conditions as in some LAs the policy was to set care home fees at a level where it most LA funded clients would not be faced with requests for top up fees unless they had a special room of some kind. Other LAs expected most residents would be asked to pay top up fees because of the low level of their fees relative to local home fees for private clients. More LAs had introduced quality enhancements for homes with five currently offering quality premia and a sixth offering extra to those with Investors in People awards. EWERC Part II. Commissioning and contracting in the selected local authorities 117 The variation in commissioning and contracting practices was found in our qualitative interviews with key actors to reflect different priorities and approaches adopted by LAs in a context where each LA was being required to make sense of a range of potentially conflicting influences on commissioning practices. We found social care commissioning not only to be influenced by the specific council‟s organisational, budgetary and political environment but also influenced by the longer term policy agendas for the development of social care. Policies towards commissioning were found to generate competing agendas from the need to support providers and develop the supply base to the need to take costs out and control price even in a context of policies aimed at driving up the quality of care delivered. Further competing agendas stemmed from whether commissioning would in the future continue to be dominated by LAs or either undertaken jointly with the NHS or devolved to users. While all LAs were being pulled in competing directions, we were able to identify differences between LAs in their espoused strategic approaches and in their implementation of policies. We therefore classified LAs according to their concerns to develop partnerships with independent providers on the one hand and to reduce costs on the other hand. This gave rise to three groups of LAs: partnership focused; those focused on cost minimisation; and those falling into a mixed category. This classification was found to have some resonances with the national user satisfaction scores as recorded by LA, with the cost minimising LAs assessed by users as providing less good quality care than the partnership or mixed categories. Some of the mixed category LAs topped the user satisfaction scores and in one case there was a particularly high share of LA directly employed staff in a 3* rated unit providing domiciliary care services, suggesting perhaps that it is share of services outsourced as well as commissioning strategies towards the independent sector providers than may influence user satisfaction scores. While we have provided a categorisation of the commissioning and contracting strategies of the LAs, a triangulation of the various sources of information on LA strategies and approaches casts some doubts on the coherence, stability and long term sustainability of some of these apparent differences in commissioning and contracting stances. Above all there was a very high rate of change in commissioning policies, some of them implemented during the course of our project. This rate of change reflected both the changing commissioning environments and the recognition of potential contradictions between some of the LAs‟ objectives and its current commissioning approach. It was thus not necessarily the case that the commissioning strategies were sufficiently stable and coherent for independent providers to be able to act on the practices to develop different approaches to managing the social care workforce. Furthermore it was also increasingly the case that LAs were becoming reliant on national providers. Some LA commissioners were concerned about the quality of these providers and about the impact on of their growth on the local supply chain and their ability to foster a diversified supply of care provision but nevertheless most LAs were increasing their contracting with national chains. LA commissioners were also aware that their current policies were vulnerable to future changes in central government policy which might, for example, reduce the finance available for social care or even reduce the role of LAs in the planning and commissioning of care due to the health integration and personalisation agendas. EWERC Part III. The provider telephone survey 118 III. The Provider Telephone Survey: Recruitment, Retention and Employment Conditions This part of the report presents the key findings concerning recruitment, retention and employment conditions for the social care workforce. The analysis draws on the telephone survey sample of 105 independent providers, including 53 independent sector residential and nursing care homes (referred to as homes) and 52 independent sector domiciliary care providers (referred to as IDPs). The data are complemented by interviews with 10 of the Local Authority domiciliary care providers (referred to as LADPs).21 This original dataset, which comprises a quantitative dataset and qualitative open-ended responses to questions, forms the basis of analysis for this part of the report as well as part IV. Our objective here is to present an introductory mapping of the descriptive statistics in order to address a set of first-order questions: what types of HR practices are in use within the sector? how much variation of practice is there both between homes, IDPs and LADPs and within these categories? do all providers face similar recruitment difficulties and staff retention problems? An understanding of both the range of approaches to human resource management deployed by individual providers and the key employment outcomes and differences therein between IDPs, homes and the LA sector is a necessary first step in our knowledge before undertaking a more detailed and complex analysis of the data in Part IV. There, we interrogate the underlying factors that are associated with good HR practices and good HR outcomes and test the statistical significance of the impact of provider characteristics on the one hand and external commissioning and labour market factors on the other in explaining variations in HR practices and outcomes. As such, it is the combination of results in both parts III and IV that generate our conclusions concerning the role of internal factors and external environmental conditions in shaping HR practice and recruitment and retention performance. 21 Two of the fourteen local authorities had no in house provision and interviews were not possible with the other two due to pressures of restructuring and other issues. EWERC Part III. The provider telephone survey 119 This part of the report is structured into six sections with each section presenting a map of results for homes, IDPs and LADPs related to a particular area of employment organisation as follows: III.1. Recruitment and selection III.2. Retention III.3. Pay and rewards III.4. Working time and work organisation III.5. Employee training and development III.6. Performance management, job autonomy and employee voice EWERC Part III. The provider telephone survey 120 III.1. Recruitment and selection Recruitment and selection practices are a core element of what care organisations do and are instrumental in improving their performance. But to what extent do we find similarity of approach across the different care organisations? For example, one issue highlighted in our literature review (see section I.3) is variation in use of formal and informal methods of recruitment. On the one hand, all organisations are being nudged towards greater formality by the inspection processes of the CQC and the commissioning local authority. On the other hand, providers may benefit from an informal approach to connecting with people with a known reputation. In this section we investigate this issue and other issues related to providers‟ approaches to recruitment and selection. Throughout we disentangle the variation between homes and IDPs and, where appropriate, LADPs. We begin with an overview of the extent of recruitment difficulties reported by the care organisations surveyed. III.1.1. Recruitment difficulties Our survey evidence reveals that one third of care organisations reported difficulties in the recruitment of care staff, ranging from quite difficult to very difficult. The reasons underlying these difficulties are likely to vary. While much depends on the conditions in the local labour market – the presence of competitor organisations, the level of unemployment and the availability of a suitable pool of job applicants – difficulties may also result from poorly managed recruitment procedures, an inadequate pay offer, or inappropriate working-time conditions. Here we set out a general assessment of patterns. The analysis in part IV investigates the underlying causes. Figure III.1. Percentage of organisations reporting the ease or difficulty of recruiting care workers 45 Homes IDPs LADPs 40 35 Percentage 30 25 20 15 10 5 0 very difficult quite difficult neither difficult nor easy quite easy very easy Note: Total responses: 53 (homes), 51 (IDPs) and 10 (LADPs). Missing responses: 1 (IDPs). EWERC Part III. The provider telephone survey 121 The type of care organisation matters in explaining the likelihood of recruitment difficulties. Recruitment difficulties were more likely to be experienced by IDPs than by either homes or LADPs (figure III.1). Although more homes - at 11% compared to 6% of IDPs - said recruitment was very difficult, only 17% of homes compared to 33% of IDPs said recruitment was quite difficult. Among LADPs a far smaller share reported difficulties – just 20%.22 Homes were more likely than IDPs to report recruitment of care staff to be quite easy or very easy – 56% and 41% respectively. And while only 40% of LADPs fell into this category, another 40% reported recruitment to be neither difficult nor easy, far higher than the shares reported for IDPs and homes. While these results point to significant problems in recruitment of care workers, our evidence also reveals that the recessionary conditions of 2008-2009 had in fact made matters easier for around one third of the care organisations surveyed. The UK unemployment rate increased sharply from 5.5% to 8.1% between the second quarter of 2008 and last quarter of 2009 (ELMR 2010). After a decade of relatively stable unemployment at around 5-6%, employers therefore suddenly faced a changed set of external conditions with greater numbers of people applying for vacancies. I think there‟s been a real shift with the economic climate. A year ago I would have said very difficult I think at the moment I‟d say it‟s in the middle. (RD.D.2.CL) I think it‟s very easy … Since last year I think vacancies have gone down mainly because of the credit crunch affecting overall everybody. (RD.H.1.B.S) At the moment I would say a 5, very easy, because we‟ve had such a response for our vacancies. We‟re having to filter them at the moment because we‟ve had so many, there are just so many people wanting the post, it‟s not always been like that, it‟s changed. (RD.HN.4.C.N) Table III.1. Change in recruitment conditions as a result of the 2008-2009 recession % of homes % of IDPs % of LADPs % of all No change 63.2 25.6 28.6 42.0 Some change 36.8 74.4 71.4 58.0 Recruitment easier 34.0 62.9 71.4 51.1 Recruitment more difficult 2.8 11.5 0.0 6.9 Total Responses 38 43 7 88 No response 15 9 3 27 Again, however, the experience was not shared equally among all organisations (table III.1). Domiciliary providers, both independent sector and local authority, were more likely to experience an easing of recruitment conditions, probably from a more severe situation of 22 In the last 12 months, 3 LADPs and 2 IDPs did not recruit at all while all homes had recruited new care workers. EWERC Part III. The provider telephone survey 122 shortage than applied to homes prior to the recession. Thus, the gap reported above between homes and IDPs would have been even wider were it not for the impact of the recession. As anticipated, the reasons for recruitment difficulties were varied and encompass both internal organisational factors and external labour market and other conditions. The responses from providers surveyed suggest that pay is the most common factor (table III.2), a result of either too many competitor employing organisations offering higher rates of pay or the inability of the care provider to offer a rate of pay commensurate with people‟s expectations of the value of the job. More than one in four respondents recorded pay as a main reason. Pay was an especially common reason among IDPs, accounting for more than a third of responses. It was also the most common response among care homes. However, it is significant that it was not reported as a main reason by the LADPs that responded to this question – a clear reflection of the higher rates of pay offered by local authorities (see III.3 below). The following quotes illustrate the differences: It is the price that the LA pays – it is low pay. It is the nature of the contract. If they pay us more we pass it on. (AH.D.4.DS). No [pay is not an issue]. To be honest that is because in the local authority we pay manual grade 5 plus 33.5% enhancement for working anti-social - for example for mobile night workers - plus they get essential car users and mileage. (IL.DIH.1.CP). A second important reason for recruitment problems concerns the nature of care work. Respondents told us they believed that for many people the job of a care worker was too emotionally demanding. They also emphasised the generally poor status of the work, a fact that was obviously tied to the low pay. It is very poorly paid and involves a lot of hard work, including both mental and physical, with a lot of pressure on people, especially with new legislation demands. (RD.D.1.C.S). This type of work doesn‟t have a particularly valued reputation among a whole lot of people … You need a terrific sense of … well, you‟ve got to be an angel (RD.D.2.CL). Aside from pay, the other HR practice that created problems for many care providers was the working time schedules. This was reported as a factor by twice the number of IDPs as homes, reflecting the predominance of far more flexible working-time contracts in IDPs. The 24/7 demands for work, especially the requirement for regular weekend working were a particular issue for several organisations, an issue we explore further below (section III.4). Other reasons set out in table III.2 relate explicitly to changes in the external environment, usually in the immediate locality. These include problems of local competitors – newly opened supermarkets were often mentioned by respondents – as well as observations of a „transient community‟ and the frustrating practice whereby some people registered as unemployed apply for a job primarily in order to satisfy job search requirements. My bugbear is that people telephone for the paperwork and you arrange 25 interviews and only 6 show up. They don‟t come. And they only apply so that they can be seen to be applying to get the benefits. (TE.H.3.AS). EWERC Part III. The provider telephone survey 123 Table III.2. Main reasons for recruitment difficulties % of homes % of IDPs % of LADPs % of all Pay 19.9 37.3 0.0 27.1 Nature of care work 10.0 7.9 33.3 10.3 Local Competitors e.g. new supermarkets 10.0 9.8 16.7 10.3 Transport costs 10.0 11.7 0.0 10.3 Working time Schedules 6.0 11.7 16.7 9.4 CRB delays 4.0 9.8 0.0 6.6 High or low local employment 8.0 5.9 0.0 6.5 Not suitable/ Calibre of staff 12.0 0.0 0.0 5.6 Location 6.0 0.0 0.0 2.8 People apply so that they can stay on benefit 6.0 0.0 0.0 2.8 Reluctant to train 4.0 0.0 0.0 1.9 Working conditions 0.0 3.9 0.0 1.8 Its a transient community 2.0 0.0 16.7 1.9 Visas 2.0 0.0 0.0 0.9 Can‟t drive 0.0 1.9 0.0 0.9 Childcare 0.0 0.0 16.7 0.9 Total responses 50 51 6 107 No response 3 1 4 8 While the above results concern general recruitment difficulties faced by care providers, more specific detail can be ascertained by focusing on particular types of job posts that need to be filled. Around half the sample of care organisations reported specific shortages. By far the most common shortages were for jobs requiring weekend work and unsocial hours and for night work (table III.3). The data show a clear divide between care homes and IDPs; specific shortages were far more likely to be reported among the latter – 77% of IDPs compared with 25% of homes. The difficulty of finding people to fill weekend work and unsocial hours was reported by more than two thirds of IDPs compared to less than one in ten homes, and night work problems were reported by 37% of IDPs and 15% of homes. LADPs fell somewhere between the other two types of care organisation with 40% reporting specific shortages, again with respect to jobs requiring unsocial hours working. Given the range of difficulties reported by the surveyed care organisations, it is important to investigate what types of recruitment and selection practices are utilised, and how practices vary across different organisations. We address these issues in the following section. EWERC Part III. The provider telephone survey 124 Table III.3. Labour shortages for specific job posts % of homes % of IDPs % of LADPs % of all Are there any specific shortages? Are there shortages for weekend work and unsocial hours? Are there shortages for night work? 24.5 76.9 40.0 49.6 7.5 69.2 20.0 36.5 15.1 36.5 30.0 26.1 Early morning 0.0 7.7 0.0 3.5 From particular geographical areas 0.0 3.8 0.0 1.7 Trained staff 3.8 0.0 0.0 1.7 Bank Holidays 0.0 1.9 0.0 0.9 Males 0.0 1.9 0.0 0.9 Day shifts as all on specific courses 1.9 0.0 0.0 0.9 Drivers 0.0 1.9 0.0 0.9 Total Responses 53 52 10 115 III.1.2. Recruitment practices: attracting a suitable pool of applicants Organisations in all sectors of the economy can be expected to use a range of informal and formal methods to fill vacant posts. The organisations surveyed in the care sector as part of our study fit with this notion of an eclectic approach. In particular, we find that three practices were relatively common – the informal practice of advertising vacancies by word of mouth, the more formal method of paying for ads in the local press and the similarly formal method of contacting Job Centre Plus. Each of these practices was reported by at least three in four organisations. Figure III.2 charts the range of responses for homes and IDPs, ranked by the most popular recruitment practice for each. Both IDPs and homes appear strongly wedded to the informal practice of advertising through word of mouth – close to 80% of homes and 90% of IDPs. One domiciliary provider explained that this involved asking people who worked for her to „recognise people with the kind of personal qualities we are looking for‟ (UY.D.1.C.L) and another told us that this informal approach extended to „people literally walking through the door and asking for a job application‟. It was a less frequent practice among LADPs (just 40%), possibly because of the more formalised processes associated with LA HR departments. The similarly informal method of posting ads in office or shop windows was less likely to be reported overall, but nevertheless was a regular practice among one in five homes and, perhaps surprisingly, almost half of IDPs; the popularity of this method amongst IDPs is probably explained by the fact that many have a shop front. As might be expected, given the scale of their organisation, the relatively formal practice of using internal advertisements was especially popular among LADPs; two in three reported this practice. Many organisations also retained lists of interested applicants, made up largely of people who had registered interest at a time when the organisation was not recruiting; close to two fifths of care homes used such lists and one quarter of IDPs. EWERC Part III. The provider telephone survey 125 Figure III.2. Diverse recruitment methods used to fill vacancies for care work a. Homes 100 90 80 Percentage 70 60 50 40 30 20 10 0 Ra dio i cru et afl en en n me op ps nt dro s e tm -in A HC UK Re Le op Dr et loy ag da ge ys ta ts y nc n ca es pli s ci e ap ow g l le co in er mp oth oe ern Int et Fe ing Us ing ind ert ted es ter nw tis f in to ei tic r ve Ad Lis No v ad l us eP ntr ing th tis ou er dv fm al Ce a ss do ern Int b Jo e Pr or W b. IDPs 100 90 80 Percentage 70 60 50 40 30 20 10 0 Ra dio tm to ps en dro s A HC UK i cru -in et afl Re Le op Dr et ge s ay ta nd n me ts y nc n ca es pli s ci e ap en pe loy ag ow g l le co in er mp oth oe ern Int et Fe ing Us ing ind ert ted es ter nw tis f in to ei tic v ad l us eP ntr al r ve Ad Lis No ern Int ing th tis ou er dv fm Ce do a ss b Jo e Pr or W Note: Total responses: 51 (homes), 51 (IDPs) and 9 (LADPs). Missing responses: 2 (homes), 1 (IDPs) and 1 (LADPs). Two formal methods also dominate the approach to recruitment among care providers of all types. First, four fifths of all organisations that responded to our survey said they used adverts in the local, regional or professional press. The breakdown among type of organisation is 68% of homes, 77% of LADPs and 92% of IDPs. Second, 72% of responding organisations said they relied on Job Centre Plus as a normal method for filling vacancies. Again, this more EWERC Part III. The provider telephone survey 126 formal method was more likely to be reported by IDPs than by homes, some 86% compared to 60%, respectively. A third formal method that was reported only by a small proportion of organisations was the use of fee-charging employment agencies; 6% of homes reported this practice, along with 16% of IDPs and 11% of LADPs. In addition to the prompts we used in our telephone interviews, managers also told us about other methods they regularly used. These included the internet, informal drop-ins, leaflet drops, recruitment open days, UKHCA and the radio. Certain recruitment methods appear to be more effective than others. Our survey data suggest that informal word of mouth recommendations and the formal practice of press advertising are the best ways to fill vacancies, although there is by no means a consensus, or even a majority, view on this (table III.4). Among our small sample of LADPs, three quarters favoured formal methods as most effective, with two thirds opting for press advertising. The views of care homes and IDPs were more varied. Homes were far more likely than either IDPs or LADPs to favour informal methods; the most common response to our survey question (43% of homes) was that the informal word of mouth method is the most effective way to fill vacancies. However, the relatively formal methods of press advertising and Job Centre Plus were also identified as most effective by 28% and 19% of homes, respectively. By contrast, IDPs (like LADPs) tended to identify formal practices as most effective; 38% reported press advertising and 30% Job Centre Plus, compared with around 23% favouring informal practices. Table III.4. Managers’ views regarding the most effective method for filling vacancies % of homes % of IDPs % of LADPs % of all 42.6 23.4 0.0 30.1 4.3 0.0 11.1 2.9 2.1 0.0 0.0 1.0 4.3 8.5 11.1 6.8 Formal methods: Press advertising 27.7 38.3 66.7 35.9 Jobcentre plus 19.1 29.8 11.1 23.3 Total responses 47 47 9 103 No response 6 5 1 12 Informal methods: Word of mouth recommendations Notice in office or shop window Mixed methods: Other agencies Internet, open days, other methods* Note: * Other methods include the internet, council workforce development and recruitment open days. A small proportion of providers considered other mixed methods, in the sense of formal and informal, to be the most effective way to fill vacancies. For example, 2% of homes and 8% of IDPs believed the internet was the most effective method, while another 2% of homes believed their local council‟s workforce development initiative was the most effective way. One LADP reported that recruitment open days were the most effective practice. EWERC Part III. The provider telephone survey 127 The recruitment of senior care workers was considered an especially important issue among managers of organisations responding to our survey. However, the filling of such posts is unlike the filling of vacant care worker posts since it is more usually filled through internal promotion, and therefore reflective of the organisation‟s approach to training and career development for incumbent staff. As one manager told us, „I like to encourage people and know that I have developed them. If you get someone new, they don‟t know the standards‟ (IL.H.4). In an effort to unpack these differences in approach our survey questionnaire therefore asked respondents whether they normally recruited externally or from within their existing staff of care workers. In fact, the majority of establishments in our telephone interview sample recruited senior care staff from within their existing staff (table III.5). This is a positive practice insofar as it gives care workers something to aim for and the prospects of career progression. Only two organisations out of the total sample of 115 relied wholly on external recruitment to fill vacant senior care posts. It was far more common for care organisations to recruit from internal applicants; 56% relied on this method exclusively. In addition, slightly more than one in three organisations recruited from both internal and external routes. It is notable that 6% of organisations surveyed did not employ senior care workers and therefore did not provide care workers an internal opportunity for career progression. Table III.5. Internal and external recruitment of senior care workers Existing staff % of homes % of IDPs % of LADPs % of all 54.7 53.8 70.0 55.7 Externally 1.9 1.9 0.0 1.7 Both from existing staff & externally 34.0 40.4 30.0 36.5 Don‟t have senior care workers 9.4 3.8 0.0 6.1 Total responses 53 52 10 115 The set of management processes used in recruitment was very standardised among the different organisations. Nearly all managers who responded to the survey used application forms requiring a full work history (99%), carried out formal interviews (96%) and relied on formal job descriptions and person specifications (93%) (figure III.3). In addition, nearly all organisations required character references – with 88% asking for references after the interview and 18% prior to the interview. Once again there is variation by type of care organisation. Around two in three IDPs used initial telephone screening compared to only around one in three homes and one in ten LADPs. Another difference concerns the requirement for applicants to produce a CV; this applied to 61% of homes compared with only 39% of IDPs and 22% of LADPs. Finally, IDPs and LADPs were twice as likely to use aptitude testing as care homes (43%, 44% and 22%, respectively). EWERC Part III. The provider telephone survey 128 Figure III.3. Features of the recruitment process in homes and IDPs 100 Homes 90 IDPs 80 Percentage 70 60 50 40 30 20 10 0 Application requires full work history Formal interview Job References descriptions after and person interview specifications Initial telephone screening CV Aptitude Testing Informal interview Aptitude test References at interview before interview Aptitude test at induction Note: Total responses: 51 (homes), 51 (IDPs) and 9 (LADPs). Missing responses: 2 (homes), 1 (IDPs) and 1 (LADPs). Table III.6. Alternative practices when local recruitment fails % of homes % of IDPs % of LADPs % of all Extend efforts to surrounding areas Attempt a more national recruitment drive 52.8 48.1 44.4 50.0 18.9 21.2 11.1 19.3 Use other agencies 20.8 11.5 11.1 15.8 Contact other agencies specifically for migrant workers 13.2 19.2 0.0 14.9 Direct overseas recruitment 17.0 9.6 0.0 12.3 Total No. 53 52 9 114 No response 0 0 1 1 Given the pre-recession difficulties of recruitment, our survey included a question that asked respondents about their strategies for filling vacancies if unable to recruit locally. Half the sample reported they would extend efforts to surrounding areas under such circumstances (table III.6). Use of other agencies was not a popular method, used by just 16%. The option of contacting agencies, or intermediaries which specialise in providing migrant workers was also not a very common practice, only reported by 19% of IDPs, 13% of care homes and none of the LAPDs. However, a surprising 12% of organisations - all from the independent EWERC Part III. The provider telephone survey 129 sector - did in fact report recruiting care workers directly from overseas, including 17% of care homes and nearly 10% of domiciliary care providers. III.1.3. Selection: choosing the right applicant While different recruitment methods enable organisations to access varying pools of job applicants, it is likely that there will be variation in organisations‟ approach to what attributes among job applicants provide the best fit with the job vacancy. Our survey asked respondents to identify those attributes among job applicants they considered necessary or desirable. The question included ten prompts and also allowed managers to identify other factors. Perhaps unsurprisingly, given the intensive personal contact required in the job of a care worker, close to nine in ten managers in our sample considered a positive attitude and a friendly nature to be necessary of job applicants (figure III.4). A further two factors were also very important necessary factors - availability for weekend work (70% of homes and 66% of IDPs) and availability for early starts or evening work (66% of homes and 54% of IDPs) – reflecting the 24/7 demands of work in the care sector. Indeed, all LADPs (not shown in figure III.4) reported availability for both weekend work and for early starts and evening work as necessary factors. Figure III.4. Attributes considered necessary among job applicants 100 Homes IDPs 90 80 Percentage 70 60 50 40 30 20 10 0 Positive attitude/ friendly Available weekend Available work earlies/evenings Own transport Ability to drive Care-related skills Lives locally Experience caring for family/friend Qualifications (NVQ2+) in care Note: Total responses: 50 (homes), 50 (IDPs). Missing responses: 3 (homes), 2 (IDPs). EWERC Recommended by Formal care work employee experience Part III. The provider telephone survey 130 Table III.7. Attributes considered necessary and desirable among job applicants a. Homes % of respondents Necessary Desirable 90.0 70.0 66.0 28.0 10.0 6.0 6.0 6.0 4.0 13.7 29.3 27.5 62.7 52.9 51.0 70.6 78.4 52.9 Total No. 50 51 No response 3 2 Necessary Desirable 88.0 66.0 54.0 28.0 14.0 10.0 8.0 6.0 6.0 39.6 33.3 16.0 40.0 52.0 68.0 74.0 86.0 72.0 64.0 100.0 58.0 61.2 50 2 50 2 Positive attitude/ friendly nature Availability for weekend work Availability for early starts or evening work Skills related to care work Experience of caring for family member or friend Recommended by another employee Formal experience of care work* Qualifications - NVQ2 or above in care Lives locally b. IDPs Positive attitude/ friendly nature Availability for weekend work Availability for early starts or evening work Lives locally Skills related to care work Qualifications - NVQ2 or above in care Experience of caring for family member or friend Recommended by another employee Formal experience of care work* Own transport Ability to drive Total No. No response c. LADPs % of respondents Necessary Desirable 77.8 100.0 100.0 55.6 11.1 11.1 0.0 33.3 11.1 11.1 0.0 0.0 33.3 88.9 33.3 77.8 66.7 44.4 Total No. 9 9 No response 1 1 Positive attitude/ friendly nature Availability for weekend work Availability for early starts or evening work Skills related to care work Experience of caring for family member or friend Recommended by another employee Formal experience of care work* Qualifications - NVQ2 or above in care Lives locally Note: *e.g. care home or other home or agency By contrast, evidence of skills related to care work or qualifications in general care (at NVQ EWERC Part III. The provider telephone survey 131 level 2 or higher) were only considered necessary in a small fraction of the independent sector organisations surveyed. Just one in four (24%) reported skills as necessary and one in ten reported qualifications. Such factors were instead far more likely to be reported as „desirable‟ rather than necessary, by two thirds or more of all organisations surveyed. The results in table III.7 above demonstrate the majority of care organisations do recognise the value of qualifications in care work, as well as formal or informal experience of care work and care-related skills (all factors highlighted in italics in the table), but are unwilling to use these factors to rule out candidates. The exception to this pattern are the public sector providers. LADPs were far more likely to report care-related skills and qualifications as necessary factors among job applicants – 56% and 33%, respectively, compared with 28% and 6% of homes and 14% and 10% of IDPs. On the one hand, this may reflect the lack of an available pool of ready-skilled job applicants, even during the recession. However, judging by the comments made by several respondents, it also reflects a genuine prioritisation of personality attributes over proven skills among public sector LADP managers. Somebody may come with a string of qualifications but really not be suitable at all. Or, conversely, zero qualifications but with a lifetime of experience of looking after people that would be fine. (ON.DIH.1.DP). Other factors cited as necessary by a small number of organisations were „lives locally‟ (in fact more than one quarter of IDPs said this was necessary), „recommended by another employee‟ and „formal experience of care work‟. The four attributes highlighted in italics in table III.7 refer to skills, qualifications and experience related to caring work. Across the different providers there was considerable variation in the extent to which these four skill-related attributes were considered necessary or desirable among job applicants. Figure III.5 presents the variation among homes and IDPs using an indicator from 0-8 that assigns 2 points where the provider reported a skill-related attribute as necessary and 1 point where it was reported only as desirable. Nearly half of both homes and IDPs score 4 out of 8 on this measure. A surprisingly high share (16%) of IDPs score 2 or less, meaning that they only reported two out of four skill-related attributes as desirable or just one attribute as necessary; the same was true of 12% of homes. Only 2% of homes and 2% of IDPs register the full score of 8, meaning they reported all four skill-related attributes as necessary among job applicants. Among LADPs, the scores are higher; nearly two thirds of LADPs score 5 or 6, 13% score 4 and 25% score 3. EWERC Part III. The provider telephone survey 132 Figure III.5. Measure of providers’ preferences for skill-related attributes among job applicants 50% homes 45% IDPs 40% 35% 30% 25% 20% 15% 10% 5% 0% 0 1 2 3 4 5 6 7 8 Indicator of provider need for skills and qualifications among job applicants Note: The four skill-related attributes are qualifications (NVQ level2 and above) in care, skills related to care work, formal experience of care work and experience of caring for a family member or friend. See table III.7 for details. 1 point is assigned to each attribute reported as desirable and 2 points to each necessary attribute. Among all the different attributes that organisations value among job applicants, respondents were also asked to identify the single most important factor. Unsurprisingly, perhaps, respondents were most likely to select a positive attitude and friendly nature over any other factor (table III.8). Two in three organisations cited this factor. All other factors accounted for fewer than one in ten responses. Nevertheless, among LADPs one in four cited carerelated skills as the most important factor, compared with just 4% of IDPs and 6% of homes. Interestingly only a handful of respondents considered availability for early starts or evening work (8%) and availability for weekend work (4%) as the most important factor in applicants when recruiting. This is somewhat paradoxical as we saw above that many managers reported staff shortages for weekend work and evening work. Nevertheless, some comments by managers did highlight this juggling of priorities: I suppose if the positive attitude and friendly nature presents itself, they‟ve still got to have a good availability. Just because somebody‟s really really friendly and really really nice, if they‟ve only got the availability of 10am until 2pm Monday, Tuesday, Wednesday, we are not going to take them on … So if they say, „Yes, I can start early three days a week because that‟s all I want‟, and they‟re dead bubbly, then you are going to take them on. Because we don‟t look for full-time workers. We are looking for people that work - 25 hours is a good number for people to work. (ON.D.1 DN). EWERC Part III. The provider telephone survey 133 Table III.8. The most important attribute required of job applicants % of homes % of IDPs % of LADPs % of All Positive attitude/friendly nature 76.6 56.5 62.5 66.3 Availability for early starts or evening work Skills related to care work 6.4 10.9 0.0 7.9 6.4 4.3 25.0 6.9 Availability for weekend work 0.0 8.7 0.0 4.0 Recommended by another employer 0.0 4.3 0.0 2.0 Formal experience of care work 2.1 2.2 0.0 2.0 Own transport 0.0 0.0 12.5 1.0 (Other) Reliability 0.0 8.7 0.0 4.0 (Other) Communication skills 4.3 0.0 0.0 2.0 (Other) Willingness to learn 2.1 0.0 0.0 1.0 (Other) Commitment 2.1 0.0 0.0 1.0 (Other) Honesty 0.0 2.2 0.0 1.0 (Other) Understanding 0.0 2.2 0.0 1.0 Total responses 47 46 8 101 No response 6 6 2 14 As well as looking for a particular mix of personal attributes – a friendly nature, a caring attitude towards elderly people and a commitment to wok different hours – our survey was also designed to identify whether or not managers also sought to compose a particular mix of care workers, differentiated by gender, age, ethnicity and so on. One reason care organisations may seek to do this is to reflect the demographic composition of their users; male care workers may be in demand by elderly men in need of care and similarly there may be a demand for care workers from particular ethnic backgrounds. We began by asking managers if they were satisfied with the composition of their care workforce. In relation to the numbers of young and old workers, male and female and ethnic mix, most organisations responding to our survey– over 80% - reported that they were satisfied. The degree of satisfaction was far higher among care homes – some 96% - compared to 74% of IDPs and only 40% of the 10 LADPs. Of the 23 organisations that reported dissatisfaction, we further queried the particular reasons for this (see table III.9). Ten organisations reported a preference for a more ethnically diverse profile (which may include wanting more white workers) and a similar number desired more male care workers. Three organisations stated they wished to have more young workers. The difficulties of extending the recruitment pool to these particular groups were articulated by some of the managers we interviewed: I‟d like to see more men in this area of work, I feel frustrated at times that our staff don‟t get the recognition that they deserve they are considered at the lower end of the scale in terms of the working classes, … And I‟d like to see a better representation of minorities. Now that‟s very difficult because of cultural differences and requirements which make it hard to recruit and also for some of the minority cultures to work in this field. (OM.D.2.DN). Ethnicity is an issue in terms of recruitment, there are a number of Chinese speaking and Somali speakers; but this changes and we may lose staff with these languages. Sometimes we EWERC Part III. The provider telephone survey 134 can‟t match specific requests. I don‟t know how we have managed to cope because it can be a problem. (IL.DIH.1.CP). Men are thin on the ground. We have a lot of male service users who prefer a man to come in to them. Having male staff limits you, as you can‟t send a male into a female service user. (IL.D.3 CL). Table III.9. Reasons for dissatisfaction with the composition of the workforce % of homes % of IDPs % of LADPs % of all Happy with composition of workforce 96.2 74.5 40.0 81.6 Not happy with composition and would prefer: More younger employees 3.8 25.5 60.0 18.4 0.0 7.7 28.5 13.0 More men 33.3 53.8 28.5 43.5 More ethnically diverse profile 66.7 38.5 42.9 43.5 Total responses 53 51 10 114 No response 0 1 0 1 III.1.4. Selection problems In an effort to explore further the consequences of the recruitment and selection context, we wanted to test the extent to which organisations were forced to hire people who perhaps did not quite meet the selection criteria. Conversely, mindful of the effects of rising unemployment during the period of our fieldwork, we also wanted to assess the degree to which organisations felt they enjoyed the luxury of selecting from a pool of numerous suitable candidates. Our first finding concerns the extent to which organisations sometimes hired a person who was known at the point of hiring to be less than the ideal match for the vacant job post. Quite surprisingly, more than two in five care organisations in our sample (41%) reported they occasionally, often or very often employed staff who did not possess as many of the desirable qualities as they would like (table III.10). Open-ended responses to this question suggest that organisations sometimes took on people without the desired experience, or without the desired NVQ qualifications. Others employed the person on a temporary basis or used them to cover staff on sick leave. The results suggest this was more of a serious problem for IDPs, 17% of which said this situation occurred „often‟. It is possible that the varying responses relate to labour market conditions, such that those providers experiencing recruitment difficulties (as reported in Figure III.1) would conceivably be more likely to make a less than ideal hire. However, interrogation of the data suggest there is not a strong relationship, neither for homes nor IDPs; those facing difficult recruitment conditions were as likely to report occasionally or often hiring people without the desirable skills as to never or almost never hiring such people. Only among homes that reported easy recruitment of care workers do we find some evidence of an influence, with twice as many saying they never or almost EWERC Part III. The provider telephone survey 135 never hired individuals without the desirable skills. Another factor that might help explain the variation in hiring practices is the provider‟s preference for skills and experience among job applicants (as reported in Figure III.5 above). Again, there is little evidence of a strong relationship. And once again only among homes do we find that for those with a medium to strong preference for skill-related attributes (a score of 4 of more on the 1-8 scale), the likelihood of never or almost never hiring individuals without the desired skills is twice that of occasionally or often hiring such individuals. Table III.10. Percentage of organisations that knowingly hire people who lack the full set of desirable qualities % of homes % of IDPs % of LADPs % of all Very often Often 1.9 0.0 0.0 0.9 3.8 17.3 0.0 9.6 Occasionally 34.0 32.7 0.0 30.4 Almost never 34.0 15.4 40.0 26.1 Never 26.4 34.6 60.0 33.0 53 52 10 115 Total responses In contrast a significant minority of organisations did not face problems in attracting sufficient numbers of suitable care workers and in fact often had to turn away people who were suitable for the job. Approximately one in three care organisations reported that they occasionally, often or very often were in the position of having to reject applicants who would nevertheless be acceptable care workers (table III.11). For one in ten organisations this occurrence happened often or very often, especially among independent sector and LA organisations providing domiciliary care. To some extent this finding is likely to reflect the impact of the recession with an increasing number of people seeking jobs. Nevertheless, the majority of organisations reported that this happened never or almost never. This finding suggests that most organisations simply do not experience the luxury of selecting from several candidates who are all suitable for the job post. At the same time, however, some organisations may be able to find alternative means of fitting such candidates into the organisation, as the following quote illustrates: If we thought we had found somebody good then we would always look at our other care company because I think if we felt that we had found a genuinely suitable person then we wouldn‟t want to lose them. (UY.D.2.B.S). All organisations delivering care to the elderly must apply for Criminal Records Bureau (CRB) checks on selected job candidates in order to ensure those individuals are eligible to work with vulnerable adults.23 We investigated two recruitment issues associated with CRB 23 The administrative success of CRB checks has been subject to criticism over recent years. The system was renovated and relaunched with a new IT system under a contract with the IT firm Capita in 2002, but was subsequently plagued by problems which led to the delayed opening of schools and unfilled vacancies in many care organisations. EWERC Part III. The provider telephone survey 136 checks – whether or not organisations had not recruited applicants because of delays in the CRB checks and whether or not applicants had failed CRB checks. In both cases, we were interested in identifying the extent to which these problems caused organisations to lose potential recruits over a two-year period. Table III.11. Percentage of organisations that reject suitable applicants for care work % of homes % of IDPs % of LADPs % of all Very often Often 0.0 1.9 0.0 0.9 5.7 13.5 20.0 10.4 Occasionally 30.2 7.7 50.0 21.7 Almost never 35.8 34.6 20.0 33.9 Never 28.3 42.3 10.0 33.0 53 52 10 115 Total responses In fact, a majority of organisations, 55% of the 115 surveyed, had experience of not recruiting qualified job applicants due to delays in their CRB checks in the previous two years. A smaller share, 36%, had a similarly negative experience as a result of an outright failure of CRB checks (table III.12a and b). With respect to CRB delays, a far higher share of IDPs reported problems than homes. Indeed, 28% of IDPs failed to recruit between 11 and 30 individuals in the previous two years as a direct result of CRB delays, and in 2% of IDPs more than 30 individuals are said to have been lost. A similar pattern is true of reported problems arising from CRB failures with around half of IDPs experiencing a loss of potential recruits compared to only 21% of homes. Many of our respondents took the opportunity as part of the telephone survey to voice criticism over the administrative process of submitting CRB checks. The following quotes are illustrative: This is one of the bones of contention with me. It is a little bit better now. It used to take up to 4 months last year … We consequently lost staff. Now it is a little better and we can get them in 3 weeks. Others take 8 to 10 weeks. This is just unacceptable. When it comes in they have found another job outside care. (LK.D.6.CL). We have a lot apply but they want to start work straight away. As we have a 7-week wait for CRB we lose people. (HD.D.1). We have to wait two months and people take other jobs. It is a real problem here. So we now ask them [job applicants] to foot the bill for the CRB. (AH.D.1.BL). EWERC Part III. The provider telephone survey 137 Table III.12. Recruitment failures caused by problems with CRB checks a. Number of people not recruited in previous 2 years due to CRB delays % of homes % of IDPs % of LADPs % of all 64.0 28.0 6.0 2.0 0.0 23.3 30.2 16.3 27.9 2.3 50.0 50.0 0.0 0.0 0.0 45.5 30.3 10.1 13.1 1.0 Total responses 50 43 6 99 No response 3 9 4 16 0 1-5 6-10 11-30 Over 30 b. Number of people not recruited in previous 2 years due to CRB failures % of homes % of IDPs % of LADPs % of all 0 78.8 48.9 50.0 63.8 1-5 19.2 27.7 50.0 24.8 6-10 1.9 12.8 0.0 6.7 11-30 0.0 8.5 0.0 3.8 Over 30 0.0 2.1 0.0 1.0 Total responses 52 47 6 105 No response 1 5 4 10 EWERC Part III. The provider telephone survey 138 III.2. Turnover and retention The care sector faces considerable challenges in managing staff turnover and retention. Estimates for England for 2010 suggest turnover rates as high as 22% for all care workers. Across the different provider types turnover rates of 24% are recorded in the domiciliary care sector and among homes with nursing provision and 21% in homes without nursing provision (NMDS 2010). Such high rates are problematic. Organisations may be forced to deliver care services without the adequate quota of staff. They will have to commit time and money to what may feel like a continuous process of managing recruitment and selection. And high staff turnover clearly limits the ability of managers to cement together an environment where experience, loyalty and careers add up to a committed staff. In this section, we map the patterns of staff turnover and staff retention for IDPs, homes and LADPs. III.2.1. Staff turnover Evidence from a range of datasets and studies of the care sector suggests there is an acute problem with staff turnover. In our survey of care providers we sought to provide alternative measures of turnover, utilising both self-reported, subjective measures, as well as staffing data on quits and retention among new starters and all care workers. Figure III.7. Managers’ subjective views about the level of staff turnover 50 45 Homes IDPs LADPs 40 Percentage 35 30 25 20 15 10 5 0 very high quite high about right/acceptable quite low very low Note: Total responses: 52 (homes), 52 (IDPs) and 10 (LADPs). Missing responses: 1 (homes). Figure III.7 presents managers‟ assessments of the level of turnover among their care workers, disaggregated by type of care organisation. Four in five providers (79%) were satisfied that the level of staff turnover was acceptable or low. This was especially true of LADPs, none of which reported high turnover among care workers, and to a lesser extent among homes, among which just 15% reported high turnover. IDPs were most likely to report EWERC Part III. The provider telephone survey 139 high staff turnover – some 31% - and IDPs were the only type of organisation to report „very high‟ staff turnover. Some of the open-ended answers to our survey provide a glimpse into the different causes of staff turnover among these IDPs. We have quite a high turnover. We have some staff who have been with us for 10 years but some go to a career in nursing. Some are new to the work and they may leave. We had quite a high level of turnover when the LA contract moved from block to spot last year. It meant that the work patterns changed and the work became less secure. … Otherwise it is because of the work times and the low pay. (IL.D.2.DL). There are obvious problems in comparing subjective opinions about staff turnover; what is high for one manager may be interpreted as low for another, for example. Hence, we also collected staffing figures and present below alternative quantitative estimates of turnover among care workers. The first refers to the ability of the organisation to retain new starters hired in the previous 12 months. Figure III.8 presents the percentage share of homes, IDPs and LADPs that registered different levels of retention of new starters. The total number of responses to this particular survey question is considerably below the full sample of 115, reflecting the difficulties in providing accurate information on staffing; the data refer to 45 homes, 37 IDPs and 5 LADPs. Figure III.8. Percentage retention of recruits hired in the previous 12 months 60 Homes IDPs Percentage of providers 50 40 30 20 10 0 100% 90-99% 80-89% 70-79% 60-69% 50-59% 40-49% 30-39% 20-29% Percentage retention of new recruits Note: Total responses: 45 (homes), 37 (IDPs). Missing responses: 8 (homes), 15 (IDPs). The measure of retention of new recruits was calculated as the number of new recruits retained divided by the number of recruits hired in past 12 months. The key finding is that homes are far more successful at retaining new starters than are IDPs; nearly 60% of care homes managed to retain all new starters over the previous 12 months compared to just 22% of IDPs. Nevertheless, a significant proportion of both homes and IDPs EWERC Part III. The provider telephone survey 140 reported a failure to retain more than half of new recruits – 22% of homes and 32% of IDPs. The evidence from LADPs is that new staff retention rates are much higher, although our evidence is only from 5 respondents.24 Our second quantitative measure estimates the level of staff turnover among care workers excluding new recruits. Average turnover rates of 18% were recorded for homes, 22% for IDPs and only 10% for LADPs. Overall 86% of LADPs, 62% of homes and 53% of IDPs had turnover rates below 20%. At the other end of the scale, a significant minority of IDPs (nearly one in three providers, 31%) experienced staff turnover in excess of 30%, far higher than the 13% of homes; no LADPs registered such high levels of staff turnover. Figure III.9. Level of turnover of care workers excluding new recruits 40 Homes IDPs Percentage of Providers 35 30 25 20 15 10 5 0 0% 1-9% 10-19% 20-29% 30-39% 40-49% 50-59% 60% Percentage staff turnover Note: Total responses: 45 (homes), 36 (IDPs). Missing responses: 8 (homes), 16 (IDPs). The measure of staff turnover is estimated as the number of care workers who quit in the past 12 months (excluding those recruited in the past 12months) divided by the care workforce in post twelve months earlier (calculated as the current total number of care workers minus any new starters still in post plus the number of care workers who quit (excluding quits by new recruits)). Our third measure estimates overall total staff turnover by including both the number of new starter quits and other staff quits in the calculation. The results are reported in figure III.10. These results show even stronger variation by type of provider with average turnover rates reaching 31% and 24% in homes and 11% in LADPs. Three fifths of homes (60%) had staff turnover below 20%, compared to only half of IDPs (51%). All LADPs reported turnover less than 30% (albeit applicable to a sample of just 7). At the other end, 30% of IDPs reported very high staff turnover among care workers of 50% or more; the comparable share of homes is just 13%. 24 Only eight of the ten LAs in the survey had undertaken recruitment in the previous 12 months. Of these eight we have data for five LADPs. The evidence suggests two of the five LADPs experienced 100% staff retention and three of the five reported 80-89% retention. EWERC Part III. The provider telephone survey 141 Figure III.10. Percentage staff turnover of all care workers 40 Homes IDPs 35 30 Percentage 25 20 15 10 5 0 0% 1-9% 10-19% 20-29% 30-39% 40-49% 50-59% 60-69% 70-79% 80-89% 90%+ Note: Total responses: 45 (homes), 37 (IDPs). Missing responses: 8 (homes), 15 (IDPs). Measure of total care workforce turnover in the last 12 months defined as (number of new starters in last 12 months minus number retained plus number of other staff who left) divided by current number of care workers. There are many reasons explaining turnover among care workers. Among all care providers, the most common reason, reported by around one third of organisations surveyed (35%), was family responsibilities (table III.13). Some managers suggested family issues were a particular problem given the highly feminised nature of the occupation (OM.HN.2). However, this reason also interacted with several „push factors‟ related to the working environment and HR policies of the organisation, particularly the desire for more convenient working time, which registered as the most important factor among IDPs (33%). In openended answers, managers talked about the difficulties care workers faced working weekends and long hours while raising young children; for example, at one provider (TE.HI.DL) each shift was 11 hours long and care workers were required to work alternate weekends. As such, staff quits to look for a job with more convenient working time was for many workers both a reflection of inconvenient working hours and family responsibilities. Leaving for improved job prospects was a relatively common reason. The push factor, „better pay‟, was cited by 25% of homes and 21% of IDPs (and notably no LADPs), and entering nurse training was reported by 26% of homes and 14% of IDPs. Also, many care workers were said to leave to work in another care organisation, for the NHS, local authority or another sector altogether. Finally, as might be expected, some reasons related to other push factors, such as dissatisfaction with the manager or other colleagues and lack of support in the job. EWERC Part III. The provider telephone survey 142 Table III.13. Push factors and other reasons for the turnover of care workers Push factors: More convenient working times Better Pay Unhappy with manager/office staff/team Lack of support /no promotion Other factors: Family responsibilities Nurse training Relocation Work for the NHS Work for another care provider Full-time education Not suitable – dismissal To work in a different sector Car/petrol/travel issues Health problems To work for the Local Authority Job too hard Don‟t want to/ like to train Other ambiguous Total responses % of homes % of IDPs % of LADPs % of all 15.1 24.5 11.3 3.7 32.7 21.2 1.9 3.9 10.0 0.0 0.0 0.0 22.6 20.9 6.1 3.5 37.8 26.4 26.4 18.8 7.5 13.2 7.5 5.7 3.7 3.7 0.0 1.9 3.7 5.7 30.8 13.5 7.7 11.5 19.2 15.4 15.4 11.5 9.6 3.9 5.8 1.9 0.0 13.5 40.0 10.0 0.0 10.0 10.0 0.0 0.0 20.0 0.0 10.0 10.0 0.0 0.0 20.0 34.8 19.1 15.7 14.8 13.0 13.0 10.4 9.6 6.1 4.3 3.5 1.7 1.7 10.4 53 52 10 115 Note: Question allows multiple answers by each respondent. EWERC Part III. The provider telephone survey 143 III.3. Pay and rewards III.3.1. Level of pay One of the key issues in the recruitment and retention of the social care workforce is the rate of pay for the job. For each provider we have identified the minimum, or starting rate of pay for care workers, and also a „normal‟ rate of pay, which refers to the modal rate of pay in the organisation for care workers. For example, where most workers were qualified to NVQ level 2 we took the rate paid to this group, but where only a minority were qualified we took the rate paid to the non-qualified. In some cases where a range was given, we have taken the mid-point for the normal rate of pay25. When we look at the distributions of both minimum and normal hourly pay rates for care workers it is clear that there are two significant dividing lines in the data. The first is the divide between wages paid by LAs and the wages paid by the independent sector, whether domiciliary providers or care homes. The average minimum pay across the sample of LADPs is £8.54 compared to means of £6.40 for IDPs and £6.05 for homes. Similar variation can be seen with respect to the median level of minimum pay offered: £7.90 in LADPs, £6.35 in IDPs and only marginally above the national minimum wage at £5.81 in homes. The second dividing line lies within the independent sector between the voluntary, not-for-profit homes and the for-profit homes. For example, median pay in voluntary sector homes is £7.55, significantly higher than the £5.75 median pay paid by for-profit homes. The pay gap is in part due to the differential proportion of users who are local authority funded since homes can charge their private clients higher rates and thereby fund higher pay. Our data reveal that 61% of users are LA funded in private homes but only 49% on average in voluntary sector homes. By way of an economy-wide benchmark for pay, it is notable that the median level of pay for all female part-time employees in the whole economy was £7.86 in 2009 at the time of data collection. Figure III.11 displays the range of minimum pay rates for care workers with box plots that depict the inter-decile (top and bottom points), inter-quartile (top and bottom of box) and median pay points (thick horizontal line). It is clear that minimum rates of pay are significantly higher in LADPs; the range of pay is not presented due to the small sample size. By contrast, within the for-profit independent sector there is a very high concentration of minimum pay rates at just above the national statutory minimum wage in both homes and IDPs. In the not-for-profit voluntary sector, IDPs display a narrow range of minimum pay rates but homes pay a wider range of rates at a higher level – significantly higher than the independent for-profit homes. Table III.14 presents the precise share of providers that pay a 25 Where pay data was collected after the upgrading of the national minimum wage in October 2009 we have deducted the increase of 7 pence from all wage rates. Obviously this is only a rough and ready adjustment to ensure comparability across time periods as not all rates will have been adjusted upwards. However, this is a relatively low adjustment and the data would provide a similar picture of relatively low pay, with or without the 7p adjustment. EWERC Part III. The provider telephone survey 144 minimum rate of just £6.00 or less. („low‟ or „very low‟). This accounts for 53 organisations almost half of the 111 independent providers that provided the necessary pay data. Moreover, 22% of all independent providers (for-profit and not-for-profit) set their minimum rate at the level of the national statutory minimum wage (4% of IDPs and 38% of homes). If we look at „normal‟ pay rates we find an even larger gap between LADPs and the independent sector with mean normal pay of £9.16 in LADPs and means of £6.65 in IDPs and £6.31 in homes. Differences in median pay are similarly varied at £8.61 (LADPs), £6.51 (IDPs) and £6.08 (homes). Figure III.12 presents box plots of the pay distributions in a similar fashion to the previous figure. Again, we see a strong compression of normal pay rates in the independent sector, particularly among for-profit homes and voluntary IDPs. Nevertheless, there is a clear differentiation between for-profit and voluntary independent organisations; median pay is higher in voluntary organisations than for-profit organisations, whether homes or IDPs. Overall, however, the wage distributions in all parts of the independent sector are at such a low relative level that there are no overlaps between the upper decile pay level and the median level of pay in the public sector LADPs. This is also true of minimum pay rates. Compared to the setting of minimum pay rates, fewer independent sector organisations paid a „normal‟ rate of pay at the national minimum wage – 9 homes (a 17% share) and no IDPs. But the share of both IDPs and homes paying £6.00 or less as the normal rate of pay for care work was still substantial at 23 homes (44%) and 10 IDPs (20%) (table III.15). EWERC Part III. The provider telephone survey 145 Figure III.11. The range of minimum pay rates for care workers in private and voluntary sector homes, and private, voluntary and public sector domiciliary care providers Notes: The box plots represent the following points of the pay distribution: lowest point (D10), bottom of box (D25), thick line (D50), top of box (D75), upper point (D90). Only the median pay level is presented for LADPs because of the small sample size. See table III.14 for sample sizes. Table III.14. Variation in minimum pay rates Public Private for-profit % of LADPs 0 % of IDPs 4.5 % of Homes 46.3 % of IDPs 0 % of Homes 9.1 % of all 19.8 0 27.3 39.0 33.3 9.1 27.9 Medium (£6.01-£6.90) 11.1 47.7 14.6 66.7 45.5 33.3 High (£6.91-£7.90) 44.4 18.2 0 0 27.3 13.5 Very high (£7.91- £10.90) 44.4 2.3 0 0 9.1 5.4 9 1 44 2 41 1 6 0 11 0 111 4 Very low (£5.73) Low (£5.74-£6.00) Total responses No response EWERC Voluntary Part III. The provider telephone survey 146 Figure III.12. The range of normal pay rates for care workers in private and voluntary sector homes, and private, voluntary and public sector domiciliary care providers Notes: The box plots represent the following points of the pay distribution: lowest point (D10), bottom of box (D25), thick line (D50), top of box (D75), upper point (D90). Only the median pay level is presented for LADPs because of the small sample size. See table III.17 for sample sizes. Table III.15. Variation in normal pay rates Public Private for-profit % of LADPs 0.0 % of IDPs 0.0 % of Homes 19.5 % of IDPs 0.0 % of Homes 9.1 % of all 8.1 Low (£5.74-£6.00) 0.0 20.5 34.1 16.7 0.0 21.6 Medium (£6.01-£6.90) 0.0 47.7 39.0 83.3 36.4 41.4 High (£6.91-£7.90) 11.1 25.0 4.9 0.0 36.4 16.2 Very high (£7.91- £10.90) 88.9 6.8 2.4 0.0 18.2 12.6 9 1 44 2 41 1 6 0 11 0 111 4 Very low (£5.73) Total responses No response EWERC Voluntary Part III. The provider telephone survey 147 III.3.2. Pay differentials and pay supplements The care sector appears not only to be characterised by low pay but also by very limited opportunities for pay progression. This is particularly so among IDPs where 52% paid the same rate as minimum and normal pay for care workers. In homes the tendency to pay rather lower minimum rates than in domiciliary care has led, perhaps, to more common provision of some pay increase between minimum and normal pay, with only 34% not offering any upgrade. The mean values of the pay differential were only 26 pence in homes and 24 pence in domiciliary care including those offering no increments. Of those offering some increments the mean value was 40 pence in homes and 50 pence in domiciliary care. Only 2 homes and 4 IDPs offered increments of £1 or more. The opportunities to progress beyond „normal pay‟ were usually very limited; in most cases these were limited to opportunities for promotion to senior care worker or team leader. We have information on maximum pay levels for senior care workers in 43 cases (15 IDPs, 28 homes). The information suggests there are very wide variations in the increments offered for seniors. For IDPs and homes the majority paid an extra £1.00 or less (7 IDPs, 20 homes). Of these, over half (3 IDPs and 10 homes) were paying below 50p, with the lowest rates being 25p extra per hour. Those offering the very lowest rates for seniors tended to be low payers for all staff – in 17 of these cases, the normal rate was £6 50 and below, and six of the eleven were paying the national minimum wage as the normal rate – all of these were homes. The three IDPs that paid seniors less than 50p extra all paid over £6 50 as the normal rate. Some of the managers commented on how low the pay enhancements for senior grade staff actually were: The amount of workload and responsibility they have on them is a lot.... For a minute amount of money for the amount of responsibility, it‟s just not worth it. (IL H4 BS). In fact, as shown in table III.16, fewer than half of the respondents in either homes or IDPs said that they rewarded experience/length of service with extra pay (38% of homes and 42% of IDPs). Most of these variations by experience/length of service are limited as has already been found in the small gaps between minimum rates and normal pay levels. Even fewer (8% of homes and 4% of IDPs) claimed to have variations in pay based on incremental scales. The most common factors associated with variations in pay rates were qualifications (over 60% of homes, and 67% of IDPs) and, for IDPs, weekend work (73% compared to 28% of homes). Again, these variations tend to be limited with many of the increments for qualifications at least up to NVQ level 2 more in the range of pence. Of the 25 which specified rates, the increments ranged from 7 pence to £1.02 per hour above the minimum pay rate; 23 out of the 25 paid under 50p extra, and over half of these paid less than 25p. Even for NVQ level 3, where rates were specified, some of the increments above minimum pay rates were in the range of pence. Of five IDPs, two paid 30p or less, and three paid above £1; of six homes five paid 90p or less and the sixth paid £1.27 above the minimum rate. EWERC Part III. The provider telephone survey 148 Table III.16. Main reasons for differences in pay rates for care workers % of homes % of IDPs % of LADPs % of all Experience/length of service 37.7 42.3 33.3 39.5 Incremental pay scales 7.5 3.8 40.0 8.7 Qualifications 60.4 67.3 44.4 62.3 Weekend work 28.3 73.1 55.6 50.9 Night work 24.5 32.7 88.9 33.3 Total responses 53 52 9 114 No response 0 0 1 1 Note: Multiple responses possible. Only one quarter of home managers (25%) cited night work as a source of pay variations even though all will operate night shifts on a regular basis. A third of IDPs (33%) cited night work even though not all were engaged in night work, and this suggests that where night work is undertaken by IDPs a supplement is paid. Some of the providers gave us examples of supplements for weekend work or night work, but most were a matter of pence. Home managers also paid less than IDPs for night work. Home rates varied from 20p to £1.60, while IDP rates varied from 70p to £2.02. The higher rates paid by IDPs may reflect the unpopularity of being out late in the evening in the community. Where IDP rates were given, they were commonly for work up until 10pm, although in one case it was for work up until midnight26. For weekends, the majority of rates ranged from 8p to £1.45 extra, excluding three outliers which paid a percentage of the hourly rate for weekend work – in two cases, this was 100% and resulted in extra pay of over £6 50 per hour. A few organisations (12 IDPs and 1 home) offered the additional information that they paid higher rates for Bank Holidays. Although this is likely to undercount the number making such payments, it was notable that amongst this group not all Bank Holidays were paid for: in one case only Christmas counted, another only Christmas, Boxing Day and New Year‟s Day27. Among the „other factors‟ associated with pay differentials cited by providers, the most common were senior or team leader roles, particularly among homes (30) but also IDPs (13). As we saw in Section III.1.2 (see table III.5), an overwhelming majority of providers recruited seniors from existing staff or from a combination of externals and existing staff (only one home and one IDP stated that they solely recruited seniors externally). These additional payments for seniors thus provided internal care staff with some limited prospects of pay promotion through upgrading. A much less commonly cited factor influencing pay was the needs of the client, mentioned only by 8% of IDPs. Rising dependency levels are increasing the complexity of work but so 26 No information was given on rates for those IDPs offering 24 hour service. Only three organisations cited the premia paid: in two of the cases double time was paid, in another the rate was £1.51 above the minimum pay. 27 EWERC Part III. The provider telephone survey 149 far this is not reflected frequently in pay levels. Indeed only a minority of the IDPs (26%) and LADPs (38%) that undertook intermediate care/hospital discharge work paid a different rate for this type of work (table III.17). These findings suggest that pay does not vary in line with variations in skills required in the actual work tasks, although it should be noted that some LADPs specialise in this type of work, and these results for the LADPs need to be considered in conjunction with the generally higher pay rates in local authorities. Table III.17. Payment of different rates for those providing intermediate care (where applicable) % of IDPs % of LADPs % of all Yes 25.9 37.5 28.6 No 74.1 62.5 71.4 Total responses 27 8 35 No response/not applicable 25 2 27 The majority of IDPs did not make a distinction in pay rates between care work and domestic work but 14% did pay a lower rate for domestic work along with half the LADPs (table III.18). All those providers paying lower rates to domestic staff were paying a minimum rate to care staff that exceeded the national minimum wage. Table III.18. Payment of different rates for personal and domestic work % of IDPs % of LADPs % of all Yes 13.7 50.0 80.3 No 86.3 50.0 19.7 Total responses 51 10 61 No response/not applicable 1 0 1 EWERC Part III. The provider telephone survey 150 III.3.3. Pay uprating Regular uprating of pay was common but not universal. All LADPs had a regular uprating of pay but 8% of homes and one fifth of IDPs did not have a regular uprating of pay (table III.19). Failure to increase pay could be a serious source of dissatisfaction which could impact upon staff retention, as the following quote illustrates: Well, they [care workers] didn‟t get a pay rise for two years so they weren‟t very happy and a lot threatened to leave so they [managers] had to take notice. (RN.D.2.CN). Table III.19. Provision of a regular uprating of pay % of homes % of IDPs % of LADPs % of all Yes 92.5 80.0 100.0 87.4 No 7.5 20.0 0.0 12.6 Total responses 53 50 8 111 No response 0 2 2 4 There were some marked differences between homes and IDPs in what triggered an uprating (figure III.13). The impact of LA fee levels was more important for IDPs with nearly half (43%) citing this as the most important factor compared to less than one in ten (8%) homes. In contrast changes in the statutory National Minimum Wage were more important for homes (52% citing this compared to 20% of IDPs). These findings reflect the higher share of homes using the National Minimum Wage as a minimum pay rate and the lower influence of LAs on total income for homes. Profitability was another important factor in uprating but more so for IDPs than for homes (33% compared to 19%). Performance factors also acted as a trigger in a significant minority (15% of homes and 14% of IDPs). Of those homes citing changes to the National Minimum Wage as a main factor influencing pay uprating, 85% paid under £6.00 and 65% paid the national minimum wage (figure III.14) compared to 39% for the sample of homes as a whole (see Table III.14 above). In contrast of those IDPs who cited the National Minimum Wage as a main factor, only 40% had a minimum rate below £6.00 and only 20% had the National Minimum Wage as their lowest rate (but this was a higher share than the 4% for the IDP sample as a whole). EWERC Part III. The provider telephone survey 151 Figure III.13. Main factors influencing pay uprating in homes and IDPs 60 Homes IDPs Percentage of providers 50 40 30 20 10 0 Change in NMW Completion of qualifications LA fee levels Profitability Performance Related Employee Request Note: Total responses: 52 (homes), 51 (IDPs). Missing responses: 1 (homes), 1 (IDPs). Multiple responses possible. Figure III.14. Minimum pay rates in homes and IDPs that cited change in the National Minimum Wage as a main factor in pay uprating 70 Homes IDPs Percentage of providers 60 50 40 30 20 10 0 £5.73 £5.74 - £5.99 £6.00 or over Note: Total responses: 26 (homes), 10 (IDPs). Question only applies to those providers that cited change in the National Minimum Wage as a main factor in pay upgrading (see figure III.13). EWERC Part III. The provider telephone survey 152 III.3.4. Payment for travel time, overtime and training time Payment for all time spent at work or on work related activities is clearly an important aspect of working conditions, as is receiving additional premia for working extra hours. The extent to which the conditions apply to the care staff in our sampled organisations is explored here. One of the key issues for domiciliary care workers is how travel time between clients is compensated. The actual time spent travelling may be paid for by travel time being included in work time or by staff being expected to complete tasks in under the allotted time to allow themselves time to reach the next client. The variety of practices was indicated by some of the additional responses to the question on travel costs. One provider paid a flat rate: We pay 15p per call, whether workers travel by foot, bus, or car, it is the same. (IL.D.3.BN). Another provider clearly includes a variable element into the work schedule according to estimated and actual travel times between service users: We look at the run, and we allow 7 minutes, 10, 15 minutes etc., So it‟s all factored into the run, so they are paid for the complete time. We pay travel expenses based on the mileage of the run. (TE.D.1 CN (V)). Others regard it as a relatively trivial issue due to proximity of services users: The travel is included in the hourly wage. Because we‟re quite unique here ….because ninety nine percent of the carers walk. The service users are very close to the office. (RN.D.2.CN). Travel time for some people – not for foot or bike - if people go out of their normal area to work we pay for that travel time. We only pay travel costs if they are doing something that the client needs – for example, taking them to hospital or going shopping for them. If it‟s travel between jobs, we don‟t pay, but we help with the tax claims. (LK.D.3.DS). Yet another provider pointed to the problem of comparing rates of pay across IDPs as some pay a lower rate but pay for actual travel costs and travel time while others pay a higher basic rate but no compensation for travel time: Also what our competitors tend to do is to include their mileage cost rates within their basic rates, which make them look higher when in actual fact they‟re not. (OM.D.2.DN). With these problems of interpretation in mind, the responses to the question on travel time suggest that only 20% of IDPs paid any kind of supplement whether flat rate, percentage or in one case a higher rate for a shorter visits. A higher share, 54%, paid a mileage allowance, or reimbursed petrol or public transport costs (figure III.15). Those not reimbursing out of pocket expenses may include those IDPs that rely on „walkers‟. Nevertheless, several said explicitly that they did not pay petrol or mileage but instead would volunteer to help staff claim the tax back on their tax returns. Furthermore, 38% of IDPs and 30% of LADPs said the compensation was included in the hourly rates. However, while in LADPs work time is organised in continuous shifts without unpaid breaks so that time spent travelling is paid for, EWERC Part III. The provider telephone survey 153 IDPs tended to pay just for the scheduled visit time. If travel was undertaken outside these times it was unlikely to be paid for. Figure III.15. Payment for travel among IDPs and LADPs 100 IDPs LADPs 90 Percentage of providers 80 70 60 50 40 30 20 10 0 Supplement (flat rate/%/higher rate for short calls) Reimbursement (mileage/petrol/public transport costs) Included in hourly rate Note: Total responses: 50 (IDPs), 9 (LADPs). Missing responses: 2 (IDPs) and 1 (LADPs). Multple responses possible. Table III.20. Compensation for time spent training a. Payment for time spent training % of homes % of IDPs % of LADPs % of all Yes 88.7 84.6 100.0 87.8 Not all courses 9.4 5.8 0.0 7.0 No 1.9 9.6 0.0 5.2 Total responses 53 52 10 115 % of homes % of IDPs % of LADPs % of all Yes 77.4 86.5 70.0 80.9 Sometimes 18.9 7.7 30.0 14.8 No 3.8 5.8 0.0 4.3 Total responses 53 52 10 115 b. Time off to attend training EWERC Part III. The provider telephone survey 154 Another call on staff time that is related to work but which is not direct caring work is time spent training. The majority of providers said that staff were paid for training time - all LADPs paid, as did 85% of IDPs and 89% of homes. Even those that did not pay all the time may pay some of the time, but 2% of homes and 10% of IDPs said they did not pay for training (table III.20a). An even higher share of IDPs – as we see in table III.22b below - did not pay for induction training. When it comes to time off from care duties to attend training rather than attending in their own time, the pattern was somewhat different with more homes not always providing time off – nearly one in five (19%) only did so some of the time and 4% none of the time compared to 8% and 6%, respectively, of IDPs. Around a third of LADPs also did not always provide time off (table III.20b). Only a minority of independent providers (26% of homes and 29% of IDPs) ever pay overtime premia to staff compared to more than two thirds (70%) of LADPs (figure III.16). Moreover, when this minority were asked whether this applied to all staff, or only those contracted to work a certain number of hours per week, one out of the 15 IDPs paying a premium said it was discretionary, one paid it only to TUPE transferred staff, and one only paid when staff were required to work „out of area‟. Five LADPs referred to overtime premia that only applied above a certain number of hours – one for over 36 hours, three for over 37 hours and one for over 148 hours in a four week period. Among the 14 home managers who mentioned overtime premia for extra hours, three said they only applied over full-time hours, for example, over 37 hours per week. Figure III.16. Payment of overtime premia to staff working extra hours 80 Homes IDPs LADPs Percentage of providers 70 60 50 40 30 20 10 0 Yes No Note: Total responses: 53 (homes), 51 (IDPs), 10 (LADPs). Missing responses: 1 (IDPs). EWERC Part III. The provider telephone survey 155 III.3.5. Payment for upfront costs of starting work There are three elements of upfront costs that staff considering entering care work may have to pay for; these include the costs of CRB checks, the purchase of uniforms and the cost of attending induction training if this is not paid for (this latter cost is more an opportunity cost but there may be also out of pocket costs such as travel or childcare). While most independent sector providers meet these costs there is a significant minority of providers who do not (table III.21). This is particularly true with respect to CRB checks, where only one third of IDPs paid for CRB checks up front with no strings attached and a further 2% paid but required staff to reimburse the costs if they left within twelve months. A further 12% of IDPs shared the costs 50/50 and 16% required staff to pay but reimbursed the costs if they stayed. In more than a third of IDPs (37%) prospective employees had to pay themselves for the checks. In LADPs, eight out of ten paid for the staff and only one shared the costs 50/50, but one LA did require the applicant to pay. For homes the situation was more favourable to potential employees than with IDPs with 64% of homes paying for the check and only one in four homes (26%) not paying; the remainder either shared the costs (2%) or reimbursed if the staff stayed (6%). Table III.21. Percentage of organisations that pay for CRB checks % of homes % of IDPs % of LADPs % of all Yes 64.2 33.3 80.0 51.8 50:50 1.9 11.8 10.0 7.0 Employer pays but staff pay if they leave within 12 months Staff pay but are reimbursed if they stay 1.9 2.0 0.0 1.8 5.7 15.7 0.0 9.6 No 26.4 37.3 10.0 29.8 Total Responses 53 51 10 114 No response 0 1 0 1 Payment by the employer for uniforms is more common with just under a fifth of homes, just under a tenth of IDPs and no LADPs saying that staff had to pay for uniforms, although 6% of homes and 22% of IDPs only provided one uniform and expected staff to pay for extra uniforms (table III.22a). One IDP provided protective clothing and another gave a clothing allowance for TUPE transferred staff. All but one home and all LADPs paid staff for induction training but 24% of IDPs did not pay staff for attending induction. A further two said they did not pay for part of the training (i.e. initial „orientation‟ and classroom training), and two more said they only paid if staff stayed in employment for a certain period of time afterwards (table III.22b). A summary of shares of employers not paying for the upfront costs of starting work is shown in Figure III.17. EWERC Part III. The provider telephone survey 156 Table III.22. Percentage of organisations that require staff to pay for: a. Uniforms No 1 Yes % of homes % of IDPs % of LADPs % of all 74.5 68.6 100.0 74.1 25.5 31.4 0.0 25.9 Total responses 51 51 10 112 No response 2 1 0 3 % of homes % of IDPs % of LADPs % of all Yes 98.1 68.6 100.0 85.1 Partly 0.0 3.9 0.0 1.8 Yes if staff stay 0.0 3.9 0.0 1.8 No 1.9 23.5 0.0 11.4 Total responses 53 51 10 114 No response 0 1 0 1 Note: including those who only pay for extra uniforms. b. Induction training Figure III.17. Percentage of providers not paying for upfront costs of starting work 40 Homes IDPs LADPs 35 Percentage of providers 30 25 20 15 10 5 0 CRB checks Uniforms Note: For missing responses see tables III.21 and III.22. EWERC Induction Part III. The provider telephone survey 157 III.4. Flexibility, working time and work organisation While care homes and IDPs in the independent sector offer relatively similar pay levels and conditions, there are greater differences in the employment context and employment conditions between homes and IDPs once we consider the organisation of work and working time. Both segments of the care sector face challenges; in domiciliary care the challenge is to organise work and working time to fit a fragmented and time-specific demand for care for a variable set of users located in their own homes rather than in a workplace, and to cover these demands at least from early morning until evening and into weekends. When asked about hours of care provision we found that all but seven of the IDPs (87%) provided cover until 10 pm or later with nearly one in four (23%) providing 24/7 cover and one in three (31%) finishing cover after 10pm. Moreover, seven IDPs (13%) started cover before 7 am. The LADPs also provided extended cover with all operating until at least 10pm, three out of ten providing cover until later than 10pm (another saying that in practice they operated 6-11 while in principle it should be 7-10) and three provided 24 hour cover. For care homes the challenge is always to deliver care on a 24/7 basis but with this being delivered in a fixed workplace; here the main unpredictable factors are related to bed occupancy and the needs of the service users on the one hand and the availability of staff on the other. These differences led to tailored questions being asked as well as common questions across the two subsectors. We therefore explore these arrangements separately for domiciliary care and care homes, although drawing in many places on similar questions and tables. III.4.1. Flexibility, working time arrangements and work organisation in domiciliary care Employment contracts The first and distinctive characteristic of domiciliary care is the extensive reliance on zero hours contracts. We were aware that providers may make use of zero hours contracts (Rubery and Urwin 2010) and that indeed such contracts had also been widely used in LA provisions until trade unions pressed for better employment conditions (Horrell and Rubery 1991). When asked about contracts for care workers we found that the practice was overwhelmingly dominant with 69% of IDPs only offering zero hours contracts to their staff and only 12% offering all staff some guaranteed hours, with the remainder (20%) offering a mix of zero hours and guaranteed contracts (figure III.18). This practice of zero hours contracts reflected the variability and uncertainty of workloads. By comparison, only one of the LA providers offered a mix of guaranteed and zero hours with all the other LADPs offering only guaranteed hours contracts. EWERC Part III. The provider telephone survey 158 Figure III.18. Types of employment contracts offered to care workers 100 IDPs 90 LADPs 80 Percentage 70 60 50 40 30 20 10 0 Zero hours only Mix of zero and guaranteed hours Guaranteed hours only Note: Total responses: 51 (IDPs) and 10 (LADPs). Missing responses: 1 (IDPs). Reasons given for offers of guaranteed hours within the independent sector to specific staff members included the need to retain staff who were, for example, car drivers: Zero hours only for all staff unless they drive a vehicle, in which case we offer guaranteed hours. IL.D.2.DL Or as a means of recruiting and integrating migrant workers: We had a mix. We offered guaranteed hours to overseas workers for the first year. Then they all work full time, in fact, excessive hours because they have a very good work ethic. After the first year, there is no need for guaranteed hours, because they will work full time. (LK.D.3 DS). The lack of fixed contract hours clearly gave providers discretion in their allocation of work, and their ability to determine access to enough work seemed in some cases to be used as a form of control over the staff. People who are not flexible, they don‟t get so many hours. Now we have more staff we have more control. It is important. (TE.D.1 CN (V)). In particular the zero hours contracts left staff vulnerable to loss of work and pay when their clients went into a home or hospital or died. The provider may seek to replace the work but does not guarantee so to do if new work is not immediately available. Zero hours only? All. We provide continuity of care – workers build up service users and if they lose one, we replace them as quickly as possible. We have picked up ten care plans in the last one and a half weeks. Before that all the agencies were scrambling for work. It is steady now. (LKD.6.CL). EWERC Part III. The provider telephone survey 159 Working time patterns Although most staff in domiciliary care were only offered zero hours contracts, in practice most staff in the domiciliary sector worked more than short part-time hours and many were involved in long hours working (figure III.19; table III.23). Only 4% of IDPs had the majority of their staff regularly working less than 16 hours. At the other extreme 59% of IDPs said short part-time work accounted for less than 10% of all staff (33% having no staff in this category and 27% up to 10%). Long part-time hours - between 16 and 30 - were more commonly used, with over 59% of providers having more than 50% of staff in this category and 17% with ratios of 80% or more. One in four (24%) providers had less than 20% of staff in this category, including 8% with no such staff, while at the other end 16% had 70% or more working at least 30 hours. This suggests considerable scope for varying the working time mix within domiciliary care providers. LA providers were most likely to make extensive use of long part-time work, with relatively low proportions of either short part-time or fulltime hours. Very long hours working (over 45 hours) was also far from uncommon in this sector: even though no provider primarily used long hours work over 38% of domiciliary providers had some staff working long hours. Even excluding those providers where working very long hours occurred only on occasions for emergency cover, over 34% of IDPs recorded some long hours working. Figure III.19. Proportions of staff working different hours in IDPs 80 Percentage of providers 0% 70 1-10% 60 11-20% 21-30% 50 31-50% 40 51-70% 71-80% 30 81-90% 20 91-99% 10 100% 0 Under 16 hours 16-30 hours 30-45 hours Usual weekly hours Note: See table III.23 for responses. EWERC Over 45 hours Part III. The provider telephone survey 160 Table III.23. Working-time patterns of care staff % of staff % of homes % of IDPs % of LAPDs % of all <50 100.0 95.9 100.0 98.1 >50 0.0 4.1 0.0 1.9 <50 58.8 40.8 14.3 47.7 >50 41.2 59.2 85.7 52.3 <50 39.2 67.3 100.0 56.1 >50 60.8 32.7 0.0 43.9 <50 100.0 100.0 100.0 100.0 >50 0.0 0.0 0.0 0.0 Total responses 51 49 7 107 No response 2 3 3 8 Under 16 hours? 16 – 30 hours? 30 – 45 hours? Over 45 hours? There is further evidence of extensive engagement by staff in the information on maximum numbers of days worked. Here 28% of IDPs recorded a seven day maximum working week and a further 49% had a six day maximum with only just over a fifth having a five days maximum. In contrast over half of LA domiciliary providers had a five day maximum (table III.24). Table III.24. The maximum number of days a week worked by care staff Number of days per week % of homes % of IDPs % of LADPs % of all 3 1.9 0.0 0.0 0.9 3.5 1.9 0.0 0.0 0.9 4 9.6 0.0 0.0 4.5 5 53.8 21.6 55.6 39.3 5.5 0.0 2.0 0.0 0.9 6 23.1 49.0 33.3 35.7 7 9.6 27.5 11.1 17.9 Total responses 52 51 9 112 No response 1 1 1 3 This use of six and seven day maxima reflected the prevalence of weekend working (figure III.20). Nearly three fifths of independent domiciliary providers and 89% of LADPs said that all their staff were engaged in regular weekend working. However, there appeared to be some choice in the way weekend working was organised as around 28% of IDPs had less than half the staff regularly working weekends. EWERC Part III. The provider telephone survey 161 Figure III.20. The percentage of care workers who regularly work weekends 100 Homes 90 IDPs LADPs 80 Percentage 70 60 50 40 30 20 10 0 0 – 25% 26 – 50% 51 – 75% 76 – 99% 100% Percentage of staff Note: Total responses: 50 (homes), 49 (IDPs) and 9 (LADPs). Missing responses: 3 (homes), 3 (IDPs), 1 (LADPs). Even when an organisation had a policy that all staff should work weekends the reality might prove different. Some providers claimed that staff were apparently prone to backtracking on their agreement to work weekends at recruitment. They work alternate weekends. We try to make them all work weekends, but it is really hard to get people to work weekends. We have to look closely at applicants. They say that they will work weekends, then two months in, they say they can‟t work weekends. (LKD.6.CL). All our carers, when they come for the job, they‟ll do anything. It‟s once they‟ve got in and then they say, „I can‟t do these evenings, or I can‟t do that day.‟ That‟s when it starts, once they‟re in the job. Because when they‟re interviewed they are told it‟s mornings, afternoons evenings, weekends and all that, and it‟s „Oh, yes, it‟s fine, I‟ll do anything.‟ And then you find out that they won‟t. (ON.D.2 AS). The problems of staffing weekends led some providers to try a range of different systems: We struggle to find staff who will work weekends, as everyone wants these off. We did run alternative weekend work, but now we offer one day at weekends, so that staff have to work either Sat or Sun to relieve the existing staff and give cover. Some of the extra staff only work weekends. ( IL.D.2.DL). Or they recruited specifically for the unpopular time periods: We‟ve also got carers who just want evening work, so you‟re looking around eight hours a week for them. And the same at weekends. We‟ve just got weekend workers who just want, you know, say ten hours a week. (ON.D.3 BN). EWERC Part III. The provider telephone survey 162 Working time scheduling Work scheduling is highly complex in domiciliary care because of the number of clients, their geographical spread, the need for repeat visits and the fluctuating mix of clients and demands. In this context there may be tensions between the need to provide continuity of care for service users - where the same care worker or team of care workers is always provided and the need to organise the care work into a work schedule for individual employees. To tap into these tensions we asked first about how important it was to provide continuity of care for service users. All providers responded that it was either very important or important, with 94% of independent providers, in fact, saying it was very important (table III.25). This suggests that in principle, at least, providers recognize a need to schedule work around existing allocations to users. Table III.25. The importance of organising working hours to provide continuity of care % of IDPs % of LADPs % of all Very important 94.2 77.8 91.8 Important 5.8 22.2 8.2 Neutral 0.0 0.0 0.0 Unimportant 0.0 0.0 0.0 Very unimportant 0.0 0.0 0.0 Total responses 52 9 61 No responses 0 1 1 We then asked about how important it was to schedule work to fit employees‟ circumstances. Although there was, again, strong support for this being an important factor, with 89% of IDPs saying it was important, or very important, the share saying it was very important was significantly lower, at 64%, compared to the 94% who considered continuity of care for users to be very important (table III.26). The share was even lower for LA providers with only 44% of inhouse providers saying it was important or very important. These answers may reflect the changes in LA practice where they have moved from offering domiciliary care workers fixed hours within a limited window - often school hours - to asking staff to cover hours over a more extended period including early mornings and evenings. We explored further the consequences of the variability of demands and the priority to continuity of care by asking whether staff were able to get work schedules that fitted their preferences all the time or most of the time. It is likely that they interpreted this question as referring to the range of what was possible rather than in relation to absolute preferences, as one provider noted: I think that‟s a tricky one because people‟s preferences might be working Monday to Thursday ten till two, but they know that isn‟t an option, so its whether people think the rotas are reasonable, I mean we get the occasional „I‟ve done more weekends than … ,‟ and that‟s obviously worth listening to. (RD.D.2.CL) EWERC Part III. The provider telephone survey 163 Table III.26. The importance of organising working hours to fit employees’ circumstances % of IDPs % of LADPs % of all Very important 63.5 22.2 57.4 Important 25.0 22.2 24.6 Neutral 9.6 44.4 14.8 Unimportant 0.0 11.1 1.6 Very unimportant 1.9 0.0 1.6 Total responses 52 9 61 No responses 0 1 1 Figure III.21 shows that the vast majority of IDPs – 98% - said their staff were able to get schedules that fitted their preferences all, or most of the time, but only a quarter said it was all of the time, suggesting some requirements for staff to adapt to schedules that do not match their preferences. Figure III.21. The overall matching of work schedules with care workers’ preferences for particular hours 100 Homes 90 IDPs LADPs 80 Percentage 70 60 50 40 30 20 10 0 All of the time Most of the time Some of the time Occasionally Note: Total responses: 52 (homes), 52 (IDPs) and 10 (LADPs). Missing responses: 1 (homes). We also asked IDPs whether they would expect care staff to have to tolerate working longer than scheduled due to unanticipated needs of service users or to tolerate variations in hours or location at short notice (figure III.22). On working longer than scheduled only two providers thought this would never happen and 15% of independent providers and 30% of LA providers felt it was indeed something care workers would need to tolerate; the majority, however – over four fifths of IDPs and 70% of LADPs - saw this as only an occasional requirement On variations in hours or location at short notice 85% of IDPs said that they would expect them to tolerate it often or occasionally although the majority of these put it down as occasional EWERC Part III. The provider telephone survey 164 (77%) and only 8% regarded it as a regular issue. LA providers expected more variability with 20% saying they did expect staff to tolerate such changes and 70% saying yes, occasionally. Figure III.22. The requirement for care workers to tolerate longer working hours or variations in hour due to unanticipated needs a. Tolerate longer working hours 100 IDPs 90 LAPDs 80 Percentage 70 60 50 40 30 20 10 0 Often Occasionally Never b. Tolerate longer working hours or variations in hour due to unanticipated needs 100 IDPs 90 80 Percentage 70 60 50 40 30 20 10 0 Often Occasionally Note: Total responses: 52 (IDPs) and 10 (LADPs). EWERC Never LAPDs Part III. The provider telephone survey 165 Table III.27. Staffing arrangements to cover for absences/vacations/unfilled vacancies % of IDPs % of Homes % of LADPs % of all Ask existing staff to work extra hours 90.4 Use external agencies 1.9 Use list of staff available for temp cover 0 combined with other methods 7.7 0.0 7.7 All using the method 98.1 1.9 7.7 sole method 56.6 3.8 0 combined with other methods 39.7 20.8 34.0 All using the method 96.3 23.9 34.0 sole method 80.0 0 0 combined with other methods 20.0 10.0 10.0 All using the method 100.0 10.0 10.0 sole method 73.9 2.6 0 combined with other methods 23.5 10.5 20.0 All using the method 97.4 13.1 23.5 sole method Note: Total responses: 53 (homes), 52 (IDPs), 10 (LADPs). These requirements for flexibility were further exacerbated by the reliance of domiciliary care providers on their existing staff to cover extra shifts: 80% of LA providers and 90% of IDPs only used existing staff to cover extra shifts and only one IDP from our sample of 52 used an external agency exclusively for cover. All others relied on existing staff with 8% of IDPs using a list of temporary staff in addition to existing staff to provide cover. The pattern for LA providers was similar with all using existing staff and only one combining this with an external agency and one with a list of temporary staff (table III.27). To probe further on how flexibility was managed we also asked about how easy or difficult it was to find staff willing to work extra hours, either on the day itself or with two to three days notice. The majority of providers found it easy, or very easy to find staff willing to work additional hours at 2-3 days notice (86% of IDPs and 70% of LADPs). Only 8% of IDPs and 20% of LA providers found it difficult, or very difficult to find staff willing to work additional hours with this amount of notice (table III.28). Even on the same day, the majority found it easy, or very easy to find staff to work additional hours (77% of IDPs and 70% of LA providers). However, the number recording difficulties increased when the notice was very short with around a fifth of IDPs finding it difficult, or very difficult to find staff willing to work extra hours on the same day. The comments from providers indicated that the difficulty in part depended upon how familiar staff were with the users: I suppose it depends on what you‟re asking them to do. If it‟s working with someone that they know, it‟s almost always that they will sort that out between themselves because that‟s, you know, about your commitment and knowing that person. If you want someone to do something that they are less familiar with then that might need more discussion. (RD.D.2.CL). EWERC Part III. The provider telephone survey 166 It depends on their mood and what you are asking. If it is to work extra time with an existing client, that might be okay, but if you are asking them to go out for another slot…that might be difficult. (LK.D.6.CL). Table III.28. Finding staff willing to work additional hours at short notice % of IDPs % of LADPs % of all Very easy 9.8 10.0 9.8 Easy/quite easy 76.5 60.0 73.8 Neither difficult nor easy 5.9 10.0 6.6 Quite difficult 7.8 10.0 8.2 Very difficult 0.0 10.0 1.6 Very easy 2.0 0.0 1.6 Easy/quite easy 74.5 70.0 73.8 Neither difficult nor easy 3.9 10.0 4.9 Quite difficult 17.6 10.0 16.4 Very difficult 2.0 10.0 3.3 Total responses 51 10 61 No response 1 0 1 2-3 days notice Same day It also varied according to the different ways in which staff might assess the opportunity for extra work: People will accept the rota if it‟s got the times that they can work, so they accept it but then they start to plan other things in the gaps, and then they don‟t want to give those gaps up, rightly so or wrongly so, depending on your point of view. (ON.D.1 DN). Sometimes it‟s okay, sometimes not. Before Christmas people want money. If the husband‟s laid off they want extra hours. It depends. They know holiday pay depends on the amount they work, so know if they work more their holiday pay goes up. (LK.D.3 DS). Some providers offered inducements to overcome these problems: Very easy, we pay enhanced rates, so they are knocking on our door. (LK.D.5 CN (V)). Work organisation and working time Behind the working-time patterns and schedules lies the organisation of work and, in particular, the organisation and duration of visits to clients. All the interviewees said that visit lengths were tightly defined except for one manager of an LADP who answered no to this question. We asked managers what was the minimum and average length of a visit and the modal response to this question was 15 minutes minimum and 30 minutes average where both figures were given (20 out of 29 responses). Figures III.23a and b show that short visits EWERC Part III. The provider telephone survey 167 to clients were the norm. Seven in ten IDPs (68%) had minimum length of visits below 30 minutes (including around 3% with no minimum). This includes 60% of providers reporting a minimum of 15 minutes. Only 5% of IDPs recorded minimum visits above 30 minutes. Figure III.23b shows data on average visit lengths, although the data are less complete with a total of only 28 valid responses. The most popular average duration was 30 minutes (76% of respondents) with 14% citing an average length of longer than 30 minutes and under 10% giving an estimate of average duration at less than 30 minutes. A similar pattern was found for the LADPs, with all giving either no minimum or 15 minutes but average visit lengths were said to be 30 minutes in five out of the seven cases reporting an average duration, with the two remaining cases reporting longer averages, at 45 minutes and one hour respectively. Figure III.23. The minimum and average lengths of visits to clients a. The minimum length of a visit 100 IDPs 90 LADPs 80 Percentage 70 60 50 40 30 20 10 0 No minimum 15 minutes 20 minutes 30 minutes 45 minutes or over Note: Total responses: 37 (IDPs) and 8 (LADPs). Missing responses: 15 (IDPs) and 2 (LADPs). b. The average length of a visit 100 IDPs 90 LADPs 80 Percentage 70 60 50 40 30 20 10 0 20 minutes 27 minutes 30 minutes 45 minutes 60 minutes Note: Total responses: 21 (IDPs) and 7 (LADPs). Missing responses: 31 (IDPs) and 3 (LADPs). EWERC Part III. The provider telephone survey 168 This highly fragmented structure of visits is also reflected in the approach taken to minimum working time periods (table III.29), with four in five IDPs (81%) operating a minimum working time of only two hours or less (including 63% with no minimum). Only 8% and 4%, respectively, had minimum work periods of between 2 and 4 hours and over 4 hours. In contrast LADPs were fairly evenly split between those that had no minimum work period and those that had minimum work periods in excess of two hours (14% in excess of 4 hours) with only one case having a minimum between 15 minutes and 2 hours. Table III.29. Approach to minimum length of work periods % of IDPs % of LADPs % of all No minimum 62.5 42.9 60.0 15 minutes – less than 2 hrs 18.8 14.3 18.2 2 – 4 hours 8.3 28.6 10.9 Over 4 hours 4.2 14.3 5.5 Depends/varies 6.3 0.0 5.5 Total responses 48 7 55 No response 4 3 7 When asked about how working time was organised, a wide variety of responses was obtained, in part because the organisation within an individual provider was complex and varied among staff. One issue was whether staff worked split shifts: overall only 12% of IDPs and 11% of LADPs said that this was their main pattern of working, with the vast majority saying they operated a variety of shifts (table III.30). Table III.30. Types of shift working arrangements % of IDPs % of LADPs % of all Continuous shifts 7.8 11.1 8.3 Split shifts 11.8 11.1 11.7 Variety of shifts 80.4 77.8 80.0 Total responses 51 9 60 No response 1 1 2 Many referred to the hourglass demands for care with peak demands in morning and evenings; others divided the work into four main periods - mornings, lunch, teas, bed, and either allowed staff to work mixes of these periods or joined mornings with lunches and teas with bed, or allowed for split shifts between mornings and evenings on the grounds that this suited some staff to have a break in the middle of the day: They don‟t do continuous shifts. They may do a four hour stint in the morning, you know, with travel time between the calls, then have a break for a couple of hours and then work from two till eight in the evening. (RN.D.2.CN). EWERC Part III. The provider telephone survey 169 One provider recognised that this practice caused problems as it lead to perceptions that the working day was very long even if paid hours were much shorter: Because these people are having, like, four visits a day, the carers are getting tired doing the four visits because they seem to be at work all the time, even though they get a break in between. They are thinking, „Oh, I‟ve done a twelve hour day‟ – So what I want to do is do a morning run where they do the mornings and the dinners, and then they do a tea come bed run. … So if they do a morning run they won‟t be on till the following evening so they are getting like a full day, a night and a morning off aren‟t they? (ON.D.2 AS) One provider had four shifts – two short morning and evening shifts and then two longer mornings, plus lunch and teas plus evening shifts (i.e. 7 a.m. to 10 a.m., 8 a.m. to 1 p.m., 4pm to 7 p.m. and 4 p.m. to 10 p.m.). One said they organised work in four to six hour blocks while seven said they operated a shift arrangement, in some cases involving permanent shifts but in others rotating shifts. In other cases the working time arrangements appeared to be even more variable – dependent upon both the mix of users and the availability of care staff. Four providers referred to the use of computer software to generate the working time schedules. Patterns of variability were also found in the LADPs, with rotas known at most one week or in one case two weeks in advance and more variable hours for those engaged in more specialised work such as EMI or reablement. One LADP tried to overcome the problems of split shifts by alternating shift patterns: It depends on availability. Depends. Can be split shifts – depends on carers availability – so it can be any of these. If there were split shifts we might roster it so that they worked mornings one week, then evenings the next week. (LK.DIH.1 DP). The fragmentation of work organisation raises the issue of whether or not staff are paid or not for a break between service users in their work schedules. Figure III.24 clearly demonstrates that in general staff are not paid with only 8% of IDPs saying they would provide a paid break and 88% saying the break would be unpaid. Figure III.24. Payment of non-travel breaks between service users 100 IDPs 90 LADPs 80 Percentage 70 60 50 40 30 20 10 0 Paid break Some paid, some unpaid Unpaid break Note: Total responses: 50 (IDPs) and 9 (LADPs). Missing responses: 2 (IDPs), 1 (LADP). EWERC Part III. The provider telephone survey 170 There are clearly variations between providers, but also among different types of staff within providers. 4% of IDPs and 22% of LADPs said there was a mixture of paid and unpaid breaks. Car drivers were more likely to be found replacement work, and all TUPE transferred staff were more likely to be paid: We arrange a block of clients. The TUPEd staff are all paid. The „walkers‟ (as opposed to drivers) are expected to come into the office and work on some training books or do some paper work in the office e.g. updating the client care plans – we usually can find the drivers other work. (AH.D.3.CN). If they are in Respite, we pay them. If there is a huge gap, we try to fill that for them. If they have a half hour gap, we might make them take half an hour unpaid break. (TE.D.1 CN (V)). The payment of breaks for TUPEd staff reflects current practice within LADPs where two thirds (67%) said they would provide a paid break compared to just 8% of IDPs, although efforts are made to redeploy staff when breaks occur: If [there is] no work, we bring them into the office or offer them to care schemes to work and recharge for their time. (LK.DIH.1 DP). The issue of paid or unpaid breaks appears to be related to the extent to which the labour force is very local; one factor in the acceptability of the working schedule may be not just time scheduling but also how manageable the round offered was in relation to distance. We just try to keep them as locally as possible. When we do the rotas, well, before we send the rotas out we‟ll make sure they‟re in one area and they‟re not being sent backwards and forwards. So hopefully that‟ll reduce the amount of petrol they‟re going to be using. (ON.D.3 BN). It may also be that where there is a close meshing of work with family and home responsibilities that providers feel able to ask staff to take unpaid breaks and staff may be willing to accept the arrangements. However, this may restrict the pool of labour supply on which a provider may easily draw to those where opportunities to return home for part of the day are at least seen as having some positive benefit. Only one agency normally organised work in pairs while 28% of IDPs and 10% of LADPs said care workers worked alone all or most of the time. Over 90% of LADPs and over 70% of IDPs said work in pairs might be used around half the time to reflect the specific needs of the user (table III.31). One particular type of work that may be done in pairs is care in the late evening or night time We asked whether care workers might be expected to tolerate working late at night on their own and while the majority of providers said no (64% of IDPs and 70% of LADPs), well over a third of IDPs said yes or occasionally (37%), as did 30% of LADPs (table III.32). One factor limiting the use of pairs was said to be the changing mix of clients: [Care staff work] mostly alone, some doubles. We have some double runs, but it‟s hard to keep this going as clients change frequently. (LK.D.3 DS). EWERC Part III. The provider telephone survey 171 Table III.31. The organisation of care work in pairs or alone % of IDPs % of LADPs % of all Alone or mostly alone 27.5 10.0 24.6 Half and half; Depends on needs of service user 70.6 90.0 73.8 In pairs or mostly in pairs 2.0 0.0 1.6 Total responses 51 10 61 No response 1 0 1 The issue of safety of staff – by both area and time of night - was one that some providers felt was not solely their responsibility: One of the things that we were discussing only yesterday was the effect of lone working in the current climate, asking the council whose liability is our staff‟s safety. Is it solely ours or are they going to share the liability? … But we have actually done [„double-up‟ calls] where we feel that areas are pretty unsalubrious. We put in two care workers just purely for their safety. (ON.D.1 DN). Table III.32. Working alone at night as an expected part of domiciliary care work % of IDPs % of LADPs % of all Yes 11.5 20.0 12.9 Occasionally 25.0 10.0 22.6 Never 63.5 70.0 64.5 Total responses 52 10 62 No response 0 0 0 In addition to the risks associated with night work, particularly alone, there are other risks or potentially unpleasant or dangerous conditions associated with care work. To tap into this dimension of work we asked care providers to what extent they would expect staff to tolerate working in insanitary conditions and to what extent they would be expected to tolerate working with aggressive service users. While only one provider said care workers should have to tolerate insanitary conditions on more than an occasional basis, the frequency of this problem was indicated by the 42% of IDPs and 70% of LADPs who suggested they would need to tolerate it occasionally (figure III.25 and III.26). You wouldn‟t believe the way that some people do live. Obviously what we can do is, we can take responsibility for that household and ensure that cleanliness is brought up. But it‟s very, very difficult. You can‟t go in and upset somebody and tell them that they are living in a pigsty. But you might be able to… So the answer to it is occasionally its bloomin‟ awful. It‟s smelly, it can be dirty, it can be dark and dingy. The place that they may go to might not be very salubrious. (ON.D.1 DN). EWERC Part III. The provider telephone survey 172 Figure III.25. Toleration of insanitary working conditions 100 IDPs 90 LADPs 80 Percentage 70 60 50 40 30 20 10 0 Often Occasionally Never Note: Total responses: 52 (IDPs) and 10 (LADPs). Figure III.26. Aggressive service users as an expected part of domiciliary care work 100 IDPs 90 LADPs 80 Percentage 70 60 50 40 30 20 10 0 Often Occasionally Never Note: Total responses: 52 (IDPs) and 10 (LADPs). Working with aggressive service users was an even more common part of the job with only 15% of IDPs and 10% of LADPs saying that staff would not need to tolerate it and indeed 30% of LADPs regarded it as more than an occasional problem, compared to 11% of IDPs. EWERC Part III. The provider telephone survey 173 This may reflect the more specialist nature of LADPs work in some LAs. However, the majority of both sets of providers said it had to be tolerated occasionally. III.4.2. Flexibility, working time arrangements and work organisation in care homes Employment contracts and working time Working time in care homes is not only more guaranteed than in domiciliary care but also more often full-time. Figure III.27 plots the percentage of providers that employ care workers for different numbers of weekly hours (see, also, table III.23 above). Over three fifths of responding homes had at least 50% of staff working 30-45 hours and none had a majority working short part-time hours. Nevertheless, the share of part-time working is significant considering that these homes need to provide 24 hour, 7 days a week care. Over 41% of responding homes had more than 50% in long part-time. If we look at the distribution of homes by shares of long part-time and more full-time hours we find quite a wide variation in patterns; thus over 40% of responding homes had less than 20% of staff in long part-time work but at the other end of the spectrum 25% had 70% or more in this type of working time category Similarly 16% of homes had fewer than 20% in full time work while 44% of homes had more than 70% in this category. However, although more workers are in full-time jobs than in domiciliary care, fewer work very long hours (that is, over 45 hours per week); only 25% of homes had any staff in this category compared to 38% of IDPs. Excluding those working very long hours only on occasions for emergency cover reduces the share of homes with anyone on more than 45 hours to 17%. Moreover, under 10% of care homes had a seven day maximum working week and only 33% had either a six or seven day maximum compared to 77% of IDPs (Table III.24). However, when it comes to weekend working it is equally the norm in care homes for all staff to be regularly involved in weekend work, with 70% of care homes, over ten percentage points more than IDPs, involving all staff in regular weekend working (see figure III.20 above). The pressures of staffing weekends nevertheless remained considerable. Some homes sought to solve the problem through stipulations at interview: They are expected to work weekends. It‟s a 365 day a year job. You know, weekends, Bank Holidays, Christmas Day because it‟s a 24/7 service, and at interview we ask that question. It‟s about flexibility.( HD.HN.1.C.LV). Nevertheless the problems of scheduling sometimes meant that staff might be under pressure to work more weekends than they had signed up for: Always difficult at weekends, because I like to give staff alternate weekends off, but sometimes it is difficult.(OM.HN.2.A.N). EWERC Part III. The provider telephone survey 174 Figure III.27. Proportions of staff working different hours in homes 80 Percentage of providers 0% 70 1-10% 60 11-20% 21-30% 50 31-50% 40 51-70% 71-80% 30 81-90% 20 91-99% 10 100% 0 Under 16 hours 16-30 hours 30-45 hours Over 45 hours Usual weekly hours Note: see table III.23 for number of responses. Working time scheduling As in domiciliary care the majority of homes (96%) claimed to be able to give staff work schedules that fitted their preferences all, or most of the time and a higher share of homes – almost a third rather than a quarter - were able to meet preferences all of the time compared to domiciliary providers (see figure III.21 above). In homes the problems related not so much to changes in service users but to the need to cover 24/7 particularly in holiday periods or when there is a high rate of sickness: [We have] a four-week rota. It is very difficult to organise. We always try our best to give people what they want, but at holiday times, it is very difficult. They request, and we try our best. We rota so that all have the same number of weekends off and the number of hours they want. Some work nights only, the rest work days, sometimes earlies, and sometimes lates. Staff tend to be very flexible. If someone leaves suddenly or is off sick, then we are under-staffed. We are flexible, and they are flexible and will fill in. (TE.H.4 AS). Care homes, as with IDPs, were primarily reliant on their existing staff for temporary cover with 57% relying on existing staff only and 96% using existing staff at least in combination with other methods (see table III.27 above). Only 4% used external agencies as their only source of cover: EWERC Part III. The provider telephone survey 175 It varies. Staff are usually flexible. The new Filipinos are keen to earn money to send home and they volunteer for extra shifts – they sometimes switch between housekeeping and care work. We are lucky, but they can all say no to extra work. (LK.H.4 AL). Other methods were much more common in care homes than domiciliary care, however, with 23% making use of external agencies and 33% using a list of temporary workers. Work organisation and working time The main question we asked about work organisation and working time related to first of all minimum staffing levels and secondly how working time was actually organised. The adoption of minimum staffing levels was common, with 87% of responding homes claiming to have minimum staffing levels. Further probing of what these minimum staffing levels amounted to revealed differences in ratios between day and night shifts (often with further variations for afternoons and early evenings but, as mornings had the most staff and nights the least in all cases, we concentrate on the morning to night ratio). Of the 19 cases where sufficient detail was given of variations across shifts we found that 11 had night ratios in excess of 50% of the morning shift but in eight cases the night time staffing ratios were half or less. Some homes gave us the ratios in relation to occupied beds with, for example, the ratio varying from 1 in 5 in the morning to 1 in 8 at night. In some cases the minimum staffing ratios were given as a constant over the 24 hours and therefore probably referred to night time ratios. Quite a number of homes gave ratios not just overall but in relation to number of senior or qualified staff. These minimum staffing ratios thus clearly create scheduling constraints both by numbers of staff but also qualifications and seniority. Most ratios are implicitly related to bed occupancy but adjustments to bed occupancy occur in rather large lumps as one provider with 27 beds noted that a reduction of occupancy of three lead to a reduction in staffing levels by a quarter. Because we‟re three patients down the owner has reduced numbers, reduced [staff] numbers, so I‟m not too happy about that, but that‟s the way it goes at the moment. …(ON.HN.1 BS). When it came to shift patterns the homes had different strategies as to whether they used permanent or rotating shifts with half using rotating shifts and around a third (37%) using permanent shifts. A mixture of permanent and rotating shifts was used by 14% of homes. While permanent shifts were often used to meet preferences some homes recognised that this created problems in reducing staff experience and understanding of the work of the home: And the shifts, some of the staff here ….work so many nights but we‟re trying to get away from that and have the rotated shift pattern so that everyone understands what happens 24/7. (HD.HN.1.C.LV) Further variations related to length of shifts. Most used a three shift system but at least four homes operated long shifts of 11 or 12 hours. Two homes offered long days as a choice to staff. As most involved all staff in working weekends and nights it was only a minority of EWERC Part III. The provider telephone survey 176 homes that employed some weekend only staff. Other ways of fitting hours to preferences included one home that allowed staff to choose their day off. Many also mentioned that breaks were paid although one said the home did not pay breaks for new staff and another specified that full-timers were granted a 30 minute paid break but part-timers only ten minutes. Table III.34. Use of rotations between shift arrangements in homes % of homes Rotate 50.0 Stay on same shift 36.5 Half and half 13.5 Total responses 52 No response 1 EWERC Part III. The provider telephone survey 177 III.5. Employee development and training An important element in human resource management is staff development and training. This starts with induction but continues with opportunities for training and for development through systematic appraisal systems. We address these three inter-related issues in this section in turn. III.5.1. Induction of new staff When asked about the length of induction training for new staff there was a variety of responses ranging from one day to six months. However, many respondents distinguished between an initial induction period of a few days followed by a number of weeks shadowing, working under supervision, probation and mandatory training courses. Others said the length of induction could vary according the previous experience and qualifications of the new recruit, or the length of time taken for the CRB check. The majority of providers carried out the induction training themselves. Only 3% said the training was provided by an external training organisation and a similar share reported using the local authority. A further 10% said the training was provided by themselves and the local authority, or other organisation, or a combination of all three. Table III.35 reports managers‟ perceptions of how long new staff need to become competent in the role. There is a good deal of variation of perceptions between IDPs, LADPs and homes. Over one quarter of IDP managers said new recruits would be able to do the job as well as existing staff in one week or less, compared to 15% of home managers and none of the LADP managers. At the other end of the scale only around a fifth (21%) of IDP managers thought this would take between one and six months compared with half of the LADP managers and two fifths (40%) of home managers. Table III.35. Length of time needed for new staff to do the job as well as existing staff % of homes % of IDPs % of LADPs % of all One week or less 15.4 26.9 0.0 19.3 More than one week - up to 1 month 36.5 36.5 30.0 36.0 More than 1 month up to 6 months 40.4 21.2 50.0 32.5 Depends 7.7 15.4 20.0 12.3 Total responses 52 52 10 114 No response 1 0 0 1 Some respondents observed that the length of time taken to become as competent as existing staff depended on the individual (8% of homes, 15% of IDPs and 20% of LADPs). Previous EWERC Part III. The provider telephone survey 178 experience did not necessarily mean that the new member of staff would become competent in a shorter period of time: This depends on the person. Some fit in very well. Some with a lot of experience might have developed poor practice, so sometimes it‟s better for people not to have any experience. (TE.D.1 CN (V)). Working in a care home would not necessarily prepare someone to undertake domiciliary care: It depends what their experience has been because if they‟ve worked in a very sort of institutional way then it takes a long time to undo that so it depends what the individual experience has been. (RD.D.2.CL). III.5.2. Training All establishments in the survey had some staff trained to NVQ level 2, but there was a wide variation in the proportions (between 15% and 100%). Table III.36 and figure III.28 show that attainment of NVQ level 2 was significantly higher in the homes than the IDPs, with 53% of homes having 70% or more staff trained to NVQ level 2, compared with only 33% of IDPs. On the other hand, over half the IDPs (52%) had fewer than 56% of staff trained to NVQ2 compared with under 30% of homes. Table III.36. Proportion of care workers trained to NVQ level 2 % of homes % of IDPs % of LADPs % of all 45% or less 13.7 30.8 22.2 22.3 46 – 55% 15.7 21.2 0.0 17.0 56 – 69% 17.6 15.4 22.2 17.0 70% or more 52.9 32.7 55.6 43.8 Total responses 51 52 9 112 No response 2 0 1 3 Managers were asked how likely they were to meet the Care Standards Act (2000).target of 50% of staff trained to NVQ Level 2. Close to nine in ten homes (89%) and eight in ten LADPs (80%) had already met this target (figure III.29). Although the majority of IDPs had also met the target the proportion is lower, at only 65%. However, a further 21% of IDP managers felt that they would be able to meet the target soon. In line with these findings, 14% of IDPs were experiencing difficulties meeting the target, compared with only one LADP and just under 4% of homes. EWERC Part III. The provider telephone survey 179 Figure III.28. Share of care staff in homes and IDPs with NVQ level 2 by share of providers in sample (cumulative percentage of providers) 100% 90% % of staff with NVQ 2 80% 70% 60% 50% 40% 30% 20% 10% 0% 0% 10% 20% 30% 40% 50% 60% Homes IDP's 70% 80% 90% 100% Figure III.29. Likelihood of meeting the 50% NVQ level 2 target 100 Homes IDPs LADPs 90 80 Percentage 70 60 50 40 30 20 10 0 Already met Will meet soon Experiencing difficulties Note: Total responses: 52 (homes), 51 (IDPs) and 10 (LADPs). Missing responses: 1 (homes), 1 (IDPs). We probed this question further by asking the managers who said they were experiencing difficulties meeting the 50% NVQ level 2 target, what factors were contributing to these difficulties. The responses are categorised in Table III.37. The two biggest problems for the IDPs were staff turnover and training-related problems (with providers, assessors or funding) EWERC Part III. The provider telephone survey 180 with almost 39% of responses in each of these categories. Problems concerning staff motivation and pressure of work accounted for just over 22% of responses from IDPs. Staff turnover and motivation were the biggest problems for the homes, with 38% of responses in each of these categories. One specifically mentioned having older staff who were very experienced but did not want to take qualifications. Training-related problems accounted for one quarter of responses from the care homes. Table III.37. The factors that make it difficult to meet the 50% NVQ level 2 target % of homes % of IDPs % of LADPs % of all Staff turnover 37.5 38.9 50.0 39.3 Staff motivation 37.5 16.7 0.0 21.4 Pressures of work (e.g. scheduling, fatigue) 0.0 5.6 0.0 3.6 Training provider/ assessor/ funding problems 25.0 38.9 50.0 35.7 Total responses 8 18 2 28 No response/not applicable 45 34 8 87 Figure III.30 shows the percentages of staff trained to higher levels – NVQ level 3 or NVQ level 4. As with the NVQ2,, the proportions attaining these qualifications were significantly higher in the homes, with 40% having over 20% of staff trained to these levels. The corresponding figures for the IDPs and LADPs are 16% and 20%, respectively. At the other end of the scale, only one quarter of homes had 10% or fewer staff trained to these levels, compared with 59% of IDPs and 60% of LADPs. Figure III.30. Proportion of care workers trained to NVQ levels 3 and 4 70 Homes IDPs LADPs 60 Percentage 50 40 30 20 10 0 10 percent or less 11 – 20 percent 21 – 29 percent 30 percent or more Note: Total responses: 45 (homes), 50 (IDPs) and 5 (LADPs). Missing responses: 7 (homes), 3 (IDPs), 5 (LADPs). EWERC Part III. The provider telephone survey 181 We followed this question up by asking whether any staff actually needed to have NVQ Level 3 and, if so, which staff, and whether they were recruited externally or internally trained. Table III.38a shows that 54% of IDPs and 88% of LADPs did need to have some staff trained to NVQ level 3. The most frequently mentioned role requiring NVQ3 was that of senior care worker (18 responses). In many cases it was apparent that, on attaining this qualification, the care worker would automatically become a senior care worker and receive a pay increase. Other higher level roles were also mentioned as requiring the jobholder to be trained to NVQ3 level, such as supervisors and team leaders (6 responses) and care coordinators (6 responses). Some specialised types of care were also said to require an NVQ3 trained care worker, such as hospital discharge and care for people with specific medical conditions such as diabetes. Providers‟ requirements for seniors and supervisors to have NVQ3 were sometimes not matched by [training] providers‟ willingness to accept initially people who did not already have supervisory responsibility: It‟s quite difficult to get them on Level 3 because they don‟t have supervisory responsibility, it can be difficult to get providers to take them at Level 3. (LK.D.3 DS). Table III.38. Staffing issues for care workers needing NVQ level 3 a. Requirement for some staff to have NVQ level 3 % of IDPs % of LADPs % of all No 46.2 12.5 41.7 Yes 53.8 87.5 58.3 Total responses 52 8 60 No response 0 2 2 b. Use of external recruitment of NVQ3 trained staff or internal training % of IDPs % of LADPs % of all Internally trained 66.7 100.0 73.5 Recruited externally 7.4 0.0 5.9 Both 25.9 0.0 20.6 Total responses 27 7 34 No response/not applicable 25 3 28 We asked those managers who said they needed to have some of their care workers trained to NVQ Level 3 whether these staff were recruited externally or internally trained. The majority (two thirds of responding managers from IDPs (67%) and all the responding LADP managers) said they were internally trained. Just over one quarter of IDP managers (26%) said they would fill these roles both with new recruits and/or internally trained staff. Only 7% of IDP managers said these roles would be filled exclusively with new recruits (table III.40b). EWERC Part III. The provider telephone survey 182 One employer mentioned the difficulty of recruiting people who were already qualified at NVQ level 3: Usually [we train staff] internally, as it is very hard to attract people with NVQ 3 externally. (IL.D.2.DL). Some IDPs and LADPs provided more specialised types of care, including intermediate care. Again, we asked managers whether staff providing specialised care needed extra qualifications (Table III.39). More than half of IDPs (55%) and close to three quarters of LADPs (71%) that responded said they did not. Where extra qualifications were required, two respondents said staff would need NVQ level 3, two mentioned shared protocols with NHS nurses, one mentioned a course on intermediate care provided by the local authority and others mentioned additional training units such as PEG feeding, risk assessment and palliative care. Table III.39. The requirement for staff providing intermediate care to have extra qualifications % of IDPs % of LADPs % of all No 54.5 71.4 58.6 Yes 45.5 28.6 41.4 Total responses 22 7 29 No response/not applicable 30 3 33 Managers were asked what training courses were offered to staff and whether they were optional or compulsory. In each case they were asked whether specific courses were optional or compulsory and then to identify any other courses which were offered. Table III.40 shows the results for compulsory courses with the corresponding results for optional courses in brackets. Firstly, it will be noted that the percentages for „compulsory‟ and „optional‟ total more than 100 in some cases. This is because some respondents indicated that some courses were compulsory for some staff and optional for others (e.g. training in „Use of Equipment‟, which may depend on the needs of the service users that the individual cares for, or the „NVQ level 2‟ course which may be compulsory for new staff but not for longer serving staff). Secondly, we know there are some courses which are mandatory for all staff („Health and Safety‟, „Service User Handling‟ and „Infection Control‟), but the responses for „compulsory‟ for these courses in some cases amount to less than 100%. We assume this is an oversight. The first five specifically-mentioned courses were offered by all, or at least 90% of employers, with similar results across the three sectors. Of the other specifically named courses, „First Aid‟, „Medication Management‟ and „Parkinson‟s Care‟ were more likely to be compulsory in IDPs than homes, possibly reflecting the fact that those care homes with nursing would have a trained nurse on duty at all times. NVQ2 was said to be compulsory in 82% of homes, 84% of IDPs and 89% of LADPs. Eighty three respondents mentioned other compulsory courses. The most frequently mentioned were those related to „Protection of EWERC Part III. The provider telephone survey 183 Vulnerable Adults‟ and „Safeguarding‟ (16 homes, 11 IDPs and 3 LADPs), followed by „Fire Safety‟ (13 homes). Other courses mentioned related to specific conditions or specialised types of care which some staff may have to undertake, or courses undertaken to comply with the Skills for Care Common induction standards. One provider mentioned that more courses were becoming compulsory as the needs of service users changed: All staff are now being trained in dementia care as there are many more referrals of those with dementia and numbers are increasing. (IL.D.2.DL). Table III.40. Compulsory and optional courses offered (optional courses in brackets) % of homes % of IDPs % of LADPs % of all Health and Safety 92.0 (12.0) 97.9 (0.0) 100.0 (0.0) 95.3 (6.5) Food hygiene 92.0 (14.0) 93.8 (12.5) 88.9 (22.2) 92.5 (14.0) Service user handling 98.0 (4.0) 100.0 (2.1) 100.0 (0.0) 99.1 (2.8) Use of equipment 94.0 (6.0) 95.8 (12.5) 88.9 (0.0) 94.4 (8.4) Infection control 94.0 (8.0) 91.7 (12.5) 100.0 (0.0) 93.5 (9.3) First aid 72.0 (32.0) 91.7 (8.3) 44.4 (55.6) 78.5 (23.4) Medication management 52.0 (38.0) 95.8 (10.4) 100.0 (0.0) 75.7 (22.4) Dementia care 52.0 (48.0) 43.8 (56.3) 44.4 (55.6) 47.7 (52.3) Diabetes care 16.0 (74.0) 14.6 (75.0) 11.1 (88.9) 15.0 (75.7) Loss and depression in elders,bereavement 20.0 (72.0) 16.7 (70.8) 11.1 (77.8) 17.8 (72.0) Parkinson‟s care 4.0 (80.0) 18.8 (72.9) 11.1 (88.9) 11.2 (77.6) NVQ 2 82.0 (24.0) 83.3 (25.0) 88.9 (0.0) 83.2 (22.4) When asked which specific courses were optional the pattern of responses reflected the responses to the question on which courses were compulsory. A wide range of other courses were mentioned as being optional, including NVQ3 and NVQ4. One respondent said the courses on offer were too numerous to mention. Optional courses were said to be especially valuable as staff had specifically requested to do them: There is lots and lots of training apart from induction. They are sent a questionnaire asking what they want and there are lists on the training board and they can sign up. It is very fruitful if they specifically ask for training. They get a lot out of it. (LK.D.6.CL). Figure III.31 shows that the shares of providers having attained the Investors in People award, or working towards it, were similar for homes and IDPs, but were only around a third for all providers. In contrast, the majority (83%) of LADPs had attained the award. EWERC Part III. The provider telephone survey 184 Figure III.31. Achievement of the Investors in People Award 100 Homes 90 IDPs LADPs 80 Percentage 70 60 50 40 30 20 10 0 Yes, or working towards No Note: Total responses:45 (homes), 47 (IDPs) and 6 (LADPs). Missing responses: 8 (homes), 5 (IDPs), 4 (LADPs). III.5.3. Appraisal and staff development Staff appraisal systems seem to be widely established in independent as well as LA providers with only one home and one IDP saying they did not carry out appraisals. Most carried out appraisals annually, with one even saying once every 18 months; a slightly higher percentage of IDPs (27%) than homes (21%) carried out appraisals more frequently than annually (table III.43). In over half of cases appraisals were carried out by the manager alone in both homes (58%) and IDPs (51%) and were involved in the appraisals in over three quarters of homes (79%) and 59% of IDPs. This close involvement by the manager is reflective of the relatively small size of the establishments. The higher share of „other‟ staff carrying out appraisals in IDPs at 41% reflected the more widespread use of care coordinators or team leaders and supervisors in domiciliary care to manage a more dispersed and indeed often larger workforce. To probe further on approaches to staff development, we asked how training needs were identified, first whether they were assessed by appraisal and second if they were identified by employee request. A sizeable minority answered no to both (14% of homes and 23% of IDPs) and a further 10% of homes only identified needs through employee request. Overall over three quarters identified needs through the appraisals system, with 56% of those homes and IDPs using appraisal also using employee requests as a means of identification. EWERC Part III. The provider telephone survey 185 Table III.41. Staff appraisal arrangements a. Frequency of appraisals % of homes % of IDPs % of LADPs No appraisal or only casual 1.9 1.9 0.0 % of all Regular but less frequently than annual 0.0 1.9 0.0 0.9 Yearly 77.4 69.2 55.6 71.9 Six months to one year 7.5 5.8 22.2 7.9 3 to 6 months 3.8 17.3 22.2 11.4 More frequently than 3 months 9.4 3.8 0.0 6.1 Total responses 53 52 9 114 No response 0 0 1 1 % of homes % of IDPs % of LADPs % of all Manager 57.7 51.0 33.3 52.7 Other 23.1 41.2 66.7 34.8 Manager and Other 19.2 7.8 0.0 12.5 Total responses 52 51 9 112 No response 1 1 1 3 % of homes 13.5 % of IDPs 23.1 % of LADPs 10.0 % of all 17.5 Employee request 9.6 0.0 0.0 4.4 Appraisal alone or appraisal plus employee request 76.9 76.9 90.0 78.1 Total responses 52 52 10 114 No response 1 0 0 1 b. Who carries out appraisals c. Identification of training needs Neither EWERC Part III. The provider telephone survey 186 III.6. Performance management, job autonomy and employee voice Important issues for recruitment and retention are how staff are managed within the workplace; how performance is managed, the autonomy and discretion offered to employees and opportunities for employee voice and communication. We consider the telephone survey data corresponding to these issues in this section III.6.1. Performance management The most common practices used for performance monitoring were through the medium of supervisors in all three types of providers - homes (81%), IDPs (85%) and LADPs (70%). For IDPs and LADPs we also asked if there was any direct observation of staff and 69% of IDPs and 80% of LADPs said they did undertake direct observation (figure III.32). We also asked those involved in domiciliary care whether they used electronic monitoring and 31% said it was currently in use; however we know from the interview data with LAs that this share is set to rise. User surveys by providers were used to monitor performance in 29% of homes, 47% of IDPs and 30% of LADPs. User surveys by the local authority were used by half of LADPs, but only 6% of homes and 22% of IDPs. However, 74% of homes, 55% of IDPs and 40% of LADPs said they used other methods to monitor performance. These included investigations of monitoring, CQC inspections, appraisals and spot checks. Figure III.32. Types of staff monitoring a. Homes 100 Percentage of providers 90 80 70 60 50 40 30 20 10 0 No Yes Supervisors? EWERC No Yes User surveys by care provider? No Yes User surveys by LA? No Yes Other methods? Part III. The provider telephone survey 187 b. IDPs 100 IDPs 90 LADPs 80 Percentage 70 60 50 40 30 20 10 0 No Yes Electronic monitoring? No Yes Supervisors? No Yes Observation? No Yes User surveys by care provider? No Yes User surveys by LA? No Yes Other methods? Note: Total responses for different questions: 53, 49, 48, 50 (homes); 51, 52, 51, 51, 51, 51 (IDPs) and 10 for all questions (LADPs). For some managers electronic monitoring was used solely because of contractual commitments and they were concerned about the impact on both staff and their own revenues of moving to paying by the minute or even five minute blocks: Instead of paying per care call they are only now going to pay per minute. So we are actually moving now to paying people in five minute pay bands rather then per minute because I think it‟s a bit childish. So if they do 26 minutes they‟ll get paid 30. So it will be rounded up. But also if they spend 90% of the scheduled time in a service user‟s home we will also pay the travel time. So that‟s an incentive for them to keep our income levels high, because the less they do the less we get and it soon spirals out of existence. (ON.D.1 DN). Table III.42. Managers’ perceptions of the most effective method for dealing with performance monitoring % of homes % of IDPs % of LADPs % of all Disciplinary only 6.7 12.2 11.1 9.7 „Soft‟ measures plus disciplinary 8.9 28.6 33.3 20.4 Training and „soft‟ measures only 84.4 59.2 55.6 69.9 Total responses 45 49 9 103 No response 8 3 1 12 However, one IDP commented on how it had enabled them to tighten their control of the care workforce: Now [performance problems] it is people running late or leaving early before the full amount of the call. ….We have investigated, and it is usually people arriving late for their first call EWERC Part III. The provider telephone survey 188 and then never catching up. They leave early – maybe 15 or 10 minutes early and tell us it is because the client told them to leave early. We now have a system that they have to call into the office if the client tells them to leave early. If it‟s someone with dementia we follow this up; it may be the same person always reporting that their clients tell them to go. Call monitoring has helped us analyse these issues. (IL.D.1). Most providers preferred to use „soft‟ measures such as training, one to ones, supporting staff, changing schedules etc. to deal with poor performance (over 80% of homes, almost 60% of IDPs and over 55% of IDPs), rather than disciplinary procedures (Table III.42). We also asked what were the most common problems of poor performance (table III.43). The most frequently mentioned were absenteeism and sickness (18% of homes, 37% of IDPs and 10% of LADPs), timekeeping (8% of homes, 40% of IDPs), and skimping on time spent with service users (8% of homes, 27% of IDPs and 10% of LADPs). These findings reflect the nature of work in domiciliary care, where staff usually work unsupervised. Other problems mentioned were complaints from service users, not following correct procedures, lack of skills and training, personal or family problems affecting work, poor team working and language skills. Table III.43. Managers’ views on the most common problems of poor performance % of Homes % of IDPs % of LADPs % of all Absenteeism, sickness 18.0 36.5 10.0 25.9 Timekeeping 8.0 40.4 0.0 22.3 Skimping on time or services provided 8.0 26.9 10.0 17.0 Poor attitude, motivation 20.0 7.7 10.0 13.4 Complaints from service users 0.0 13.5 30.0 8.9 Not following correct procedures 14.0 0.0 20.0 8.0 Lack of skills, training 4.0 5.8 10.0 5.4 Personal or family problems 8.0 0.0 0.0 3.6 Poor teamworking 6.0 0.0 0.0 2.7 Poor language skills 4.0 0.0 0.0 1.8 No problems 12.0 3.9 10.0 8.0 Total responses 50 52 10 112 No response 3 0 0 3 Note: Multiple responses possible. In their additional comments on the nature of performance problems we encountered a range of responses, with some attributing the main problems to gaps in training or understanding of procedures while others felt the problems lay mainly with attitudes: It‟s about practice issues not using the right techniques with moving and handling and not following procedure. (HD.HN.1.C.LV). EWERC Part III. The provider telephone survey 189 Not understanding professional boundaries, it‟s never meant, it‟s never malicious but most of the problems that we do encounter tend to be around staff overstepping boundaries. (OM.D.2.DN). Another talked about the difficulties of disentangling poor performance from problems of meeting users‟ expectations: I think it‟s a bit of both at this moment in time. We have staff going in with guidelines, service users wanting over and above and we do have a bit of racism and the others are staff not getting to their shifts on time. (RD.D.1.C.S.). To link issues of performance management directly back to issues of recruitment and retention we asked whether providers felt obliged to put up with poor performance because of problems of staff shortage (figure III.33). As might be anticipated, most said they did not put up with poor performance (70% of homes, 57% of IDPs and 70% of LADPs) - as to do so would reflect negatively on their organisation. However, the remaining 30% of homes, 43% of IDPs and 30% of LADPs admitted that they were forced to put up with poor performance, at least sometimes. Figure III.33. Share of providers who said that recruitment difficulties sometimes forced them to put up with problems of poor performance 100 Homes 90 IDPs LADPs 80 Percentage 70 60 50 40 30 20 10 0 no yes Note: Total responses: 53 (homes), 51 (IDPs) and 10 (LADPs). Missing responses: 1 (IDPs). Absenteeism featured as a particular concern. The majority of providers (94% of homes, 84% of IDPs and all LADPs) said they collected figures on absenteeism (Table III.44). Some of EWERC Part III. The provider telephone survey 190 the national providers had specific regulations and procedures that were used to manage absenteeism: The company does it on a regional basis. After 4 periods of absenteeism, then staff go through disciplinary proceedings. (IL.D.1 CN). More than one quarter of organisations surveyed believed rates of absenteeism were quite high or very high (figure III.34). The evidence suggests the problem is particularly acute in IDPs (35%), compared to just over 15% of homes. More surprising, however, is the very high share of LADPs who report high absenteeism – 70% - but this may be related in part to more generous sick leave provision in the public sector. Table III.44. The collection of figures on absenteeism % of Homes % of IDPs % of LADPs % of all Yes 94.0 83.7 100.0 89.7 No 6.0 16.3 0.0 10.3 Total responses 50 49 8 107 No response 3 3 2 8 Figure III.34. Managers’ views about rates of absenteeism among care staff 60 Homes IDPs LADPs 50 Percentage 40 30 20 10 0 Very high Quite high Acceptable Quite low Very low Note: Total responses: 53 (homes), 51 (IDPs) and 10 (LADPs). Missing responses: 1 (IDPs); Question asked was, „What do managers consider rates of staff absenteeism to be?‟ (Q173). The differences in views as to whether the level of absence was too high, low or acceptable may reflect different perceptions and attitudes as well as different levels; respondents were asked to tell us how they measured absenteeism and to give us the data but the methods used were too variable to report here. One IDP was particularly adamant that absenteeism would not be tolerated: EWERC Part III. The provider telephone survey 191 I don‟t tolerate it. I have had one or two people who are always having sickies. It goes into their files and I get a pattern. They forget what reasons they have given, and how many days they have had off, but we write it down. My deputy has had one day off in 20 years, I have had one week off in 19 years. (TE.H.3 AS). Others saw absenteeism as a problem related to the age of the workforce and the nature of the job – including the impact of problems in relationships with users. Where it is sickness, we have a system of letters and dates that are trigger points. I speak to them one to one and then it goes to HR. They have not helped much so far. But workers are old, and they are tired and prone to infection. (AH.D.3.CN). Absenteeism; [its] low confidence; personal chemistry. (TE.H.2 BS). Yet others stressed the problems of managing sickness for a dispersed workforce: Three field care supervisors actually spend time with the staff and we‟ve tried return to work interviews, but … somebody that works four miles away from here that doesn‟t have a car finds it very difficult to come in to the office for a half hour to be told that they shouldn‟t be having sick but, you know, „I‟ve had gastroenteritis‟, what can I do?‟(ON.D.1 DN). To assess the approach to managing performance we asked about what methods they had found most effective in managing poor performance. We have recoded those responses into three categories: those that mentioned disciplinary methods only; those that mentioned softer measures such as training alongside disciplinary measures and those that only mentioned softer measures such as training, one to ones, supporting staff, changing schedules and so on. The vast majority of homes (84%) mentioned only soft measures. IDPs were more varied with around three fifths only mentioning soft measures but 28% mentioned disciplinary measures alongside soft measures (with LADPs showing a similar pattern). Only a minority 12% – mentioned only disciplinary approaches. III.6.2. Discretion and autonomy Opportunities to exercise discretion and autonomy at work have the capacity both to contribute both to the quality of the jobs and to the quality of the care provided. However, the granting of discretion may provide challenges for management, particularly in a context of tightly specified commissioning. To probe these issues we asked a series of questions related to both time constraints on tasks and autonomy in tasks. As the work environment is quite different between domiciliary and care homes we discuss the results in turn (table III.45). Although all IDPs said that client visits were tightly defined, a majority still expressed the view that staff did have time to carry out their work to a high standard with 79% saying yes and a further 17% agreeing that this applied to some extent. In practice only two IDPs said this was not the case. LADPs were, in fact, less positive with only 60% saying yes, 30% stating to some extent and 10% - that is, one provider- saying no. There was more recognition of time constraints on a specific dimension of care, that is developing good relationships with clients; again although the majority were positive, 15% of IDPs said they were not able to do EWERC Part III. The provider telephone survey 192 this and a further 17% only to some extent. For LADPs the shares were quite similar at 10% and 20% respectively. This aspect of care may be regarded as more voluntary by some providers but one provider emphasised its importance: Because they may be the only person that they have seen all day or all week. People are elderly, lonely, don‟t have any other social contact. They see this as a part of social contact so we do encourage it. (ON.D.1 DN). Table III.45. Types of opportunities for staff to improve their performance % of homes % of IDPs % of LADPs % of all Yes 90.4 78.8 60.0 82.5 To some extent 9.6 17.3 30.0 14.9 No 0.0 3.9 10.0 2.6 Having the opportunity to put into Yes practice the training qualifications To some extent they have gained? No 94.3 100.0 90.0 96.5 5.7 0.0 10.0 3.5 0.0 0.0 0.0 0.0 Being free to prioritise and carry out tasks in ways to improve the quality of care? Yes 73.6 40.4 60.0 57.4 To some extent 26.4 44.2 40.0 35.7 No 0.0 15.4 0.0 6.9 Having the opportunity to develop Yes good relationships with service To some extent users? No 94.3 67.3 70.0 80.0 5.7 17.3 20.0 12.2 0.0 15.4 10.0 7.8 Being encouraged to exchange ideas with other carers of new ways of working/best practice? Yes 90.6 84.6 100.0 88.7 To some extent 9.4 11.5 0.0 9.6 No 0.0 3.9 0.0 1.7 53 52 10 0 Having enough time to carry out the work to a high standard? Total responses Both IDPs and LADPs were universally positive about opportunities to put training into practice within the care work environment with none answering negatively and only one LADP answering to some extent. An almost similar positive response was found for opportunities for care workers to pass on ideas to others to improve care. There was more doubt, however, about whether care staff were free to prioritise and carry out tasks in ways to improve care; only 40% of IDPs agreed and a further 44% said to some extent with 15% saying no. None of the LADPs said no and three fifths said yes and two fifths to some extent. Thus there was some recognition of constraints on the autonomy of care staff to determine priorities or change ways of carrying out tasks. The same questions were posed to the home managers. The responses from homes were even more positive than for the IDPs. There were in fact no negative answers to any of the questions and the share saying to some extent rather than simply yes fell below 10% in all cases, except for the question about freedom to prioritise and carry out tasks in ways to improve the quality of care. Even here almost three quarters of homes said yes (74%) and EWERC Part III. The provider telephone survey 193 over a quarter to some extent, with the yes response well above the share of IDPs answering yes (40%). This apparent lower degree of discretion for domiciliary care applies in a context where most domiciliary care workers operate unsupervised while care workers in homes are often working in teams. In a fixed workplace with senior staff always on duty, care home managers may feel it less necessary to specify priorities and ways of working than in the unsupervised domiciliary care context. III.6.3. Employee voice and communication In contrast to local authorities, most independent sector providers do not recognise trade unions or follow collective bargaining (figure III.35). In our sample only 15% of homes and 8% of IDPs recognised trade unions. However, voluntary sector providers were more likely than for-profit providers to recognise unions – 24% and 9%, respectively. But in general, outside the public sector, opportunities for employee voice depended more on management initiatives than formal provision for voice. All the providers in the sample held at least annual staff meetings and over 90% held them at least quarterly (table III.46). Homes were more likely than IDPs to hold meetings every month or more frequently. The reason for this was undoubtedly the greater difficulty of arranging staff meetings for domiciliary care staff who work in the community rather than in a fixed location but on the other hand the need for staff meetings may be consider greater in IDPs. Figure III.35. Union recognition and use of staff attitude surveys 100 Homes 90 IDPs LADPs 80 Percentage 70 60 50 40 30 20 10 0 Recognise a trade union Carry out staff attitude surveys Note: Total responses to the two questions: 53 and 52 (homes); 51 and 52 (IDPs); 9 and 9 (LADPs). Perhaps reflective of the greater difficulties of direct communication IDPs were more likely than homes to carry out staff attitude surveys - 83% compared to 58% (figure III.35). Some EWERC Part III. The provider telephone survey 194 comments made by interviewees for the telephone survey indicate, however, that these surveys did not always generate a high response rate. Yes, but the one I did, no-one filled it in and returned it to me. (IL.H.2). [Company X] do [undertake a staff survey] after you have been on contract for 9 months. I am not involved and have no idea of the result. I think that not many responded. (AH.D.3.CN). Table III.46. Frequency of staff meetings % of Homes % of IDPs % of LADPs % of all Between every three months and yearly 10.0 9.6 0.0 8.9 Between one and three months 44.0 63.5 40.0 52.7 Every month or more 46.0 26.9 60.0 38.4 Total responses 50 52 10 112 No response 3 0 0 3 EWERC Part III. The provider telephone survey 195 III.7. Summary In this part of the report we presented a general mapping of the HR practices and employment conditions in the social care sector, paying special attention to the similarities and differences between our two main categories of care providers – residential and nursing care homes (referred to as homes) and independent sector domiciliary care providers (referred to as IDPs) – as well as a third category of local authority domiciliary care providers (referred to as LADPs). The results draw on the combined quantitative and qualitative data from our telephone survey. In exploring the types of HR practices deployed across the sector, the variety of practices between IDPs, homes and LADPs and the patterns of employment conditions, this part of the report has set out the descriptive statistics required for the subsequent more detailed statistical analysis presented in part IV. Therefore, before turning to the next stage of our interrogation we summarise the key results from this preliminary mapping exercise. The six sections of this part of the report were organised around key areas of HR policy and practice. Beginning with the key area of recruitment practices, the survey evidence underlined the problems facing all care providers with one in three reporting difficulties recruiting care workers. IDPs were more likely than homes to report difficulties but were also more likely to have witnessed an easing of problems during the recession, suggesting that the gap in experience has narrowed in the last couple of years. Respondents to our survey, especially from IDPs, believed the most important reason they faced difficulties was the low level of pay. And the need to fill weekend and unsocial hours shifts was a real challenge for all providers, but again especially for IDPs, 70% of which recorded shortages in this area. As anticipated, section III.1 found that care providers use a range of formal and informal recruitment methods, although homes were more likely than IDPs and LADPs to prefer informal methods over formal methods. In the selection process, again the data point to a wide range of practices, with evidence that IDPs were more likely than homes to utilise aptitude tests and pre-screening telephone interviews. Perhaps surprisingly – although again this may reflect the recessionary conditions at the time of data collection – providers were unlikely to use external agencies to fill vacancies. Nevertheless, 17% of homes and 10% of IDPs had recruited from overseas directly. While providers sought a wide range of attributes among job applicants, the most common, reported by nine in ten providers, was a positive and friendly attitude towards care work; this was said to be the single most important attribute by three in four homes and over half of IDPs. Availability for weekend work, as well as early and evening shifts, was also required by a majority of providers, with strong similarity among homes and IDPs. There was a notable difference of views among public and private sector provider managers such that LADP managers placed more emphasis on skills associated with care than did providers in the independent sector. While providers have a clear notion of what they required in a recruit, a significant proportion – some four in ten – reported occasionally or often having to hire people (with full knowledge of what they were doing) who lack the full set of desired EWERC Part III. The provider telephone survey 196 attributes – a result that is all the more striking given the relatively loose labour market conditions during 2008-2009. At the same time, a third of providers reported often or occasionally rejecting candidates who were suitable for the advertised job. This result points to the likelihood of differential local labour market effects in shaping HR practices, an important issue that is interrogated in detail in part IV.4. A further external factor that impinges upon recruitment practices is the need to apply for CRB checks; more than half our sample of providers had lost one or more job applicants as a result of delays in CRB checks and a third as a result of CRB failures. The mapping of turnover and retention conditions in section III.2 showed that while a majority of providers expressed satisfaction with levels of staff turnover, the data point to high levels: the turnover of care workers averaged 24% for homes and 31% for IDPs. Homes were better than IDPs at retaining new recruits but 22% of homes and 32% of IDPs had lost more than half of their new recruits in the past year. Homes were less likely to report very high levels of staff turnover; close to a third of IDPs reported turnover of care workers excluding new recruits of more than 30%. Average rate of turnover, excluding new recruits, were 22% for IDPs and 18% for homes. Reasons for worker quits are varied and again differed among homes, IDPs and LADPs. The search for more convenient working hours was a strong underlying factor at one third of IDPs and the search for better pay at close to one quarter of both homes and IDPs – although this was not an issue at any of the LADPs in our survey. Many care workers quit for career reasons, with one in four homes citing nurse training, and a very common reason was family responsibilities, reported by more than a third of providers. The evidence on pay and rewards in section III.3 demonstrates the very low value assigned to the work of adult care in the UK independent sector and especially so among for-profit organisations. Homes pay lower minimum rates than IDPs with a third of homes in fact using the statutory minimum wage, despite its role in the labour market as a floor to wages, not as a going wage rate. Those paying above the statutory minimum do not pay significantly more – seven in ten homes and one in three IDPs paid a minimum of less than £6.00 (just 27 pence more than the national minimum wage). It is notable that no LADPs set such a low minimum rate for care workers, a reflection of the stronger collective wage bargaining power of trade union representing care workers in the public sector. Our analysis of „normal‟ pay rates – the rate paid to most care workers in each organisation revealed very low levels and little variation across independent sector homes and IDPs with the exception of voluntary sector homes where the average normal pay was relatively high. At nine of the 52 homes surveyed the normal rate was in fact the same as the statutory national minimum wage. This finding underlines a more general finding of limited opportunity for pay progression in these organisations. In more than half of IDPs the minimum rate paid to care workers is exactly the same as the normal rate. Even where providers pay more for promotion to a senior care worker, the rate of pay is usually no more than £1.00 higher. And these employers do little to encourage investment in skills; reward for the NVQ level 2 qualification in care varied from as little as an additional 7 pence per hour to EWERC Part III. The provider telephone survey 197 £1.02 above the minimum rate of pay; indeed, 23 of the 25 providers that offered a higher rate set an hourly rate at no more than 50 pence higher than the minimum. The results are a disappointing reflection of the unwillingness and/or inability of these employers to reward more complex work appropriately. Regular uprating of pay was common but not universal. Factors influencing the decision to uprate pay included changes in the statutory national minimum wage, especially among homes which is directly related to their greater likelihood of setting minimum rates at the minimum wage floor. Important influences on IDPs‟ uprating of pay, by contrast, included the level of LA fees and the profitability of the organisation. There were variable practices for paying travel time to domiciliary care workers. A small share of IDPs and LADPs (less than one third) paid a supplement; most opted to reimburse petrol or public transport costs; and a significant share claimed the compensation was included in the hourly rates. By contrast, there appeared to be a near universal approach towards paying care staff for time spent training; only around one in ten providers (all in the independent sector) failed to compensate all training time. However, there is no standard practice of paying a premium for overtime work. Most LADPs do follow this practice, but only around a quarter of IDPs and homes. Finally, the data reveal a surprisingly high incidence of independent sector providers that are unwilling to fund the upfront costs of starting work, such as paying for CRB checks, uniforms and induction training. Section III.4 examined HR practices of flexibility, working time and work organisation. Among IDPs, there is a very strong flexibilisation of employment characterised by very limited use of guaranteed hours (just one in ten IDPs), strong prioritisation given to user needs in scheduling work and a near universal expectation that workers must tolerate longer hours at short notice (occasionally or often). The data suggest providers use work scheduling as a major form of control over the workforce; the near standard practice (nine in ten IDPs) of offering zero hour contracts may in part explain the finding that nine in ten IDPs find it easy or very easy to find staff willing to take extra hours at short notice. Some providers made it clear that staff were expected to cooperate in variations to schedules if they hoped to be allocated their desired number of hours in the future. By contrast, the practice of offering zero hours contracts has been abandoned by public sector providers where nine in ten offer guaranteed hours. Behind the working time practices lies the organisation of work, scheduled around visits to clients. The minimum duration of visits tended to be 15 minutes and the average length no more than 30 minutes. Three in five IDPs failed to set any minimum working time and a further fifth set a minimum time of less than two hours. The fragmentation of work into very short blocks of time created further problems for staff because nine in ten IDPs did not pay for breaks. Among homes, care workers were more likely to work full-time than in IDPs and to be offered guaranteed hours. Nevertheless, there was still a significant share of part-time working in homes and fewer care workers worked very long hours than in IDPs. Overall, a EWERC Part III. The provider telephone survey 198 higher share of homes than IDPs claimed to be able to match employees‟ working time preferences all of the time, suggestive of a somewhat weaker employer-led approach to flexibility. A major issue in homes was matching staffing working hours with bed occupancy with evidence of change occurring in lumps rather than incrementally as homes lost or gained occupants. Section III.5 found that most providers were strongly engaged in training provision, including induction training and training to NVQ levels 2, as well as regular staff appraisals. Even where staff required NVQ level 3 or 4 skills, three in four providers provided the training inhouse rather than buy in external provision. There is nevertheless variation in approach towards staff development. For example, the results suggest IDPs were more likely than homes or LADPs to believe a newly recruited care worker ought to be competent in their job within a week‟s induction training. Homes and LADPs were more likely to allow a period of one to six months for induction. Similarly, attainment of NVQ level 2 qualifications was higher in homes than in IDPs. More than half of homes and LADPs had more than 70% of care workers qualified to level 2 compared to a third of IDPs. Also, nine in ten homes had already met the now abolished national target of having at least half the staff trained to level 2 compared to just two thirds of IDPs. Two key factors explaining the failure to reach the target were high staff turnover and training related problems such as funding. The final section III.6 covered inter-related practices towards performance management, job autonomy and employee voice. Use of appraisals was frequent throughout the sector and most providers favoured soft over hard methods to improve performance, but poor performance, including absenteeism, had at times to be tolerated in four out of ten IDPs. With regard to monitoring, a third of IDPs use electronic monitoring and a significant share of both homes and IDPs rely on user surveys conducted by both the LA and the care provider. Timekeeping issues were also a cause of poor performance, again especially notable among IDPs. The management approach towards encouraging workers to exercise discretion and autonomy at work is covered in great detail in part V of this report. Here, we only reported the very basic, descriptive data. Most providers were confident their care workers enjoyed the opportunity to deliver high quality services, to develop good relations with users and exchange ideas about good practice care delivery. However, a significant proportion expressed doubt. For example, more than four in ten IDPs and one quarter of homes believed workers were not fully able to prioritise and undertake tasks in ways to improve the quality of care. Also around a fifth of IDPs and LADPs recognised that workers were not fully able to take the time needed to develop better relationships with service users. Finally, the survey results confirmed expectations that in the independent care sector the employment relationship is highly individualised; our survey data suggest only 15% of homes and 8% of IDPs recognised collective representation through a trade union, albeit with slightly higher figures among not-for-profit voluntary sector providers. In its place, providers held staff meetings, with most organising such meetings every one to three months. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 199 IV. The Impact of Organisational, Commissioning and Labour Market Factors on HR Practices and Outcomes This part of the report brings together the various factors identified in the research framework for the project that could be expected to impact upon the recruitment and retention of the social care workforce. Following the mapping of HR practices and HR outcomes in Part III, the analysis here uses statistical methods to interrogate the patterns in more detail. The main data source used in this part is again the telephone survey of providers but we also supplement this establishment-based survey with information from interviews with HR directors or equivalent at the headquarters of ten national chains of providers. There are six sections to this part of the report, organised as follows: Section IV.1 presents the organisational characteristics of the sample of providers - by size, ownership and quality star rating - and identifies the management capacities and support structures within the independent sector; Section IV.2 identifies the HR practices adopted by type of provider and creates an index of „good‟ HR practices by which to compare the range of poor to good HR practices, including for separate HR practices and for a summary measure; Section IV.3 uses these indices together with detailed wage data for the providers in the sample to explore the linkages between LA commissioning practices and good HR practices and outcomes; Section IV.4 undertakes a similar exercise in relation to local labour market factors and explores the association between local pay levels and other measures of local labour market demand with the likelihood of providers adopting good HR practices and enjoying good HR outcomes; Section IV.5 interrogates these divergent influences on HR practices and HR outcomes through multivariate statistical analysis and considers the relationships for IDPs and homes between organisational characteristics, LA commissioning practices, local labour market factors, good HR practices and good HR outcomes; Section IV.6 explores providers‟ views on the social care policy and commissioning environment drawing on both the telephone survey and the survey of national providers at headquarters. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 200 IV.1. Organisational characteristics and the management of independent sector providers A key issue for the recruitment and retention of the social care workforce is the capacity of the independent sector to recruit, retain and manage a skilled and committed workforce, now that the local authorities have, for the most part, outsourced the majority of service delivery. The capacities of the independent sector will depend upon their organisational and management characteristics and their business strategy and position. We thus start this chapter by identifying the key organisational and market characteristics of our sample of independent providers and also introduce into the analysis the national chains that we have interviewed at national level (section IV.1.1). In section IV.1.2 we explore the organisation of the HR function and associated issues such as approaches to performance management within our telephone survey of establishments and our survey of ten national companies. IV.1.1. Organisational characteristics Table IV.1 shows the key organisational and market characteristics of the telephone survey sample of 115 providers. The sample of 105 independent providers was relatively evenly split between homes and IDPs, with 53 and 52 respectively, complemented by interviews with 10 LADPs. Among the 53 homes 56% were offering only residential care and 43% were offering nursing care. Size of establishment is often regarded as a characteristic with significant implications for the management of HR. These implications may be both positively and negatively related to size with the smaller workplaces more able to manage through informal and „friendly‟ work relations, which may have positive benefits for retention. Larger establishments may be in a better position to professionalise HR and possibly to make step changes in volume or quality of service delivery. However, size of organisation may also matter, with small establishments as part of larger organisations able to rely on regional or headquarter assistance to professionalise. As the target sample was specified at local level, it was not possible to include type of organisation as a specific characteristic - particularly in view of the problems of securing access discussed in part I (section I.7). However, the sample was reviewed as a rolling total and, as table IV.1 reveals, it covers a wide range of both size of establishment and type of organisation. The most frequent size category for homes was 25 to 49 staff while for IDPs it was somewhat larger, at 50 to 99. IDPs were also more likely to be part of a chain, particularly national chains (as opposed to local chains, which are defined as having more than one establishment, but usually less than ten, situated in one, or in neighbouring local authority areas). Nearly half the sample of establishments were in fact part of national organisations; this fits with evidence from LAs and from UKHCA that there has been a marked increase in the role of national organisations, EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 201 particularly in domiciliary care. However, most of the national providers included in the sample here have been in operation for at least two years and generally longer. Overall only three IDPs were newly established. Table IV.1. Organisational characteristics of the telephone survey providers Size Chain (local or national) or single agency Is it a private, public or voluntary organisation? Star rating Homes IDPs LADPs Total Total sample size 53 52 10 115 Very small 0-24 15 5 0 20 Small 25-49 24 9 0 33 Medium 50-99 12 24 0 36 Large 100+ 2 14 10 26 chain - local 14 10 0 24 chain - national 19 31 0 50 single home/agency Private 20 11 10 41 42 46 0 88 Public 0 0 10 10 Voluntary 11 6 0 17 1 Star 9 5 0 14 2 Star 31 37 4 72 3 Star 13 10 6 29 How many local authorities engaged with 1 council only 28 32 10 70 More than 1 25 20 0 45 What proportion of your service users are local authority funded 0-25% 13 1 0 14 26-50% 8 3 0 11 More than 50% Yes 32 48 10 90 25 34 6 65 No 28 18 1 47 3 3 Are any, of your service users are partly or wholly funded by the PCT? What % of beds are currently vacant? Missing 0% 13 1-10% 29 More than 10% What proportion of hours are done under block and spot contracts Missing < 2 years Spot only Mainly spot (>50%) Mainly Block (50% & >) Block only How long has the Home/IDP/LADP been operating? Do you belong to an Employers‟ Association? EWERC 11 Not asked of homes Not asked of homes Not asked of homes Not asked of homes Not asked of homes Not asked of IDPs Not asked of IDPs Not asked of IDPs Not asked of IDPs Not asked of IDPs Not asked of IDPs 25 3 28 3 0 3 12 0 12 5 7 12 7 0 7 0 3 13 29 11 0 3 > 2 < 5 years 8 14 0 22 >5 years Yes 45 25 35 23 10 2 90 50 No 12 18 5 35 Missing/don‟t know 16 11 3 30 Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 202 The majority of homes and IDPs were private, for profit organisations, but Table IV.1 shows that 21% of homes and 12% of IDPs were run on a voluntary, not-for-profit basis. Less than half the organisations - 50 out of 115 - definitely belonged to an employers‟ association and 35 said they did not but there was a high share of managers who were not able to answer (30 out of 115). Table IV.1 also gives data on the sample by star rating awarded by CQC. The most popular category is 2* with 72% of the 115, but 14% are 1* providers and 29% are 3*. To explore the role of national organisations further, we decided to undertake a separate survey of 10 national organisations at headquarters level; table IV.2 provides the details of their organisational characteristics. These also showed a range of different size characteristics with the number of homes in ownership varying from 40 to over 700 and the number of branches of IDPs varying from 15 to over 60 (or around 150 if franchised branches for one national chain are included). All but the smallest of the domiciliary chains operated with a regional as well as a national structure. The importance of LAs in shaping the markets for the independent sector is confirmed by the information for the sample, particularly for domiciliary care where all but four IDPs relied on LAs for more than 50% of their business. The picture was more mixed for homes where 21 recorded sources other than LAs as accounting for more than 50% of their business and 13 of these said that LAs accounted for less than a quarter of their activity. The likelihood of relying primarily on private funding was much higher in some parts of the country than others. As one home manager commented in a southern location in respect of her owner‟s policy: They are unusual in the area as they take local authority people – most don‟t because of the money. (LK.H.2 AS (V)). Responses to the question at the end of the telephone survey on levels of fees charged revealed quite wide differences among some providers between the fees charged to private clients and those received from the LA especially for homes in all the southern LAs (see section IV.3.1 for further details). Concerns over dependence on LAs were expressed by some of the national providers, both in relation to the low fees paid by LAs and in relation to the likelihood of reduced business from LAs in the future due to budget constraints. One national provider of homes shared a presentation on their business plan where it was clearly stated that in the south they were mainly concentrated on servicing private clients and it was only in the north where their focus was on relationships with LAs. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 203 Table IV.2. Characteristics of national providers a. Domiciliary care providers NATDOM1 NATDOM2 NATDOM3 NATDOM4 NATDOM5 Size Large Large Large Large Small National/local terms and conditions Local. Local. Local. Local. Local. National/local training and induction Standard induction. Standard induction. Standard induction Standard induction Standard induction. Training company and local. Training company- based. Training companybased Training company-based Training company and local National recruitment policies and procedures. National recruitment policies and procedures. National recruitment policies and procedures. National recruitment policies and procedures. National recruitment policies and procedures Regional structure Regional structure Regional structure Regional structure Bonus scheme for managers. Traffic light system based on quality, financial and HR targets For company branch managers, based on the contribution of the branch to the centre Performance bonus for managers based on KPIs (HR and business targets) Bonus scheme for managers based on achieved targets (KPIs red-amber-green). Currently emphasis on R&R. Centralised/decentralised Performance targets/bonuses EWERC Bonus system for managers. Targets on quality, business Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 204 b. Care homes NATHOME1 NATHOME2 NATHOME3 NATHOME4 NATHOME5 Size Large Large Small Very large Medium National/local terms and conditions Local. Local. National salary scale, local determination of position. National pay rates for care staff negotiated with GMB. Local but aiming to standardize by region. National/local training and induction Company based with regional support. Standard induction. Training company and local. Training company and area based. Company and local based. Standard induction. Training company and local. Centralised/decentralised National recruitment policies and procedures. National recruitment policies and procedures. National recruitment policies and procedures. National recruitment policies and procedures. National recruitment policies and procedures. Area structure Regional and area structure Regional structure Regional structure Regional structure Performance targets/bonuses 30%bonus scheme for managers based on targets set by themselves – main ones are marketing, occupancy and care delivery. Bonus scope for managers of 25% based on financial performance and quality. Quarterly and year-end bonus scheme for managers. KPIs for care and financial performance. Bonus for managers based on financial performance and quality (including HR). Annual bonus for managers based on Balanced Scorecard approach (incl. ability, people management, finance). Role of LAs v private clients 60% of business from LAs and PCTs. South dominated by private fee payers but north more mixed. Decreasing number of public funded referrals. Fee freezes and reductions from LAs. 90% of business from LAs and PCTs. 80% of business from LAs and PCTs. Pressure on fees. Looking to grow private side. 80% of business from LAs and PCTs. Both under economic pressure. Anticipates less business coming from them. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 205 Sixty of the 105 independent providers dealt with only one LA but 45 were engaged in working for more than one local authority; for homes this was unsurprising as many placements are made out of area but nearly 40% of the IDPs also worked for more than one LA. In addition well over half of the sample did at least some work for the NHS through Primary Care Trusts. The contract arrangements for the IDPs varied with 28 working on an only or mainly spot basis and 17 on a mainly or only block basis (7 missing answers). A further indicator for homes of the state of the market is the number of bed vacancies; here we found a wide range of situations with 13 recording no vacancies, 29 had vacancies of up to 10% but 11 had vacancies in excess of 10%. Box IV.1. National providers’ comments on private versus LA funded clients The south [of England] seems to be very private fee funding driven, whereas the north is sadly more blurred and Scotland is a different funding altogether. Recruitment Director, NATHOME1 One of the challenges for us is that a huge proportion of orders come from local authorities and PCTs. So nearly 80% of our business is from local authorities and PCTs and only 20% from private paid. So when you look at challenges, I mean, at the moment the sort of fees that one gets from local authorities and PCTs are significantly lower than the fees that you can charge to private individuals and, obviously, in the present financial climate, one of the big concerns is that‟s going to come under even more pressure if those PCTs and local authorities are challenged in terms of their own budget. Group HR Director, NATHOME 4 I suppose the key business challenge really arises from the state of finances of the country as a whole. We are certainly noticing fewer public funded referrals. Corporate Services Director, NATHOME2 IV.1.2. Management in the independent sector As most IDPs and homes are small at the establishment level, a key issue for the development of capacity in the sector is the availability of either inhouse expertise or external support - for establishments that are part of chains. We did not investigate directly the capacity or calibre of managers via the telephone survey as it would have been difficult to address this subject with the managers as interviewees and the value of the information collected would have been questionable. However, we did explore the issue of management capacity and calibre, including sources of management recruitment and issues of training and turnover, with the ten national providers. This was seen as a key issue for the quality of the care service, including in turn the recruitment and retention of the care staff, by both the LA interviewees (see part II) and by the national providers themselves. Recruitment of managers was identified as problematic by some of the national providers, leading in some cases to the use of agencies to search for applicants. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 206 I am finding increasingly that we are having to use recruitment firms because people are not responding to adverts. Managing Director, NATDOM 5 Others were also stressing the need to standardise and professionalise their recruitment policies. Historically, all recruitment, there was certainly no central HR control over it. It was all really done locally. … And what they have been doing is working with line managers, the area managers now, to help them with things like home manager recruitment and just simple things like you know let‟s get an up to date role profile with some competencies and let‟s actually look at standard things to ask at interviews, things to find out about the person, which we didn‟t have before. So we‟ve brought a bit more standardisation into that. Group HR Director, NATHOME 4 There was a particular focus on the development of more standardised, more extensive and more professional training for managers, to improve retention of the managers in the first place but also to improve their employee relations skills to improve recruitment and retention of the social care workforce (see Box IV.2). Box IV.2. National providers’ approach to training managers What we‟ve actually tried to do is to pull together a more standardised home manager induction programme because that had also previously been run largely locally and, to be honest, was a bit hit and miss in terms of what people got or didn‟t get…. Because when we‟ve been doing some analysis of turnover, quite a lot of our staff turnover happens within six months or certainly within the first two years and we think that a lot of that is linked to, are we getting the recruitment right in the first place? And having done the recruitment, are we inducting and sort of embedding people into the organisation properly? And right now we‟re probably not. So our staff turnover, for example, as at November last year, was standing at sort of 27%, 28% which meant that last year 12,000 left and joined this organisation. That‟s like 1,000 people a month. …..If you could get to grips with turnover, then actually there would be an enormous benefit to the business because there would be money to be saved in terms of recruitment fees, agencies, adverts that sort of thing, but also the amount of time that home managers could have to actually spend on looking after their residents, as opposed to recruiting and inducting new people, would be of massive benefit… So we‟ve kicked off a project to run a lot of training in employer relations issues for home managers, because as a business we haven‟t really invested in training people beyond what I think of as the operational training. We spend a lot of time and money on things like NVQs in care but we don‟t do much in terms of management development. So, a home manager is really running quite a complicated difficult little business and we‟ve done really very little to equip them to do that. Group HR Director. NATHOME 4 So when [managers] start with the business there‟ll be an induction into the business, who we are, our values, how we operate and the training and managing teams, managing IT systems, managing budgets and all the finance. So there‟s a fairly extensive induction covering all of those areas. We have a directory of training courses available in more specialist areas. So there‟s a EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 207 wide variety of clinical specialist courses, right the way through covering more specialist courses in finance, HR. So managing people and then through to some just simply looking at management training and their management expertise. We offer ILM qualifications at both level three and level four to our managers and we‟re also about to launch an undergraduate level course in Dementia, which will be available for people to apply For. So there‟s a very wide range of training. HR Director NATHOME 3 However, while national providers were seeking to improve their policies with respect to recruitment and development of managers, they were also aware that a dedicated local manager, or indeed owner, could add to the effectiveness of the organisations through additional commitment and local knowledge (see box IV.3). However, they also stressed that many managers of establishments owned by national chains were appointed locally and brought local knowledge to the post. Overall the national providers felt that they were better placed to help managers through periods of change and restructuring and that the level of turbulence in the sector might spell the end for committed, local but less professional management. However, some still felt that they had not yet built upon the advantages of being a national organisation offering better and more structured career opportunities to their staff, including managers. Box IV.3. National providers’ views on the advantages and disadvantages of being a national organisation i) Local has its advantages What you find with the smaller independent provider is that - local services for local people. And it is very important for the commissioners that there is that local feel. And when you‟re a national provider that is difficult. (HR Director, NATDOM 1) What you tend to find with smaller operations ….is that there is a different emotional connection to the employer. And higher quality. Because these people have built businesses, what you do find is that some of the branch managers are of a higher calibre. So some of our best branch managers have come via acquisitions of small independent providers. (HR Director, NATDOM 1) What you will find is that us and [a competitor] are less responsive to the local market and the local providers will be much more aligned in terms of what they‟re offering, against the bigger providers. So they‟re more nimble it would appear. (HR Director, NATDOM1) ii) But national organisations have more resource and provide more support for change I guess we‟ve got more resource to put it in, in terms of training, developing people. And we‟ve got more of a communication network and we can use tools to help, more than a small business could. But I think the big challenge with the larger organisations is sometimes the scale of EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes operation is that sometimes there are gaps in getting things done the way you‟d like. And I think we‟ve done a lot to improve that. But I‟m not sure it‟s small versus large, I think it‟s mixed. (Managing Director, NATDOM 4) I think if you‟re a national provider with a good reputation then it‟s so much easier. They‟re still local; they may be national but they‟re still very local. …. (HR Director, NATHOME 5) I myself have run a care home for a single provider and I think they do have a battle to get properly skilled people because you don‟t have the support structure. So it‟s quite a scary thing to be on your own managing a home (Recruitment Director, NATHOME 5) Easier [for national providers to recruit] because we can be more competitive with salaries. We have more resources than smaller business and because we have more branches, we can look at regional recruitment opportunities as well. (National Recruitment Manager, NATDOM 3) I think the larger providers, you‟ll certainly see within the next 12 to 18 months, a much more sophisticated use of things like websites to recruit and pre screen staff and channel them through to the right branch thus in fact reducing the manpower required to recruit but delivering as good or better results. So I think there will be a widening there of efficiency but I don‟t see massive differences at this point. (Commercial Director, NATDOM 2) iii) Changes to the policy environment may be having particularly negative effects on small providers The change to effectively straight line or pro rated, minute by minute charging or payment is really having a fairly substantive impact on the underlying profitability of domiciliary care businesses. So at the moment I think, because the recruitment market is benign, the impact has, in fact, been less dramatic. I think when recruitment gets tighter and the training and recruitment costs start to lift, that is going to hammer domiciliary businesses and I think where we‟ll see the pain first will be in the smaller providers. (Commercial Director, NATDOM 2) I think the challenges for the next couple of years are going to be working within the budgetary constraints. I think that‟s going to be major issue. I think the implementation of personalisation will bring its own challenges. I think that [there will be] a lot of turmoil at the smaller provider level because they will just not be able to cope with all these challenges, I think, that‟s going on. (Managing Director, NATDOM 5) Small local providers which are a dying breed with all the legislation and everything else. (National Recruitment Manager, NATDOM 3) iv) But national organisations are still not leveraging their advantages I don‟t think we‟re seeing any of the benefits of being a big national organisation. …So well designed induction and well designed training programme, some of the things that you could maybe sell at interview, aren‟t really currently in place. And … we ought to be able to offer a way of potential career progression than if you go and work in a little local home that‟s only got, I EWERC 208 Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 209 don‟t know 360 staff and that‟s their total business. But because we haven‟t really thought like a big national employer, we haven‟t actually got all the things in place that you would expect us to have. (Group HR Director, NATHOME 4) When we consider management structures at the establishment levels, it is of course the case that those that belong to chains, particularly national chains, are more likely to have access to support from a specialist HR department or manager (table IV.3). Around one third of IDPs and close to half of the homes did not have access to such expertise. However, of those that had this external support, only 30 to 40 percent reported that this expertise was based either inhouse or locally with three fifths to two thirds saying it was further afield (table IV.4). Where such support is available it is said to be very wide ranging by around one third of respondents (table IV.5). A similar percentage refers to assistance with grievance and discipline while recruitment and absence management are explicitly mentioned by around one tenth of the respondents respectively. Table IV.3. Presence of a specialist HR manager or department a. IDPs All Very small &small medium large Local chain National chain Single site/agency 1* 2* 3* % with a specialist HR manager or department 69.2 64.3 70.8 71.4 90.0 83.9 9.1 60 70.3 70 % without 30.8 35.7 29.2 28.6 10.0 16.1 90.9 40 29.7 30 b. Homes All Very small Small Medium & Large Local chain National chain 1* 2* 3* 100.0 Single site/ agency 10.0 % with a specialist HR manager or department 52.8 20.0 58.3 78.6 50.0 44.4 54.8 53.8 % without 47.2 80.0 41.7 21.4 50.0 0.0 90.0 55.6 45.2 46.2 However, even among national providers the extent of HR support may be limited. One home that was part of a national chain commented that monitoring of absence had only really just started in its organisation. We‟ve just started doing that, we‟ve got a HR department and all of our staff are required to complete a return to work form if they‟ve been off sick or off with their children or whatever EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 210 reason then they have to complete that, and so the HR department are starting to collate that information. (OM.H.1.B.NV). Table IV.4. Location of the specialist HR manager or department % of Homes % of IDPs Total On-site 7.1 0.0 3.2 Local 32.1 32.4 32.3 Further Afield 60.7 67.6 64.5 Total responses 28 34 62 No response 0 2 2 Box IV.4 provides examples of the support provided to their branch managers according to the interviews with national providers at headquarters. Some of the managers interviewed in the telephone survey revealed how important such external support can be: We‟ve got now, only in the last 3 months, we have an HR business partner and they‟re CIPD qualified and she‟s just about saved my life as I was doing it all before. So yes we do have a specialist, and in fact we did have one person but now that‟s developing into a team. I mean they don‟t necessarily do all the work but they oversee everything right down to career development and training that sort of thing. (OM.D.2.DN). Another manager commented on the importance of external support for non standard activities such as recruiting migrants: I am now in a position to recruit foreign nationals, so they give me advice about what I need for somebody from Poland or Hungary for example. And disciplinary and sickness issues and they will come up and sit in on interviews with staff if necessary. (AH.D.3.CN). Table IV.5. Types of support provided by specialist HR manager/department % of Homes % of IDPs % of LADPs Everything that we ask 31.9 38.6 33.3 % Total Responses 35.0 Grievance and disciplinary 36.2 25.0 44.4 32.0 Recruitment 8.5 11.4 0.0 9.0 Contracts/Legal/Policy 10.6 11.4 22.2 12.0 Attendance and sickness 6.4 4.5 0.0 5.0 H&S and welfare 2.1 0.0 0.0 1.0 Training 4.3 4.5 0.0 4.0 Immigration 0.0 4.5 0.0 2.0 Total responses 47 44 9 100 No response 8 9 3 20 Note: of those who have a specialist HR manager or department, 53 providers responded (some gave multiple answers) and 20 providers did not respond. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 211 Box IV.4. HR support services They all have identified regional support. And again, if you compare the quota of HR people per head, if you look at the healthcare environment you would invariably be looking at one HR person per 110 to 140 staff. For us, and we‟ve got the biggest HR resource that we‟ve ever had, and in the 12 months that I‟ve been in post we‟ve doubled the size of our department, we‟ve got one per 496. So there is access to the support, but I suppose it‟s indicative of the industry. HR Director, NATDOM 1 From a people perspective, I mean there were only 11 people in the HR team so their impact on the business was really absolutely minimal. They were doing the best they could in the circumstances in terms of they were creating policies and management guidelines but actually being able to engage with management and help them with their people management issues, they just really weren‟t able to do…..We‟re going to have HR Managers on the ground, three or four per region, and at the moment we‟ve just got one interim in each region promoting some help, and then we‟re recruiting for some specialist roles, resourcing, learning and development, employer relations and so on. So that‟s the second strand. The third strand is what I call people management framework. Basically, as a business, we have never spent any time saying what kind of employer do we want to be? What is the deal between us and our employees and if they bring all their skills and capabilities and competencies to work, what can they expect in return in terms of things like appropriate working environment, tools to do the job, support to do the job, training and development, reward and recognition? So we started quite a big piece of work on that. Group HR Director, NATHOME 4 So specifically with HR we have a central, not a distributed HR team, where any manager can ring, email for advice, but also that team does a lot of dedicated training on things like disciplinary and grievance procedures. So every manager will have had the opportunity to have a full day understanding some basics of employment law, how they translate into our procedures and how we operate those procedures, and we repeat that to pick up new starters, maybe every six months or so. Corporate Services Director, NATHOME 2) We have an HR helpline, which is monitored from our support centre and it‟s an advice line for managers to call about any operational HR queries. But then in the division there is a HR business partner to deal with anything that‟s more complex and perhaps to help coaching the manager, an area manager that needs further support in an issue or the more strategic work. So the immediate support is available on the end of a phone via the advice line but there is personal contact for the more complex issues. (HR Director NATHOME 3) One managerial task that was particularly burdensome for IDPs was the scheduling of work. This managerial problem was being addressed in some organisations by the application of software (see example below from a local chain) but we did not collect systematic evidence on the extent to which there were differences in the use of technology to assist in key managerial tasks by type of organisation, although this could be an area of interest for future research. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 212 We use the care manager system (computer) and this takes 75% of the nightmare out of putting together the jigsaw. We assign customers to care workers, and the computer does this according to whether they are walkers, bike riders, or car drivers. We split [X] into two areas – North and South and once the jigsaw is in place, using Care Manager, it all seems to work quite well. Most care workers are flexible. We do some work outside of [X] in the boundaries, and go into agricultural areas. Care Manager tells us if we are overloading one care workers, if they say they will only work X number of hours or only up until 12 noon – it doesn‟t let us overload them with work. LKD.6.CL EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 213 IV.2. HR practices and outcomes by provider characteristics Part III provided an overview of the range of HR policies pursued by both homes and IDPs. In this section we explore the telephone survey results for evidence first of variations in HR strategies by type of provider, focusing on issues of size, ownership, CQC star quality and public/private or voluntary status. Second, we explore the range of variations in the set of HR strategies adopted by these individual providers: that is how far we find some providers adopting sets of good HR practices across the range of dimensions and at the other end of the spectrum whether there are some providers who have poor or weak HR practices across the spectrum. Third, we report on providers‟ views on what would do most to improve recruitment and retention in social care. To simplify the analyses we have streamlined the questionnaire data as presented in part III by transforming the variables into indicators, sub-indices and indices, as described in appendix table IV.A1 and in box IV.5 all taking values between 0 and 1. Depending upon the nature of the indicator/index, we use the relative level of the mean values to identify whether policies are more favourable to employees or indicative of more professional and/or high performance practice (closer to one) or alternatively less favourable to employees or indicative of either more informal or lower trust HR practices. The direction of measurement for each indicators/sub index/index is set out in the appendix tables IV.A1 to 4. We include in our discussion not only the quantitative evidence but also the qualitative material both from the telephone survey of providers and from our interviews with national providers. Box IV.5. The dataset We further divide the data into what we have termed the standardised dataset. This refers to 33 indicators of HR practices and 6 indicators of HR outcomes for 102 providers. These indicators apply to both homes and IDPs and meet the criteria that missing values should not exceed 10%. A similar 10% cut off was used to eliminate three providers from the standardised data set. For these providers and indicators we have then imputed the relatively small number of missing values as the mean for the sub index across all selected providers (see appendix IV.A.1 for details). The 33 HR practice indicators have been further subdivided into 18 sub-indices and 6 indices covering pay levels, pay strategies, recruitment; employee development, working time and work organisation. The six outcome indicators have been combined into 4 sub-indices and 2 indices covering recruitment and retention outcomes and skill and training outcomes. For all other data that we use in the analysis we do not include imputed values. These include in particular: i) data collected specifically about domiciliary care, due to the difference in the questionnaire; and ii) turnover data, for which due to the difficulties we had in requesting providers to give us the detailed information needed to calculate these data we have had to analyse the turnover data separately and for a maximum of 82 independent sector providers instead of 102 for the standardised data set. Also for other indicators excluded where the missing values exceeded 10% we have not imputed any values. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 214 IV.2.1. HR practices and outcomes by provider characteristics Box IV.6 provides an overview of the construction of indicators, sub indices, and indices of HR practices. We present the full information on variations in HR practices measured by the 18 sub-indices and 6 indices by size, ownership and star category in appendix IV.A.2. We also provide appendix tables on the individual indicators where significant 28 differences between types of providers have been identified. These tables present some indicators additional to the standardised set (those excluded for too many missing variables and some specific domiciliary HR practices) (see appendix table IV.A3). Box IV.6. Indices (X) and sub-indices (SI) from the standardised dataset HR PRACTICES INDICES AND SUB-INDICES: XPAYLEVELS SIPAYLEVEL SIPAYUPGRADE XPAYSTRAT SIPAYIMP SIPAYOPPCAR XEMPDEV SIEMPVOICE XRRPRACT SIRECRUITPR SIRECRSELEC XWT SIWTSTFFPREF SIWTWEND XWO SIWOTIME XHRPRACT 28 Index of pay levels Pay levels Regular upgrading of pay SIPAYUNSOCIAL SIPAYTRAIN Pay for unsocial hours Pay for training SIPAYUPFRONT Payment of upfront costs Index of pay strategies Opportunities for pay improvement Opportunities for career Index of employee development practices Employee voice practices SIEMPAPP Employee appraisal Recruitment and retention practices index Formality of recruitment process Selection by skills, qualifications or experience SIRECRETEN Role of push factors in staff quits Index of working time practices Work schedules that fit staff preferences Weekend working SIWTLHOURS Long hours/long weeks SIWTTOFFTRAIN Time off for training Index of work organisation practices Time discretion at work SIWODISCRET Task discretion at work Overall index of HR practices Specifically, we calculate the probability that the results we have obtained occurred by chance or not. When we say that a statistical test is significant at the 95% confidence level, we mean that we are at least 95% certain that a result is genuine (i.e. not a chance finding), or that there is less than a 5% probability of something occurring by chance. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 215 Overall the picture is one of limited variation across these different provider characteristics, certainly when compared to the large differences found between LAs and the independent sector, as we discuss further below. This puts the discussion of good and bad HR practice within the independent sector into context; on the whole, as we already saw in part III, few providers are conforming to standard HR practice, particularly in domiciliary care where contracts are primarily on a zero hour basis and not all time at work is paid for. With these caveats in mind, we turn to the evidence of variations by provider characteristic. Size of establishment The categories we use for the analysis for size of establishment are different for homes and IDPs due to differences in the sample distribution: very small and small categories are separately identified for homes but combined for IDPs and medium and large separately identified for IDPs to reflect the sample distributions – see table IV.1. Box IV.7. Significant differences between providers in HR practice indicators by size of establishment (Standardised dataset) Homes: XEMPDEV: medium/large establishments significantly higher score on employee development and voice than small establishments SIPAYOPPCAR: SIEMPAPP: SIWTWEND: IP15: IWO4: very small establishments significantly greater career opportunities than for medium/large establishments. medium/large establishments significantly higher utilisation of appraisals than small establishments significantly less extensive use/ requirements for weekend working in small than medium/large establishments (10% sig. only) very small establishments significantly more likely than medium /large to offer opportunities for progression to senior care worker very small establishments significantly more likely than medium /large to offer opportunities to prioritise and carry out tasks in ways to improve the quality of care IDPs: SIPAYTRAIN: SIRECRSELEC: IP13: IWT4: IWT8: EWERC large establishments significantly more likely to offer time off for training than the very small and small establishments (at 10% level) large establishments significantly more likely to use more formal methods of recruitment than the very small and small establishments very small/small establishments significantly more likely to pay for induction than large establishments (at 10% only) large establishments significantly less likely to have all staff working weekends than both medium and very small/small establishments very small/small establishments significantly less likely than medium establishments to have higher shares of staff working long hours Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 216 Looking first at sub-indices and indices we find very few notable differences in HR practices by size of establishment for either homes or IDPs. For homes some of these relationships were in the expected direction - for example, larger establishments making more use of appraisals. But others were more counter-intuitive- such as very small establishments being more likely to offer opportunities for promotion to senior care workers. Other relationships were significant but not linearly related to size (see box IV.7). For IDPs again there is some evidence of more formal HR practices among large establishments particularly with respect to recruitment methods and time off for training. However, there are also some counter-intuitive findings, particularly that large IDPs are less likely to pay for induction training. On working time, large establishments appear to have more freedom not to have all staff working weekends (although this is the opposite to homes). It should also be noted that we found no significant differences by size of establishment in relation to the specific indicators that only apply to domiciliary care. Ownership There is perhaps a greater expectation of differences by ownership structure, particularly as the national chains have made significant advances into the market over recent years and may be doing this in part on the basis of differences in HR practices. For homes there are some important differences, but they are not all consistently in one direction (box IV.8). Three pay variables show significant differences but in two cases national chains provide the best conditions: they are more likely than single agencies to have regular pay upgrades and more likely to cover upfront costs of entering work than single homes and local chains (including specifically being more likely to pay for uniforms), but national chains are the least likely to pay for unsocial hours. National chains are more likely to have long working hours or 6 or 7 day weeks (and the indicators on long hours working also shows a similar pattern). One indicator, one sub index and one index suggested that local chains were significantly less likely to provide for various types of autonomy at work also showed some significant differences by but in this case the values were lower of local chains than both national chains and single home and the overall variation in values were low so these are not included in the graphics illustrating the most significant variations by indicator. However, for IDPs there are virtually none of the standardised indicators that show any significant differences between national chains, local chains and single agencies. National chains and local chains were more likely than single agencies to carry out staff attitude surveys. Beyond this indicator which could be expected to be related to organisations with more resources, the only other indicator showing any significant differences suggested that long hours working was made more use of by national chains. One indicator not included in the standardised set due to missing variables was found to have a significant difference: single agencies were less likely to have the Investor in People award than local chains. Again no EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 217 significant differences by ownership were found in relation to the specific indicators for domiciliary care. Box IV.8. Significant differences in HR practice indicators between providers by ownership Standardised dataset Homes: XWO: local chains significantly less likely than single homes and national chains (latter 10% sig. only) to provide autonomy over time and task in work organisation SIPAYUNSOCIAL: SIPAYUPGRADE: SIPAYUPFRONT: SIWTLHOURS: SIWOTIME: IP12: IWT8: IWO5: national chains significantly less likely than single homes to make unsocial hours payments (10% sig.only) single homes significantly less likely to have a regular upgrading of pay than national chains (10% sig.only) national chains significantly more likely than single homes and local chains (latter 10% sig.only) to pay for upfront costs of starting work national chains significantly more likely than local chains (10% sig. only) to have staff working long hours/ more than 5 days local chains significantly less likely than single homes and national chains (latter 10% sig. only) to provide time autonomy in work organisation national chains significantly more likely than local chains and single homes (both 10% sig. only) to pay for uniforms national chains significantly more likely than local chains to have staff working long hours (10% sig. only) local chains significantly less likely than national chains and single homes to provide opportunities to exchange idea with other carers IDPs: IHR3: IWT8: single agencies are significantly less likely than national chains or local chains (latter 10% sig. only) to carry out staff attitude surveys national chains significantly more likely than local chains to have staff working long hours Non standardised dataset IDPs: IOUT3: local chains were significantly more likely to have the investor in people award than single agencies These limited findings on differences between national chains and more local organisations in homes, but particularly in domiciliary care, chimes with the information we obtained through our survey of national providers with respect in particular to pay. All national domiciliary care providers stressed that they fixed pay at the local level according to the policy of the LA (see EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 218 box IV.9) and in one case even paid different rates to staff in the same branch according to which LA they were working for under subcontract. There was thus no attempt by any of the national IDPs to establish a national pay policy. This was also the case in two of the national chains of homes but two did have a national pay scale, one of which was negotiated with a trade union and another was working towards that objective. One of the national chains stressed that location within the national pay scale depended, nevertheless, on local factors. Some national providers stressed that they did try to standardise on more indirect forms of pay even if they had to vary actual pay levels in line with the LA. Even the one national provider that recognised a union did not guarantee either a negotiated wage increase or pay significantly in excess of the minimum wage as this quote reveals: This year we had a lot of difficulty with the pay review and we ended up imposing the pay review because the union were looking for a lot more. We were only paying about 11/2% across the board. We pay around 10 or 15p an hour more than the minimum wage rate at the moment. Group HR Director, NATHOME 4 Box IV.9. National providers’ pay strategies: the main influence is the local authority [Payment for travel time, travel costs] - That‟s generally included in the rates as things which we do. Depending on the contract and the area, we would pay mileage or travel expenses. But it varies. Managing Director, NATDOM 5 [Pay] also varies - the contact is with the local authority and they are only willing to pay a certain amount ... there‟s only so much scope you have to pay to the care workers. So again some of it is determined by how much you could afford to pay the care workers. Managing Director, NATDOM 4 We don‟t have any national rates. We have purely local rates, and so some parts of the country it‟s national minimum wage, in other parts it would be significantly higher than that and London South East would be the obvious candidate just because that‟s what the market demands. But also, in London you do get higher fee rates and again, there‟s got to be a match between money coming in and money going out. Corporate Services Director, NATHOME 2 Local pay - we tried to look at standardising but it‟s impossible. National Recruitment Manager, NATDOM 3 We can‟t pay the same rates everywhere. Because we get paid differently in different places. But as a company we have certain basics. So our bank holiday rates are double across the country, whatever we get paid here. We pay for all the training, it doesn‟t matter what the local authorities, and we provide uniforms, it doesn‟t matter what the local authority said. Managing Director, NATDOM 5 EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 219 Working time and contract arrangements were also not significantly different on most dimensions. One branch manager of a national chain indicated that zero hours contracts were the widely accepted industry norm when s/he described a plan to move to guaranteed hours as „a bit radical‟. We are doing an analysis at the moment to see what would happen if we put all of our care staff on salaries, a bit radical I know but what we are looking to do is to see if it‟s viable…I think that could ultimately change the face of the social care system and in terms of the status of the staff it would raise them up (OM.D.2.DN) However, one of the national domiciliary chains in our national provider survey blamed variations between LAs for their inability to have standard working time conditions. It‟s difficult to standardise across the country. For example, you can‟t have a standard start time. In some authorities they start at 7 in the morning or 8 in the morning and finish at 8 at night. In others, it‟s 6 to 6. This kind of thing. Managing Director, NATDOM 5 However, one area where we might anticipate more marked difference in the future is in the use of more formal or systematic recruitment methods. The national chains already had national recruitment procedures and policy advice but while most recruitment was still done at local and branch level there was evidence in a number of the interviews of moves towards providing more active support at regional level. However, this greater centralisation might not be at the expense of informal methods as we also found some evidence in the case studies of national chains formalising word of mouth recruitment patterns through the development of voucher schemes as incentives to staff to recommend new recruits. Box IV.10. Recruitment of care staff in national providers [Recruitment previously done at branch level]. But we‟ve changed that model to what we call a regional resourcing lead network. What it was like was that we would have a recruitment coordinator in each branch, and the recruitment co-ordinator was basically an ex care worker who‟d done his or her backing and who knew how to turn on a computer. And there was insufficient technical knowledge and insufficient understanding of the link between capacity and quality, and capacity in grants. So we changed that and we said, well let‟s remove that model and put in a career recruiter, so a professional recruiter who would cover a cluster of branches. They‟re called regional resourcing leads. HR Director, NATDOM 1 So very much it‟s locally engaged with national support. That‟s our philosophy on a number of things, like when we come on to recruitment and retention, it‟s - again, you can‟t do this centrally alone. You need the local buy in and local management, owning the situation. Managing Director, NATDOM 4 it would be a local management decision about who they recruit. We don‟t force the hand of the local management, we expect they would meet certain criteria and if they want a second opinion they can involve people from the centre. Managing Director, NATDOM 4 EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 220 [Setting up] new Regional Recruitment teams: Branch managers had no time to focus on recruitment. It was the last of their priorities. They had no time or resources for recruitment so they were reactive the whole time. Interviews [are held] at branch level - it is down to the individual manager to make the ultimate decision. National Recruitment Manager, NATDOM3 The personnel manual in the recruitment procedure spoon feeds all of the managers. So here‟s the steps you take, these are the forms you need to use, here‟s the standard letter, standard contract. So it‟s all there. Corporate Services Director, NATHOME 2 The need for support to local establishment managers in the area of recruitment is indicated by this account of the efforts a local chain manager had to go to secure an increased workforce after a successful tender: I‟ve had to recruit a lot really especially since January so what I‟ve done is take a PowerPoint presentation and use that to give people an understanding of what we do, how we do it, our approach to staff and then they can make an informed decision about whether we‟re a) what they hear floats their boat in terms of coming to social care but also it‟s about making an informed decision about the kind of employer we are and if they like how we go about and present things. Anybody who has responded to the Jobcentre Plus advert or to the newspaper advert that I put out in January where we said if you can tick some of these boxes or aspire to tick some of these boxes then we would be interested in talking to you because we are looking for support workers, we‟re looking for supervisors, we‟re looking for mentors, and so since January we have had over 600 people make contact with us over the phone, my business development manager who took the post on the 25th January and started working on the 26th we have seen over 300 people in small groups of up to a maximum of ten, we have today offered 27 people jobs. (UY.D.1.C.L) This case illustrates both the sheer scale of the recruitment effort and the management challenges this poses for single or small chain organisations. CQC star rating When we look at HR practices by CQC star rating we find that there is fairly systematic evidence that 3* homes provide better pay and pay related conditions than 1* and 2* homes (2 indices, 4 sub-indices and 4 individual indicators on pay all show this relationship). However, when it comes to recruitment practices it is 2* homes that seem to have the best practices and when it comes to employee voice indicators, 3* homes have less developed practices than either 1* or 2* homes. There is thus only clear evidence in relation to pay indicators that higher rated homes have higher quality HR practices (box IV.11). For IDPs there are no significant indices or sub indices by star rating and those individual indicators that show some significant differences tend to indicate somewhat counter intuitive relationships. Thus, although 3* IDPs are more likely to pay extra for qualifications and are less likely to have all staff working weekends, indicators that we take to be indicative of HR EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 221 quality, they are also less likely to carry out staff surveys. When indicators from outside the standardised data set are considered, we find that 3* homes are also less likely to pay for travel or provide paid breaks, although they are more likely to offer a longer minimum work period, None of this suggests a vey strong relationship between quality of HR practices and the star rating attached to the IDP. Box IV.11. Significant differences in HR practice indicators between providers by star rating Standardised dataset Homes: XPAYLEVELS: XPAYSTRAT: XRRPRACT: XEMPDEV: 3* homes offer significantly higher pay than 1* and 2* (latter 10% sig. only) 3* homes offer significantly better pay strategies than 1* and 2* 1* homes have significantly lower quality recruitment practices than 2* homes 3* homes offer significantly worse employee development and voice practices than 1* and 2* homes 3* homes offer significantly higher pay than 1* (10% sig. only) SIPAYLEVEL: SIPAYUNSOCIAL: 3* homes significantly more likely to make unsocial hours payments than 1* and 2* 3* homes offer significantly worse employee voice practices than SIEMPVOICE: 1* and 2* homes 2* homes have significantly better recruitment practices than SIRECRUTPR: either 1* or 3* homes IP1: 3* homes offer significantly higher minimum pay than 1* IP6: 3* homes significantly more likely to pay more for qualifications than 1* IP8: 3* homes significantly more likely to pay extra for weekend work than 2* (10% sig.only) IP9: 3* homes significantly more likely to pay extra for night work than 2* and 1* (latter 10% sig. only) IDPs: IP6: IHR3: IWT4: 3* IDPs significantly more likely to pay more for qualifications than 2* 3* IDPs significantly less likely to carry out staff attitude surveys than 1* 3* IDPs significantly less likely to have all staff working weekends than 1* (10% sig. only) Non standardised dataset IDPs: IPDOM1: IWTDOM2: IWTDOM3: EWERC 1*significantly more likely to pay for travel than 3* 1*significantly more likely to provide a paid break than 2* 3* significantly more likely to provide a longer minimum work period than 2* (10% sig.only) Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 222 Public, private or voluntary status Part III has already provided considerable evidence of the divide between the HR practices in the independent sector and those prevailing in the local authorities, primarily LADPs. To bring this information together table IV.6 provides a summary of the overall scores within the six areas of HR practices and for the overall index of HR practices 29. First of all, in comparing homes and IDPs, we find that homes score slightly better overall, but the difference for the summary index is not statistically significant. The only statistically significant difference between them is in work organisation where homes score more strongly than IDPs; otherwise differences add at most 0.03 to the score. When LADPs are considered, not only is the summary index of HR practices for LADPs more than 19% higher than for the independent sector IDPs they also score on average over 16% higher than the independent sector homes (table IV.6a). These differences are significant and the same applies for higher scores for LADPs compared to both homes and IDPs for pay levels, recruitment practices and employee development. However, for pay strategies, although LADPs score higher than both homes and IDPs, there is only a significant difference with IDPs. For working time LADPs score worse than both IDPs and homes (difference significant only with IDPs), possibly reflecting the problems that LADPs have experienced in moving their staff from standard hours to more flexible and unsocial hours working, such that they place more stress on requiring staff to be flexible. For work organisation LADPs score somewhat better than IDPs but lower than homes (neither difference is significant), suggesting that these scores reflect the different nature of the work between homes and domiciliary care. It is notable that voluntary, not-for-profit providers score higher than for-profit providers on all the indicators of HR practices. Considering the aggregate index for homes and IDPs combined, the difference between voluntary providers and for-profit providers is statistically significant and represents a gap of some 10% (Table IV.6b). Two other results are statistically significant: the score for the index of pay levels is 20 per cent higher for voluntary providers than for private for-profit organisations (reflecting our analysis in part III); and voluntary providers score substantially higher on the index of recruitment and retention practices. Finally, when we look at the indicators that are specific to domiciliary care providers (table IV.6c), we find again that LADPs are significantly more likely to pay for travel time, to offer guaranteed hours, to provide a paid break but are significantly less likely to attach importance to matching staff preferences for working time. Other differences are not significant. 29 In order to produce an estimation for LADPs we imputed 16 missing values out of 280, which represent 5.7% of total values. This translated as 3 imputed values for the indicator IWT8 (30% of the sample of 10 LADPs), 2 imputes for the indicator IP3 (20% of the sample) and 1 impute for 11 different indicators (10% of the sample). EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 223 IV.2.2. HR outcomes by provider characteristics By HR outcomes we refer to the ability of providers to recruit and retain a skilled and committed workforce. Thus indicators of HR outcomes relate to ease of recruitment, ability to retain staff, avoidance of high absenteeism, and ability to meet training targets. Table IV.6. Differences in indices and indicators of HR practices by provider type a. X indices of HR practices and outcomes Homes IDPs LADPs LADPs score as % of homes LADPs score as % of IDPs 0.61** (L) 0.63** (L) 0.90** (H,I) 147.5 142.9 XPAYLEVELS Index of pay levels XPAYSTRAT Index of pay strategies 0.68 0.65* (L) 0.78 * (I) 114.7 120.0 XRRPRACT Index of recruitment and retention practices 0.61** (L) 0.63** (L) 0.81** (H,I) 132.8 128.6 XEMPDEV Index of employee development 0.58** (L) 0.59** (L) 0.77** (H,I) 132.8 130.5 XWT Index of working time 0.65 0.64* (L) 0.55* (I) 84.6 85.9 XWO Index of work organisation 0.95** (I) 0.84** (H) 0.88 92.6 104.8 XHRPRACT Index of all HR practices 0.68** (L) 0.66** (L) 0.78** (H,I) 116.2 119.7 XRROUTCOMES Index of recruitment and retention outcomes Index of training outcomes 0.68** (I) 0.45**,* (H,L) 0.58* (I) 85.3 128.9 0.81** (I) 0.63** (H) 0.78 96.3 123.8 XTRAINSKILDEV b. X indices for public, private for-profit and private not-for-profit providers Public Private Forprofit Private Voluntary Voluntary score as % of public Voluntary score as % of private XPAYLEVELS Index of pay levels 0.90** (F,V) 0.60** (P,V) 0.72** (P,F) 80% 120% XPAYSTRAT Index of pay strategies 0.78** (F) 0.65** (P) 0.73 94% 112% XRRPRACT Index of recruitment and retention practices 0.82** (F) 0.60** (P,V) 0.71** (F) 87% 118% EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes XEMPDEV Index of employee development Index of working time XWT 224 0.77**,* (F,V) 0.57** (P) 0.62* (P) 81% 109% 0.55* (F) 0.64* (P) 0.65 118% 101% XWO Index of work organisation 0.88 0.89 0.91 103% 102% XHRPRACT Index of all HR practices 0.78**,* (F,V) 0.66** (P,V) 0.72**,* (F,P) 92% 110% XRROUTCOMES Index of recruitment and retention outcomes Index of training outcomes 0.58 0.56 0.60 103% 108% 0.78 0.71 0.76 98% 107% XTRAINSKILDEV c. Indicators of HR practices Sample size IDPs LADPs IDPs LADPs IPDOM1 Compensation for travel costs/travel time 0.38* 0.61* 51 9 IHRDOM1 Performance monitored by electronic monitoring 0.69 0.80 51 10 IWTDOM1 0.55 0.45 52 10 IWTDOM2 Domiciliary care workers expected to tolerate variation in hours or location at short notice Paid break between service users 0.12** 0.78** 50 9 IWTDOM3 Minimum length of a work period 0.23 0.56 45 8 IWTDOM4 0.77** 0.39** 52 9 IWTDOM6 Important attached to organising working hours to fit employees‟ circumstances Staff required to work alone late at night 0.76 0.75 52 10 IWTDOM7 Contracts offered to care staff 0.23** 1.00** 51 10 Note: A single * indicates a minimum 90% confidence level (p < 0.1), ** indicates a 95% confidence level (p < 0.05). For table IV.6a, I, H, L are used to indicate differences with IDPs, Homes, LAPDs respectively For table IV.6b, P, F, V are used to indicate differences with Public, Private for-profit, Private not-for-profit respectively For the standardised dataset we were only able to include a restricted set of outcome measures due to problems of missing data on staff turnover. The measures (see box IV.12) include perceptions of recruitments difficulties (including questions on ease of recruitment and on presence or otherwise of a labour shortage); perceptions of level of staff turnover; perceptions of level of absenteeism (data on actual absenteeism was presented by managers in too many diverse ways to be usable for comparisons); and ability to meet NVQ2 training targets (actual share trained and position in relation to the 50% targets). For non standardised indicators we have used three indicators of staff retention: these include indicators of the share of new recruits retained, of overall staff turnover and of staff turnover excluding new recruits over the past 12 months (with baseline staff level 12 months previously). EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 225 Box IV.12. Indices (X) and sub-indices (SI) from the standardised dataset XRROUTCOMES Index of recruitment and retention outcomes SIRECDIFF Recruitment difficulties SITO Perceptions of staff turnover XTRAINSKILDEV SIABSENT Perceptions of absenteeism Index of training outcome Size For homes, appear larger size to be disadvantageous with respect to HR outcomes. The overall index for recruitment and retention outcomes shows medium and large establishments faring significantly worse than both very small and small establishments (box IV.13). Medium and large establishments also have worse perceived levels of both absenteeism and staff turnover. Training outcomes are also worse in medium/large homes when compared to very small establishments. However, recruitment difficulties are perceived to be worse in very small establishments. For IDPs large establishments also have worse perceived problems of recruitment and retention but the significant differences are primarily with medium establishments. This also applies to perceived staff turnover rates and to the presence of labour shortages. As with homes, very small/small establishments consider recruitment difficulties to be more severe than is the case for large establishments. None of the indicators on actual staff turnover in the non standardised data set were found to yield any significant differences with size of establishment. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 226 Box IV.13. Significant differences in HR outcome indicators between providers by size Standardised dataset Homes: XRROUTCOMES: perceived recruitment and retention outcomes significantly worse in medium/large establishments than small and very small establishments absence rates in medium/large establishments significantly SIABSENT: worse than in small or very small establishments perceived turnover rates significantly worse in medium/large SITO: establishments than small and very small establishments ( latter 10% sig.only) SITRAINSKILDEV: training outcomes significantly worse in medium/large establishments than very small establishments(10% sig.only) recruitment difficulties significantly worse in very small than SIRECDIFF: small establishments ( 10% sig. only) IDPs: XRROUTCOMES: perceived recruitment and retention outcomes significantly worse in large establishments than medium establishments perceived turnover rates significantly worse in /large SITO: establishments than medium establishments recruitment difficulties significantly worse in very small/ small SIRECDIFF: establishments than large establishments IRC7: large establishments significantly more likely to have staff shortages than medium Ownership For both homes and IDPs the only significant results relate to training outcomes: for homes the single homes score highest and have significant differences with both national chains and local chains but for IDPs it is local chains that score highest and have significant differences at 10% with national chains and also a higher value than for single agencies although this difference is not significant. Again the staff turnover data are not significantly related to ownership for either homes or IDPs (see box IV.14). Box IV.14. Significant differences in HR outcome indicators by ownership Standardised dataset Homes: SITRAINSKILDEV: IOUT1: EWERC single homes have significantly better training outcomes than national chains or local chains ( latter 10% sig.only) single homes have significantly better training outcomes than national chains Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 227 IDPs: SITRAINSKILDEV: IOUT1: local chains have significantly better training outcomes than national chains (10% sig.only) local chains have significantly better training outcomes than national chains Star rating Neither homes nor IDPs recorded any significantly different HR outcomes by star rating. Public, private or voluntary sector status Table IV.6a shows that homes have the best and IDPs have the worst scores on the recruitment and retention index and on the training index with LADP scores falling in between. The differences are significant on recruitment and retention outcomes between IDPs and both LADPs and homes, and on training between homes and IDPs.. The better performance on HR outcomes for homes even compared to LADPs where HR practices were superior to both IDPs and homes, suggests that it is more difficult to recruit and retain workers in domiciliary than residential care. That is for the same standard of HR practices the nature of the work in domiciliary care may lead to worse HR outcomes than in homes. The overall difficulty of the job may thus be considered to require a higher standard for employment practices in domiciliary care than residential care. Table IV.6b also shows that HR outcomes in the voluntary sector are close to or above those in the public sector LADPs, but as our sample of not for profit organisations is weighted towards homes this result may reflect in part the better outcomes in general for homes. The voluntary sector scores are clearly better than the for profit sector, however, and while there is still an issue of oversampling of homes in this case the results refer to the combined private sector sample of homes and IDPs and is thus more indicative of better outcomes for the voluntary sector (see section IV.5 for our multivariate analyses which untangle some of these effects) EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 228 IV.2.3. HR practices and strategies by individual provider Figure IV.1 shows the range of scores among individual providers by the six indices of HR practices (separately for homes and IDPs), and figure IV.2 portrays an overview of the overall HR practices index, comparing homes, IDPs and LADPs. The spread of values for the individual indices is relatively large, amounting to 42% to 83% of the available value range for homes and 65% to 83% for IDPs. Only the work organisation index has a range below 50% and this is only for homes. The spread of values for the six indices is wider than that found for the HR practices index, the mean of the six, where the range is only 28% for homes and 33% for IDPs, indicating that there is some balancing between low and high scores across the range of HR practices for the individual providers. The range for LADPs is even narrower at 16%; thus not only do LADPs score higher on average than independent sector providers but also they all tend to be concentrated towards the top end of the distribution. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes Figure IV.1. Range of scores of providers for the six indices of HR practices a. Homes b. IDPs Note: Standardised data set EWERC 229 Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 230 Figure IV.2. Summary measure of index of HR practices for homes, IDPs and LADPs IV.2.4. Employer views on the effectiveness of HR strategies Overall the scope for differences in HR strategies is limited within social care, a condition that was clear to many of the providers whom we interviewed in the telephone survey. We asked the providers what HR policies they thought would do most to help recruitment and retention. The option which was chosen that had the highest percentage of providers at saying it would improve (over three fifths of independentsector providers) and the lowest share saying that they had already been able to implement such a policy was „pay increases‟ (Table IV.7). LADPs, in contrast, felt they had already implemented this policy. It is clear from these answers that many providers are of the view that they are paying less than they ought to for care staff. They attribute this to the limited fee levels available for care work. Well I mean again with the care staff it‟s to do with economics can we afford to do it, because that is our biggest cost area because even if we just give 10 or 20p extra an hour across our care staff that is a phenomenal amount of money, and as we‟re a not for profit charity so we‟re in a difficult situation as our margins are very tight (OM.D.2.DN) The care staff] should be on eight pound an hour really, shouldn‟t they? No, it‟s true though. [If I could] pay their wages, I would love to give them that. … And it‟s quite sad you know, because it‟s a hard job, a tiring job. They‟ve got to have a lot of patience and compassion with them. (ON.H.2 ML) EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 231 The next most popular HR improvement for homes was recognition of variations in service time of day/weekends/type of care/skill etc. However while many more homes than IDPs felt it would improve retention (35% to 14%) a relatively high share of both sets of providers (26% of homes, 21% of IDPs) did not think it would improve matters. The next most popular way of improving recruitment for IDPs was increased opportunities for internal promotions – but, while a fifth of IDPs thought this would help, a quarter thought it would not; a fifth of homes also thought more internal promotion would help and a lower share, 15%, thought it would not, with the balance made up by a higher share of homes saying they had already implemented this policy. There were also mixed views over more flexible hours to suit employee preferences; the majority thought they had already implemented this policy and those that had not mainly thought it would not help. Training was the main policy improvement that around four fifths of all independent sector providers felt they had already implemented; more homes than IDPs felt there was scope for further improvements but few felt it would not help. Two policies were relatively unpopular with the providers; the first was improved non pay benefits where they were more – up to 44% in the case of IDPs - who did not think this would help. The second was more discretion and autonomy in their job. The homes were much more likely than IDPs to feel they had already implemented this as a policy but those who had not were much more likely (2:1) to believe it would not help rather than it would help. Hostility to increased discretion was very evident from the IDPs: 45% did not feel it would help, only 37% had implemented such a policy and only 18% felt it would help. LADPs took a similar line, with two thirds saying they had implemented it and one third saying it would not help. These views were reinforced by some of our interviewees: No [more discretion] – this would spell disaster, if you have knowledge of people….if have variation and don‟t work to a high standard. (TE.D.1 CN (V)) No [more discretion] – that might help but it wouldn‟t help service provision – people would make the wrong judgements. (LK.D.3 DS) Well, yes, they are shown how to do the job and how they done is done to the best of their ability – we don‟t want robots working here. But I wouldn‟t want them straying off the correct way of doing things. (LK.H.3 BL) That said, a few commented on the restrictions on autonomy and on time to do a good job that came from the contracting arrangements. … it would be nice to give them more autonomy, it‟s dictated by social services. (HD.D.1) Providers were also given the opportunity to cite other HR policies that they could implement to assist recruitment and retention. Most of the other responses referred, however, to changes in external policies (see section IV.5 below for questions that explicitly tapped into external changes by LAs in particular). The main additional HR policies referred to improving the status EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 232 of the job and making staff feel valued (through recognising staff efforts, arranging social events, providing mobile phones etc). Table IV.7. HR policies most likely to improve recruitment and retention % of homes % of IDPs % of LADPs % of All 20.4 77.6 2.0 49 4 7.7 86.5 5.8 52 0 0.0 100.0 0.0 7 3 13.0 83.3 3.7 108 7 62.0 32.0 6.0 50 3 64.0 30.0 6.0 50 2 12.5 75.0 12.5 8 2 59.3 34.3 6.5 108 7 Would recognising variations in service -time of day/weekends/type of care/skill etc. improve Recruitment and retention 34.8 13.5 Have already implemented 39.1 65.4 would not improve 26.1 21.2 Total responses 46 52 No response 7 0 12.5 87.5 0.0 8 2 22.6 55.7 21.7 106 9 Would improved opportunities for internal promotion improve Recruitment and retention Have already implemented would not improve Total responses No response 19.6 65.2 15.2 46 7 19.6 54.9 25.5 51 1 14.3 71.4 14.3 7 3 19.2 60.6 20.2 104 11 Would more flexible hours to suit improve Recruitment and retention Have already implemented would not improve Total responses No response 15.2 67.4 17.4 46 7 3.9 78.4 17.6 51 1 0.0 100.0 0.0 6 4 8.7 74.8 16.5 103 12 Would improved non-pay benefits improve Recruitment and retention Have already implemented would not improve Total responses No response 15.0 52.5 32.5 40 13 13.0 43.5 43.5 46 6 14.3 71.4 14.3 7 3 14.0 49.5 36.6 93 22 0.0 66.7 33.3 6 4 13.3 53.1 33.7 98 17 Would improved opportunities for training improve recruitment and retention Have already implemented would not improve Total responses No response Would pay increases improve Recruitment and retention Have already implemented would not improve Total responses No response Would more scope for care workers to exercise discretion over how to provide care? improve Recruitment and retention 9.3 18.4 Have already implemented 69.8 36.7 would not improve 20.9 44.9 Total responses 43 49 No response 10 3 EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 233 IV.3. LA commissioning and contracting and provider HR practices and outcomes IV.3.1. The influence of LA fee levels on pay Domiciliary care If we plot the level of fees offered by LAs against the normal rates of pay paid by the IDPs in our survey (Figure IV.3) we find that for IDPs, the level of LA fees is an enabler but not a determinant of higher pay for care staff. Nevertheless, normal pay rates above £7 an hour were only found in LAs where the fee level was at least £13 an hour. In Figure IV.4 we plot a trend line of best fit between the normal rate of pay and the level of LA fees. The implication of the trend line is that for every pound in increased LA fees, normal pay increases by 19p an hour. This may not be considered a very good return on higher fees given that that majority of IDPs costs are labour costs, the worker‟s normal pay rate. For this model, the R2 value is 0.37, which means that the LA fee level accounts for 37% of the variation of workers‟ pay across providers. Figure IV.3. A comparison of LA fees and normal rates of pay in IDPs EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 234 Figure IV.4. Trend line of best fit between LA fees and normal rates of pay in IDPs £10 y = 0.186x + 4.19 R² = 0.367 Normal rates of pay £9 £8 £7 £6 £5 £10 £11 £12 £13 £14 £15 £16 £17 £18 £19 £20 LA fees Homes For homes there is an even less clear cut relationships between LA fees and normal pay rates. To provide an estimate of LA fee levels that has more relationship to an hourly wage we have divided the weekly fee by 40, giving a fee ranging between £8 and £14. Wages paid are low and relatively similar between £8 and £10 an hour; they are somewhat higher at £12 and £14 an hour though not at £13 an hour (Figure IV.5). Plotting a trend line between fees and normal pay rates shows that for every £1 extra in fees paid normal pay increases by 14p per hour (figure IV.6). Not only is this a lower boost to pay even than for IDPs but LA fees also explain less of the variation in normal pay rates: the R2 value is only 0.20, which means that the LA fee level accounts for just 20% of the variation of workers‟ pay. For homes a lot of the costs relate to housing costs not just labour costs so this weaker relationship between fees and wages was not unexpected. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 235 Figure IV.5. A comparison of LA fees and normal rates of pay in homes Figure IV.6. Trend line of best fit between LA fees and normal rates of pay in IDPs £8.5 y = 0.137x + 4.85 R² = 0.197 Normal rates of pay £8.0 £7.5 £7.0 £6.5 £6.0 £5.5 £7 £8 £9 £10 LA fees EWERC £11 £12 £13 £14 Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 236 Figure IV.7 plots the level of wage rates in care homes against the percentage of service users funded by LAs. This shows a tendency for normal pay by provider to be concentrated at the bottom end of the distribution- under £6 an hour- where the residential home is primarily dependent upon the LA. Where more than 50 per cent of the business comes from non LA sources only 18 percent of providers pay at this level compared to 77% of those homes where more than 85% of the business comes from LA supported clients. Figure IV.7. Composition of homes paying different normal pay rates by proportion of LA funding < £6 £6 - £6.50 > £6.50 8% 18% 29% 36% 64% 15% 27% 53% 77% 36% 18% 18% <50% 50-70% 71-84% >=85% % of service users funded by LAs These variations in the business are of course linked to the income levels in the area and thus indirectly to wage levels The evidence we collected on the differences in the prices charged by providers to private versus LA clients is summarised in box IV.15. The pattern of charging varied by region for both homes and domiciliary care but many fewer of the IDPs compared to homes relied on private clients for a significant share of their markets (see table IV.1). EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 237 Box IV.15. Comparison of LA and private fees levels The gap between private and LA fee levels was much greater for homes and especially for homes located in the southern LAs. This gap was found to be in hundreds of pounds per week- from £100 to £300 and more in a few cases. In the northern and midlands LAs there was much less evidence of differences between the LA rate and the rates charged to private residents; several said they had no private residents and some said they charged the same even though rates were low. We identified a few examples of higher fees in excess of £100- one in AD where the LA had said top up fees were rare and another, less surprisingly, in RD where the LA fee was known to be below the going rate in the area, with those without capacity to pay top ups placed in cheaper homes located in areas bordering the LA. The pattern for domiciliary care was more varied with some IDPs even in more depressed and areas also charging top ups to private clients while some southern IDPs would only add a modest top up or around £1 an hour or so. Only one IDP said it charged more than a £3 an hour top up to private clients (one in XD where the private rate was £7.50 above the LA rate). This varied pattern may reflect tighter pricing policies by LAs in some depressed areas. A few IDPs gave a range of fees that were lower than the LA rates but these may have included fees for basic cleaning. Only one in a midlands LA- OM- said they charged less to private clients but several said they charge the same rate. Practices varied within an LA- for example in one of the low fee LAs IL , three IDPs effectively charged the same rate to private as well as LA funded clients while a fourth asked for a top up of £2 an hour. IV.3.2. HR practices and outcomes by type of LA We have used two alternative classifications of LA commissioning policy to explore links with the HR practices and outcomes for independent sector providers. Our first classification involves the partnership, mixed and cost minimising categories developed in part II of this report. Our second classification defines categories of LAs according to the level of LA fees. Table IV.8 provides a summary of the overall X indices by homes and IDPs by the partnership categorisation and table IV.9 provides a similar summary using the LA fees categorisation. Full details of indices and sub-indices for the standardised dataset are presented in appendix tables IV.A11 through IV.A.14. Partnership, mixed and cost minimising local authorities To summarize the overall results for the partnership categorisation, a number of significant differences in sub-indices and indices were found for homes although the direction of the relationship did not always accord with expectations that partnership would promote good HR practices or outcomes. However, for IDPs there are almost no significant differences except for EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 238 the summary index of HR practices where providers in partnership LAs score significantly better than those in cost minimising LAs. Pay sub-indices and indices were the most frequently found to be significant for homes (box IV.16); pay levels, pay for unsocial hours, opportunities for pay improvements and the aggregate Xpay levels all revealed significant differences in the expected direction with partnerships having the best conditions but the differences were sometimes only significant with mixed and sometimes only significant with cost minimising LAs. Similar patterns were found for the individual indicators on normal pay, extra pay for qualifications and for weekend work. Furthermore, paid time off for training was, contrary to expectations, significantly more common among providers in cost minimising areas, although the aggregate differences were not large. Box IV.16. The significance of LA commissioning strategy (partnership, mixed, cost minimising) in explaining differences in HR Practice indicators among providers Standardised dataset Homes: XPAYLEVELS: XEMPDEV: pay levels significantly higher in partnership than mixed LAs. employee development and voice practices significantly better in cost minimising than in partnership or mixed LAs (10% sig.only). pay levels significantly higher in partnership than mixed and cost SIPAYLEVEL: minimising LAs SIPAYUNSOCIAL: pay for unsocial hours significantly more common in partnership than mixed LAs opportunities for pay improvements significantly higher in SIPAYIMP: partnership than cost minimising LAs pay for training significantly higher in cost minimising LAs than SIPAYTRAIN: in partnership and mixed LAs (10% sig.only) weekend working less common/ less of a requirement in SIWTWEND: partnership than mixed LAs staff less likely to be working long hours or long weeks in mixed SIWTLHOURS: than in partnership or cost minimising LAs SIWTTOFFTRAIN: staff least likely to be given time off for training in mixed compared to partnership or cost minimising LAs (latter 10% sig.only) IP2: normal pay levels significantly higher in partnership than mixed (10% sig. only) and cost minimising LAs IP6: extra pay for qualifications significantly higher in partnership than mixed LAs (10% sig. only) IP8: extra pay for weekend work significantly higher in partnership than mixed and cost minimising LAs IP14: pay for training significantly higher in cost minimising than mixed LAs(10% sig. only) IWT4: staff less likely to be all working weekends in partnership than mixed LAs IWT8: staff less likely to be working long hours in mixed than in partnership LAs EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 239 IDPs: XHRPRACT: significantly higher scores in partnership than cost minimising LAs IHR2: frequency of staff meetings significantly higher in cost minimising than partnership LAs Non standardised dataset IDPs: IWTDOM1: staff in cost minimising LAs significantly more likely to be expected to tolerate changes in hours or location at short notice The only other sub-index where partnerships were clearly associated with higher HR practice scores was that related to requirements for weekend working in homes, although providers in the mixed areas scored the lowest, a pattern reaffirmed in the indicator on share of all staff involved in weekend working. The sub-index on working long hours and 6/7 days found providers in partnership and cost minimising LAs to have lower scores than providers in „mixed‟ LAs. The indicator for working long hours shows a similar pattern with mixed having the fewest staff in this category. When it came to time off for training, however, those in the mixed areas scored the lowest. Finally, for employee development and voice we find those in cost minimising LAs scored the highest, with the score significantly different from both of the other two categories (box IV.16). This has parallels to the other apparently perverse result where 3* providers had worse employee voice and development than 1* categories by CQC (see box IV.1 above). For IDPs, as we have already noted, it is only the overall HR practices index that reveals any significant differences and here the pattern is for providers in partnership LAs to have significantly higher scores than those in cost minimising LAs. Even at the level of indicators there is only one significant result, with this time providers in cost minimising LAs more likely to carry out staff attitude surveys. Box IV.17. The significance of LA commissioning strategy (partnership, mixed, cost minimising) in explaining differences in HR Outcome indicators among providers Standardised dataset Homes: SITRAINSKILLDEV: SIRECDIFF: IOUT1: EWERC training outcomes significantly better in mixed than in partnership or cost minimising LAs recruitment difficulties significantly worse in partnership than cost minimising LAs (10% sig. only) shares of staff trained to NVQ2 significantly better in mixed than in partnership (10% sig. only) and cost minimising LAs Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 240 When it comes to HR outcomes, again there are no significant results for IDPs. For homes those in partnership LAs face significantly greater recruitment difficulties than those in cost minimising LAs and those in mixed LA areas have significantly better training outcomes than either of the two other types of areas (box IV.17). None of the indicators of actual staff turnover were found to be related to this classification of LA commissioning. Table IV.8. Summary indices for homes and IDPs by partnership, mixed and cost minimising type of local authority (mean values of indices) a. Homes All Partnership LAs Mixed LAs Cost minimising LAs 0.61 HR PRACTICES XPAYLEVELS XPAYSTRAT XRRPRACT XEMPDEV XWT XWO XHRPRACT Pay levels Pay strategies Recruitment & retention practices Training & development 0.61 0.67 0.54 (**M) (**P) 0.68 0.64 0.72 0.65 0.67 0.67 0.58 0.55 0.55 0.66 (*C) (*C) (*M P) 0.65 0.59 Working time Work organisation Index of all HR practices 0.65 0.95 0.68 0.67 0.94 0.69 0.62 0.96 0.66 0.66 0.93 0.68 Recruitment & retention NVQ training targets 0.68 0.81 0.68 0.75 0.67 0.94 0.68 0.73 (** M) (** P C) (** M) All Partnership LAs Mixed LAs Cost minimising LAs 0.63 0.65 0.63 0.66 0.68 0.66 0.64 0.65 0.66 0.55 0.60 0.55 XEMPDEV XWT Pay levels Pay strategies Recruitment & retention practices Training & development Working time 0.59 0.64 0.61 0.64 0.60 0.60 0.55 0.67 XWO Work organisation 0.84 0.86 0.84 0.78 XHRPRACT Index of all HR practices 0.66 0.68 0.66 HR OUTCOMES XRROUTCOMES XTRAINSKILDEV b. IDPs HR PRACTICES XPAYLEVELS XPAYSTRAT XRRPRACT (** C) 0.62 (** P) HR OUTCOMES XRROUTCOMES XTRAINSKILDEV Recruitment & retention NVQ training targets 0.45 0.63 0.46 0.55 0.45 0.73 0.44 0.63 Note: Full details in appendix tables IV.A11 and IV.A12. P, M, C used to indicate difference from partnership, mixed and cost minimising LAs respectively EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 241 High, medium and low fees local authorities To explore the influence of LA fees on HR practices and indicators we have collapsed our four categories of fee levels developed in Part II into three categories. This was to avoid having only two LAs in each of the very low categories. Note that in comparison to the partnership, mixed, cost minimising classification we have different measures for LAs between homes and IDPs. This classification of LA influences revealed many more significant effects for IDPs compared to the partnership classification above; for homes, the number of significant indicators is very similar. For IDPs the summary index of HR practices is also still significant, with providers in low fee areas having significantly lower aggregate HR practice scores than those in high fee areas; the medium fee areas have a medium score but the difference is not significant. A high share of the consistent relationships apply to pay indicators (box IV.18). For homes the pay level, pay improvements and the overall pay index all show significantly higher pay levels in high fee areas compared to low fee areas. High fee areas are also best for unsocial hours payments but medium fee areas are the worst. At the individual indicator level we also find significant differences between high and low fee areas for minimum pay, normal pay and extra pay for qualifications or weekend work. For IDPs indicators for pay levels and pay improvements are significantly lower in low fee areas compared to either medium or high fee areas. Pay for unsocial hours is significantly higher in high fee to low fee areas. Again at the individual indicator level, we find significant differences between high and low fee areas for minimum pay, normal pay and extra pay for qualifications but extra pay for weekend work is lowest in medium fee areas. Box IV.18. The significance of LA fees (high, medium, low) in explaining differences in HR practice indicators among providers Standardised dataset Homes: XPAYLEVELS: pay levels significantly higher in high than low fee LAs pay levels significantly higher in high than low fee LAs SIPAYLEVEL: SIPAYUNSOCIAL: pay for unsocial hours significantly more common in high than medium fee LAs opportunities for pay improvements significantly higher in high SIPAYIMP: than low fee LAs weekend working less common/ less of a requirement in high than SIWTWEND: low fee LAs (10% sig. only) staff more likely to be working long hours or long weeks in high SIWTLHOURS: than in medium or low fee LAs staff significantly more likely to be able to exercise discretion at SIWODISCREET: work in low than in high fee LAs IP1: minimum pay significantly higher in high than low fee LAs IP2: normal pay significantly higher in high than low fee LAs IP6: extra pay for qualifications significantly higher in high than medium or low fee LAs EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes IP8: IWT4: IWT8: IWO4: 242 extra pay for weekend work significantly higher in high than medium or low fee LAs Staff less likely to be all working weekends in high than low or medium LAs (latter 10% sig. only) Staff less likely to be working long hours in medium fee than in high fee LAs Staff in low fee LAs significantly more likely to be able to prioritise tasks to improve care than in high fee LAs IDPs: XWO: staff in high and low fee areas significantly more likely to be able to exercise discretion at work than in medium fee LAs (latter 10% sig. only) XHRPRACT: significantly higher scores in high than low fee LAs pay levels significantly lower in low fee LAs than in medium or SIPAYLEVEL: high fee LAs pay for unsocial hours significantly more common in high than SIPAYUNSOCIAL: low fee LAs (10% sig.only) opportunities for pay improvements significantly lower in low SIPAYIMP: fee LAs than in medium or high fee LAs significantly less likely to have time off for training in low fee SIWTTOFFTRAIN: LAs than in medium or high fee LAs significantly more likely to have time discretion at work in low SIWOTIME: and high fee LAs than medium fee LAs IP1: minimum pay significantly lower in low fee LAs than in medium or high fee LAs IP2: normal pay significantly lower in low fee LAs than in medium or high fee LAs IP6: extra pay for qualifications significantly higher in high than medium or low fee LAs IP8: extra pay for weekend work significantly lower in medium fee LAs than in low or high fee LAs IWO1: staff in low fee LAs significantly more likely to have time to carry out tasks to a high standard than in medium fee LAs IWO2: staff in low fee LAs significantly more likely to have time to develop relationships than in medium fee LAs Non standardised dataset IDPs: IOUT3: IHRDOM1: significantly more likely to have investors in people award in medium than low fee LAs significantly more use in low fee LAs than medium fee LAs For homes, as with our partnership classification above, we again find the potentially inconsistent results that high fee areas score best on not requiring full weekend working but worst on the share with long hours and working 6 or 7 days (box IV.18).30 One relationship 30 These results are confirmed at the indicator level for the share working weekends and for long hours working although the significant difference is only between medium and high fee areas in this instance. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 243 works in a potentially perverse direction with low fee areas offering significantly higher worker discretion and autonomy than high fee areas (particularly in relation to opportunities to prioritise tasks) but the differences in aggregate scores are small.31 Table IV.9. Summary indices for homes and IDPs by low, medium and high fee paying local authority (mean values of indices) a. Homes All Low fee LAs Medium fee LAs 0.55 0.59 High fee LAs HR PRACTICES XPAYLEVELS Pay levels 0.61 (**H) 0.69 (**L) XPAYSTRAT Pay strategies 0.68 0.66 0.66 0.73 XRRPRACT Recruitment& retention practices 0.61 0.56 0.61 0.67 XEMPDEV Training & development 0.58 0.60 0.60 0.53 XWT XWO Working time Work organisation 0.65 0.95 0.65 0.95 0.63 0.95 0.66 0.93 XHRPRACT Index of all HR practices 0.68 0.66 0.67 0.70 XRROUTCOMES Recruitment & retention 0.68 0.69 0.61 0.70 XTRAINSKILDEV NVQ training targets 0.81 0.86 0.95 (** H) HR OUTCOMES (** H) 0.68 (** M L) b. IDPs All Low fee LAs Medium fee LAs High fee LAs HR PRACTICES XPAYLEVELS Pay levels 0.63 0.60 0.61 0.68 XPAYSTRAT Pay strategies 0.65 0.59 0.68 0.68 XRRPRACT Recruitment& retention practices 0.63 0.56 0.65 0.66 XEMPDEV Training & development 0.59 0.54 0.60 0.62 XWT Working time 0.64 0.58 0.68 0.63 XWO Work organisation 0.84 0.87 (* M) XHRPRACT 0.75 0.91 (**L *H) (** M) Index of all HR practices 0.66 0.62 (** H) 0.66 0.70 (** L) XRROUTCOMES Recruitment & retention 0.45 0.39 0.51 0.43 XTRAINSKILDEV NVQ training targets 0.63 0.71 0.67 0.49 HR OUTCOMES Note: Full details in appendix tables IV.A13 and IV.A14. H, M, L are used to indicate significant differences with high, medium or low fee LAs respectively 31 The results detailed in appendix table IV.A13 show mean aggregate scores of 0.93 (all homes), 0.96 (Low fees homes), 0.93 (Medium fees homes) and 0.89 (High fees homes). EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 244 For IDPs low fee area providers are significantly less likely to provide time off for training than either medium or high fee LA providers. The two remaining practices that are significant relate to work organisation – namely, time allowed to complete tasks and form relationships (SIWOTIME) and the aggregate work organising index (XWO). However, here the main finding is that providers in medium fee LAs are less likely than those with either higher or lower fees to provide sufficient time for high quality work (box IV.18). At the individual indicator level the significant differences in either time for carrying out tasks or time to develop relationships are between low and medium fee LAs only. None of the specific domiciliary variables were found to be significantly related to fee levels. Among the other non standard indicators, for IDPs medium fee LA providers were more likely to have the investor in people award than low fee LAs. Providers explicitly identified the level and form of LA fee as a major factor in their HR practices decisions. For example one provider explicitly linked the upgrading of staff pay to whether or not there was an upgrade in fees paid by their LA. They [the LA] haven‟t offered enough over the last year, so we have not upgraded staff for 18 months. Prior to that they got one regularly each year. (LK.D.3 DS). Another regarded their decision not to pay mileage as a direct reflection of the lack of a mileage allowance in the LA fee. I do think care workers should be paid more than what they do get paid, especially because they don‟t pay mileage, it‟s very difficult. And they are needed, you know, care workers are essential. So I think if they did contribute towards mileage that would be definitely beneficial. (ON.D.3 BN). However, for some providers it is the general change in labour market conditions - for example, the increased legal minimum holiday entitlements – that have increased costs. This year and last year, it was an increase in holiday hours, because we‟ve got a large staff and staffing costs are about I think 70% of our turnover and so increased holiday hours makes a big difference to that so what we‟ve had to do in considering this year and last year, so holiday hours have gone up from 4 times your contracted hours to 5.6, which is obviously quite a leap. (RD.H.3.A.L) As most independent sector providers are operating at the bottom of the set of employment conditions, any raising of minimum standards for the labour market as a whole is likely to have a disproportionate effect on the organisation and it is not clear that LA fees are always upgraded in line with such changes to minimum labour market conditions of employment. With respect to HR outcomes, we found that among homes, providers in high fee areas had the worst outcomes in regard to meeting NVQ training targets; medium fee area providers performed the best but there were significant differences between both low to high and medium to high fee area (box IV.19). These findings are confirmed by each of the indicators making up the sub-index - that is, the measure of the actual share of staff trained to NVQ level 2 and the EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 245 likelihood of meeting the 50% NVQ level 2 target. For IDPs the only outcome variable to be significantly associated with LA fees was that relating to subjective evaluations of staff turnover which were worse in low fee areas. This is perhaps the first result indicating that more positive commissioning might act to provide better absolute outcomes (where results are in the opposite direction, LA commissioning may still be helping if the alternative of a low fee might be even higher turnover). For homes, high fee areas had the best overall turnover rates but none of the paired comparisons by fee level were significant. For IDPs the share of new recruits retained was significantly lower in low fee LAs compared to medium fee LAs, and the average for high fee LAs was similar to that for medium fee LAs even if there was not a significant difference (box IV.19). Other staff turnover indicators did not yield any significant results. Box IV.19. The significance of LA fees (high, medium, low) in explaining differences in HR outcome indicators among providers Standardised dataset Homes: SITRAINSKILLDEV: IOUT1: IOUT2: training outcomes significantly worse in high than medium or low fee LAs (latter 10% sig.only) shares of staff trained to NVQ2 significantly higher in medium than high fee LAs providers in high fee areas significantly less likely to meet NVQ target than in medium (10% sig.only) or low fee areas IDPs: significantly worse perceptions of staff turnover in low fee paying LAs than in medium fee areas SITO: Non standardised dataset IDPs: IRT2: EWERC Share of new starters retained significantly lower in low fee to medium fee LAs (10% sig.only) Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 246 IV.4. Labour market conditions and provider HR practices and outcomes IV.4.1. The influence of local labour market conditions on pay Figure IV.8 compares the level of normal pay in our sample of providers to the median hourly pay for female part-time workers in the specific LA labour market. LAs listed along the horizontal axis are ranked by the level of the local labour market median female part-time pay rate (from high to low reading from left to right). The first point to observe is that for the two LAs with the highest local median rates (AW and RN), the relative level of normal pay for care workers in the surveyed providers is the lowest for all the providers in our sample. A second point to observe is that, where pay levels reach a high percentage of the local labour market female median rate or even exceed it, this applies to only some of the providers in the area so that the effect is to spread out the ratios, suggesting wide variations in pay strategies between providers. This mirrors the findings for local labour market fees (section IV.3.1) that not all providers react in the same way either to LA fees or to local labour market conditions. Figure IV.8. Providers’ normal pay for care workers by LA, relative to the local market median for female part-time workers 110% 100% 90% 80% 70% 13 14 UY IL 12 ON 11 TE 10 RT 9 OM 8 LK 7 RD 6 AD 5 AH 4 HD 3 XD 2 RN 1 AW 50% 0 60% Note: The different points on the vertical lines represent the ratio of normal pay for each provider organisation to the median hourly pay for female part-time workers in the specific local authority labour market. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 247 In general we can observe a high concentration of pay levels between 75% and 90% of the relevant median. This finding underlines the low level of pay in the sector as the median level of female part-time hourly pay is only 65% of male full-time hourly pay at the national level. There are only 6% of providers paying above the local labour market median for female parttimers and only16% paying above 90%. At the other end of the spectrum 21% of the sample paid below 75% of the median and all providers in one LA, classified as a „cost minimising‟ LA but located in a high wage area (outer London), paid rates below 60% of female part-time median pay. IV.4.2. The influence of local labour market conditions on HR practices and outcomes To explore the impact of local labour market conditions on HR practices and outcomes we use the combined measures of labour market demand and local labour market pay conditions developed in part I (see section I.7 and appendix table I.A1 and appendix figure I.A1).On this basis we have divided the LAs into weak, medium and strong labour demand. Labour demand leads to the highest number of significant differences between providers for homes, although for IDPs variation in LA fees (section IV.3.2) generated a wider range of significant results. Not all relationships are in predictable directions but most suggest that providers do have to improve their HR practices when located in local labour markets characterised as strong demand areas. Table IV.10 summarises the results for the different summary indices. For homes, labour demand is significantly associated with four overall indices: for pay levels, working time and the summary index of HR practices it is the strong labour demand areas where the scores are highest. By contrast, the index for work organisation suggests that discretion at work is lower in strong demand areas, perhaps suggesting that workers are more under pressure in these areas (box IV.19). There are less strong relationships at the aggregate index level for IDPs: only the index for work organisation is significant but here it is the medium demand areas that offer less discretion than either weak or strong demand areas. Notably no significant differences among IDPs in different local labour markets were found for the overall HR practices index even though they were found for LA fee levels (see box IV.15 above). Local labour market demand is significantly related to pay levels for both homes and IDPs. As anticipated, pay levels are highest in strong demand areas. For homes the main differences are between strong and weak areas32 while for IDPs it is low wages in weak demand areas relative to both medium and strong demand areas that stands out. Unsocial hours payments are also more common in strong demand areas and this time for both homes and IDPs the main 32 The sub-index measures for pay levels among homes are 0.46 (strong demand areas), 0.31 (medium) and 0.20 (weak) (see appendix table IV.A15). EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 248 differences are between strong demand and other areas. Homes also record significant results for pay upgrade opportunities and the overall X pay levels index also has significant differences between both strong and medium with weak demand areas. At the indicator level both homes and IDPs record minimum and normal pay to be lower in weak demand areas and extra pay for weekend work to be higher in strong demand areas, although the exact pattern of significant differences varies. For homes extra pay for qualifications is also significantly higher in strong demand areas but for IDPs there is a somewhat perverse result that staff are more likely to have to pay for their own uniforms in medium compared to weak demand areas. There is also one significant result for a pay indicator that applies specifically to IDPs (IPDOM1), which suggests that those providers in strong demand areas are more likely to pay for travel than those in medium demand areas. Box IV.19. Significant differences among providers in HR practice indicators by labour demand (weak, medium, strong) Standardised dataset Homes: XPAYLEVELS: XWT: pay levels significantly lower in weak than medium or strong demand areas working time arrangements significantly better in strong than weak demand areas (10% sig.only) XWO: opportunities to exercise discretion significantly lower in strong than in weak or medium (10% sig.only) demand areas XHRPRACT: overall high practices score significantly higher in strong than medium or weak demand areas. pay levels significantly higher in strong than medium (10% SIPAYLEVEL: sig.only) or weak demand areas SIPAYUNSOCIAL: pay for unsocial hours significantly more common in strong than weak demand areas SIPAYUPGRADE: regular pay upgrading less common in weak than strong or medium demand areas. weekend working less common/ less of a requirement in strong SIWTWEND: and medium than weak demand areas staff more likely to be working long hours or long weeks in strong SIWTLHOURS: than in weak demand areas staff significantly less likely to be able to exercise discretion at SIWODISCREET: work in strong than in medium or weak demand areas working time significantly more likely to be matched to employee SIWTSTFFPREF: preferences in weak than strong demand areas SIWTTOFFTRAIN: staff significantly more likely to be given time off for training in strong compared to weak demand areas IP1: minimum pay significantly higher in strong than weak demand areas IP2: normal pay significantly higher in strong than weak demand areas IP6: extra pay for qualifications significantly higher in strong than weak demand areas (10% sig.only) IP8: extra pay for weekend work significantly lower in weak than EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes IWT4: IWT5: 249 strong or medium demand areas (latter 10% sig. only) staff less likely to be all working weekends in strong than medium or weak demand areas availability for weekend work more likely to be a recruitment requirement in weak than strong or medium demand areas IDPs: XWO: opportunities to exercise discretion significantly lower in medium than in weak or strong demand areas pay levels significantly lower in weak than medium or strong SIPAYLEVEL: demand areas pay for unsocial hours significantly more common in strong SIPAYUNSOCIAL: than medium or weak demand areas significantly more likely to have time discretion at work in SIWOTIME: weak and strong than medium demand areas IP1: minimum pay levels significantly lower in weak than medium or strong demand areas IP2: normal pay levels significantly lower in weak than medium or strong demand areas IP8: extra pay for weekend work significantly higher in strong than medium demand areas IP12: staff significantly more likely to have to pay for uniforms in medium than weak demand areas (10% sig.only) IWT4: staff less likely to be all working weekends in strong and medium (10% sig.only) than weak demand areas IWO1: staff in medium demand areas significantly less likely to have time to carry out tasks to a high standard than in weak or strong demand areas IWO2: staff in medium demand areas significantly less likely to have time to develop relationships than in weak or strong demand areas Non standardised dataset IDPs: IPDOM1: IHRDOM1: IOUT3: IWTDOM5: staff significantly more likely to be paid for travel time in strong than medium demand areas significantly more use of electronic monitoring in weak than strong demand areas significantly more likely to have investors in people award in medium than strong demand areas minimum lengths of visits significantly more likely to be longer in medium than strong demand areas For IDPs there are few strong relationships with local demand conditions other than for pay. The only other HR practice areas for IDPs to reveal significant differences at the sub-index level are those related to work organisation (as found for LA fee levels, box IV.17) and again here it is the medium demand area that scores significantly worse than strong or weak demand areas (a finding mirrored in two of the individual indicators in this area, IWO1 and IWO2, box IV.19). With regard to working time, the indicator on staff working weekends suggests that it is EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 250 more common among providers in weak labour demand areas for all staff to be working weekends. Another finding from the specific domiciliary indicator list suggests that minimum lengths of visits tend to be longer in medium than strong demand areas. Finally, IDP providers in medium labour demand areas are more likely to have the Investors in People awards than in strong demand areas. For homes weak demand areas were less likely to provide time off for training than strong demand areas and this relationship was significant.33 We also find a series of working time indicators that are significant, including the overall working time index, XWT. However, the directions of effects are mixed. The summary index for working time suggests working-time arrangements are significantly better in providers located in strong than weak labour demand areas (although only at the 10% level, table IV.10). Strong and medium labour demand areas are significantly less likely to require all weekend working than weak demand areas. This is demonstrated by the sub-index, SIWTWEN, as well as by the individual indicators on the share of care workers working weekends (IWT4) and the recruitment requirement for weekend working (IWT5) that also suggest that weak areas are more likely to impose this requirement. On other measures, however, homes in weak labour demand areas score better – specifically, on matching working time preferences, on long hours and 6/7 day working. Homes in strong labour demand areas also score worse than medium or weak demand areas on two work organisation variables: namely, the sub-index of the extent of discretion allowed in the job and the summary index of work organisation (box IV.19). Finally, we find that certain HR outcomes are associated with labour demand conditions in the local labour market (box IV.20). Achievement of NVQ targets, captured in our sub-index of training (SITRAINSKILLDEV), is negatively associated with labour demand: for homes it is weak demand areas that have better training outcomes than those in medium or strong demand areas but for IDPs it is more that strong demand areas have by far the worst outcomes. For IDPs, medium labour demand areas were also significantly less likely to perceive problems of absenteeism than was the case in weak or strong demand areas. As with our analysis of variation in local authority commissioning arrangements (section IV.3.2), the results again reveal no significant relationship between differences in labour demand and actual staff turnover levels. 33 The scores on the 0-1 sub-index are 0.93 (strong labour demand) and 0.76 (weak labour demand), with a significant difference at the 5% level (table IV.10). EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 251 Table IV.10. Summary indices for homes and IDPs by labour market conditions (mean values) a. Homes All Strong demand Medium demand Weak demand 0.69 (**W) 0.71 0.65 0.57 0.68 (**W) 0.91 (**W *M) 0.70 (**M W) 0.64 (**W) 0.69 0.57 0.64 0.67 0.97 (*S) 0.69 (**S) 0.50 (**S M) 0.65 0.59 0.54 0.60 (**S) 0.97 (**S) 0.64 (**S) HR PRACTICES XPAYLEVELS Pay levels 0.61 XPAYSTRAT XRRPRACT XEMPDEV XWT Pay strategies Recruitment & retention practices Training & development Working time 0.68 0.61 0.58 0.65 XWO Work organisation 0.95 XHRPRACT Index of all HR practices 0.68 Recruitment & retention NVQ training targets 0.68 0.81 0.71 0.72 (**W) 0.62 0.76 (*W) 0.68 0.94 (**S *M) All Strong demand Medium demand Weak demand 0.67 0.66 0.65 0.57 0.66 0.87 (* M) 0.68 0.61 0.63 0.66 0.56 0.68 0.72 (**S W) 0.64 0.59 0.66 0.57 0.63 0.57 0.88 (** M) 0.65 0.44 0.46 (**W *M) 0.50 0.73 (* S) 0.43 0.78 (** S) HR OUTCOMES XRROUTCOMES XTRAINSKILDEV b. IDPs HR PRACTICES XPAYLEVELS XPAYSTRAT XRRPRACT XEMPDEV XWT XWO Pay levels Pay strategies Recruitment & retention practices Training & development Working time Work organisation 0.63 0.65 0.63 0.59 0.64 0.84 XHRPRACT Index of all HR practices 0.66 Recruitment & retention NVQ training targets 0.45 0.63 HR OUTCOMES XRROUTCOMES XTRAINSKILDEV Note: Full details in appendix tables IV.A15 and IV.A.16. S,M.W are used to indicate significant difference from strong , medium and weak demand areas respectively. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 252 Box IV.20. Significant differences among providers in HR outcome indicators by labour demand (weak, medium, strong) Standardised dataset Homes: SITRAINSKILLDEV: IOUT1: IOUT2: training outcomes significantly better in weak than medium(10% sig.only) or strong demand areas shares of staff trained to NVQ2 significantly higher in weak than strong demand areas providers in high fee areas significantly less likely to meet NVQ target than in medium (10% sig.only) or low fee areas IDPs: SITRAINSKILLDEV: SIABSENT: IOUT1: IOUT2: EWERC training outcomes significantly worse in strong than medium(10% sig.only) or weak demand areas significantly worse perceptions of staff turnover in weak and strong demand areas than in medium demand areas (latter 10% sig.only) shares of staff trained to NVQ2 significantly higher in weak than strong demand areas providers in strong demand areas significantly less likely to meet NVQ target than in weak demand areas Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 253 IV.5. Internal and external environmental factors associated with good HR practices and HR outcomes The above sections have investigated the way in which the quality of HR practices and outcomes among homes and IDPs vary by a range of key factors, including organisational characteristics (the size and ownership status for example, considered in part IV.2), LA commissioning environment (level of fees and partnership orientation, for example, considered in part IV.3) and local labour market conditions (considered in part IV.4). Considering each set of factors in turn, our analysis so far suggests a number of significant associations between these internal and external factors and the propensity of providers to adopt good HR practices and enjoy good HR outcomes. To explore these associations further, this section reports the results of multivariate statistical analyses. The first set of analyses was designed to identify the factors associated with the adoption of good HR practices. The second set aimed to explore the relationships between environmental factors, organisational characteristics and good HR practices on the one hand, and good HR outcomes on the other. IV.5.1. Exploring the factors associated with the adoption of good HR practices In this section, our aim is to identify, using multivariate analysis, those factors that help explain differences among homes and among IDPs in the quality of different HR practices – specifically, pay practices, recruitment and retention practices, employee development practices, working time practices and work organisation practices. In line with our over-arching analytical framework for this project (figure I.1) our proposition is that these HR practices are likely to be influenced by key external environmental factors that vary across provider and local authority, namely the commissioning and contracting practices of LAs and local labour market conditions. In addition, we know from our analysis above (section IV.2), as well as from an extensive literature on the factors shaping the design of „HR bundles‟ (eg. Kepes and Delery 2007, Purcell 1999), that organisational characteristics of the sample of providers are likely to influence the ability and willingness of providers to adopt better HR practices. As such, we also include factors such as size, ownership and profit-making status. We carried out two types of multivariate analysis. First, we undertook a cluster analysis based on the standardised dataset of HR practice indicators in an attempt to identify distinctive clusters among homes and IDPs in their approach to HR. However, the cluster analysis produced relatively unstable and not very distinctive groupings and is therefore not presented here. The second type of multivariate analysis consisted of a number of regressions. We used the method of backwards regression. Details of this method along with explanatory notes for our style of presentation of regression results are included in appendix IV.A3. In order to investigate the effects of environmental and organisational factors on the different HR practices EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 254 we entered seven independent variables consisting of two LA commissioning variables (three for homes), two labour demand variables and three organisational characteristics. Box IV.21 provides the full details of each independent variable. The labour demand variables consist of a measure of local labour market demand and the median level of pay for all female part-time workers in the local labour market, both derived from national statistics (see section I.7.1 and appendix table I.A1 and appendix figure I.A1). There are also two LA commissioning variables, the categorisation of partnership, mixed or cost-minimising LA (as derived in part II above) and the actual fee level paid to the provider. Box IV.21. Description of the dependent and independent variables used in the regressions on HR practices For each regression the effects of a number of independent variables were tested on the different HR practices among homes and IDPs separately. The six HR practices variables, plus a summary index variable, are as follows (see, also, box IV.6 above): HR practices: XHRPRACT: Overall summary index of HR practices XPAYLEVELS: Index of pay levels XPAYSTRAT: Index of pay strategies XRRPRACT: Index of recruitment and retention practices XEMPDEV: Index of employee development practices XWT: Index of working time practices XWO: Index of work organisation practices And the seven independent variables (eight for homes) are as follows: LA commissioning variables: Details of measure: partnership=3, mixed=2, cost minimising=1 Partnership LA Actual £ fee levels LA fee levels For homes only, the proportion of service users % dependency on LA LA funded Labour demand variables: Local labour demand Female part-time pay Organisational characteristics: Size Ownership: national chain, local chain, single establishment Private for profit or voluntary sector EWERC Scored 2 to 6 Actual £ median pay rates for locality Actual size, number of employees National chain is the reference category Voluntary sector is the reference category Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 255 The regression results are presented from two models in each case. This is because there is a high correlation between two independent variables, LA fee levels and local labour market demand34. Consequently we ran the regressions twice - first with the LA fees but not labour demand (model i) and again with the labour demand variable, omitting the LA fees variable (model ii). Tables IV.11 and IV.12 present the results for IDPs and homes, respectively. We only report here the results for those indices of HR practices where the explanatory power of the independent variables is relatively strong, using the measure of the adjusted R2 as a benchmark (see IV.A.5). For IDPs, several environmental factors and organisational characteristics appear to have a significant association with the quality of HR practices (table IV.11). As anticipated, the local authority commissioning policy appears to have a strongly significant influence on HR practices. Both LA fee levels and the partnership orientation of the LA have a positive and significant influence on HR practices. The partnership variable has a significant positive association with the summary index of HR practices (model ii), the index for pay levels (model i) and the index for pay strategy (model ii). And the LA fee level variable has a similarly positive and significant relationship with the summary index (model i) and the pay strategy index (model i). For IDPs, therefore, HR practices are significantly associated with the local authority environment. Relations with a more partnership-oriented and high fee paying LA, as opposed to a cost minimising and low fee payer LA, are beneficial for the adoption of better HR practices. Three organisational characteristics are also helpful in explaining the variance of HR practices among IDPs. These are whether or not the IDP is a private profit-making organisation (as opposed to a not-for-profit IDP), whether or not it is part of a local chain (rather than a national chain) and the size of organisation. Holding all other factors constant, HR practices in profitmaking IDPs are inferior to those in the voluntary not-for-profit sector. The results presented in table IV.11 suggest this result is significant for the summary X index (models i and ii) and for the index of pay strategy (models i and ii), with confidence intervals of more than 99% in all cases. Being part of a local chain, on the other hand, exerts a positive influence on the index for pay strategy (model i) compared to IDPs that are part of a national chain. The size of workforce of IDPs has a negative effect, insofar as larger IDPs are significantly associated with a worse index for pay strategy (models i and ii). Local labour market factors appear to play a less important role in explaining variance of HR practices among IDPs. The variable for female part-time earnings exerts a significant positive effect on the index for pay strategy (models i and ii), such that IDPs in areas of relatively high female part-time earnings are more likely to register a better index for pay strategy. 34 LA fee levels are highly and positively correlated to local labour market demand factors, with a coefficient r = 0.66, which is also highly significant at p < 0.001. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 256 Table IV.11. The effects of environmental factors and organisational characteristics on different indices of HR practices for IDPs a. Summary index of HR practices (XHRPRACT) i) With LA fees Partnership LA LA fee levels -Single establishment Private for profit -- Coefficient Significance 0.23 0.24 n.s. * 0.17 -0.46 n.s. *** ii) With labour demand Partnership LA -Female part-time pay -Private for profit Size Coefficient Significance 0.32 ** 0.19 n.s. -0.45 -0.169 ** n.s. Coefficient Significance 0.22 n.s. 0.18 -0.22 n.s. n.s. Coefficient Significance 0.32 ** 0.31 -0.19 -0.30 0.20 -0.37 ** n.s. ** n.s. *** Note: OLS regression, sample 50 (IDPs). Adjusted R2 of 0.32 (model i), 0.32 (model ii). b. Index of pay levels (XPAYLEVELS) i) With LA fees Partnership LA Female part-time pay -Private for profit Coefficient Significance 0.334 0.13 ** n.s. -0.20 n.s. ii) With labour demand Partnership LA -Local labour demand Private for profit Note: OLS regression, sample 50 (IDPs). Adjusted R2 of 0.11 (model i), 0.12 (model ii). c. Index of pay strategies (XPAYSTRAT) i) With LA fees -LA fee levels Female part-time pay -Size Local chain Private for profit Coefficient Significance 0.24 0.24 * * -0.30 0.23 -0.39 ** * *** ii) With labour demand Partnership LA -Female part-time pay Local labour demand Size Local chain Private for profit Note: OLS regression, sample 50 (IDPs). Adjusted R2 of 0.31 (model i), 0.31 (model ii). For homes, the overall results of the regression models suggest that the same environmental factors and organisational characteristics (plus the additional measure of dependency on LAs) offer weaker explanatory power for the variance of HR practices (table IV.12). Moreover, the LA commissioning environment appears to play a less significant role in influencing HR practices in homes than in IDPs. This is most apparent for the summary index of HR practices where we find neither the LA fee variable nor the LA partnership variable appear as significant variables. These variables are nevertheless both significant (strongly significant in the case of LA fees) for the index for pay levels for homes (model i). The regression suggests a 99% confidence interval for the result that homes contracting with high fee paying LAs have a significantly higher index for pay levels. The result for the LA partnership variable runs EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 257 counter to the result for IDPs since it suggests a negative association (albeit at a less strong level of significance than our result for IDPs). Like IDPs, a key variable is the private for-profit organisational characteristic. When a home is a private sector profit-making organisation, its summary index of HR practices and its index of pay levels are significantly worse than those for voluntary sector homes (models i and ii). Another organisational characteristic, the size of the home, is negatively associated with the index of pay levels, which compares to its negative influence on pay strategy for IDPs. A key difference with the results for IDPs is that the local labour market factor of median female part-time earnings emerges as an important variable for explaining the variance in the summary index measure (models i and ii). The results suggest that the higher the pay for women in part-time jobs in the local area, the better the overall measure of HR practices in homes. This factor is not significantly associated with pay levels in homes (although it exerts a positive influence in model ii), but does display a strongly significant association with the index of pay strategy (models i and ii) and the index of recruitment and retention practices (model ii); neither result is reported in table IV.12 due to the low overall explanatory power of the regression models. Table IV.12. The effects of environmental factors and organisational characteristics on different indices of HR practices for homes a. Summary index of HR practices (XHRPRACT) i) With LA fees -Female part-time pay -Size Private for profit Coefficient Significance 0.32 ** -0.15 -0.28 n.s. ** ii) With labour demand Coefficient Significance -0.13 0.25 0.24 -0.14 -0.27 n.s. * n.s. n.s. ** Coefficient Significance -0.21 n.s. 0.12 0.45 -0.14 -0.25 0.14 -0.35 n.s. ** n.s. ** n.s. ** Partnership Female part-time pay Local labour demand Size Private for profit Note: OLS regression, sample 52 (homes). Adjusted R2 of 0.15 (model i), 0.15 (model ii). b. Index of pay levels (XPAYLEVELS) i) With LA fees Partnership LA fees --% dependent on LA Size Local chain Private for profit Coefficient Significance -0.29 0.50 * *** -0.14 -0.31 0.19 -0.35 n.s. ** n.s. *** ii) With labour demand Partnership -Female part-time pay Local labour demand % dependent on LA Size Local chain Private for profit Note: OLS regression, sample 52 (homes). Adjusted R2 of 0.36 (model i), 0.41 (model ii). EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 258 The regression results provide a surprisingly contrasting set of explanations for the two indices of pay practices for IDPs and homes. In terms of the conventional measure of explanatory power (the adjusted R2), the selected environmental factors and organisational characteristics provide a relatively good explanation of the variance of pay levels among homes but a poor explanation for IDPs. Indeed the opposite holds for the index of pay strategies where we only report the results for IDPs since the regression models for homes had very poor predictive power.35 For homes, three factors have a significant negative association with the index for pay levels (model i) - being a private sector organisation (a 99% confidence level), being in a partnership LA (only a 90% confidence level) and being of large size. LA fees work in the anticipated opposite direction with higher fees having a positive and strongly significant effect on pay levels. Two other variables remain in but are not significant: that is, being in a local chain compared to a national chain which has a positive effect on pay and having a high dependency on the LA for clients which has a negative effect. Model ii yields very similar results except that the significance of the partnership variable disappears and local labour demand has a strongly positive and significant effect, providing an effective substitute for LA fee levels (as anticipated given its strong positive correlation). These relatively plausible results, where fee levels and labour demand have strong positive effects on pay levels, are not replicated for IDPs. Nevertheless, for IDPs partnership does have a positive impact on pay levels (significant in model i). No other variables are significant; median female part-time pay in the area has a positive effect on the pay level index (model i) while being a private sector organisation has the usual negative effect (models i and ii). In terms of the index of pay strategies, for IDPs we find the same negative influence of organisational size and being a private for-profit organisation (strongly significant for models i and ii) as we found for the index of pay levels for homes. Positive effects derive from the labour demand variable, median female part-time earnings, along with LA fees and being a local chain rather than a national chain. Partnership-oriented LAs also have a positive and significant association in model ii. The regression models generated poor levels of prediction for four indices of HR practices, namely recruitment and retention practices employee development, working time and work organisation. For all four indices the adjusted R2 measure consistently fell below 0.2. In sum, these multivariate statistical results lend support to one of the main propositions of this research, namely that the LA commissioning environment plays a strong and significant role in shaping the quality of HR practices. IDPs that contract with high fee paying LAs and partnership-oriented LAs display a better overall index of HR practices than other IDPs. And for homes, while the LA commissioning environment does not appear to be associated with the 35 For the regression estimating the effects on the index for pay levels the adjusted R2 measures for homes are 0.36 (model i) and 0.41 (model ii) and for IDPs are 0.11 (model i) and 0.12 (model ii). For the regressions on the index for pay strategies the measures of R2 for homes are 0.07 (model i) and 0.07 (model ii) and for IDPs, 0.31 (model i) and 0.31 (model ii). EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 259 overall measure of quality of HR practices, it has a strongly significant association with pay levels such that those homes contracting with high fee paying LAs are more likely to register a high index of pay levels than other homes. Conditions in the local labour market also matter; homes in areas where the median pay for women in part-time employment is relatively high are likely to provide high quality HR practices; for IDPs the same variable has an important, similarly positive, association with the index of pay strategy. And finally, certain characteristics of the organisation also facilitate our explanation of variance of HR practices. The size of the workforce and the for-profit status appear to exert a negative effect on key HR practices among both IDPs and homes, and IDPs that are local chains benefit from a higher index of pay levels than IDPs that are part of national chains. IV.5.2. Exploring the factors associated with good HR outcomes In addition to exploring the factors associated with the quality of HR practices, we also used a similar regression method to interrogate HR outcomes. Again, following the analytical framework set out in part I of this report, we sought to test the impact of the external environment – the type of LA commissioning and the local labour market context – and organisational characteristics (as above). In addition, given that the bundle of HR practices deployed in a particular organisation is likely to have a significant effect on the quality of HR outcomes, we expanded the number of independent variables to include the seven indices of HR practices (see appendix table IV.A17). Drawing on the data from the telephone survey of providers, we constructed four measures of HR outcomes that exploit both the subjective views of managers and the quantitative workforce data. A first measure of recruitment and retention outcomes (XRROUTCOMES) is an aggregate index of managers‟ subjective views about recruitment difficulties, staff turnover and staff absenteeism. A second measure of training outcomes (XTRAINSKILDEV) combines workforce data on the proportion of the care workforce qualified to NVQ level 2 and managers‟ views about the future likelihood of their training at least 50% of their staff. The third and fourth outcome measures are alternative quantitative measures of staff turnover – the overall staff turnover rate for care workers (RT3) and the turnover rate excluding new recruits (RT9).36 Tables IV.13 and IV.14 present the results for the first two measures of HR outcomes – recruitment and retention outcomes and training outcomes – for IDPs and homes, respectively. Across all regressions, the equation of association between the selected independent variables and outcome variables provides a relatively low level of explanation; the adjusted R2 varies from 0.10 to 0.29. Nevertheless, a number of variables appear to be significantly associated with variation in these two HR outcomes. 36 While we have near complete data from providers for the first two outcome measures, it proved very difficult to obtain reliable staff turnover data and as a consequence we have run regressions on smaller samples than we would have liked – 37 IDPs and 45 homes. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 260 A first finding is that a key set of HR practices represented by the index of working time, which reflects a mix of indicators such as the requirement for weekend and long hours working and time off for training, exhibits a strongly significant and positive association with recruitment and retention outcomes for IDPs (table IV.13). In both models (i and ii), this finding suggests that the more IDPs are able to offer attractive (and less demanding) working time schedules the better are the outcomes for recruitment and retention. Here is strong evidence, therefore, that recruitment and retention outcomes can be shaped through attention to what is perhaps one of the most important areas of HRM in IDPs given the complex nature of work schedules. Two further significant variables are the organisational characteristics of size and ownership. IDPs that are part of a local chain (model i) are significantly associated with recruitment and retention outcomes that are higher than those of national chain providers. The size of a provider‟s workforce tends to lower HR outcomes (models i and ii) with larger providers significantly associated with lower scores for recruitment and retention compared to smaller IDPs. As might be anticipated, strong local labour market demand appears to have an adverse impact, with IDP managers in areas of strong labour demand more likely to register negative views about recruitment difficulties and staff retention. Table IV.13. The effects of environmental factors, organisational characteristics and HR practices on indices of HR outcomes for IDPs a. Index of recruitment and retention outcomes (XRROUTCOMES) i) With LA fees --Size Local chain XWorking Time Coefficient -0.31 0.22 0.35 Significance ** * ** ii) With labour demand Coefficient Significance 0.26 -0.29 -0.30 0.20 0.39 n.s. * ** n.s. *** Partnership Local labour demand Size Local chain XWorking Time Note: OLS regression, sample 50 (IDPs). Adjusted R2 of 0.20 (model i), 0.22 (model ii). b. Index of training outcomes (XTRAINSKILDEV) i) With LA fees -LA fees -Local chain XPay Levels XEmployee Development Coefficient Significance -0.31 ** 0.29 0.15 0.14 ** n.s. n.s. ii) With labour demand Coefficient Significance Partnership -Local labour demand Local chain XPay Levels -- 0.17 n.s. -0.49 0.27 0.14 *** ** n.s. Note: OLS regression, sample 50 (IDPs). Adjusted R2 of 0.14 (model i), 0.20 (model ii). Being part of a local chain is also significantly associated with better training outcomes among IDPs (models i and ii). In other words, holding all other variables constant, IDPs that are EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 261 members of a local chain are more likely than national chain members to report high levels of NVQ trained care workers and/or to have high expectations about the share of staff who will be trained. The variable that registers the strongest significance is the local labour market demand variable (a 99% confidence interval). As with recruitment and retention outcomes (and also similar to our evidence on pay strategies, above), labour demand displays a negative association: IDP managers in areas of high labour demand are significantly less likely to report favourable training outcomes compared to IDPs in areas of weak labour demand. This might be considered surprising since providers in areas of high demand facing strong competition for labour might be expected to seek to improve the bundle of employment conditions on offer to workers, including the opportunities for skill formation. However, what appears to be happening is that where providers experience poaching of skilled workers, they are less inclined to invest in training provision or their investments may not yield as high outcomes due to higher rates of staff turnover. A further surprising result concerns the nature of association between LA fees and training outcomes for IDPs. While our results for HR practices above suggest a clear positive association with the level of LA fees to providers, here we find instead a negative association. The result is confirmed by a correlation test on the two variables which shows a negative correlation, -0.29, significant at the 95% level. The results for homes suggest the same independent variables provide a very weak explanatory model for the measure of recruitment and retention outcomes but a relatively strong explanation for the index of training outcomes (table IV.14). Only one variable is significantly associated with recruitment and retention outcomes among homes, that of workforce size. As with IDPs, the larger the home the worse are managers‟ views about recruitment difficulties and retention outcomes (models i and ii). More variables are associated with the measure of training outcomes; also, the results are the same for models i and ii due to the weak explanatory value of LA fees and local labour demand. Homes that are single establishments are significantly more likely to be associated with better training outcomes compared with national chains. Competition for female labour in areas with relatively high levels of median earnings for part-time jobs has the apparent effect of reducing training outcomes among homes, much like the labour demand measure for IDPs. And, like our results for IDPs, we find a strongly significant (99% confidence level) and positive association between the training outcome and the set of HR practices that constitute our index of work organisation. Thus, training outcomes are likely to be better in those homes that have a positive approach towards giving staff the time to deliver quality care and to develop relations with users, as well as the opportunities to exercise discretion in improving the way they work. This may suggest that when time is squeezed in general, so are opportunities for training. The regressions for the third and fourth measures of HR outcomes, namely overall staff turnover (RT3) and staff turnover excluding new recruits (RT9), draw on a more restricted sample of respondents to the telephone survey(37 IDPs, 45 homes) due to difficulties in obtaining detailed turnover data from all respondents (see section I.7 and III.2). The results explain a very high proportion of observed variance among IDPs (the adjusted R2 measure is greater than 0.60 for both measures) but a comparatively lower proportion of variance among EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 262 homes (with R2 values of around 0.20, similar to the above results).37 Corresponding with this overall finding, the regressions suggest that many more variables are significantly associated with measures of staff turnover in IDPs than is the case for homes. Table IV.15 presents the results for IDPs with separate columns identifying those factors that are significantly associated with a lower rate of staff turnover and those associated with a higher rate of staff turnover. We only present the results for model i (with LA fees and without the variable for local labour demand) since the results from model ii are equivalent for the total staff turnover measure and very similar for the measure of staff turnover excluding new recruits. Full details of coefficients for the independent variables are in appendix table IV.A20. Table IV.14. The effects of environmental factors, organisational characteristics and HR practices on indices of HR outcomes for homes a. Index of recruitment and retention outcomes (XRROUTCOMES) i) With LA fees Size X Pay Levels X Pay Strategy X Employee Development X Work Organisation Coefficient Significance ii) With labour demand Coefficient Significance -0.26 0.19 -0.19 -0.23 * n.s. n.s. n.s. Size X Pay Levels X Pay Strategy X Employee Development -0.26 0.19 -0.19 -0.23 * n.s. n.s. n.s. 0.14 n.s. X Work Organisation 0.14 n.s. Note: OLS regression, sample 52 (homes). Adjusted R2 of 0.10 (model i), 0.10 (model ii). b. Index of training outcomes (XTRAINSKILDEV) i) With LA fees Female part-time pay Local chain Single establishment Private for profit XPay Strategy XRecruitment&Retention practices XWork Organisation Coefficient Significance ii) With labour demand Coefficient Significance -0.27 0.20 0.34 -0.19 0.17 -0.19 ** n.s. ** n.s. n.s. n.s. -0.27 0.20 0.34 -0.19 0.17 -0.19 ** n.s. ** n.s. n.s. n.s. 0.35 ** Female part-time pay Local chain Single establishment Private for profit XPay Strategy XRecruitment&Retention practices XWork Organisation 0.35 ** Note: OLS regression, sample 52 (homes). Adjusted R2 of 0.29 (model i), 0.29 (model ii). A clear finding for IDPs is the significance of association between a range of HR practices and the two measures of staff turnover (table IV.15). However, good HR practices appear to have both positive and negative effects. For the measure of total staff turnover (RT3), four good HR 37 Unlike the above regressions, the models testing the staff turnover measures used indicators of HR practices rather than the summary index measures. As such, many more independent variables were entered as potential explanatory factors (see appendix table IV.A.20). EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 263 practices are associated with lower staff turnover and three good HR practices are associated with higher staff turnover. For the measure of staff turnover excluding new recruits (RT9) we find a significant association between four good HR practices and low turnover and between five good HR practices and high turnover. We must remember that the regression results only provide a test of statistical association, not cause and effect. As such, the apparently contradictory findings may be interpreted as demonstrating, on the one hand, that good HR practices in many organisations tend to encourage relatively low rates of staff turnover and, on the other hand, that high staff turnover may induce some organisations to improve their HR practices (in an effort to improve staff retention). Those practices associated with higher staff turnover among IDPs include regular uprating of pay (RT3 only), paying for CRB checks, using formal recruitment methods, fitting work schedules with employees‟ circumstances (RT9 only) and offering guaranteed hours contracts (RT9 only). The indicator on formal recruitment methods could feasibly work in the opposite direction to what we anticipated, if for example recruitment by word of mouth leads to more committed staff. However, it is very difficult to come up with any explanations why the other four practices could do anything other than tend to reduce staff turnover. This suggests that the direction of cause and effect is likely to run from HR outcome to HR practice. In other words, IDPs in contexts where staff turnover is a particular problem are more likely to implement better HR practices in an effort to improve staff commitment to the organisation. The HR practices associated with lower levels of staff turnover among IDPs are opportunities for pay increases, payment for weekend work (RT9 only), recognising a trade union, selecting new recruits who have care skills and qualifications (RT3 only) and provision of time off for training. The first and third of these variables are highly significant (as defined by a 99% confidence interval), such that those IDPs that offer opportunities for care workers to increase their pay and those that recognise collective representation by a trade union are strongly associated with lower rates of staff turnover. The external environment and organisational characteristics play a lesser role in shaping staff turnover compared to our other measures of HR outcomes presented above. Both larger size of provider and the partnership orientation of the local authority only appear as significant in the regression on the measure of staff turnover excluding new recruits where we find both measures are associated with high staff turnover. The level of female part-time pay in the local area is associated with relatively low levels of total staff turnover (RT3 only). For homes the regression results suggest the relationship between HR practices and staff turnover measures is more straightforward, albeit revealing a far smaller list of significant variables (table IV.16). Just two indicators of HR practices are significantly associated with staff turnover and in both cases the regression results suggest good practice is associated with lower staff turnover. Just like IDPs, those homes where managers value caring skills and experience among job applicants are more likely than other homes to enjoy low staff turnover. For the measure of staff turnover excluding new recruits (RT9) a further indicator of HR EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 264 practice, the share of staff who regularly work weekends, also displays a significant association. Here, the results suggest that those homes where a smaller proportion of care workers regularly work weekends enjoy lower staff turnover, excluding new recruits. Table IV.15. Factors associated with higher and lower measures of staff turnover in IDPs a. Total staff turnover (RT3) Factors that reduce staff turnover Factors that increase staff turnover LA commissioning environment: -- -- Labour market demand: Higher female part-time pay (**) -- Organisational characteristics: -- -- HR practices: Pay upgrading opportunities (***) Recognition agreement with trade unions (***) Skills and qualifications desirable among job applicants (*) Time off from care duties to attend training (*) Regular uprating of pay (***) Employer pays for CRB checks (***) Use of formal recruitment methods (***) b. Staff turnover excluding new recruits (RT9) Factors that reduce staff turnover Factors that increase staff turnover LA commissioning environment: -- Partnership (***) Labour market demand: -- -- Organisational characteristics: -- Larger Size (*) HR practices: Pay upgrading opportunities (***) Extra pay for weekend work (**) Regular uprating of pay (**) Employer pays for CRB checks (***) Use of formal recruitment methods (***) Work schedules that fit staff preferences (**) Offering guaranteed hours contracts (**) Recognition agreement with trade unions (***) Time off from care duties to attend training (**) Note: see Appendix table IV.A20 for details. As with IDPs, the local labour market appears to have limited association with variation in staff turnover rates with the exception of female part-time pay which has a negative association with total staff turnover. A distinctive result for homes is the differentiation between private for profit organisations and voluntary not for profit organisations. The former are significantly associated with higher levels of staff turnover on both measures, total staff turnover and turnover excluding new recruits. For homes, therefore, the private for profit status is negatively EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 265 associated with three of our four HR outcome measures, a result that serves as a cautionary warning to further advances in the role of private sector providers in delivery of health and social care. The opposite association is found for the organisational characteristics of single establishment (compared to national chain homes); single establishment homes are significantly more likely to register lower staff turnover. Table IV.16. Factors associated with higher and lower measures of staff turnover in homes a. Total staff turnover (RT3) Factors that reduce staff turnover Factors that increase staff turnover LA commissioning environment: -- -- Labour market demand: Female part-time pay (**) -- Organisational characteristics: Single establishment (*) Private for profit (*) HR practices: Skills and qualifications desirable among job applicants (**) -- b. Staff turnover excluding new recruits (RT9) Factors that reduce staff turnover Factors that increase staff turnover LA commissioning environment: -- -- Labour market demand: -- -- Organisational characteristics: Single establishment (*) Private for profit (*) HR practices: Skills and qualifications desirable among job applicants (*) Lower % of staff regularly working weekends (*) --- Note: see Appendix table IV.A21 for details. In summary, through the method of multivariate analysis this section has demonstrated a number of statistically significant associations between factors in the internal and external environment and the likelihood of IDPs and homes implementing good HR practices and enjoying good HR outcomes. Our guiding framework for analysis was figure 1.1 from part I of this report, which presents the key factors likely to influence the HR approach of care providers. Several findings deserve highlighting. In relation to the adoption of HR practices, the notion that the quality of LA commissioning (specifically higher fees and a partnership orientation) is associated with better HR practices was confirmed for the summary index of HR practices among IDPs and for the index of pay levels for homes. However, these positive influences interact with several other factors that are more difficult to shape through strategic EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 266 policy action. In particular, conditions in the local labour market (especially the median level of female part-time pay in the locality) display a significant association with the variation in our measure of pay strategy practices among IDPs and the summary index of HR practices among homes. Also, two organisational characteristics have a significant impact; smaller providers and not-for-profit providers are more likely than larger providers and for profit providers to implement good HR practices. Our analysis of factors associated with HR outcomes points very strongly to the significant role of HR practices, especially among IDPs, suggesting a possible linear cause and effect relationship from internal and external factors through to HR practices and then to HR outcomes. However, as we have argued, in some cases good HR practices may be induced by pressure from local labour market conditions, in an attempt to reduce very high levels of staff turnover. As a consequence not all good HR practices are associated with better HR outcomes. Nevertheless, the results did highlight a significant association between IDPs‟ use of better working time practices and better recruitment and retention outcomes, as measured by our summary index of recruitment and retention conditions. Moreover, a bundle of good HR practices in IDPs - good pay practices (opportunities for pay upgrading and paying a premium for weekend work), trade union recognition, appreciation of care skills and care experience when selecting new recruits and provision of time off for training – is associated with low turnover among care workers. Those good HR practices what were found to be associated with higher turnover included some basic employment conditions such as regular uprating of pay, employer paying for CRB checks, fitting work schedules with employees‟ circumstances and offering guaranteed hours contracts, suggesting that employers may only provide some of the basic employment protections when required to do so by high labour demand and associated turnover levels. Likewise, the association of formal recruitment methods with higher turnover may reflect either a need to extend recruitment beyond informal networks in areas of high demand or alternatively that more informal methods yields more stable and committed employees. Among homes fewer HR practices are identified as significant. Nevertheless, it is notable that good work organisation practices, such as encouraging discretion in the job and facilitating time to undertake caring duties, are associated with high scores on our training outcome measure for homes. Two other HR practices are associated with lower staff turnover rates in homes - the identification of care skills when selecting good recruits and the facility for some staff to avoid regular weekend working. For both homes and IDPs certain organisational characteristics also matter in explaining variation in HR outcomes, namely: the smaller the provider the better the summary index of recruitment and retention outcome; national chain providers appear to have worse training outcomes than single establishment homes and than local chain IDPs; and not-for-profit homes enjoy better staff turnover than for profit homes. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 267 IV.6. Providers’ views on the social care policy and commissioning environment IV.6.1. Providers‟ attitudes towards and experiences of local authorities We asked providers how they would rate their relationships with the LA on a five point scale from very good to very poor: 81% of care homes and 87% of IDPs regarded their relationship as either very good or good and only 6% of homes and 6% of IDPs regarded their relationship as poor or very poor, the rest remaining neutral. Despite this relatively low level of variation in answers to the question, when we compute average scores by individual LA we do find some relationship between our classification of LAs and providers‟ responses concerning their relationships with the LA. Table IV.16. Measure of providers’ satisfaction with LA relationship (1-5 scale, very poor to very good) IDPs average score Homes average score All average score Partnership LAs: AH LK RN UY XD 4.6 4.3 4.5 4.7 4.2 4.5 4.2 4.7 3.0 4.4 4.6 4.3 4.6 4.4 4.1 Mixed LAs: AD OM ON RT TE 4.5 4.3 4.2 5.0 5.0 3.5 4.7 3.5 3.3 3.0 4.0 4.6 3.9 4.3 4.2 Cost minimising LAs: AW HD IL RD 4.7 3.2 3.7 3.7 4.5 4.0 3.8 4.5 4.6 3.6 3.0 4.1 Providers in cost minimising LAs tend to display lower satisfaction with their relationship with the LA for domiciliary care than among providers located in partnership or mixed LAs. 38 Table IV.16 shows that among IDPs, the level of satisfaction was lowest in three cost minimising LAs – HD, IL and RD. Scores for homes were more varied with three mixed LAs - ON, AD 38 The one exception is the cost minimising local authority AW where relationships with providers were reported as relatively good. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 268 and RT – recording the worst scores but two of the cost minimising LAs also receiving below average satisfaction ratings. A number of quotes from the providers during the telephone interviews underscore the complexities of categorising relationships with the LA. Some made a distinction between their relationship with their immediate points of contact and their relationship with those making policy decisions. Others pointed to differences in their relationships with different grades or levels of staff. The difficulty is it needs to be qualified because they have a contracts officer and we get on very, very well with her. Her boss, great guy, get on well with him. But when we‟ve got an issue we have absolutely no way into the council to make any difference. …..when we‟ve got particular issues they don‟t want to know. ……So that‟s the difficulty of dealing with a public authority. You just can‟t get there to where the decisions are made. The bureaucracy doesn‟t allow you to do it. (ON.D.1 DN). I think its best to speak of the last couple of years because before that it wasn‟t so wonderful, I think that sometimes its about there are some very capable people there and some team leaders who aren‟t so good, so probably some problems with communication following things up and that is often around safeguarding issues. (RD.D.2.CL). Another distinction made was between the personal relationship and their satisfaction with funding: With regard to funding when I said we had a good relationship, well they don‟t meet our funding requirements. (RD.HN.4.C.N). Work relationship is fine, but it is the funding issue. We are the lowest paid authority. (IL. H. 4). Past poor relationships were apparently forgiven if new policies provided more financial support: I think it‟s probably a lack of support in the past. But what has improved is training. It‟s had a huge impact for us because it‟s saved us a fortune off our training budget. (RD.H.3.A.L). Some providers clearly had a negative view of the role of the LA: I think the experience we get in nursing homes is it‟s kind of almost like a policing of us rather than a supportive, or work together. (ON.HN.1 BS). Yet others attributed problems to the policies of central government rather than the LA itself: But then again, they‟re on a budget aren‟t they? It‟s the government, it‟s not them. (ON.D.2 AS). EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 269 Specific problems identified ranged from a tendency to impose the latest policy fads or concerns on providers, regardless of its relevance or priority, to insistence on contract compliance even when LAs had been informed of recruitment difficulties and staff shortages. [Its] pressures that senior management put onto you, you know it‟s other people‟s agendas … So no matter what you‟ve got planned if they say, because of an issue in another unit, every member of staff has to be refreshed in, oh I don‟t know „Violence at work‟ …then your training plan just goes out of the window. It means that you‟ve got to get everyone on that training. (HD.HN.1.C.LV). [It‟s the] contract – [there‟s] no cap on it. They are aware we have recruitment problems and we don‟t have enough staff, but they refuse to stop forcing work on us because it is part of our contract. In other words, it‟s, „You have the contract and it is your problem‟. (HD.D.1). Recurring themes among the national providers in discussing their relationships with LAs were first the variation between LAs, with only one national provider saying they did not find much variation. Others stressed differences in approach to communication; differences in the administrative details of contracts and commissioning practices (leading to great waste and duplication); and above all differences in pricing strategies. These include differences in the fixed fees: Local authorities will sometimes fix in the contract what the price should be. So I suspect they haven‟t necessarily market tested whether you can get care workers at some of those rates. So there are some anomalies there. You‟d like to think that before they came up with the charge rate they maybe had a view of what they saw in terms of care worker retention and pay. But I wouldn‟t like to say that always happens…… Managing Director, NATDOM4 And differences in their implementation of policies which affect the overall profitability of the business: If you look at some of the requirements, and this is where it gets implicated by local authorities, the advent of call monitoring, electronic call monitoring. ….Some councils have a greater rigour to that. Some councils will tell you when they expect the calls to be done. So there‟s degrees of flexibility, or not, in there. I think the other thing is some local authorities will pay mileage and visit fees, and some won‟t. Some will fund all sorts of training to support you. Increasingly that‟s diminishing. You see less and less people willing to fund care worker training so it‟s down to the providers really. (Managing Director NATDOM4). Some LAs give us the contract then move the goalposts, for example by introducing call monitoring. It is a difficult thing to do mid-contract. Some dictate to you what system to use – it is always a strain on the budget. Because of the different LAs, we find it difficult to standardise. (National Recruitment Manager, NATDOM3). Some aggressive pricing strategies were, according to some national providers, jeopardising the supply of care services. Some national providers stressed that although they would accommodate to local demands they would not do so at the expense of minimum standards set by the company. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 270 So for us it‟s not about flexing completely. It‟s actually about making sure that we have got the safeguards we want in our business. So we will always enforce the minimum standards that we see and hopefully they‟re higher or the same as the local authority requires. …We know we can be efficient and competitive in terms of our price, but for us, we will walk away from contracts if we think that the local authority is going for cheap and cheerful and basically putting lives at risk. (Managing Director, NATDOM4). Some LAs were said to be inconsistent between quality and price, expecting „the highest level of service but want[ing] to pay per minute‟ (Managing Director, NATDOM5). A further problem identified was that some LAs wanted to, …run your business for you. They insist on the structure of the branch. They tell you you have to have certain people in place, and if you don‟t they reduce the hourly rates that you claim. Micro-management and minute billing. We can only claim for every minute of care we provide and we can only pay the carers those minutes. (National Recruitment Manager, NATDOM3). One specific way in which LAs seek to develop relationships with providers is through provider forums. Most LAs hold provider forums and this is confirmed by the finding that only 9% of independent providers said their LA did not hold a providers‟ forum. Table IV.17 shows that of the 88 providers who responded to a question about their own attendance at forums, 65% said they always or mostly attended the forums. There was a notably lower attendance among the providers located in our „cost minimising‟ LAs than was the case for the partnerships or the mixed category LAs. Of the 77 who expressed a view on the usefulness of the forums, around 65% considered them to be very useful or useful. Those located in cost minimising LAs were most likely to consider them not very useful or a waste of time, accounting for 18% of all providers in these LAs. In one LA, LK, the provider forum had apparently broken down and relations between the independently run homes and the LA had only been restored through formation of an association of independent care providers to re-establish dialogue with the LA. Members of the association were now invited to sit on committees and had opportunities to communicate with councillors: We have managed to get very good dialogue with them; we communicate a lot better. From time to time, there might be a few difficulties where they reject things out of hand, but on the whole, it is innovative, there are not many counties that have this sort of joint partnership. I sit on the scrutiny committee of the council for special care and that is a voice – it is useful for informing councillors about what is actually going on. In the past, councillors hadn‟t a clue. (LK.HN.1 BS). One national provider commented on the very different approaches to managing forums across LAs reflecting different degrees of interest in communication with and listening to the concerns of the care providers: We deal with some 30 different authorities and I see 30 different examples of local authorities. What I would call good authorities are the ones who organise regular provider forums. They EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 271 consult all the providers, pretty much in advance, or at least keep them informed as to what they‟re thinking. Also [they] facilitate meetings between providers, so that they can hear a consensus view. And [they] are quite happy to accept challenges from providers, and also to listen. And quite often you find that over a period of time they implement what you have said. …Then there are the authorities who pay lip service to it. Just try and do the minimum to meet up with CQC requirements. Say, „Oh yes we are consulting and blah, blah, blah‟ - whatever. And then there are others who just don‟t do anything. And yet at the same time they impose things without any commercial awareness as to the impact this would have on the providers. ... They don‟t seem to connect up the building of the capacity and the building of the service, with the changes in the rules and the regulations. (Managing Director, NATDOM5). Table IV.17. Provider views about LA providers’ forums a. Frequency of provider attendance Always Mostly Occasionally Never Partnership LAs 50.0% 26.5% 14.7% 8.8% Mixed LAs 44.8% 17.2% 20.7% 17.2% Cost minimising LAs 32.0% 20.0% 24.0% 24.0% All LAs 43.2% 21.6% 19.3% 15.9% Note: Total responses 88, missing 17 (excluding LADPs). b. Usefulness of forums Very useful Useful Sometimes useful Not very useful Waste of time Partnership LAs 23.3% 33.3% 36.7% 3.3% 3.3% Mixed LAs 32.0% 44.0% 20.0% 0.0% 4.0% Cost minimising LAs 27.3% 36.4% 18.2% 13.7% 4.6% All LAs 27.3% 37.7% 26.0% 5.2% 3.9% Note: Total responses 77, missing 28 (excluding LADPs). The comments confirm the prevalence of very different approaches to building relationships with providers identified in our own interviews with the selected LAs. Providers were also asked what, if any, changes in the LA‟s commissioning and contracting arrangements would do most to assist them in recruiting and retaining a stable and motivated workforce. A list of options was provided (three items common to both homes and IDPs and a further two items added for IDPs) and multiple answers were accepted. A rise in LA fee levels was the most popular option, chosen by 55% of homes and 58% of IDPs. This view was also forcibly endorsed by at least one manager of an LADP. For the life of me I do not know how you can offer a service for somebody when all you receive is ten and a half quid an hour. … A woman set up a cleaning firm in [this area]. She charges twelve quid an hour at the front end. Her office is her living room. There‟s only her and her car EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 272 and she has a number of cleaners that she sends out. For that she charges twelve quid an hour. We‟re asking people to provide personal care services, with all that that involves, at ten and a half quid an hour. We have to pay a lot more, frankly, if we want a good quality service that meets the national minimum standards in a robust way that provides the level of care that people deserve. We have to pay a lot more for it. (AD.DIH1.DP). The option of more variation in price by service user or for homes by type of accommodation was selected by 31% of homes and 34% of IDPs. One home called for „much higher pay rates for those with mental health problems‟ (RD.H.3.A.L). However, one IDP felt everyone was underpaid so that the only way forward was better funding all round. No I think care, whether we‟re going in to give somebody a bath or care to someone being commoded or providing support to someone through cooking and domestic help, it all places the same demands on carers, the same training levels and the same conditions that they are working under, so it needs to be better financed. (RD.D.1.C.S). There was more variation in the third option – a more integrated approach by the LA to service delivery- with 37% of IDPs selecting this change compared to only 21% of homes. The additional items asked of the IDPs were also selected by over a third of IDPs: that is, there was fairly widespread support among providers for more scope to determine how care is delivered, higher guaranteed volumes of work and more time for a service user. However, those not selecting the option on guaranteed volumes may have sided with the provider who said that block contracts were squeezing out space for those not selected to be block contractors or preferred providers. Some more specific issues were raised under the „other changes‟ category. Some of the comments related to specific policies of their LA: for example, one home (TE.H.2) was concerned about a five to ten year lock-in written into their contracts. One home asked for „More clarity, openness and honesty‟ (XD.D.2). Among IDPs, the concerns related to the lack of attention to people in the tendering process - according to the respondent at one IDP RN.D.3) the LA commissioner needed to follow the guidelines in this respect - and others talked about the lack of attention to quality of life of users and the fact many users were lonely. One provider thought LAs should pay mileage (ON.D.4) and another that they should be speedier in their response (RT.D.2). Some providers asked for changes that went beyond the individual LA; for example one home called for registration for care staff to raise their profile (XD.H.3) and others raised concerns about complexities of the funding arrangements or about restrictive regulations on admissions to care homes. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 273 IV.6.2. Providers‟ attitudes towards and experiences of monitoring systems Through our telephone survey, we asked providers about their experience of monitoring systems. Questions were designed to cover both the role of the LA in monitoring and of the role of Care Quality Commission (previously known as the Commission for Social Care Inspection). Role of the LA in monitoring providers The providers were asked what importance they thought the LA placed on provider HR policies (table IV.18). Around 43% said that it was very important and a further 44% somewhat important, leaving only 14% of respondents who said their LA attached no importance to it. This share was highest among the mixed category of LAs and it was the providers in the cost minimising LAs that had the highest shares saying the LA considered their HR practices to be very important – at 50%. One provider in a cost minimising LA, however, made the comment that there may be greater interest in compliance with regulations than in supporting the providers to improve their HR practices. Well that‟s it they … love lots and lots of paper work and love giving lots of rules and regulations but then never support you to obtain them or keep up with them or stuff. We have tendered for work with them but sometimes its just unrealistic in terms of demands made by them. (RD.D.1.C.S). Table IV.18. Provider views about the importance the LA places on providers’ HR practices Very important Somewhat important No importance Partnership LAs 36.0% 56.0% 8.0% Mixed LAs 44.8% 34.5% 20.7% Cost minimising LAs 47.4% 42.1% 10.5% All LAs 42.5% 43.8% 13.7% Note: Total responses 73, missing 32 (excluding LADPs). The survey also included a question about whether the provider‟s LA was directly involved in monitoring or whether the LA relied on the Care Quality Commission to monitor its providers. Table IV.19 shows that around four fifths of providers said their LA was involved directly and just one fifth said the LA relied completely on the CQC. The involvement in monitoring was somewhat higher in the partnership LAs at 85% but LA involvement was higher in costminimising than in mixed LAs. Comments from the providers suggest that the amount and frequency of monitoring varies and that LA practice may be inconsistent over time: EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 274 [The LA] does do some monitoring. … They come in and check policies and procedures. but that‟s probably happened just once in the last five years. (RD.H.3.A.L). [The LA] had stopped active monitoring, but now restarted. (LK.D.3 DS). Certainly there is a lot of monitoring. [The LA] is very much better than they were I have to say. (OM.D.2.DN). They are very strict and visit the branch regularly and take away care workers‟ time sheets for audits regularly. (HD.D.1). [The LA] doesn‟t do any [monitoring], but I think that it will do in the future. We have had to send our policies, procedures, training policies, etc. (TE.H.4 AS). Table IV.19. The role of the LA and CQC in monitoring providers LA direct role CQC only role Partnership LAs 85.4% 14.6% Mixed LAs 71.4% 28.6% Cost minimising LAs 81.5% 18.5% All LAs 79.6% 20.4% Note: Total responses 103, missing 2 (excluding LADPs). Many provided examples of the types of monitoring that LAs were engaged in. The areas that were mentioned frequently were recruitment processes and turnover or training. Only one mentioned equality and diversity policies and some implied that most of the monitoring was done at the tender and contract stage. One provider said that not only was the LA involved a lot in monitoring HR, including looking at their HR policies, but they had also provided them with access to some advice from an employment law firm For some providers the involvement of the LA as well as CQC was too much: The day of the cancelled interview [with the research team], they were in all day. I wish they would talk to each other [CQC and LA], it is exhausting. (IL.H.4). There is too much inspection. The company come in, the LA, CQC. What I want from the company is for them to say that I am doing OK, and leave me. CQC is fine, but sometimes it seems as though there is too much. (IL.H.3). These views were held by some national providers who saw the active involvement of LAs in quality monitoring as unnecessary duplication and increasing problems at defining and adopting a consistent policy. I think some of them [LAs] decide to have a much greater involvement with inspection of the services that they‟re commissioning, which we think is duplication because there is the CQC that is charged with making sure quality is right in everything. (Corporate Services Director, NATHOME2). EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 275 Where we can have issues is around, from an HR perspective, it is around some of the policy stuff. Whereby we‟re having to double train people because we have, say, issues around, someone has a separate medication policy, and we from a CQC perspective have to do it one way, and then we have to do it again another way from a local authority perspective. So it can be a little bit of a struggle sometimes, where the local authority will insist on a certain type of training taking place, which is not necessarily part of the National Minimum Standards or anything mandatory. (HR Director, NATHOME5) The results presented in table IV.20 suggest that over 70% of providers were satisfied or very satisfied with CQC quality standards but that satisfaction rate fell to below 58% when asked about satisfaction with CQC quality rankings. A very high share of those ranked one star were unsurprisingly dissatisfied and nearly 27% of those ranked 2 star were also not satisfied. Even 7% of the 3* establishments expressed dissatisfaction. A repeated theme among the providers was a concern over the consistency of CQC ratings. Inconsistency was attributed both to variability among inspectors and to false impressions due to snapshot inspections. Well I think that the standards are a very good thing but I‟m not altogether sure about the Commission because I think that they‟re quite sort of inconsistent. I think that some of their inspectors are inconsistent but the standards are good. (UY.D.2.B.S). I think it would be better if it was done over a length of time rather than just a snapshot of that day that they‟ve come in. (HD.HN.1.C.LV). EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 276 Table IV.20. Providers’ attitudes towards the Care Quality Commission a. Satisfaction with the CQC’s set of quality standards Very satisfied Satisfied Neutral Dissatisfied Very dissatisfied Partnership LAs 28.3% 52.2% 13.0% 2.2% 4.4% Mixed LAs 21.1% 42.1% 26.3% 5.3% 5.3% Cost minimising LAs 32.3% 35.5% 19.4% 9.7% 3.2% All LAs 27.0% 44.4% 19.1% 5.2% 4.4% Note: Total responses 115. b. Satisfaction with the CQC’s system of quality ranking Very satisfied Satisfied Neutral Dissatisfied Very dissatisfied Partnership LAs 19.6% 37.0% 26.1% 6.5% 10.9% Mixed LAs 18.4% 34.2% 29.0% 10.5% 7.9% Cost minimising LAs 25.8% 38.7% 19.4% 12.9% 3.2% All LAs 20.9% 36.5% 25.2% 9.6% 7.8% Note: Total responses 115. c. Belief that the individual provider star ranking is fair Yes No 1 star rating 28.6% 71.4% 2 star rating 73.2% 26.8% 3 star rating 92.6% 7.4% All providers 72.3% 27.7% Note: Total responses 112; missing 3. Similar concerns over consistency were also expressed by national providers (see box IV.22). A further problem was the focus of the CQC on those rated adequate or poor with less frequent inspections for those seeking to improve from good to excellent; for some national providers this made it difficult to apply pressure to raise standards. Some of the national providers were operating their own audit and monitoring systems both to raise standards and to ensure that their homes or IDPs were ready for CQC inspections (box IV.22). Suggestions from the telephone survey respondents as to how to change or improve CQC monitoring included the following: Less attention to paperwork and more attention to people - „particularly for people who don‟t speak [they need to] use more skilful communication with people and their families.‟ (RD.D.2.CL); More focus on the needs of users through „sight of detailed care plans‟ (AH.D.3.CN); EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 277 More focus on building relationships, „to encourage organisations to meet standards and to work together with the Care Quality Commission to aim for higher standards right across the board‟. (OM.D.2.DN); More „listen[ing] to what we are saying‟ and „less tend[ency] to treat all the homes the same.‟ …. so that „what is deemed necessary in a big home where there might be different staff on each day‟ might not be in a small home where managers see and talk to their staff every day. (RD.H.3.A.L); Change to the ranking system to use the 5* system used by the hospitality industry on the grounds that „I wouldn‟t stay in a two star hotel‟ (LK.H.3 BL). Box. IV.22. The views of national providers towards care standards i) Burden of regulatory compliance The challenge is to meet the increasing expectations and burdens of regulations, of training, within a fee rate which is declining, or not increasing at the same rate. (Managing Director, NATDOM5). ii) Effectiveness of CQC I think they are in such a state of flux. I think what I‟m not satisfied about is the lack of consistency. Different inspectors have different approaches, so that‟s one thing. Not satisfied at the rate at which the inspectors are changing. (Managing Director, NATDOM5). We actually go quite far beyond CQC standards through quality. So we like to feel that because we‟re doing that we should be pretty much compliant with anything CQC would do. I think that‟s been borne out by the results of our audit inspections. I guess the complexity of that is that sometimes you are dependent upon the inspectors. Good day, bad day, or focus [on a ] particular area. (Managing Director, NATDOM4). I think for us, we have our internal audit team as well looking at different things. So for us, the combination of the two works well. Our internal quality audit is, I think, harder than the CQC was and I think, in terms of people and motivation, the thing that‟s the most difficult with CQC is that they‟re not going to be assessing their good and excellent services. They‟re focusing on the poor and adequates, which means it‟s difficult to get a good service to excellent at the moment. (HR Director, NATHOME3). The biggest problem we have is inconsistency. We have what I think is a relationship provider, which is a senior manager at their headquarters. But that person has no executive power over the inspectors all over the country. And we will get an inspector in one part of the country saying you know, you‟ve got to do xyz because regulation say so. And we‟d say, well that‟s not how we read it, with all due respect, it‟s not like how the CQC read it, and sometimes it will lead to a debate and others it will lead to, „I‟m inspector here, you do as you‟re told‟, or whatever. (Corporate Services Director, NATHOME2). EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes iii) 278 Activities to improve outcomes What we‟ve done is we‟ve now got a regulation team which helps managers. Sometimes we don‟t evidence the good things we do well and I think it‟s taking that turnaround of „you‟re good at this; lets show it‟ and we sometimes don't have the evidence, because it‟s very evidence led and they‟re constantly trying to move to an objective type of regulation. But it‟s getting our managers and supporting them to get the training records. Sometimes it is happening but it‟s how you evidence the things that are happening. (Recruitment Director, NATHOME1). Every region now has a head of service quality and they have reporting to them, a team of service quality inspectors too, who do exactly that; they go into the homes, inspect them and rate them internally and help them come up with action plans to address any issues, and then there‟s a team of service quality advisers who actually go into the homes and help them implement plans, coach and support the home manager. … Rather than waiting for CQC to come and tell us here‟s a problem, we‟re aiming to identify those kinds of things for ourselves and then we can take action so that by the time CQC come we can either say, „Yes, we know we‟ve got problems and this is what we‟re doing about them‟, or we‟ve actually tackled them and in fact CQC are looking at something rather better. (Group HR Director, NATHOME4). In addition to asking providers about their satisfaction with care standards, we also asked them to identify which of the CQC standards they found the most challenging. Table IV.21 aggregates all the answers covering the four most challenging standards for homes and IDPs separately. This reveals that the care standards that are the most difficult to meet vary between homes and IDPs, related to the nature of the service. Thus, for IDPs the most challenging standard was to ensure „service users are protected from abuse, neglect and self-harm‟, presumably as a consequence of the fact that IDP service users are located in their own homes and are only seen intermittently and by mainly one member of staff. For homes the most challenging standards is ensuring that „service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious, and recreational interests and needs‟. The difficulty in meeting this standard in part relates to differences in expectations among service users as one home manager commented: I don‟t find any of them [care standards] challenging; this is my job, so professionally I should be able to meet them. Maybe the one … to do with their [users‟] perceptions. They may expect to be tied to the bed and fed bread and water, or [they may] expect three staff in the room, chandeliers and champagne for tea (IL.H.4). The standards that relate to staffing issues - including training, skills or performance appraisal (asterixed in the table) - were mentioned only by a minority of providers, accounting for 16 out of 92 responses among homes and for 14 out of 96 among IDPs. But of course many of the standards are implicitly dependent upon quality care staff, especially in the IDPs. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 279 Table IV.21. CQC care standards most difficult to meet for homes and IDPs (aggregate scores for the top four most difficult to meet care standards) Home care standards Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious, and recreational interests and needs. Service users, where appropriate, are responsible for their own medication and protected by the home‟s policies and procedures for dealing with medicines. Service users‟ health, personal and social care needs are set out in an individual plan of care. Staff are trained and competent to do their jobs* Rank (no. of homes) 1 (18) Domiciliary care standards Service users are protected from abuse, neglect and self-harm Rank (no. of IDPs) 1 (18) 2 (10) Policies and procedures on medication and health related activities protect service users 2 (16) 3 (7) Service users receive a consistent, wellmanaged and planned service The risk of accidents and harm happening to service users and staff is minimised Service users know and benefit from having staff who are supervised and whose performance is appraised regularly* Service users treated with respect, valued and right to privacy upheld 3 (13) 6 (5) Care needs individually assessed 7 (6) 6 (5) Health, safety and welfare of service users is promoted and protected The well-being, health and security of service users is protected by the agency‟s policies and procedures on the recruitment and selection of staff Service users know that staff are appropriately trained to meet their personal care needs* Service users, relatives and representatives are confident that their complaints will be listened to, taken seriously and acted upon 8 (5) 3 (7) Service users‟ needs are met by the numbers and skill mix of the staff* 5 (6) Service users assessed and referred solely for intermediate care helped to maximise their independence and return home. Service users are helped to exercise choice and control over their lives. The home is run in the best interests of service users Service users receive wholesome, appealing, balanced diet and pleasing surroundings at times convenient to them 6 (5) No service user moves into the home without having his/her needs assessed and assured that these will be met. The health, safety and welfare of service users and staff are promoted and protected 9 (4) Service users are in safe hands at all times Service users‟ financial interests are safeguarded Service users maintain contact with family/friends/representatives and the local community if they wish. Service users are protected from abuse Service users feel they are treated with respect and their right to privacy upheld. Service users‟ health care needs are fully met Service users are supported and protected by the home‟s recruitment policy and practices Service users live in a safe, well maintained environment Service users live in a home run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully 12 (3) 12 (3) 14 (2) 9 (4) 9 (4) 14 (2) 14 (2) 14 (2) 18 (1) 18 (1) 18 (1) Note: * Care standard relating directly to HR issues such as staffing levels, skills, training and performance appraisal. EWERC 4 (10) 5 (9) 6 (7) 8 (5) 8 (5) 11 (4) Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 280 IV.6.3. Providers‟ attitudes towards, and experiences of, policy developments likely to affect social care Providers were asked to comment on two policy developments with potential implications for the social care market. One was whether the new regulations limiting non EU migrants would affect their ability to recruit sufficient or sufficiently skilled care staff. Most answering said either that they had not used migrants or that, while it would have been of concern in the past, the recession meant it was no longer a key issue. However, one or two providers expressed rather high levels of concern. For example, one home said it was „our biggest concern‟ (LK.HN.1BS) and another home in the same area had engaged a solicitor to help them obtain the right certification to enable them to continue to recruit. One home in the HD LA was concerned that some of their existing staff would fail to get the right number of points required to stay on. IDPs were also asked about what problems or opportunities they anticipated as a result of an increase in direct payments and individual budgets. Some saw this as an opportunity to improve the quality of care as users might be able to trade volume of care hours against quality: I think too many LAs focus far too much on price rather than quality, as much as they say that they do, we know that they don‟t. I think it‟s really sad that the local authorities are in that situation, they can‟t choose the best care because they can‟t afford the best care so that needs to change. I think the government needs to recognise that people deserve to choose. Some may want more hours at a lower price and lower quality of service and if that‟s what they want then that‟s fine. But equally they should be given the opportunity to choose better quality, maybe less hours but a more costly service because that‟s what they want for their circumstances, at the moment people are not getting that choice. (OM.D.2.DN). Two national providers of domiciliary care also talked about the need to upgrade the quality of both their staff and services: Traditionally a lot of domiciliary care provision has been set up around national minimum standards and that‟s the scope of the ambition. For us, what we need to do is try to look further forward and to adjust our workforce and the skills of our workforce and the way we reward our workforce and develop them in accordance with the provisions of personalisation. (HR Director, NATDOM1). As a company we are looking at changing the way we recruit - having service user involvement in recruitment and training - and the services we provide [we are] going to have to extend and offer more variety. We have a company strategy on this. (National Recruitment Manager, NATDOM3). By and large concerns over personalised budgets were prefaced with comments that the providers - both local and national - supported the idea of personalisation in principle but they had a range of concerns over practicalities. A first set of concerns related to poaching of staff and guarantees of payments as some had already experienced difficulties in extracting payment from individual budget holders. EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 281 Another one we had and we used to provide a serious amount of care for her, two carers four times a day. Very, very difficult to get payment off her. Direct payments team weren‟t interested whatsoever. They constantly advertised behind our backs for PAs for her. We lost one of our staff to her. We‟d CRB‟d her, inducted her, introduced her, we lost her. So that was another one. (ON.D.1 DN). I think it‟s just the sheer organisation of getting the money in, [compared to] having a block contract where we invoice once a quarter, same amount every quarter. (RD.D.2.CL). These concerns were also echoed by the national providers: And because if the cash is given to the individual and the individual has to spend the cash and pay the providers, and then the providers have to take a credit risk on that. Whereas if I‟m dealing with London Borough XX for example, I can - at least I know that if I‟ve done a proper bill they will pay me, I don‟t have to worry about the local authority going bust. (Managing Director, NATDOM5). Other concerns related to the potential for abuse, if families took the money but didn‟t provide the care and the problem of an individual personal assistant providing cover. Some were concerned about personal assistants not being trained or subject to CRB checks, an issue also taken up by national chains who were concerned about the lack of minimum standards for personal assistants and the unfairness of holding agencies responsible for meeting a whole set of standards while allowing individuals to take up work under personalised budgets without training or CRB checks (see box IV.23). National providers raised another set of concerns over how the system was being implemented and administered in practice, including the differences in approach between LAs and the consequent complexities, administrative costs and shifting of responsibilities onto users or agencies. Box IV.23. National providers’ views about the implementation of personalised budgets i) Actions by LAs As a principle I have no quibbles with [direct payments]. The problems I envisage are the rates of payments. Some of the local authorities are paying, in terms of direct payment, the rate is lower than what they would pay an agency. … So if you are paid less than, you have a choice. Either you have to top up the £11 to buy the service from the agency or you have to employ a personal assistant – a local, your neighbour or whoever is doing that. (Managing Director, NATDOM5). The challenge is that every single local authority seems to want to do things differently. If you look at direct payments. Sometimes people are being paid a lot less than they would if they were getting care provided through social services. Sometimes they get paid more. And the whole mechanisms by which that funding is arranged and agreed and how it‟s processed can be quite complicated. So you‟ve really got to know the local area to know how they process a direct payment. (Managing Director, NATDOM4). What I see is authorities seeing individual budgets as a way to effectively cut a substantial amount of inhouse financial administration because they‟re not laying contracts, they‟re not having to deal with the invoices coming through, reconciling invoices and timesheets etc., etc. I think they see it as a EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 282 fairly large financial incentive, a large financial incentive to pursue individual budgets. I think the other aspect is I see the direct payment level is often set substantially below the prevailing contracted rate. So not only are they saving because they‟re chucking out financial administration. (Commercial Director, NATDOM2). ii) Actions by central government All the registered providers have this problem that personal assistants are not CRB checked. They do not always pay their National Insurance or tax or whatever. And they cannot provide holiday cover, and they are not trained. … Having gone round and setting up a registered service, and everybody is going through the registered process, all the providers, we‟ve got to meet minimum requirements, you‟ve got all these conditions. To then say, actually we‟re going to have a whole lot of people who can provide service as a personal assistant. It just doesn‟t work. That‟s one big problem. And I don‟t know how much the local authorities are spending on administering the direct payment service. (Managing Director, NATDOM5). EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 283 IV.7. Summary Building on the mapping of results presented in Part III, this part of the report interrogated the findings from the telephone survey in more detail using a mix of statistical techniques and also further explored qualitative interview data from provider managers, including senior HR managers from the headquarters of ten national chains of providers. The six sections explored step by step the patterns of effects of organisational characteristics, local authority commissioning and labour market conditions on HR practices and HR outcomes experienced by social care providers. Here, we summarise the key findings of each section. We began by identifying the organisational characteristics of the sample of 115 providers included in the telephone survey, supplemented by additional details for ten national chains that also probed the pros and cons of being a national chain. The sample includes a wide range of organisations characterised by size, ownership type (including nearly half as part of national chains), public/private/not for profit status and CQC star rating, as well as by business conditions such as percentage of bed vacancies, role of block contracts and reliance of service users on LA funding. The extent of management support for HR practices was found to be stronger in national and local chain providers, with less than one in ten single establishment providers benefiting from a specialist HR manager. Nevertheless, only a third of all providers had support available locally or on-site. Given these different provider characteristics, section IV.2 analysed the statistical relationship between size, ownership, CQC star rating and public/private/voluntary status and the variety of HR practices and outcomes, drawing on a specially constructed, „standardised‟ dataset from the telephone survey. Central to our analysis is the use of carefully defined indices and sub-indices of HR practices and HR outcomes. These establish a standardised measure of quality for defined HR practices such as pay levels, employee development, recruitment and retention and working time, and for defined HR outcomes, including recruitment and retention, training and staff turnover. Our objective was to identify those characteristics that are associated with good practice and good outcomes. Key results include the following: Homes, IDPs and LADPs: - there is very little overall difference in use of good HR practices between homes and IDPs, but the public sector LADPs register significantly higher on four out of six indices, especially pay levels and employee development; - homes deliver better HR outcomes than IDPs or LADPs despite the better HR practices in LADPs, suggesting that the nature of domiciliary care work requires a higher standard for HR practices; Size differences: - there are mixed effects of size on HR practices by size of establishment (among other findings, examples include larger homes making more use of appraisals, EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 284 smaller homes being less likely to require weekend working, and larger IDPs more likely to offer time off for training); - large homes and large IDPs tend to have worse recruitment and retention outcomes than smaller providers as measured by management perceptions, and more training outcomes but there are no significant differences by size in quantitative measures of staff turnover; Ownership differences: - national chain homes are more likely than other ownership types to have staff working long hours and long weeks, and least likely to pay premiums for unsocial hours, but more likely to provide regular pay uprating; - there is limited evidence of differences among IDPs by type of ownership and this fits with the qualitative interview data, which highlights local design of HR practices, such as pay-setting for example, among national chains; - single establishment homes score better on training outcomes than chains and local chain IDPs score better training outcomes than national chains; CQC star rating differences: - homes with a CQC 3* rating provide significantly better pay and pay-related conditions than 1* and 2* homes, but worse employee development and voice opportunities; - 3* IDPs are more likely to pay for qualifications than 2* IDPs; 3* IDPs are less likely to have all staff working weekends than 1* IDPs. Public, private and voluntary sector status - Public sector LADPs score higher on most indicators of HR practices than both homes and domiciliary care with working time and work organisation the two exceptions where homes score higher, suggesting that these are affected by the nature of domiciliary care work. Voluntary organisations score higher than for profit independent sector providers, particularly on pay levels, although this may reflect the higher share of private clients among voluntary sector homes in our sample (see part III.3). - The public sector LADPs do not score better on HR outcomes than homes, despite better HR practices. The low outcome scores for all in domiciliary care suggests that a higher standard of HR practice is required for similar HR outcomes in domiciliary compared to the home sector. The voluntary sector has better outcomes than the private sector and similar to the LADPs but the sample of voluntary sector organisations is skewed towards homes. Evidence from the interview data underlined the relatively limited variation in quality of HR practices among independent sector providers. A willingness to pay more to care workers was constrained by a perceived inability to raise revenue through charging higher LA fees. Managers identified several HR practices as possible levers to improve recruitment and EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 285 retention outcomes but tended not to value improving workers‟ discretion at work or their nonpay benefits. A second set of results identified the impact of the LA commissioning environment on quality of HR practices. The interview data suggest LA fees play an important role in determining the level of care workers‟ pay. However, our analysis shows that while higher fees facilitate the payment of higher pay they do not guarantee higher pay. For IDPs, for every £1 increase in hourly fees, the rate of pay increases on average by just 19 pence and for homes by just 14 pence. Reliance on LA funding among homes does appear to dampen pay rates; the greater the share of LA funded clients the greater the likelihood of them paying care workers very low rates of pay. As with pay levels, there is positive, albeit relatively weak, support for the idea that LA fees positively influence the quality of HR practices. The results suggest higher fee paying LAs support a higher score for the summary index of HR practices for IDPs, as well as a higher index of pay levels for homes. The quality of other HR practices is higher on average in high fee areas but differences are not found to be statistically significant. Fee levels offered limited explanatory value for differential HR outcomes, with the exception of training outcomes being surprisingly worse in high fee areas than in medium or low fee areas. Using the categorisation of local authorities as adopting partnership, mixed and cost minimising approaches to contracting for elderly care services (from part II of the report), we found that these differences offered some value in explaining differences among homes but not for IDPs. Among homes contracting with partnership-type LAs, most sub-indices of pay practices scored higher and weekend working was less likely to be required. At the same time, however, homes in cost minimising areas were most likely to have adopted good employee development and voice practices. Like fee levels, this categorisation of LAs offered limited value in explaining differential HR outcomes, with the exception of training outcomes in homes (better in mixed LA areas) and recruitment difficulties in homes (worse for those in partnership areas than in cost minimising areas). Section IV.4 presented a similar analysis of HR practices and outcomes considering the effects of local labour market conditions rather than LA commissioning. A first significant finding is that in their approach to pay setting, just as we found with LA fee levels, not all providers respond to local labour market pay levels (at least with respect to median pay levels for female part-time workers in the LA area) in the same way. Around a fifth paid below 75% of the local median, one in six paid above 90% of the median and the rest in between. Using the more general categories of strong, medium and weak labour market demand (developed in part I), the findings point to a tendency for providers to respond to strong labour market conditions by improving their HR practices. For homes, this is particularly true of the indices that measure the quality of pay levels and working time, as well as the summary HR practice index. Other sub-indices support these findings, including greater use of pay practices that reward unsocial hours and lesser requirement of regular weekend working in homes located in strong labour demand areas. Two counter-intuitive results, however, are that these same homes are also less likely than others in less strong labour demand areas to implement EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 286 good work organisation practices (such as encouraging workers to use discretion to manage the timing and tasks of care duties) and less likely to match working time with employee preferences. For IDPs, several results follow those for homes, including the measures of good quality practices towards pay levels, payment for unsocial hours and the requirement for staff to regularly work weekends - all of which are better in strong labour market areas. The results for the measure of work organisation are again counter-intuitive, this time suggesting that IDPs in strong and weak labour demand areas implement better work organisation practices than IDPs in medium demand areas. The labour market appears to shape HR outcomes also. In particular, achievement of NVQ targets is negatively related to labour demand, with an especially strong penalty effect on IDPs in strong labour demand areas. This may be an indication of poaching of qualified workers in tight labour markets, a problem than is not confined to the social care sector. While sections IV.3 and IV.4 usefully illuminated the direction and significance of associations between organisational characteristics and environmental factors on the one hand and HR practices and outcomes on the other, section IV.5 applied multivariate statistical methods (backwards regression models) to interrogate these associations further. The headline findings for IDPs are as follows: a partnership, high fee paying LA environment is positively associated with good HR practices, yet does not display a strong association with measures of HR outcomes (with the exceptions of two counter-intuitive results that partnership LAs are associated with high staff turnover on one measure and high fee paying LAs are negatively associated with training outcomes); local labour market factors play a role insofar as female part-time pay levels are positively associated with the quality of pay strategies, the measure of local labour demand is negatively associated with recruitment and retention outcomes and areas with high female part-time pay have lower staff turnover; several organisational characteristics explain some of the variation in HR practices and outcomes, including: - IDPs with for-profit status and of a larger size are more likely to have poor quality HR practices; - local chain IDPs benefit from a higher index of pay strategies than national chain IDPs and better recruitment and retention outcomes (subjective measure) and training outcomes; and a number of HR practices are associated with good HR outcomes in IDPs, including: - good working-time practices (such as not requiring weekend and long hours working and providing time off for training) are positively associated with recruitment and retention outcomes (both subjective and quantitative measures); - a recognition agreement with trade unions is strongly associated with lower staff turnover; EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 287 - and the practices of providing pay upgrading opportunities, paying a premium for weekend work and identifying skills and qualifications among job applicants are all associated with lower staff turnover; Given the complexity of the organisation of care work it is no surprise to find that some results point in unanticipated directions. In particular, our regressions on the two quantitative measures of staff turnover suggest that several good HR practices are associated with worse outcomes. Examples include regular pay uprating, paying for CRB checks, use of formal recruitment methods and offering guaranteed hours contracts. In these cases the cause and effect may run the other way – that is, only in conditions of high staff turnover are managers persuaded to introduce basic employment conditions and protections such as guaranteed hours contracts. The headline results for homes offer a similarly interesting and varied set of findings, as follows: the character of the LA commissioning environment has only a limited association with quality of HR practice, with the important exception of high fee paying LAs being strongly and positively associated with good pay level practices; local labour market factors play a strong role through the level of female part-time pay in the locality registering a strong positive association with quality of HR practices yet worse training outcomes, and local labour demand is positively associated with quality of pay level practices; three organisational characteristics figure in the explanation of differentiated HR practices and outcomes: - larger size homes are associated with worse pay level practices and worse staff turnover (quantitative measure) - private, for-profit homes are very strongly associated with worse HR practices, including pay level practices; - single establishment homes have better training outcomes than national chain homes; and, finally, the quality of HR approach towards work organisation practices is strongly and positively associated with training outcomes. In the final section we assessed providers‟ views on social care policy and the commissioning environment in order to provide a more nuanced account of relationships between providers and LAs and to assess views about planned policy developments. Most providers rated their relationship with LAs as good or very good. However, providers in cost minimising LAs generally displayed the lowest levels of satisfaction. The quality of relationships depended on a variety of factors such as the expertise of LA partners, satisfaction with the funding arrangements, approach to communication and (unwelcome) involvement in providers‟ business decisions. One important mechanism to strengthen relationships was LA providers‟ EWERC Part IV. The impact of organisational, commissioning and labour market factors on HR practices and outcomes 288 forums. However, providers in cost minimising LAs were least likely to find these useful and experienced the least frequent attendance. Providers identified particular changes in commissioning arrangements that might improve recruitment and retention. The most popular change was a rise in fee levels, followed by greater variation in price by service user and, especially among IDPs, a more integrated LA approach to service delivery. Other specific changes identified included a greater role for providers to determine how care is delivered, higher guaranteed volumes of work and more time for a service user. Most providers believed LAs attached importance to their HR practices (especially recruitment practices and training provision), with around four in ten saying this was very important for LAs. General monitoring of providers tended to be undertaken directly by the LA, with only a fifth or so reporting sole monitoring by the CQC; where both were involved in monitoring this was sometimes perceived as excessive. More than two thirds of providers were satisfied with CQC quality standards but only slightly more than half the quality rankings; most of those dissatisfied were providers with a one star rating. Providers‟ suggestions about how to improve CQC monitoring include greater focus on user needs, strengthening relationships with providers, better communication and recognition of diverse provider practices. Finally, providers expressed a number of concerns with respect to the new policy of direct payments and individual budgets. Most supported the principle of personalisation of care but voiced doubts about the practicalities, including problems of poaching of staff and managing the multiple invoices for payments, as well as concerns about the lack of training and CRB checks for new personal assistants. EWERC Part V. Recruitment and retention in the care sector: a case study approach 289 V. Recruitment and Retention in the Care Sector: A Case Study Approach The aim of the case studies was twofold: to explore the HR practices of care sector providers in more detail, in particular by exploring how these were experienced by care workers; and to explore and understand some of the personal motivations and expectations of those who enter the sector. These perspectives, we believe, provide insights into how providers could put in place HR practices to facilitate smoother entries into the sector and foster longer term commitments to care work. Given the impact of LA commissioning and contracting on the HR practices of providers we selected four local authorities with very different commissioning arrangements. The four LAs include two from the north of England and two from the south, and include one very low paying LA (IL), one low paying LA (ON), one medium paying authority (RN) and one high paying (XD). Two (XD and RN) were classified as having commissioning environments that typified a partnership arrangement. IL fitted the cost minimisation classification and ON pursued a mixed approach (indeed it changed approach towards more cost minimisation during the period of study-see part II above). Within each LA, we carried out five case studies of providers: two domiciliary care, two care homes and one local authority provider (in three cases a local authority based domiciliary care provider and in IL a local authority owned home). We have used a simplified coding system for the providers included in this case study sample; the relationship between the codes used here in part V and those used for the same providers in the wider telephone survey are outlined in appendix table V.A1. We ensured the provider organisations spanned a range of different types and sizes and included national chains, local chains and not-for-profit organisations. Qualitative interviews with care staff and senior care staff were used in conjunction with the survey data already collected and reported in parts III and IV. The case study data played a central role in the methodology of the project to provide more in-depth data on range of areas including: firm level practices and their impact on recruitment and retention in the care sector; the characteristics and experiences of care workers including their entry into the sector, their desire to stay or leave, and the levels of satisfaction with key aspects of their employment; the linkages, where they exist, between commissioning practices, employer practices and job quality issues for care workers; differences, where they exist, between the views of established staff and those of new recruits to gauge potential problems in retention in the sector; Part V. Recruitment and retention in the care sector: a case study approach 290 linkages, where they exist, between the provision of good quality care and good quality care jobs This part of the report is organised as follows. Section V.1 introduces each LA‟s approach to commissioning and provides comparisons across the four LAs of key indicators of HR practices within the five providers per LA included in this part of the study. These comparisons focus on pay and benefits, working time, work organisation and training and development. Key HR outcomes relating to recruitment and retention are also compared. Two detailed comparative case studies of national providers are also presented; in each case we have included two branches of the same national chain among our 20 case studies and each branch is located in a different LA with contrasting commissioning strategies and contracting practices. These case studies provide insights into the relative importance of LA commissioning practices over company policy in shaping HR practices. In this first section the analysis draws on data from the telephone survey of managers, building on our analysis in parts III and IV. The subsequent sections analyse the issues from the care worker perspective. We identify key themes that emerge from interviews with care workers across all 20 case study organisations in the four local authorities. Section V.2 explores care workers‟ perspectives on recruitment into care work, while section V.3 considers the factors influencing retention among the care workers. Section V.4 considers care workers‟ perspectives on the key HR practices related to pay and working time while section V.5 considers their perspectives on the organisation of care work and how this impacts on the quality of care they can provide. Section V.6 completes this exploration by looking at perspectives on and experiences of training and development practices. Section V.7 concludes. Although most of the analysis draws on qualitative data, it has also been possible to quantify some of the responses as nearly 100 interviews were carried out, 88 with care staff. Thus the case studies provide both some indepth data and some more general insights into care workers‟ perspectives, an area of research which has been relatively neglected. Part V. Recruitment and retention in the care sector: a case study approach 291 V.1 Case studies in four local authorities: exploring the impact of commissioning and contracting arrangements V.1.1 Introducing the local authorities The following four boxes give an overview of the LA commissioning environment in the four local authority case studies, identifying the aspects of each that had led to their subsequent categorisations as partnership (for XD and RN), mixed (for ON) and cost minimising (for IL). Box V.1. Partnership local authority XD The XD local authority is based in the south of England and covered rural as well as urban areas. Its commissioning approach could be regarded as typifying a partnership approach that put HR issues at the heart of contracting. It was a high paying LA with fees ranging from £16 per hour to £28 per hour for domiciliary care and a relatively large inhouse facility covering over 40% of care provision. The independent sector fees were raised in response to providers asking for a higher fee to remunerate the staff properly to encourage retention. The LA had also moved to block contracts (for 11 providers although 24 still provide spot services) in response to provider feedback that recruitment and retention was being hampered by the lack of guaranteed hours. Overall the LA had adopted an approach of enabling independent sector domiciliary care providers to offer similar terms and conditions as those enjoyed by staff in the internal service. For example, they claimed to be only accepting tenders for organisations that paid workers £7.00 per hour but some of our case study organisations were paying lower rates. However, to offset some of the costs of paying higher fees they had introduced electronic monitoring which changed the way of invoicing and was deemed to be more efficient. According to published data this LA also had the highest average fee of our 14 LAs for external home providers (note the interview data suggested a somewhat lower fee) and had in fact moved out of residential care provision by transferring its homes to one voluntary organisation with the result that more than half the provision is based on block contracts. It did not have any quality enhancements for higher quality homes but said it would only normally make placements in homes rated 2* or 3* by CQC and never in zero rated homes. Top up fees were relatively common and most clients in local homes were not LA funded. Box V.2. Partnership local authority RN The RN local authority case study is based in the south of England. Overall it had adopted a strategic approach to promoting quality by offering quality enhancements to domiciliary care providers for meeting HR targets (and requiring these to be spent on staff bonuses or incentives, training or team building) and in adopting a fair commissioning strategy for care homes which should in principle involve no placements in homes which do not achieve a 2* or 3* CQC ranking. Fees were also higher in homes meeting higher quality standards. However, this strategic approach was adopted in conjunction with a policy of only paying a medium-level fee of £13.10 despite being a relatively high wage area and not paying travel time on the grounds that a district provider would get 55% of the work in their contracted area. Extra payments were, however, made for Part V. Recruitment and retention in the care sector: a case study approach 292 weekend work. RN contracts with ten preferred providers and the key performance indicators (KPIs) that IDPs were expected to meet to receive additional payments included keeping turnover less than the national average, ensuring continuity of care and the take up of work; meeting NVQ training targets etc. RN had not introduced electronic monitoring and was piloting outcome-based care with one of the case study providers. RN also commissioned jointly with the NHS. This joint commissioning was proving more of an obstacle than a support for the fair contracting policy as the NHS commissioners were said to be still keen to explore ways of keeping prices down while the LA had come to a view that this would only lead to low quality. However, the fair commissioning strategy had not been fully implemented due to a shortage of homes with good or excellent ratings in the area. Fees paid by RN for home placements were rated as high but top up fees were relatively common but not universal. RN only provided short term residential care in LA owned facilities but had only a low share of block contract beds in the independent sector. LA funded clients were a minority in most care homes. Box V.3. Mixed case study local authority ON The ON local authority is based in the north of England. The commissioning approach of this LA contained strong elements of both cost minimisation and partnership. ON espoused a partnership approach in its discussion of its relationship with providers and up to and including the time of the interview at the LA, there was substance to the claim that it had taken steps to ensure that IDPs paid for travel time, by paying a higher fee for short term visits and monitoring IDPs to ensure travel time was paid for. It also symbolically paid double time for bank holiday working. However, it combined this approach with a relatively low fee level of £11.17 and during the course of the project had discontinued the practice of paying more for short visits as a consequence of introducing electronic monitoring and indeed instead was introducing a system of paying only far actual minutes spent at the user‟s home. ON had moved to single pricing for domiciliary care some years ago to try to prevent poaching of care workers between providers. It now had ten preferred providers and 7 spot contractors. For homes ON only provided a low level of fees and was still engaged directly in the provision of both long term and short term care but most of the provision was joint with the NHS around intermediate care. It paid a little more for homes with Investors in People awards and was considering a wider quality enhancement framework. Top up fees were found in some but not all homes and the LA was aware sometimes private residents subsidised those funded by the LA, who are often a minority of residents. Box V.4. Cost minimising local authority IL IL is based in the north of England. We have classified this LA as a cost minimising LA in part on the grounds that it paid very low fees for both domiciliary care (£10.78 per hour) and also for care homes (the lowest of the 14 LAs) with no quality uplifts. The LA used spot contracts except in one case where a provider had been awarded a block contract to provide the hospital discharge service. There was a set price for domiciliary work of £10.78 per hour with few variations and no increases for bank holidays. There were no enhancements for short visits and the move away from block contracting had also removed payments for travel time. A premium payment for higher quality care Part V. Recruitment and retention in the care sector: a case study approach 293 had also been removed on the grounds that all providers now met the quality threshold. The LA contract managers considered that the shift from block to spot contracting had affected recruitment and retention of staff but commissioning policy was developed independently from contract management in this LA. With respect to care home placements the LA paid a very low fee and despite being a low wage area anticipated that most LA-funded residents would still be asked for top up fees. Although over 40% of placements were under block contracts to the independent sector, these were said to be political and historical legacies and were being phased out. The LA itself was only involved in short term care. The LA had a strong quality framework for monitoring IDPs and care homes but this was not linked to any financial incentives. V.1.2. Pay practices of providers by local authority. Comparison of key indicators relating to pay (see table V.1) shows that although there is some relationship between LA commissioning price and the wages paid by providers, such that pay rates are marginally higher in the high fee compared to the low fee areas, with pay rates hovering around the level of the national minimum wage (£5.73) in both IL and ON providers. However, pay levels were only slightly higher in southern locations despite much more generous fee levels: for example in one national chain fee levels were £4 to £5 an hour higher in the southern than in the northern LA but wage levels were only 25 pence per hour higher (see table V.1 to compare pay levels between XDDom1 and ONDom2). In another national chain fee levels were around £2 an hour in the higher compared to the lower fee LA but wage levels were only about 50 pence higher (see table V.1 to compare pay levels between RNDom1 and ILDom1). This evidence suggests that national chains are not passing on more favourable commissioning practices by improving employment conditions in the sector and instead pay wages that are further down the local labour market wage hierarchy. Table V.1 Pay practices across the case study providers Normal pay rates £ Area XD RN ON IL Case 1 Case 2 LA case Home 7.34 6.50 Dom 6.50 7.26 Home 6.60 6.50 Dom 6.51 7.14 Home 6.21 5.73 Dom 6.05 6.25 9.13 Home 5.73 6.08 11.82 Dom 6.00 6.00 8.41 11.11 Travel Payments 2 Unsocial hours payment1 Case 1 Case 2 LA case Case 1 Case 2 LA case Y Y Y DK Y M T T N N Y Y Y N N T N N Y Y N N N T N N Y N Y N N 1 Y – Yes; N- No; DK – Don‟t know T – Time; M-mileage only; N-none 2 The case study organisations are typical of the providers surveyed in stage two of the project in that pay varies according to provider type. The LA inhouse providers all pay higher rates of Part V. Recruitment and retention in the care sector: a case study approach 294 pay, all pay for travel time and all but one pay enhancements for unsocial hours and in contrast the lowest paying providers are care homes, particularly in the cost minimising and mixed LAs. The data relating to travel payments and unsocial hours also shows the influence of the LA commissioning environment. None of the IDPs in RN paid travel time or mileage which is consistent with RN‟s policy not to pay travel time. In contrast the IDPs in XD paid a mix of travel time and mileage, although where only mileage was paid the manager reported that in a rural area the lack of payment for travel time was still a reason for recruitment and retention problems. Only care homes in XD paid extra to care staff working unsocial hours; all other care homes offered no enhancement. Significantly, the two providers in IL that paid enhancements for unsocial hours did so because one was an LA care home and the other ILDom2 had been awarded the LA hospital discharge contract. V.1.3. Working time practices of providers by local authority There is mixed evidence as to the impact of the LA commissioning environment on the case study providers‟ working time practices. If we firstly look at the type of contracts on offer, table V. 2 shows only two out of eight IDPs (XDDom2 and ILDom2) offered guaranteed hours and these had block contracts with the LA. While this shows the LA enabling good practice in these cases, the data on other dimensions of working time show just as many variations within LAs as across LAs. Table V.2 Working time practices across the case study providers Maximum working week1 Area XD RN ON IL Case 1 Case 2 Home 6 6 Dom 6 5 Home 7 6 Dom 7 6 Home 5 5 Dom 7 6 Home 5 5 Dom 7 6 LA case Case 1 Case 2 M M M A M M M M M M 5 A 7 5 5 Contracts3 Match staff preferences2 LA case Case 1 Case 2 LA case M Z G G S Z Z G M M Z Z G A M M A M Z ZG 1 Days A-all; M-most; S-some of the time 3 Z- zero hours; G- guaranteed hours; ZG- mixed 2 Three quarters of the 20 case study providers said they matched preferences most of the time. Four reported that they matched preferences all of the time and three of these were in IL and ON, the non partnership authorities. One LADP in RN said they only matched hours some of the time; this is in line with a general finding that those working for LADPs have less Part V. Recruitment and retention in the care sector: a case study approach 295 flexibility in terms of choosing their hours compared to those working for independent providers possibly because LADPs have moved from 9 to 5 type work schedules to very flexible ones, related to their more specialist re-ablement work. This means they pay much less attention to employee preferences compared to the past. The type of provider is an important factor in explaining variations in the maximum working week. LADPs all had a maximum working week of five days although the LA care home had a maximum working week of seven days. However, some of the lowest paying homes in IL and ON only had a five day maximum working week. There was thus no obvious bundling together of poor pay practices with poor working time practices or indeed good with good; nor indeed any systematic trade-off between good working time and poor pay, for example. There were also no patterns relating to this and the LA strategy; so although no providers in XD had a maximum working week of seven days in the partnership, two providers in RN, the other partnership LA, had a policy of maximum seven day working. In this area company policy appears to the key factor shaping HR practice. V.1.4. Work organisation of providers by local authority We compared the case study providers across three indicators of work organisation. Not only were these indicators expected to reveal the influence of LA commissioning and provider practices on how care work is organised but they could also be expected to have an impact on the quality of care jobs and on the quality of care for service users. The first two indicators tap into the opportunities to use discretion to prioritise tasks and develop good relationships with service users (see section I.4 for the links between these aspects of work organisation and the quality of care). The third indicator relates to the use of electronic monitoring which is linked directly to LA commissioning practices. Table V.3 gives a breakdown of this data for each case study provider. Nine out of twenty managers reported that care workers were free to prioritise tasks, six of the nine being from care homes. However, no provider in XD said yes to this and our analysis of the manager telephone survey data from the case study providers suggest that there are conflicting views as to whether increasing care worker discretion was a good or bad HR practice. These findings mirror evidence in part IV (section IV.2) that managers did not consider changes to work organisation as a mechanism to improve recruitment and retention. The quoted responses in box V.5 from one provider manager in ON sum up the reservations some managers have about giving care workers the opportunity to prioritise tasks to improve quality care, especially those working for IDPs where such freedom may have cost implications if electronic monitoring is in place. However, as we have seen in section I.4, a certain amount of flexibility is deemed to be an important factor in service users‟ definitions of quality care and managers appear to have a view that runs counter to such perspectives where the focus instead is on following contracting requirements and care plans. Part V. Recruitment and retention in the care sector: a case study approach 296 Table V.3 Work organisation across the case study providers Freedom to prioritise tasks in ways that improve the quality of care1 Opportunities to develop good relationships with users1 Electronic monitoring2 Case1 Case2 Case1 Case2 LAcase Case1 Case2 LAcase Home SE SE Y Y Dom N SE N Y Y Y Y Y Home Y Y Y Y Dom SE SE SE Y SE N N N Home Y Y Y Y Y Dom SE N Y Y Y Y Y Y Y Home Y Y SE SE Y Y Dom Y SE Y Y N N Area XD RN ON IL LAcase SE Y 1 Y - Yes; N – No; SE - Some extent Y - Yes; N – No 2 Box V.5 Work organisation that encourages discretion: a manager’s views on whether it is a good or bad practice? Q. Are staff free to prioritise and carry out tasks in ways that they feel will improve the quality of care? A. No. We have to stick to a care plan which is provided by social services, and we have to do the tasks that are on there. Q: [So they have to do that in a strict order]? A: They do, yes. If anything else is required by the service user they have to phone up and let us know first. (ONDom2, manager) Providers were more positive about care workers‟ opportunities to develop good relationships with service users. Sixteen out of twenty providers said care workers were able to do this. There appeared to be no obvious relationship between this and the LA commissioning environment although the only provider that said this was not possible, XDdom1, had also said care staff were not free to prioritise tasks. It would seem in this provider there was limited discretion and ability to develop good relationships and both could be related to electronic monitoring. An interview with a care coordinator at the provider suggests this is the case. I would say [the job of a care worker is] more difficult [than in the past] and generally that‟s because of the paperwork involved as well…..Because they‟ve got to write more and more, that‟s more and more details, spend more time looking at the plan. With the log in, log out, obviously it‟s not taking into account how long it takes to actually get in the house. Because they‟re paid by the minute. Plus when they leave, you phone out, and then Miss Bloggs turns Part V. Recruitment and retention in the care sector: a case study approach 297 round and says, “Oooh dear, could you just put the bin out?” And then they‟ve got to do that. And then you‟ve got to say,:”Alright, I‟ll see you again”, and ... get out past the lock up and obviously none of that‟s taken into account with the log in, log out (XDDom1, Care Coordinator, age 38, 3 yrs in post) Table V.3 shows that electronic monitoring was in use in the two LAs - XD and ON- that specified its use in its commissioning. This use of electronic monitoring did appear linked to perceived lower levels of discretion for care workers as the only IDPs that said workers had no freedom to prioritise tasks to improve quality of care were XDDom1 and ONDom2. These providers were also part of the same national chain so this may either have been a general company policy to limit care worker discretion or alternatively a company policy in response to electronic monitoring in those specific LAs that used this practice to ensure care workers were able to carry out the commissioned tasks in the designated time. However, it is notable that all providers in ON reported that staff could develop good relationships, even though electronic monitoring was also in place. Overall the case-study findings suggest those working in IDPs have less discretion to prioritise tasks as the majority report this was possible only to some extent. Thus company policy, the LA commissioning environment and the nature of the work may all play a part in explaining why work organisation takes the form it does in specific providers. V.1.5. Training and development of providers by local authority A comparison of some of the key indicators relating to training reveals the limited influence of the LA commissioning strategy on this aspect of HR practice. Table V.4 shows that some of the lowest paying case study providers in local authorities with the lowest fees perform particularly well on meeting statutory requirements relating to training. This fits with the overall findings from the telephone survey that training outcomes were worse in high fee areas ( see part IV, section IV.3). In contrast two of the case study providers in RN had not met the NVQ level 2 target even though they had been set KPIs by the LA relating to training targets. The case study care homes were more likely to have NVQ level 2 qualified staff although this could reflect increased opportunities for care workers to complete any associated paperwork in the workplace rather than a stronger commitment by providers to meeting statutory requirements and training. The payment for time spent in induction training and length of induction are also indicators of providers‟ commitment to training. The XD partnership authority stands out with induction training paid by all providers, ranging from a minimum of four days to a maximum of three months. However, other trends do not relate to the LA commissioning environment. Induction training was more likely to be both longer and to be paid for in all care homes across all four local authorities. Company policy may also explain differences in policies towards induction. For example, XDDom1 and ONDom2 were part of the same national chain and both offered four days induction training. Part V. Recruitment and retention in the care sector: a case study approach 298 Table V.4 Training and development across the case study providers Area XD RN ON IL Home Dom Home Dom Home Dom Home Dom Length of induction1 Paid induction2 NVQ attainment level3 Case 1 Case 2 Case 1 Case 2 Case 1 Case 2 3 3 Y Y 3 2 1 2 Y Y 1 3 3 3 Y Y 4 4 1 1 L N 1 1 3 3 Y Y 4 4 1 1 3 N Y Y 1 4 4 1 3 2 Y Y Y 4 3 4 3 2 Y Y 2 3 LA case 2 2 LA case Y Y LA case 1 4 1 1: 4 days or less; 2: 5 days to 2 weeks; 3: More than 2 weeks Y – Yes; N – No; L – paid later if staff stayed 3 1: Up to 45%; 2: 46% to 55%; 3: 56% to 69%; 4: 70% or greater 2 V.1.6. Comparing national providers in different LA environments Boxes V.6 and V.7 compare the HR practices in place in provider organisations that were part of the same national chain but located in different LAs. These two national chain case studies can illuminate the impact of LA commissioning versus company policy on HR practices as a whole and on specific elements of HR practices as the case study establishments are located in LAs that span southern and northern locations and partnership, mixed and cost minimising commissioning and contracting practices. Box V.6. A comparison of a national providers’ domiciliary care establishments in a partnership and cost minimising local authority (RNDom1 and ILDom1). Background: Both RNDom 1 and ILDom1 were part of the same national chain and were rated 2*by CQC. RNDom1 was based in a partnership authority that paid medium level fees and ILdom1 was based in a cost-minimising authority that paid very low fees. Both providers found recruitment easy and had turnover between 10-20%. RNDom1 reported staff shortages in contrast to ILDom1 that reported no shortages. Pay: RNDom1 paid £6.51 with enhancements in contrast to its equivalent in IL which paid £6.00 with no enhancements. Thus LA fee levels were higher in RN by around £2 an hour but wages paid were only 51 pence more in the RN branch than in the IL branch. Not only is there only a limited increase in line with LA fee levels but also the stronger labour demand in RN compared to IL has had limited impact in raising wage levels, as is perhaps indicated by the greater staff shortages in the RN branch. High unemployment in IL may be enabling providers to pay very close to the NMW without much impact on recruitment and retention. RNDom1 also paid enhancements for weekend work: this was in line with the RN commissioning policy of paying for weekend work as well as with perhaps pressure from strong labour demand. Of the nine providers in RN that were surveyed in the telephone survey, seven out of nine providers paid enhancements for weekend working and five out of nine paid enhancements for evening work. In contrast, in IL, only three out of nine of the providers in the telephone survey offered enhancements for weekend Part V. Recruitment and retention in the care sector: a case study approach 299 working and only one offered enhancements for evening work. In IL there was no commissioning policy encouraging unsocial hours payments. Working Time: Both providers had a six day maximum working week. However, there were differences in relation to efforts to match staff preferences; ILDom1 reported matching staff preferences all of the time whereas RNDom1 reported to do so only most of the time. Training: Both providers had short paid inductions, although in RNDom1 this was not paid initially but only if staff stayed. ILDom1had met the NVQ target but RNDom1 had not done so. Work Organisation: Electronic monitoring was not in place in either LA but the two providers differed in terms of whether care staff were able to prioritise tasks and develop good relationships. ILDom1 reported this was the case whereas RNDom1 where reported only to some extent. Summary: It would appear that the commissioning environment, combined to some extent with local labour market factors, has an influence on pay practices, particularly unsocial hours payments. Other dimensions of HR practice appear to be more influenced by company policy rather than the commissioning environment. In some cases variations in responses between the two branches may also be a result of managerial discretion at branch level. For example, even though electronic monitoring was not in place in either location the two branch managers reported very different approaches to care workers‟ discretion and to payment for induction. Box V. 7 A comparison of a national providers’ domiciliary care establishments in a partnership and mixed local authority (XDDom1 and ONDom2) Background: Both XDDom 1 and ONDom2 were part of another national chain and were both rated as 3 * providers by CQC. Both reported staff shortages. XDDom1 found it neither easy nor difficult to recruit whereas ONDom1 found it quite easy. However, ONDom2 had much higher staff turnover at over 30% compared to 10-20% in XD. Pay: XDDom1 paid £6.50 while its northern counterpart ONDom2 paid £6.25 with a weekend enhancement of 22p. However, fee levels were £4 to £5 an hour higher in the southern LA than in the northern LA location so this 25 pence extra shows a very marginal impact of LA commissioning practices on pay levels offered. XDDom1 also paid mileage, possibly a reflection of its rural location and XD‟s willingness to pay a higher fee in rural areas. ONDom2 was in a more urban location. However, both paid enhancements for unsocial hours and ONDom2 was atypical in doing so if we compare this with the other data collected in the telephone survey from providers in ON. Only three out of nine providers paid an enhancement for weekend work and only one out of nine paid extra for evening work. In this sense ONDom2 had put in place a pay practice that was not typical of those on offer by other providers despite limited LA fees and this may show the influence of company policy. The LA in ON did pay extra for bank holidays but had discontinued other unsocial hours payments. Working Time: Both providers had a 6 day maximum working week and matched worker preferences most of the time. Work Organisation: Both providers said care staff could not prioritise tasks to improve the Part V. Recruitment and retention in the care sector: a case study approach 300 quality of care and this could be related to the impact of electronic monitoring which was in place in both LAs. Training and Development: Both providers had four days paid induction training and neither had met the NVQ level 2 target. However, the high level of staff turnover at ONDom2 is likely to have been an obstacle to meeting training targets, but the same did not apply to XDDom1. Summary: In this case the LA commissioning environment had limited influence on pay practices. A much higher fee led to only a marginal difference in wage levels, although the payment of mileage may be related to commissioning practice. Work organisation was also shaped by commissioning practices since the requirement to use electronic monitoring, as in both these LAs, limited the freedom of providers in this area. However, in the areas of training and working time it would appear that it is national firm policy that is primarily shaping HR practices. The two comparative case studies suggest that the policies of national chains are playing a significant role in both shaping HR practices and in limiting the actual impact of favourable commissioning and contracting practices on employment terms and conditions. This reinforces the picture presented in part IV as well as from the evidence from the case study providers in these four LAs. A key finding is that the LA commissioning environment may be an enabler of better practice but there are variations between providers in the extent to which they respond to more favourable commissioning practices. Furthermore, although there is variation in practices across providers, this variation is around a very low level of basic employment conditions and protections. However, we also need to consider the possibility that national providers are cross subsidising providers in low fee paying LAs where they may be making losses through retaining higher margins in higher paying LAs. If this were to be the case, and national providers‟ overall profits are either low or even negative, then the key driver of low pay can still be said to be LA commissioning V.1.7. Overview of HR outcomes for providers by local authority Drawing again on evidence from the telephone survey, we can assess the performance of the case-study providers with respect to HR outcomes, measured by various indicators of recruitment and retention. Table V.5 presents the HR outcomes for the 20 providers and shows that there is no straightforward relationship between practice and outcomes. The data on HR outcomes show that ten out of 16 independent sector providers considered it easy or very easy to recruit care workers. Two of the four providers in the low paying IL LA reported it to be quite difficult or very difficult to recruit but this was not replicated in ON, the other low pay area where all providers considered it quite easy or very easy. Perhaps surprisingly the LA providers were the most likely to respond that it was neither easy nor difficult or quite difficult (all three LA case studies for which we have responses). In contrast there was a majority view among independent sector providers that they did face specific labour shortages. This applied to nine out of 16 and seven of these were IDPs out of a total of eight IDPs. The two LADPs in high wage areas also felt they faced specific labour shortages. Part V. Recruitment and retention in the care sector: a case study approach 301 We have two measures of staff turnover, one the overall rate and one excluding turnover among new recruits. On both measures the two case study IDPs in ON stand out as experiencing very high levels of turnover, although the rates are particularly high when new recruits are included. However, beyond these two providers, turnover rates were more variable within than between LAs even for the independent sector providers but this was even more the case if the LA providers are considered where turnover rates were low in the three LAs for which we have data. If we look in detail at overall turnover rates in these providers and compare them to the national average turnover rate for care workers of around 22% ( see part I.5 (Eborall et al. 2010)) we find that only the two IDPs in ON have rates above this level and of the rest the majority (seven out of thirteen ) are clustered slightly below this level in the range 18% to 22%. Of the six with rates below 18%, five are homes and only one is an IDP. However, they are drawn from all four LAs. This suggests that to the extent that partnership LAs are associated with better HR practices, at most these are tending to alleviate otherwise very high turnover rates. Table V.5 HR outcomes across the case study providers Ease of recruitment1 Area XD RN ON IL Case1 Case2 QE N Dom N QE Home VE N Dom QE N Home QE VE Dom QE QE Home QE VD Dom VE QD Home LA case Specific staff shortages2 Staff turnover rate excluding new recruits 4 % Case1 Case2 Case1 Case2 21 17 23 17 11 MD 14 MD 19 12 20 13 18 22 16 15 16 5 11 5 Case1 Case2 N Y Y Y N Y Y Y N N QD Y Y N 101 56 6 48 21 6 N N N N 19 6 MD 19 7 MD N Y 19 18 MD 4 N QD LA case Level of staff turnover in the last 12 months3 % Y Y LA case 6 7 LA case 5 7 1 VD - very difficult, QD - quite difficult N - neutral QE - quite easy VE - very easy Y- Yes N- No 3 for definition see Appendix IV.A1.4 IRT3 MD= missing data 4 for definition see Appendix IV.A1.4 IRT9 MD= missing data 4 2 The data on HR outcomes show that ten out of 16 independent sector providers considered it easy or very easy to recruit care workers. Two of the four providers in the low paying IL LA reported it to be quite difficult or very difficult to recruit but this was not replicated in ON, the other low pay area where all providers considered it quite easy or very easy. Perhaps surprisingly the LA providers were the most likely to respond that it was neither easy nor difficult or quite difficult (all three LA case studies for which we have responses). In contrast there was a majority view among independent sector providers that they did face specific labour shortages. This applied to nine out of 16 and seven of these were IDPs out of a total of eight IDPs. The two LADPs in high wage areas also felt they faced specific labour shortages. Part V. Recruitment and retention in the care sector: a case study approach 302 We have two measures of staff turnover, one the overall rate and one excluding turnover among new recruits. On both measures the two case study IDPs in ON stand out as experiencing very high levels of turnover, although the rates are particularly high when new recruits are included. However, beyond these two providers, turnover rates were more variable within than between LAs even for the independent sector providers but this was even more the case if the LA providers are considered where turnover rates were low in the three LAs for which we have data. If we look in detail at overall turnover rates in these providers and compare them to the national average turnover rate for care workers of around 22% (see part I.5 (Eborall et al. 2010)) we find that only the two IDPs in ON have rates above this level and of the rest the majority (seven out of thirteen) are clustered slightly below this level in the range 18% to 22%. Of the six with rates below 18%, five are homes and only one is an IDP. However, they are drawn from all four LAs. This suggests that to the extent that partnership LAs are associated with better HR practices, at most these are tending to alleviate otherwise very high turnover rates. Moreover, not all „good‟ HR practices may induce lower turnover. For example, some managers from case study providers suggested that extensive induction and high levels of training could be a reason for some turnover, particularly of trained staff. Some do [leave]. Social care is quite popular at the moment. Rehab assistants. Usually NHS offer better terms and conditions than we do. That‟s my latest one, I‟ve got one of my NVQ 3 girls going. But often it‟s for advancement. Because we put people through NVQ 2 and then NVQ 3, which is a springboard to higher positions. (XDHome1, Manager). I think, to be quite honest, because we train our care assistants up to NVQ3 as much as possible, and when they‟ve got their [NVQ] three then we encourage them to try to do better. Now, some come back „cos the grass isn‟t greener, you know, but quite a few have gone to hospital and whatever and doing their training. (ONHome1, Manager). This reveals why HR outcomes are not directly related to HR practices; not only will local labour market factors play a role but also internal policies to train and develop staff may increase their external opportunities. Furthermore, the personal motivations of care staff and their experiences will also be a big part of the story of recruitment and retention in the care sector and while they will be shaped by these organisational and local labour market factors they will not be determined by them. An analysis of the case study interview data will now follow and we will look at care worker attitudes and motivations towards the job and areas of HR practice in more detail. Part V. Recruitment and retention in the care sector: a case study approach 303 V.2. Care workers’ perspectives on recruitment Drawing now on the interviews with care workers, we explore the attitudes and experiences of care workers, focusing specifically in this section on the process of recruitment, including why people entered the care sector and how they heard about care job vacancies. We also highlight any findings that relate to specific HR practices that may make some providers more attractive to potential recruits than others. Appendix table V.A2 provides information on the employment roles of the 98 respondents; 88 were directly involved in care work while a further 10 had a variety of roles in supporting care work. For much of the analysis the sample is limited to the 88 care workers but where relevant we use the whole sample. In this section because all 98 interviewees were recruited as care workers, our analysis draws on data from the whole case study sample. V.2.1 Factors that influence entry into the care sector All interviewees were asked why they had chosen to work in the social care sector as a care worker. It was possible to identify four dominant factors that shaped entry; the nature of the job and the search for meaningful work the influence of family and social networks the opportunity for a change of direction/career the search for convenient working time. The nature of the job and the search for meaningful work Previous research has shown that „making a difference‟ and doing a job that involves helping others is important to those working in the care sector and for many of the interviewees it was simply this that was given as the reason for entering the sector. For many care work was a job that gave the opportunity to be engaged in satisfying and meaningful work, often in contrast to previous work they had done (box V.8). Box V.8. Care work as an opportunity to make a difference and do meaningful work I think I originally chose it because of the satisfaction it gave me, and to actually see the outcomes for individuals, which I think was very rewarding for me as an individual. (RNLADP, Service Manager, age 45, 21 yrs in post) When I was made redundant [from retail] for the third time, I knew that I didn‟t want to work in retail any more after all these years, I wanted to do something a bit more meaningful, that give me more satisfaction from a human point of view (RNDom2, Care Worker 3, age 57, 6 months in post) I wanted to do something where I actually was making a difference. I had, for example I had one job where for half a day I worked in tele-sales, cold calling, and I left at lunchtime. It‟s the only job I‟ve Part V. Recruitment and retention in the care sector: a case study approach 304 ever walked out on, because it‟s just a horrendous job and I did not want to do something like that. (RNDom2, Care Coordinator, age 24, 3 yrs 6 months in post) I just think it‟s nice to be able to help somebody that can‟t do anything for themselves or can‟t do a lot for themselves, it‟s just a good feeling to see that you‟ve done something for them, you know, it‟s an achievement. (ONDom2, Care Coordinator 1, age 54, 2 yrs in post) Just wanted a career change. It‟s very monotonous [office work], I mean office work is very well paid, but it‟s not all about money. You know, it‟s job satisfaction. I like the buzz here, it‟s very nice. It‟s a nice environment and I‟m very much a people‟s person, that‟s why I‟m good at what I do. (RNHome2, Care Worker 1, age 54, 1 yr 10 months in post) Some care workers identified the distinctive characteristics of care work in homes compared to IDPs, or vice versa, and used these distinctions to describe why one type of work was chosen over the other (Box V.9). For some working for IDPs, the unsupervised nature of domiciliary care work meant they felt autonomous, an attribute that was very attractive to them. They also liked the idea of moving around between different places and meeting different people. In contrast some of those working in care homes had worked for domiciliary care providers in the past and found it too rushed and had chosen to work in care homes. Older workers in particular said working in one place was less tiring while younger workers with no access to transport also chose care homes. Box V.9. The advantages and disadvantages of working in IDPs The advantages Being my own boss, because I‟m obviously out on my own most of the time. I occasionally go out with other care workers, on double-up runs, but mostly I‟m on my own. So I‟m my own boss as such. (XDDom1, Care Worker 2, age 37, 2 yrs in post) You‟re all the time in different places…And I‟m bored when I‟m sitting in one place, so that‟s why. (RNDom2, Care Worker 1, age 22, 10 months in post) It‟s something different on your own, you‟re not in one place, somebody watching you while you‟re working all time, you‟re out and about…..You meet different people. (ONDom1, Care Worker 1, age 48, 3 yrs in post) The disadvantages Too much pressure [in domiciliary care providers]. I mean because you didn‟t have the time, like say if you had to do their dinner for „em[users], it‟s like you‟re rush, rush, rush, don‟t have time to talk to „em, time to get their dinner, you know, how you want it, and then you‟re off to your next one then….No, I didn‟t like it, it wasn‟t me. (ONHome2, Care Worker 1, age 47, 8 yrs in post) I didn‟t fancy home care because of the transport and I don‟t drive. (ILHome2, Care Worker 4, age 29, 3 weeks in post) Part V. Recruitment and retention in the care sector: a case study approach 305 The influence of family and social networks The case study approach allowed us to contextualise responses about the attractiveness of care work to this group of workers. This revealed first of all the importance of family and social networks in influencing these decisions. Thirty-six out of 88 care workers (and 38 out of the whole sample of 98 interviewees) cited informal experiences of looking after elderly relatives, neighbours or children as the main motivating factor when deciding to enter care work (box V.10). This is an important finding because it meant that 40% of our sample of „stayers‟ and new recruits had some knowledge about what the job involved before they entered the organisation. Seventeen of these were working for IDPS compared to 15 who were working for care homes (including four who were working for the LAhome). Four out of 15 care workers working for LADPs cited this as a motivating factor. Box V.10. Informal experience of caring for family and the elderly Why did you choose to work in the social care sector? Basically because it‟s all I‟ve done, personally, through my life, if you know what I mean….I‟ve never done it officially but I‟ve done it unofficially with family members...My Nan, my granddad and my son. (ILDom1, Care Worker 2, age 34, 8 months in post) It‟s something that I‟ve wanted to do for a long time but I just felt I wasn‟t ready. You know when the children have grown up and that. And then I was looking after my father in law who has got dementia and he is in a nursing home. So I helped my mother in law with him a lot. And went round and was helping her. And when it came to changing him, because he was incontinent, it was me that actually did it, and I didn‟t think twice about doing it. My mother in law, she couldn‟t do it. And it was from that and then quite a few people over the years said, you‟re quite good with old people. Why don't you work with them. (XDHome1, Care Worker 3, age 44, 3 yrs in post) Because I obviously care for my children, so I‟m already used to caring. And with care work what we do is very similar to looking after children basically, apart from obviously adults. So I was used to it. So I thought well it‟s the best job really for me to do. And I enjoy caring. So, it‟s my sort of job. (XDDom1, Care Worker 2, age 37, 2 yrs in post) No, it weren‟t just the hours. I mean I looked after an elderly neighbour once, I used to like go in every day and see to her and I thought I‟d always fancied doing something like that. (ONDom1, Care Worker 1, age 48, 3 yrs in post) Related to this was also the influence of family and friends on entry into care (box V.11). Two thirds of the interviewees (64 out of 98 interviewees) mentioned that family or friends worked in care and 11 of these stated that this was the main influence on why they entered care while the majority recognised that this knowledge of the care sector through personal contacts influenced their entry in some way. Quite a few of the new recruits we interviewed were younger workers who had family members, often mothers, working in the care home or the IDP they were working for. Many care workers cited being encouraged by family Part V. Recruitment and retention in the care sector: a case study approach 306 members and friends to do the job and others recognised that being surrounded by care workers influenced their decision to enter. Box V.11: The influence of family and social networks on entry into care work Our [sister-in-law] loves it, she kept saying, „It‟s, just perfect for you, you would just love it.‟ And she was right. (ONDom1, Care Worker 4, age 43, 5 months in post) I spent a lot of time with my Nan, like I say, my Nan worked in care for about 30 years. So often when I was at her house I‟d hear different things from when she was out working. It‟s just kind of, they didn‟t push me into care, but I think it‟s something that I‟ve wanted to do, hearing stories from my Nan and my aunty. (ONDom2, Care Coordinator and Care Worker, age 26, 5 yrs in post) My mum done it, my Nan done it first, obviously, then my mum‟s been doing it for about ten years. She started off as a cleaner and then become a carer in her home and she‟s been there for ten years. My cousin was working in my old home which I got a job in and then my sister was like, „Oh, I‟ll come and join you too.‟ So she come into it…..My mum said, „Give it a go.‟ But I was just like I need to do something, I just can‟t be bothered to do hairdressing any more. And I couldn‟t hack working in a shop or things like that, so I just thought, oh. Everything‟s worth a try, ain‟t it, you don‟t know if you‟re gonna like it or not until you try it. (RNHome2, Care Worker 3, age 21, 3 months in post) Yes. My mother was a nurse, so yes. And she had a lot of experience in that area…Yeah. I think it did [influence me] because she introduced me to care and she was quite passionate about what she did as well, so I think it did have a big influence on my future. (RNLADP, Service Manager, age 45, 21 yrs in post) Therefore many of the care workers had already had experience of informal care in the home and knew what the job entailed. In relation to recruitment, this meant that on entry into the sector many already had a reserve of tacit knowledge and skills that had been built up through informally caring or having close relationships with those who did the job. How this relates to the recruitment process will be discussed in the next section. Care work as a new direction Many of our interviewees talked about their entry into the care sector as a „career change‟. It was often a result of a „push‟ factor into the sector; for example a change in personal or work circumstances such as redundancy and divorce. The case study interviews allowed us to see in practice how the recessionary effect, as discussed in Section III.1, eased recruitment difficulties for providers. Of the 50 care workers who had entered the care sector in the last two years, nine mentioned they had been actively looking for work before they started their Part V. Recruitment and retention in the care sector: a case study approach 307 current post and five of these had been made redundant39. Others had simply decided they wanted to leave a job, often higher paid, that they were dissatisfied with and it was the „pull‟ factors of training and opportunities that made the sector attractive. Providers that emphasised training and careers either in the advert or in interview were more successful at attracting those who wanted a career in care. For these, working as a care worker was a stepping-stone to something else or an opportunity to gain training and qualifications. Box V.12. Care work as a new direction I‟d been made redundant for nearly seven months. I found the job through a newspaper but a friend of mine that was working for the same company had got made redundant at the same time, she‟d applied here as well. And so I follow in the footsteps basically. (XDLADP, Care Worker 2, age 55, 4 months in post) I was made redundant, sort of. And then approaching 50, I felt this was a good job that I could do efficiently and well. (XDDom2, Care Worker 1, age 53) I just wanted a complete career change. I didn‟t want to go in another factory. I just wanted something totally different. And it is. (XDLADP, Care Worker 3, age 52, 7 yrs in post) Well, I was obviously looking and came to my interview and like had an interview with Gloria and she was like very helpful and like 'cos I came with no experience was more willing to give me the experience I needed. Cos quite a lot of other place I applied for are a bit dubious with no experience…..More helpful, more willing to sort of teach me and train me, very nice place. (RNHome1, Care Worker 2, age 19, 6 months in post) Because I am studying mental health nursing. So it‟s like a way of getting into nursing, so I know how to care about people. Getting experience first…..I was just walking past. When I came in, I asked them if they were going to train me, so that I know what I was going to do. (XDDom2, Care Worker 3, age 28, 4 months in post) Convenient working hours The final dominant factor that shaped entry into the sector was the search for work that fitted family circumstances or other interests. Ten interviewees identified the hours on offer in the care sector as the main reason why they entered. As box V.13 makes clear, some care workers were able to negotiate very convenient hours for themselves but often these were not representative of the hours of work across the sector as they might involve limited weekend work and hours that fitted around home commitments. Thus those expressing satisfaction were doing so more with respect to their own specific hours, than those that typified the sector. It is important to note that the care worker who chose to work for the inhouse service 39 The issue of redundancy and job insecurity prior to the care workers taking up their current position was not part of our initial investigation and there were no specific questions relating to this. Therefore it may be the case that at the time of the interviews recent redundancy may have been more common than the data suggests. Part V. Recruitment and retention in the care sector: a case study approach 308 because the hours fitted in with school hours may not have been able to negotiate these hours if she was a new recruit and the types of hours she mentions are no longer typical. Indeed others referred to the hours as a reason for deferring entry into the sector. The use of zero hours contracts was mentioned; a lack of guaranteed work meant that anyone who was reliant on a wage to bring up their family could not take a risk on the unpredictable hours on offer. Therefore the case study interviews show that the pattern of working hours in the care sector are far from being a „pull‟ for everyone. Box V.13. Care work and working hours: a help and a hindrance in attracting a wider pool of candidates Why did you enter the care sector? Because it is something to do with when you are both full-time and you have to juggle around the time with looking after your kids and then the time working full-time as well. So it took me three years to decide I need to get into the kind of job that would suit our time and schedule. Because a clerical job is normally like office hours. It is not flexible enough. …I laid down my cards to [the manager] - we have got the schedule ready, my wife and myself. And then I told him already when I applied for this job, I can only work in the afternoon, …. (XDHome1, Care Worker 2, age 31, 6 months in post) I'm in a new country and this is the second job I‟ve had, and I‟m really a clothing designer,… I like how flexible the time is, so I can say that yes, I‟m available to work these days, and also .. I think that was the main one but I enjoy working with people also but I would have to say being flexible with my hours was the main reason [I entered the care sector]. (RNDom2, Care Worker 4, age 32, 2 weeks in post) I left my job [at the hospital] because it was weekends and it was a split shift, so I literally done from the seven till one and then had to go back and do five till ten, so it was giving up every weekend. And then this one, when you were home helps you could start at nine and finish at two thirty, so I could take my children to school and pick my children up from school, which I feel is an important thing to do. (RNLADP, Care Worker 4, age 46, 20 yrs in post) But the variability in the hours had been a pull away from the sector in the past for other care workers I‟ve wanted to do this forever but because I‟d two kids I couldn‟t, because of the hours (…) and I was a single parent, so I needed a steady wage and steady hours. Which you don‟t get steady hours in this job. (ONDom1, Care Worker 4, age 43, 5 months in post) I‟ve always wanted to work with the elderly but whilst my daughter was younger, you can‟t easily do the different shift hours. but once she got old enough I just said, well I‟m getting out of this, and came into caring. (XDLADP, Care Worker 3, age 52, 7 yrs in post) Part V. Recruitment and retention in the care sector: a case study approach 309 V.2.2. Role of employers versus employees in access to information on care job vacancies The case studies were designed to investigate the recruitment process from the employee perspective. In particular we wanted to know how people heard about care jobs and if they were responding to a formal vacancy (employer-led recruitment) for a care job or whether it was through informal means (employee-led). Table V.6 shows that 45% of the interviewees heard about the job via informal means, referred to here as employee-led recruitment, while 55% entered through formal practices or employer-led recruitment. This pattern applied to both IDPs and care homes but three quarters of those entering LAs did so through formal practices. Similarly, around three fifths of those working for national chains or for single homes or agencies were recruited formally but this only applied to 13% of the people who worked for a local chain. Table V.6 Employer-led and employee-led recruitment Sample No. Employee -led Recruitment (%) Employer led Recruitment (%) Domiciliary 40 43% 58% Homes 38 58% 42% LADP/ LA Home 20 25% 75% Local authority 20 25% 75% Local chain 16 88% 13% National chain 48 40% 60% Single home 14 43% 57% 98 45% 55% a. By type of care provider b. By Organisation Type Totals Formal recruitment in the case study interviews included press advertising or radio advertising, placing an advert in a shop window, using the job centre or an employment agency or advertising on the internet. Only three people mentioned finding out about the job via the internet. We found that those looking to enter the care sector as a career change were influenced by particular HR practices rather than informal knowledge and reputation. Providers who emphasised training in advertisements made themselves attractive to a pool of recruits that wanted a career in care and LA providers that emphasised secure employment, quality of care and the adherence to strict procedures were also attractive to the care workers. Employee-led recruitment took a number of forms; for some it involved ringing around homes to see if there were vacancies or walking in to the office of the provider and asking if there were any jobs. The most common way employee-led recruitment took place in practice was through informal social and family networks; when care workers were asked how they heard about the job or vacancy it was often friends or family who already worked for the Part V. Recruitment and retention in the care sector: a case study approach 310 agency that passed on knowledge about vacancies and shortages in specific providers and encouraged them to apply. This informality was found across all four LA areas regardless of the age profile in each case study local authority. This supports the survey findings that a significant share of providers (43% of the managers in care homes, 23% of managers of IDPs but none of the LADPs) found word of mouth recruitment to be the most effective method of recruitment. The lower share among IDPs may in part reflect the higher share of national chains in the IDP sample who made more use of formal methods. Employee-led recruitment in practice Box V.14 shows the ways employees can take the initiative and enter the care sector without seeing a formal advertisement about a vacancy. The role of informal networks is central in this process. Linked to this theme of networks is the localised nature of recruitment in the care sector. Informal networks were effective because care workers worked in a very localised area. This meant that chance encounters with friends who worked in the care sector could be the way knowledge about opportunities was passed on. Fifty-seven out of 88 care workers reported that they lived in or close to the area they worked 40. It meant that shop window advertising and simply walking past providers who were visible was an effective way for providers to recruit. Box V.14. Employee-led recruitment in practice; informal and local knowledge Informal networks and word of mouth recruitment I got divorced and needed a change of direction; I fell into care as I needed a job and a friend suggested [ILDom2]. I had heard about [ILDom2] and its reputation – there are now 4 providers in [IL] and this is the leading one. (ILDom2, Senior Care Worker 1, age 39, 8 months in post) Yes it was through my sister - actually one of our friends told us about the jobs here. And she also works here. (XDDom2, Care Coordinator and Care Worker, age 23, 1 yr in post) I heard good things from the person that worked here, and they pay better than some of the other agencies, and those are the two factors… They‟re more organised than some of the other ones. (RNDom2, Care Worker 4, age 32, 2 weeks in post) Well, sort of when I first applied with [the agency] because my friend that works in this section had put my name forward to them that‟s where I was offered the work. (RNLADP, Care Worker 3, age 43, 2 yrs 6 months in post) I wanted to do it all the time but I thought it was hard to get into, and then a friend who I worked with in the shop where I worked, her sister worked here, so it was like by word of mouth. So I just 40 However care workers had very different definitions about what travel-to-work distances constituted being close to where they worked. For example, some care workers who lived three or four miles away from where they worked responded that they did not live close to the area where they worked while others defined this distance as being close to work. Part V. Recruitment and retention in the care sector: a case study approach 311 came along and just asked if there was any jobs going. (ONHome2, Care Worker 3, age 42, 2 yrs in post A friend that I‟d worked with in my other job and I saw her when I was out shopping and I said, „You know, I‟ve had to give it up because of my back.‟ And she said, „Well, this is just a little rest home that I work in.‟ And I thought, well, yeah, I can manage that. (RNHome1, Senior Care Worker, age 54, 6 months in post) So I decided, I thought right, perhaps I‟ll go to a nursing or residential home. So I just randomly just rang all the nursing homes around like here, I think St Luke‟s. So I just randomly rang….I got an application form from four of them, and then got an interview for two of them. And then I sort of liked it here. So…It just seemed more friendly. (XDHome2, Care Worker 4, age 44, 3 yrs in post) Well, I‟d applied for two, both care companies, and I got jobs at both, but the office for this one was nearer to me than the office for the other one, so, and I was accepted first by [ONDom1] so I came here. (ONDom1, Care Worker 3, age 49, 4 yrs in post) Voucher schemes to encourage the use of existing care workers‟ social networks recognise the pool of potential recruits that can be tapped into via existing employees. Three of our case study organisations operated a voucher scheme (XDDom1, ONDom2 and ILDom1) which involved offering, on average, a £50 bonus payment for employees who introduced a friend to the sector which was paid once the person who introduced had worked more than 40 hours. Interestingly these were national chains and the majority of the people we interviewed who worked for these organisations were recruited formally (table V.6). However, it would appear that national providers are increasingly recognising that word of mouth recruitment has been operating quite well for many local providers and they are seeking ways of integrating this recruitment practice into more formal systems. In many respects this is unsurprising. It could be argued it is a more reliable method than others, as the tacit knowledge that is gained from having family members and friends in the sector manages the expectations of those entering the organisation and this may increase their propensity to stay. It is also a reliable form of entry from the employee perspective. The reputation of providers and knowledge about the employer is passed on by existing employees which is an invaluable source of information when care workers are choosing between providers. However, an increased focus on informal recruitment methods may have implications for expanding and diversifying recruitment into care as we discuss in section V.7. Suitability of job applicants and the emphasis on informal experience and skills We also asked all interviewees to describe their experiences of the recruitment process and what skills and qualities the provider had looked for when they applied for the job. In line with the general telephone survey findings reported in part III, all the independent case study organisations identified a positive attitude and friendly nature as the most important factor in assessing the suitability of a job applicant for a care job. The views of the LA providers were Part V. Recruitment and retention in the care sector: a case study approach 312 more mixed with two LADPs reporting a positive attitude was the most important factor and one LADP41 (ONLADP) saying skills for care were the most important factor. Interviewees‟ accounts of the recruitment process (box V.15) show how providers value the informal skills built up through experience of caring in the home. Many of the unqualified interviewees appreciated being judged on this rather than formal qualifications. Box V.15. The recruitment process and the stress on informal skills There wasn‟t nothing on qualifications but it was all, because, like I said, mine‟s all basically down to personal experience…… And like when they seen what I‟d done with family members and that it was basically the same, it was the same as the job, if you know what I mean. (ILDom1, Care Worker 2, age 34, 8 months in post) My mum had dementia towards the end of her life. So I understood how that affects people as well. So I had some sort of insight into that as well…..I told them about my dad and I told them about my mother‟s situation towards the end of her life. And I suppose because I‟d been down that road already and I knew the insights into what the job could probably be throwing at me, then they seemed to be more than happy that I could probably cope with it………I don‟t remember them saying that you need this and this, and they needed ... ….I suppose they took it on face value on my general attitude on things like that. And I think to a certain extent that is a better way to look at people. Because I applied for numerous amounts of jobs and I think to a certain extent because of my age as well, people weren‟t looking at me. (XDLADP, Care Worker 2, age 55, 4 months in post) No. They just asked what my exam results were. Which I couldn‟t remember. It was a very long time ago. And apart from that, no. I had the interview and they didn‟t seem to want anything special. (XDLADP, Care Worker 1, age 50, 3 yrs in post) 41 The ILLADP also said skills for care were most important but this was not included in the cases studies as it was LAHome that was studied Part V. Recruitment and retention in the care sector: a case study approach 313 V.3. Care workers’ perspectives on turnover and retention In this section we examine the intentions of the care workers we interviewed to stay with their current employer and to stay in the sector and the reasons given for these intentions. The problems of examining turnover from a sample of interviewees that does not include „leavers‟ has been discussed in section I.8. Nevertheless, through our case studies we explored those aspects of care work that the interviewees did not like and also their perceptions and experiences of why new entrants to care work may leave. Together these provide us with some insights into the cause of staff turnover and staff retention. V.3.1. Care workers‟ intentions to stay or to quit Table V.7 gives a breakdown of the case study interviewees‟ intentions to quit: 89% of the sample intended to stay in the social care sector and over half (54%) said they would expect to be working for their current employer in five years time. Half of those working for care homes (19 interviewees, all of whom were care workers) said they intended to stay with their employer compared to only 38% of those working for IDPs (15 interviewees, 13 of whom were care workers). Among those working for LAs, 90% intended to stay (16 of the 18 stayers being care workers). A further 4% of all interviewees said they probably would stay, leaving 27% who said they did not expect to stay and 15% who were unsure. Table V.7. Care staffs’ intentions for employment over the next five years Sample No. Yes (%) Probably (%) Unsure (%) No (%) 39 38 5 20 35 care homes 38 50 5 16 29 LAs 20 90 0 5 5 all types of providers 97 54 4 15 27 38 89 0 5 5 care homes 36 86 0 6 8 LAs 20 90 5 0 5 all types of providers 94 88 1 4 6 a. With current employer in 5 years?1 Workers in: domiciliary care b. In Social Care in 5 years? 2 Workers in: domiciliary care 1 One missing response- domiciliary care worker workers 2 missing responses- 2domiciliary care workers, 2 care home Out of 26 who said they intended to leave, 22 were care workers and they gave a number of reasons for intentions to quit. Working for the NHS and nurse training were the reasons most often given for leaving. Low pay was only cited by one care worker as a reason to leave, although the better pay in the NHS may mean that when care workers stated they intended to Part V. Recruitment and retention in the care sector: a case study approach 314 leave for the NHS, pay could be a factor shaping this choice. Pay is certainly an important factor cited by managers as reported in part III. A quarter of respondents in the management survey also identified working in the NHS as a reason why care staff leave (see section III.2) but in many instances our case study data suggests that care workers were not actively seeking work in the NHS. Instead it was often presented as an aspiration for the future, often discussed in quite vague terms. The case study below gives an indication of the ambiguity of some of the care workers‟ responses when they identified leaving the sector to work for the NHS (box V. 16). Table V.8 Reasons for care workers’ intentions to leave Workers in all provider types (%) 19.2 Domiciliary care workers (%) 21.4 Care home workers (%) 18.2 Work for the NHS 19.2 7.1 36.4 Move to home country 7.7 To work in a different sector 11.5 14.3 Lack of support /no promotion 7.7 14.3 More convenient working areas 3.8 7.1 Better Pay 3.8 7.1 Work for another care provider 3.8 7.1 To work for the Local Authority 3.8 7.1 Retirement 3.8 Total responses 22 Nurse training Workers in LA care providers (%) 18.2 100.0 9.1 12 9 1 Box V.16. Case study ONHome2: the ‘pull’ factor of the NHS Summary This provider was in an LA classified as „mixed‟ according to its commissioning practice and staff reported high levels of job satisfaction despite being dissatisfied with staff shortages and low pay. All care workers felt supported by their manager and one was studying for her NVQ 3. There were opportunities to progress in the care home; for example, the manager had asked two of the staff if they wanted to become senior care workers but they were undecided as to whether they would like to do this because of the extra responsibility for little extra pay. Although they were happy many aspired to move into working for the NHS in the future although they did not seem to have any concrete ideas about how they would go about this. Will you still be working for your current employer in 5 years time? Possibly be here or I‟ve even considered hospitals and stuff like that, to sort of, well, I‟ve done this for twenty five years, if I don‟t do it now I won‟t do it, type of thing. But on the whole I‟m content where I am at the moment so if I was to move it would be …It would be something like the NHS. (ONHome2, Senior Care Worker, age 43, 5 yrs in post) Part V. Recruitment and retention in the care sector: a case study approach 315 I think I‟ll still be in the caring profession, but I would like to work in the hospital. That‟s what I want to do. (ONHome2, Care Worker 3, age 42, 2 yrs in post) No. I don‟t know. Hospital, I hope. (ONHome2, Care Worker 1, age 47, 8 yrs in post) I‟ll still be in this kind of job, whether it‟ll be in this place or not, I don‟t know. (ONHome2, Care Worker 2, age 26, 3 yrs in post) How I feel now I‟d like for to stay here, definitely…..but I say I‟d look at hospitals, that‟s in a couple of years that I‟d look at the hospital. I‟m not ready for anything like that yet, definitely not. (ONHome2, Care Worker 4, age 24, 6 months in post) The patterns with respect to intentions to stay or quit were relatively mixed, with 58% saying they would stay or probably stay and 42% saying they would definitely leave or were unsure. Nevertheless the fact that only 27% of those we interviewed definitely intended to quit may be influenced in a large part to the high level of job satisfaction reported by the care workers. To explore these issues further, we also asked directly about what the job of a care worker involved on a daily basis, what they liked and disliked about their job and also the nature of their relationships with service users. All 88 care workers said they enjoyed their work. All highlighted the rewarding nature of the job related to helping people, working with the elderly and building relationships with service users. Care workers spoke with passion and enthusiasm about their work and were clearly committed and dedicated to providing a good quality service to users (box V.17). Significantly, they used their discretion in forming their relationships with users and spoke of the need to adapt the ways they interact with different users to provide a quality service. Box V.17. High levels of job satisfaction: making a difference and building relationships They‟re elderly, they‟ve had their life and you‟ve got to make their last years or whatever as comfortable as possible. To me, I would treat them as if they were my family. I mean some have challenging behaviour but you just deal with it. You don‟t get aggressive with them, you just keep on a level par with them. I mean some you can have a bit of banter with, some you can‟t, you know which to step back from. But no, I love the job. Love it. (ONHome2, Senior Care Worker / Deputy Manager, age 60, 9 yrs in post) And you have to be understanding, you have to be able to understand your clients and make sure that they understand you. And you need to be able to - not change so much with different people but you know how you can talk to one client and how you can‟t talk to another. Everyone‟s different and you just have to find a way with everybody. (XDDom2, Care Coordinator and Care Worker, age 23, 1 yr in post) Making a difference to people‟s lives – making an impact – it could be a sociable thing, a wink of the eye, a joke, any form of communication with them. If I don‟t get the wink from this man I know he‟s not comfortable – and then I make him comfortable and then he winks. It‟s giving them something Part V. Recruitment and retention in the care sector: a case study approach 316 back for me. (ILDom2, Senior Care Worker 1, age 39, 8 months in post) You go and someone can be very depressed the first time you meet him or her and then you going on your days it can cheer them up, so you get job satisfaction. You know, I‟ve had clients that are bedridden and now they‟re walking with a Zimmer because they‟ve had that encouragement. ..So it‟s a lot of job satisfaction really, and it‟s very, very rewarding. (ONDom1, Care Worker 2, age 33, 6 months in post) Levels of satisfaction were shaped by different aspects of the job, depending on the type of provider they worked for (box V.18). Those working in homes identified the family atmosphere of working in a care home and working as part of a team as one of the aspects of the job they enjoyed. In contrast, those working for IDPs identified the autonomy of being able to work unsupervised and not working in one place as one of the most enjoyable aspects of their job42. Those working for LADPs also enjoyed working in different places and spoke in terms of „working in the community‟ and focused on the challenging and rewarding aspects of the re-ablement role that many of those working for the inhouse service were now involved in. Box V.18. Working in different types of providers brings different sources of job satisfaction Care Workers in IDPs It‟s something different on your own, you‟re not in one place, somebody watching you while you‟re working all time, you‟re out and about. (ONDom1, Care Worker 1, age 48, 3 yrs in post) I feel as though I‟m my own boss, sort of like going around, and I feel as though I‟ve like helped people, you know. (RNDom1, Care Worker 1, age 41, 11 months in post) you‟re going in and making, you are making a difference to somebody. The only person they might see that day. I just like chatting with them, socialising with them, just doing anything that I can to help keep them in their own homes. (RNDom1, Care Worker 2, age 51, 2 yrs in post) Care workers in care homes I just think it‟s like loads of grans and granddads, it‟s like really close and family; and it‟s nice to help people. It‟s just a nice thing to do; it‟s something to give back isn‟t it really. It‟s like having lots of nans and granddads, and you all have different ways to talk and to interact with them, and you know how they feel and you can make them happy and vice versa, if I‟m having a down day, they can bring me up. It‟s just nice. (ILHome1, Care Worker 3, age 23, 3 yrs in post) It‟s nice when you see a smile on the resident‟s face. It‟s nice helping, it‟s nice when you make a difference to someone, it‟s like a family atmosphere as well. (ILHome1, Senior Care Worker, age 38) I like that it‟s a small residential home. So everybody is looked after on a personal level. And the 42 Note two of the quotes are from RNDom1; further details on this case study are given in box V.32 Part V. Recruitment and retention in the care sector: a case study approach 317 team that you work with have been here a long time so they know the residents and you get to know them and you know their abilities. So you can help - if they need help and they can help you. It‟s a good team. (XDHome2, Care Worker 3, age 26, 2 months in post) Care workers in LADPs I like the challenge of, there‟s nothing worse to me than when I‟ve got a client that you can‟t get to … do what you know is, what is good for them, you know what I mean? I get a real sense of achievement when I can get them to do something that they‟ve never wanted to do. You know, even if it‟s just like having a wash, you‟d be amazed how many just won‟t wash, and when you can get a relationship with them where they trust you, 'cos at the end of the day they don‟t wanna have somebody washing them, because it‟s perhaps a final admittance that they need help, and when you can finally get them to let you help them, I enjoy that. I enjoy, you know, the achievement of it. There‟s nothing more frustrating to me than when I can‟t get somebody to help themselves really. (ONLADP, Care Worker 3, age 43, 14 yrs in post) I love meeting people, I like the fact that you‟re not stuck in one place, you are actually out and about in the community with clients that are not, you‟re not just in a care home, for instance, you are out in the community with clients. (ONLADP, Care Worker 1, age 22, 11 months in post) It‟s rewarding, it‟s challenging. Yeah. It‟s rewarding and it‟s challenging and I like the colleagues that I work with. (RNLADP, Care Worker 4, age 46, 20 yrs in post) I like people. I must admit I do, I like it, especially now if we‟re managing to get them sort of on their feet more than they were before. I don‟t know, I can‟t imagine doing anything else, to be honest, although I don‟t particularly wanna say I‟m gonna do it till I‟m 65, I can‟t imagine me doing anything else. (RNLADP, Care Worker 2, age 45, 15 yrs in post) This gave us a more complete picture of why, despite the low pay and uncertain hours, it was only a minority of care workers who intended to leave. As we have seen, motivations to enter the sector were often related to the nature of care work; being able to help others, to make a difference, to do meaningful work and to build on rewarding personal experiences of informal care in the home. Motivations to enter the care sector are important to understand because these reveal the expectations about the job of those entering the sector. This has a direct impact on levels of retention. It is often whether the organisation and the job can fulfil expectations that determine job satisfaction and consequently whether people will stay or leave. The descriptions above of care workers‟ feelings about their jobs reveal that in many cases the role did fulfil care workers‟ expectations. Part V. Recruitment and retention in the care sector: a case study approach 318 V.3.2. Factors that may contribute to turnover Insight into causes of turnover can be gleaned from responses to questions about those aspects of the job care workers did not like (table V.9). Forty-two percent of the care workers interviewed said there was nothing they disliked about the job. Of those who did report aspects of the job they did not like, issues relating to pay (including the lack of compensation for time spent travelling between users) and working time were most often mentioned. This suggests that dissatisfaction is often related to the way care work is managed rather than the job itself. Table V. 9 Aspects of the job care workers were unhappy with % of care workers Nothing 42.0% Low pay / Lack of travel pay 19.3% Working time 10.2% Difficult clients 9.1% When clients deteriorate / die 9.1% Being asked to cover/absent staff 6.8% Stressful/Chaotic/Exhausting 4.5% Short staff 3.4% Lack of autonomy / time 3.4% Unpleasant parts of the job 2.3% Travelling between users 1.1% No promotion opportunities 1.1% Not working in preferred geographical areas 1.1% Working with agency carers 1.1% Language difficulties 1.1% More paperwork 1.1% Increased Privatisation 1.1% Expectations of male carers (to do heavy work) 1.1% More responsibility and threat of litigation 1.1% Total respondents =88 Part V. Recruitment and retention in the care sector: a case study approach 319 Perceptions of why staff leave The care workers were also asked why in their experience new recruits into care work may tend to leave. Two main issues were mentioned: the nature of the job and the unpredictability of working hours. With respect to the nature of the job, many of the care workers said that those who enter, particularly younger people, did not know what the job entailed and it was for this reason many new recruits left quite quickly (box V.19). This contrasted with the personal experiences of many of those we interviewed, who, as already mentioned, had experience of informal caring in the home and/or had contacts working in the care sector before they entered the sector. This meant they had some prior knowledge of what the job entailed. Their view was that new recruits often expected it to be more like the traditional „home help‟ role and those who left often had found the job to be more complex than they had expected. Box V. 19. The nature of the job as a reason for staff quits. I don‟t think they[new recruits] come into it with their eyes open. They don‟t think about what domiciliary care involves, it‟s the old, I think they still think of the old home helps, when it was a bit of cooking, a bit of cleaning, keeping them company, that‟s what they thought it was. You can tell them what domiciliary care involves, but until they actually see it themselves then they don‟t actually realise, and that‟s where we hit the problems. They go through all their theory training in the classroom, you send them out, and I think that‟s when reality hits (ONDom2, Senior Care Worker 2, age 36, 1 yr 6 months in post) I think a lot of them went, especially young girls who are18, I think they come into it thinking it‟s you‟re just gonna go in and make someone‟s tea and then they realise it‟s not that. You‟re gonna see some distressing, you know, sights, especially when you go on double-ups, and they can‟t hack it, so they‟ll go. It‟s not for them. (ILDom2, Care Worker 4, age 37, 7 yrs in post) Mainly because .. a lot of it comes from the way you‟re paid, doesn‟t it. If you‟re not paid enough for a job then people don‟t see it as a proper job, it‟s just a little part-time thing that people do. That‟s how people see it a little bit. And that we just go round making cups of tea for people. (RNDom1, Care Worker 3, age 50, 1 yr in post) Another reason put forward by care workers for staff quits was the unpredictability of working hours and the pressure to do extra hours because providers were often short staffed. As we have seen in section III.4 a very high share of independent sector providers and LADPs said it was easy, or very easy to find staff willing to work additional hours at short notice and by and large providers tend to depend on existing staff to cover shortages. However, what the survey did not tell us is that this could be a reason for staff turnover. Indeed, pressures to change working-time arrangements had made one care worker leave her previous provider (box V. 20). Part V. Recruitment and retention in the care sector: a case study approach 320 Box V. 20. Unpredictable working time as a reason for staff quits. I mean it‟s not as easy as people think it is. I mean it‟s not a nine to five job, you know, it can be unsocial hours, you do get mithered a lot from our end, 'cos you know, work has got to be covered. It doesn‟t matter how many staff we‟ve got off there‟s still the amount of people to look after, and I think a lot of 'em, you know, they get fed up of being pestered. It‟s not a job you finish, you go home and you‟re left alone till t‟ next day. You try not to bother people but if work needs covering then you have to mither 'em. (ONDom2, Senior Care Worker 2, age 36, 1 yr 6 months in post) I was working from very early in the mornings, never .. they used to pester me night and day to work, and when you‟ve got children you‟ve gotta have some time to yourself and I was never left alone so I got alternative employment. (RNLADP, Care Worker 3, age 43, 2 yrs 6 months in post) But it‟s mostly because of the hours [why people leave]. If you‟ve young families this job wouldn‟t suit. (ONDom1, Care Worker 4, age 43, 5 months in post) Part V. Recruitment and retention in the care sector: a case study approach 321 V.4. Care workers’ perspective on pay and working time V.4.1 Pay and travel time Data was gathered on care workers‟ attitudes towards pay as well other paid benefits such as enhancements for unsocial hours working and travel pay. We have seen that 19% of care workers identified dissatisfaction with pay as an aspect of their job they did not like but we have also shown that it was not cited as a reason to leave the sector, although it could be argued the attraction of the NHS is linked to the better pay on offer in the health sector. We asked all care workers whether they thought the pay they received for the job they do was reasonable. Table V.10 gives a breakdown of care worker perceptions of their pay and shows that out of a sample of 88 care workers, 35% thought the pay was reasonable, 64% thought it was not reasonable (1% unsure). Those working in care homes were most likely to perceive the pay as unreasonable; only four care workers out of 36 (11%) thought their pay was reasonable. Table V. 10 Care workers’ perceptions of pay as reasonable Sample No. % saying pay is unreasonable 59 % who don’t know 0 Domiciliary care 34 % saying pay is reasonable 41 Care homes 36 11 86 3 LAs 18 72 28 0 All types of providers 88 35 64 1 By contrast 72% of care workers employed by LAs perceived their pay to be reasonable comparing it favourably to the pay on offer in the independent sector. Significantly, it was not only the basic rate of pay that was discussed by those working for LADPs; all of the LAPDs in our sample paid for travel time and paid mileage and this was intrinsically linked to care workers‟ positive perceptions (box V.21). When IDPs followed similar practices, interviewees were likely to be more positive. For example, in XDDom2 pay practices mirrored LAPDs; they paid mileage and travel time and also good enhancements for unsocial hours. Three out of four care workers perceived their pay to be reasonable in this organisation. Of those who perceived their pay to be fair, there was often a reference to good weekend enhancements. This varied by local authority: in XD, every provider paid enhancements for unsocial hours but in RN and ON, while domiciliary care providers paid enhancements for weekends, care homes did not. In contrast in IL, the cost minimising LA, three providers did not pay enhancements including one IDP (see section V.1). Table V.11 shows that there was a relationship between the LA the care workers worked in and the likelihood they perceived the pay as reasonable. In the partnership authorities where fees were higher nearly half of the care workers interviewed perceived pay to be fair (45% in RN and 48% in XD) compared to Part V. Recruitment and retention in the care sector: a case study approach 322 only 23% of care workers in IL. Care workers working for IDPs in the high fee paying partnership LA of XD were more likely to consider their pay to be reasonable compared to those working for IDPS in other LAs. Box V. 21. LADP care workers’ attitudes to pay and non-pay benefits I would say yes [it is reasonable] I know that they [the council] look after their staff better than the private company, they pay better, their conditions are better, you know. (ONLADP, Care Worker 3, age 43, 14 yrs in post) Our pay is very good for what we do. I‟m not saying it‟s a piece of cake but when you compare our pay to, especially private sector, we‟re very well paid… There‟s hundreds of agencies out there that I could work for but their pay is far less than ours, and we have other perks as well, like travel. (RNLADP, Care Worker 2, age 45, 15 yrs in post) 'Cos you see them advertising and I know people that are working, and on the whole a lot of them are on like £6.50 an hour, and the main problem with agency and with us as well is they don‟t get paid their travel time. So in between calls, whereas I know my next call now from here is about eight miles away, nine miles away. Now, if I didn‟t get paid for that and I‟m in a traffic jam for half an hour, 45 minutes I‟ve lost 45 minutes pay. So you‟re behind. (RNLADP, Care Worker 2, age 45, 15 yrs in post) Regardless of which local authority care workers worked in, those working in care homes thought their pay was unreasonable. Furthermore, the perception of pay as unreasonable in IL shows that those working in local labour markets characterised by high unemployment were just as likely to think the pay was unreasonable as those working in higher wage areas as the quotation below shows; I think we‟re grossly underpaid. I think we‟re in the firing line for all the mucky jobs and grossly underpaid….It‟s minimum wage. It is a minimum wage city, isn‟t it. (ILDom1, Senior Care Worker 1, age 50, 1 yr 8 months in post) Table V.11 Care workers’ perceptions of pay by local authority area Number of care workers who perceived their pay to be reasonable By LA % IDPs Homes LA providers All ON 2 0 4 6 29 RN 3 2 4 9 45 IL 3 1 2 6 23 XD 6 1 3 10 48 All 4 LAs 14 4 13 31 35 Part V. Recruitment and retention in the care sector: a case study approach 323 Among the 56 people who said their pay was not reasonable for the work they do, a number of themes arose in their discussions (box V.22). One of the striking findings was the absence of any discussion of the employer‟s role in determining low pay. Rather, care workers talked about the undervalued nature of care work in general and some appeared to accept a trade-off between rewarding work and well paid work. Box V.22. Independent sector care workers attitudes to pay and non-pay benefits I just think it‟s a badly paid profession, it always has been and nobody‟s doing anything about it to make it any better. I always think if they paid more money they‟d get a higher calibre of people coming through anyway. (RNDom1, Care Worker 3, age 50, 1 yr in post) I think it [the pay] should be a little bit more. But, like I say, I love the job, so I mean it‟s not an issue with me…. (ON.Dom1, Care Worker 3, age 49, 4 yrs in post) Working as a care assistant is generally not particularly well paid, but … to a certain extent the reward is the job itself…. Knowing that you‟re able to make a difference to people‟s quality of life by being there and doing your job properly. (RNHome2, Care Worker 4, age 48, 1 yr in post) Yeah. I mean my son‟s in [ retail store], stacking shelves and he‟s on like £8 an hour. But it‟s not the type of job that you can work for money, it‟s a job that you‟ve gotta like and love. (ILHome2, Care Worker 1, age 50, 2 yrs 6 months in post) Yes [it is reasonable]. I find that I like the work more, I like getting up of a morning and coming to work more than I did previously. (ILHome1, Care Worker 1, age 30, 1.15 months in post) Yeah. I think, I think maybe, I think pay would be a question if you didn‟t like what you were doing. I think when you enjoy what you‟re doing, it‟s a bonus. (ILDom1, Senior Care Worker 2, age 45, 1 yr 6 months in post) This data would appear to support the idea that care workers are „prisoners of love‟, accepting low wages because of altruistic motivations and the intrinsic rewards of the job (see section 1.4). However, while the evidence suggests that some do accept the low wages because of compensating rewards, these findings also need to be put into the context of care workers‟ previous work histories that have shaped their expectations about wages and job quality. The majority of the sample had worked in low paid, low skilled jobs in sectors such as retail, hospitality, administration, and factory work. These jobs were low paid and often described as monotonous. In contrast care work was found to be more interesting and rewarding than their previous jobs. It is the limited range of opportunities available to unqualified workers in general that led the low pay in care work being at least tolerated as the opportunity to have both higher pay and interesting work did not appear to be an option. These influences can be illustrated when we look at younger workers‟ perceptions of pay (box V.23). Half of the total sample of under 30s in the sample felt the pay was reasonable compared to just over a third of the whole sample. Those who did consider it reasonable tended to relate their experience in care work to their low expectations, based on their Part V. Recruitment and retention in the care sector: a case study approach 324 earnings in the past rather than to specific organisation policies. It is also notable that pay tends not to rise with experience in care work, so younger staff may be more likely to consider the pay reasonable than those with many years of experience in the sector. Box V.23. Young people and perceptions of pay Well, for my age it is, yeah. It‟s not too bad. (RN.Home1, Care Worker 2, age 19, 6 months in post) Yes. I‟m not really bothered about how much I get paid. Because I feel rewarded because of what I‟ve done. But the pay is fine, yes, it‟s alright. (XDDom1, Care Worker 1, age 18, 8 months in post) It is more money, yeah .. in a nursery you would think you‟d get paid a bit more money …they‟re putting their children‟s lives in your hands, you would think that you‟d get paid more, but you don‟t. So it‟s nice to come here and feel like, you know, 'cos you get paid a little bit more you actually feel you‟re being a bit more valued. Like they actually appreciate what you‟re doing. (RNDom2, Care Worker 2, age 24, 1 yr in post) Some care workers did voice criticisms of their employer‟s policy on pay and a minority linked the pay to the commissioning practices of the local authority. As discussed above, when policies about pay were discussed, it was often in relation to enhancements or travel pay rather than the basic pay. It was the lack of these that was often at the centre of discussions about pay when people perceived it to be unreasonable (box V.24). Box V. 24. Lack of travel pay as a source of dissatisfaction You‟re not getting paid for your distance you walk to, each (…) house, people‟s houses, just for what you‟re doing….And I think you should get paid for your distance (…), 'cos that‟s all in your job. ….Because we have to go out to various places and pay bus-pass fares and things. And I don‟t see why we should have to pay to go to work, if you know what I mean. (ILDom1, Care Worker 3, age 25, 1 week in post) I‟d like to get paid from the time I start to the time I finish, instead of being paid just for the calls I do. For example, I was out for 5½ hours yesterday in the evening. But I only got 3½ hours pay. Because of all the travelling here, there and everywhere, by the time I leave home and the time I get home, I was out for, as I say, 5½ hours. Which is a bit of a shame, because it‟s two hours of my time that I‟m not getting paid for. And I do think to myself, oooh, that‟s the worst part of the job I think…Our manager has tried putting it forward but it‟s up to social services, and they say “No, we‟re not going to give you any more money”. So she can‟t give us any more money. (XDDom1, Care Worker 2, age 37, 2 yrs in post) The quotations in box V.24 show how some workers made links between the LA commissioning environment and the lack of travel pay. The impact of commissioning practices was also becoming increasingly felt through the implementation of electronic monitoring. This was in place in two of the case study LAs and one care worker raised the Part V. Recruitment and retention in the care sector: a case study approach 325 issue of how this was affecting her pay because she may be told by service users to leave their homes before she is scheduled to leave (see box V.25). As this practice spreads and becomes more commonplace care workers may become more directly conscious of the role of the LA‟s practices on their pay. Although electronic monitoring practices are designed to monitor providers, the inevitable outcome is increased monitoring of care workers with potentially negative impacts on their take home pay. Box V. 25. Electronic monitoring and the impact on pay So you only get paid for what you clock in for. So if you‟re there ten minutes, you only get paid that ten minutes. …..Even if they say, “You can go now, I‟ve done everything, there‟s nothing else for you to do. There‟s no point in you staying. You get on dear and get on with your other jobs”…..So you can think you‟re getting a five hour shift and you actually end up only doing 3½ hours, because some of the clients don‟t want you to stay, (XDDom1, Care Worker 2, age 37, 2 yrs in post) This discussion of pay shows that dissatisfaction with pay alone is only part of the story when trying to explain recruitment and retention difficulties. Pay may deter people from entering care work and even among those who have entered, such as our sample of care workers, the majority consider their pay to be unreasonable. Nevertheless, the majority wanted to stay in the sector and with their employer. To understand this commitment further, other HR practices relating to working time, work organisation and training are examined to see what bundles of practices and trade-offs between particular advantages and disadvantages of the job help create the group of „stayers‟ that our sample represents. V.4.2 Working time We have already discussed the somewhat conflicting findings relating to working time and recruitment. Although working hours on offer in the care sector can be both a reason to enter the sector and a reason to defer, in practice only nine care workers identified issues relating to working time as an aspect of the job they were dissatisfied with. Table V.A3 in the appendix gives a breakdown of the working hours of our sample of interviewees. This shows that over half of the sample (54%) worked full-time hours (between 30-45 per week): this applied to 58% of interviewees in IDPs and 63% of those in care homes. Although there were only 20 interviewees in the sample working for the LAs, these tended to work fewer hours than those working in the independent sector: only 30% worked full-time hours and 70% worked long part-time (16-30 hours per week). None of those working for an LA worked over 45 hours compared to 18% of those in IDPs and 5% of those in care homes. Although the sample is too small to generalise from, these figures suggest that social care is far from a short hours, part-time work sector. To explore the care workers‟ views on working time, we asked whether they were working the hours they preferred, why they preferred these hours and if their employer was able to Part V. Recruitment and retention in the care sector: a case study approach 326 match their work schedules with their preferences. In the telephone survey five case study managers said they matched care workers working time preferences all of the time, 14 said they matched them most of the time and one LADP said they only matched preferences some of the time. Care workers were in fact more positive about their working time arrangements. Seventy-two out of 88 care workers said their working hours matched their preferences. Of those who said they did not work hours that matched their preferences, the majority were new recruits who wanted more hours, or disliked the fragmented and unsocial nature of the hours. Eight said they had no preference or reported that they worked contracted hours which implied limited choice over hours but they did not give any indication whether these were preferred hours or not. Significantly, out of the eight care workers that reported they did not work their preferred hours, five of these worked for LAs (out of a sample of 20 LA care workers). This gives some support to a trend that was discussed in section V.1 where care workers working for LADPs appear to have less working-time flexibility compared to those care workers working for other providers. New recruits in particular who were often hired to provide cover for holidays and sickness could work very varied hours. Many of these care workers wanted to build up a round of clients and wanted more work. Dissatisfaction over not being given enough hours could lead to the newly recruited thinking about leaving the organisation because of the impact on their pay (box V.26). Box. V. 26. New recruits dealing with the unpredictable and fragmented working time in the care sector I asked for 40 hours a week and I‟ve only been getting 21…..Yeah. Because I‟d rather have, do you know what I mean, set hours like I thought it was, but when they, you know what I mean, when you‟re starting they‟re not set out like that, they‟re just all different, so that was a problem for me. I‟m a bit unsure whether to stay here or what. Gonna get back in touch with [employment agency]. (ILDom1, Care Worker 3, age 25, 1 week in post) I need to work a certain number of hours in a week and I can only go on for like a certain length of time and if I‟m not getting those hours then there‟s no point in me staying. (RNDom2, Care Worker 4, age 32, 2 weeks in post) It can fluctuate quite a bit. I find it quite hard sometimes when I‟ve got a gap in the day that‟s over eight hours. Like this morning I was getting people up. Then I‟m not on until around about 20 past 7 tonight when I‟ve got to go back out again. And I find it very hard. I find it - because you‟re just winding down. The body‟s winding down and then you‟ve got to - and I‟m looking at the clock from 5 o‟clock on, just keep looking at the clock because you don‟t want to miss that. Because you have to go out and do double ups and things like that. (XDLADP, Care Worker 2, age 55, 4 months in post) Oooh, it can vary. I‟ve got 12 permanent hours I do a week and then I cover sort of hours for people on holiday, things like that, and I can be doing about between about 18 to about 40 hours a week. Sometimes more. (RNHome1, Care Worker 2, age 19, 6 months in post) Sometimes I can do 25, sometimes 35, sometimes 40 or 50, depends on how much staff we‟ve got. (ILDom1, Care Worker 2, age 34, 8 months in post) Part V. Recruitment and retention in the care sector: a case study approach 327 However, for some the fragmented hours were the reason why they entered the sector and stayed. The split shifts in particular could fit in with school times if family or friends were available to cover in the evenings and some older workers preferred them. Yet for others, the hours were seen to be incompatible with a family life and, as we have seen in the recruitment and retention discussion, they could be the reason for not delaying entry or for leaving the sector. Some care workers felt very dissatisfied with the practice of providers using existing staff to cover shortages and the unpredictability involved in being asked to do hours at short notice. One care worker was employed in an organisation with a very high turnover rate and there was a sense that existing staff were constantly being asked to cover. She believed new staff who did not like saying no to their new employer were doing too many hours and this made them leave (box V.27). Another one talked about how difficult it was working unpredictable hours; Box V.27. Care workers not achieving work-life balance ..they‟re always ringing you up asking you to do extras all the time, can you do this, can you do that, 'cos somebody‟s rang in, you see. They‟ve just asked me now, 'cos it‟s my weekend off. I work every other weekend and she just said, „Do you want to work this weekend?‟ I said no. ……I mean when they [new recruits] first start they don‟t like saying no….They think, oh well, they‟ll think I‟m no good at the job, so they end up doing all these extra hours what they don‟t really wanna do. (ONDom1, Care Worker 1, age 48, 3 yrs in post) I feel this is a hard job – you get attached to people, and it‟s a lot of care, and a lot of people can‟t do it. It‟s like you are not appreciated, it‟s hard working, and its long hours, it‟s not fitting your job round your life, it‟s fitting your life round your job. You don‟t know what you are doing one day to the next hours wise. (ILHome1, Care Worker 3, age 23, 3 yrs in post) However, for others the offer of more hours and the ability to earn more money by working extra hours was the attraction of the job and the only way they could earn a living wage, thus enabling them to stay working in the sector. The quotations in box V.28 are from care workers working long hours, often over 45 hours a week. The opportunity to build up a weekly wage through additional hours may be a further factor why a third of workers considered their pay to be reasonable, despite the very low hourly rate of pay. Box V.28. Long hours working to earn a living wage It is the hardest profession, it is not reasonable. I wouldn‟t go for a £7 (an hour) job through because I love this job. It is poor. I have to work an extra 20 hours per week to earn a salary – there is no recognition as a profession. (ILDom2, Senior Care Worker 1, age 39, 8 months in post, 40-50 hours a week). It‟s long days. I mean I started at quarter to seven this morning and I won‟t be finished till half seven, quarter to eight tonight. I‟m off in the afternoon and then I‟m back on at three. If you‟ve got Part V. Recruitment and retention in the care sector: a case study approach 328 kids you just couldn‟t do it. -I work every hour they give me. …This is my first weekend off in about six, seven weeks, I‟ve always done a bit of overtime for them. I‟m cream-crackered (ONDom1, Care Worker 4, age 43, 5 months in post, 40-60 hours per week – 6.45 am – 7.45 pm). But I used to do, that‟s what I‟m used to, you see. In my old home I used to do 72. But the thing is you get used to earning a certain amount of money and if you cut that down to, say you‟re contracted to 36, you think, oh God, how can I survive on that? (RN.Home2, Care Worker 3, age 21, 3 months in post, 48-60 hours a week). 'Cos if you want they‟re flexible, if you wanna do more overtime, if you wanna earn more money there is more money sometimes there to be earnt. (ILDom1, Care Worker 1, age 29, 1 yr 6 months in post, 30 hours a week)). Yes. If I didn‟t do weekends, I wouldn‟t make up my money. (XDDom2, Care Worker 1, age 53, time in post unknown). For some care workers, therefore, satisfaction with hours may underpin their decision to stay in the sector. Many talked of a trade off between hours that fit in with their needs and circumstances and low pay, the former being the most important factor in their job choice at this point in their lives. Fundamentally, while in many discussions of pay the employer was not identified as a key agent, in respect of working hours a manager who showed flexibility in hours scheduling was highly appreciated (box V.29). Box V. 29. The ‘good employer’ as the one who matches working time preferences They‟re really, really good. Yeah, we can choose our hours, and they‟re also very good, 'cos I look after my mum and they‟re really good here if I‟ve got a hospital appointment or something like that with her, they‟re absolutely brilliant with me. (RNHome2, Care Worker 2, age 56, 2 yrs in post) And also it‟s like here they‟re very good, I‟ve a got a five year old and because my husband works in the NHS, they‟re very good about swapping my hours around. I go to the person who does the rotas, which has all come through Nick as well. It‟s not just me, there‟s other people with children that need to change their hours and they really accommodate us. They work out who‟s on holiday and they change your hours, so they are very good like that. (XDHome1, Care Worker 3, age 44, 3 yrs in post) We don‟t have guaranteed hours, so we only get what we‟re given. But the co-ordinators are excellent. They do actually try and give us what they can and help us out. A very good team, very good office. The ladies are lovely. (XDDom1, Care Worker 2, age 37, 2 yrs in post) Part V. Recruitment and retention in the care sector: a case study approach 329 Care coordinators realised how important this was for care worker satisfaction; It‟s very important to us[that staff get preferred hours]. We don‟t work people outside their availability unless they agree to work. If we wanted someone to do any extra, we would always ask them, we wouldn‟t just give them work… Everyone, when they start, they fill in availabilities and we do not work people outside these‟. (XDDom2, Care Coordinator and Care Worker, age 23, 1 yr in post) Hours become important in recruitment and retention if we look at intentions to quit; a crosstabulation of the data demonstrates that those who were unhappy with their hours were more likely to intend to leave their current employer (table V.12). Four of the eight people who said they were unhappy with hours were likely to quit their employer and three out of five of the care workers on contracted hours with no choice also said they would not be with their current employer or were unsure if they would be. Table V.12 Satisfaction with working hours by intention to stay with current employer Sample No. Intending to be with current employer in five years % of care workers Yes Probably Unsure No Happy with hours 72 56% 6% 17% 22% Unhappy with hours 8 50% 0% 0% 50% No choice offered* 5 40% 0% 40% 20% No Preference 3 67% 0% 0% 33% Total 88 55% 5% 16% 25% *These interviewees did not say whether they were happy or unhappy with their hours The above discussion has shown the idiosyncratic nature of the hours worked by care workers. They are a result of a negotiation between the manager or care coordinator and the care worker and what is a push factor for one care worker (getting asked to do too much cover, getting split shifts) is a pull factor for others (getting the extra hours they need, getting some wanted gaps in the day). In general in our case study organisations across all LAs the providers‟ requirements for flexibility were met by staff and it would appear to be the case that managers were by and large also meeting staff‟s requirements for flexibility. Part V. Recruitment and retention in the care sector: a case study approach 330 V.5. Care workers’ perspective on work organisation and the quality of care Managers‟ perspectives on whether the current system of work organisation was allowing work to be carried out to a high quality standard were collected in the telephone survey. In section V.1 we discussed the management perspectives on aspects of work organisation that we have identified as particularly important in creating both good quality care jobs and opportunities for care workers to deliver good quality care. This revealed that managers of the IDP case studies, in particular, perceive there to be some limitations on workers‟ freedom to prioritise and carry out tasks in ways to improve the quality of care. They also perceive some restrictions, but not as many, on care workers‟ opportunities to develop good relationships with service users. Nevertheless, the majority of the care workers we interviewed identified the relationships with service users as a key source of job satisfaction, and many others identified the autonomy they had as a reason why they liked the job. These divergent views suggest there are some contradictions between managers‟ and care workers‟ accounts of how work was organised. This section will explore these contradictions in more detail. In the case studies we explored the extent to which care workers felt they were able to deliver the best quality care. We asked about the concrete ways they could use their discretion to improve the care they provided and also their ability to develop good relationships with users. We were also able to explore the impact of the LA commissioning environment by interviewing care workers who worked in LAs where electronic monitoring was in place. As section V.1.6 has shown, managers from two IDPs that were part of the same national chain but located in different LAs (XDDom1 and ONDom2) reported that care workers had low discretion and that there were also some limitations on care workers being able to develop good relationships. Both were in LAs where electronic monitoring was in place. We were particularly interested in care workers‟ perspectives in these cases and if this LA policy and/or provider policy shaped their experiences of work and their ability to deliver good quality care. Boxes V.30 and V.31 use some of the qualitative data collected from care workers in XDDom1 and ONDom2 to illustrate their experiences of discretion and relationships with users. Box V.30. Case study of XDDom 1: care worker perspectives in a ‘low discretion’ national provider in a partnership LA Manager and coordinator perspectives: Staff do not have the freedom to prioritise tasks and do not have time to spend time talking to service users. There are time constraints on staff delivering the best quality care because of electronic monitoring and the increased paperwork this brings. Management reported that although electronic monitoring is a good management tool they were dissatisfied with the practice of using minute-to-minute invoicing. Part V. Recruitment and retention in the care sector: a case study approach 331 Care worker perspectives: Time constraints but workers feel they can overcome these Sometimes I find I haven‟t got enough time. But if that is the case and I find I go in there three or four times, I found that I‟m taking more than the half hour I‟m given, then I will let the office know and they‟ll ring social services, and say, this lady‟s going to need extra time, because our care workers are taking longer. So it gets changed that way. As long as you open your mouth and say, they‟ll do something about it. If you don‟t say anything, nothing will get done. So you have to speak out and say. (XDDom1, Care Worker 2, age 37, 2 yrs in post) There‟s always time. You make the time. And if it means you run over a few minutes then you run over. But then on some calls you can only be there 10 minutes and it‟s a half an hour call. So you do make up a bit of time. So you do what you have to do and I always say, is there anything I should be doing. Even if it‟s not in the care plan. It might be put the washing on the bed, or put the washing on the line. You do it. I don‟t see why people don‟t do it. I have terrible issues with people who don‟t even do the basics like wash up and empty bins and things. (XDDom1, Senior Care Worker, age 42, 3 yrs in post) Task autonomy: changing the way you do things Yes. Sometimes [I do change], yes. You‟ve got to remember, a lot of old people are set in their ways as to how they want it to be. So that‟s how it is. But if you‟ve got an idea that can make their life easier, they are open to it. But it depends if they like it or not. And you have to go with them. It‟s freedom of choice. They choose, or their family chooses if they‟re not in the position to choose. (XDDom1, Senior Care Worker, age 42, 3 yrs in post) I‟ll just do it [if she finds an easier way to lift a client] And then I‟ll make a note of it in the care plan, and then next time I speak to them [the office] I‟ll say, oh well I tried this, but everybody has their own way. And if you‟re on a double up run, you both do it differently. But you work together. As long as your aim is the same purpose at the end of it, you just do it. (XDDom1, Senior Care Worker, age 42, 3 yrs in post) Opportunities to develop relationships Yes. I think it‟s vital that you go in and you speak about you. I don‟t think you should go in miserable. And I know we all have bad days. But I think you should go in there upbeat and chat. And talk about different things. …I‟m always talking about my family. My daughter did a sky dive and one of the ladies I visit, sponsored her, so I took photos in to show her, even though she[the user] ended up in hospital. …Because some of those people don‟t see anybody. They don‟t go out. They sit in that house 24/7. So by talking about something completely different I think it‟s nice for them. (XDDom1, Senior Care Worker, age 42, 3 yrs in post) Box V.30 shows that in XDDom1 electronic monitoring does not seem to have affected opportunities for care workers to develop relationships and „go the extra mile‟ in the way managers and coordinators believed it had (although it did have an impact on pay, see section V.1.2). The care coordinators were very aware of the issues that arise with electronic monitor- Part V. Recruitment and retention in the care sector: a case study approach 332 Box V.31. Case study of ONDom2: care worker perspectives in a ‘low discretion’ national provider in a mixed LA Manager and coordinator perspectives: Staff do not have opportunities to prioritise tasks but are able to develop relationships with users. There was a reluctance to encourage staff to exchange ideas and best practice but continuity of care was considered to be very important and the manager said time was built into care packages for care workers to be able to have time to develop good relationships. Are staff encouraged to exchange ideas with other care workers about new ways of working or best practice? A: Only at staff meetings, but obviously we have to be made aware of it first because it has to get authorised, they wouldn‟t be allowed to just change things (ONDom2, Manager) Care worker perspectives: Lack of task autonomy I think sometimes what annoys me, it‟s sort of your hands are tied a lot of the time, because we‟re commissioned by social workers we can only do what they instruct us to do, and sometimes we‟re the ones who are seeing service users on a daily basis and we‟re seeing what they need, and sometimes it‟s not always easy to get them what they need, and I think that‟s frustrating. There‟s a lot of red tape you have to go through. (ONDom2, Senior Care Worker 2, age 36, 1 yr 6 months in post) Not really, no [freedom to prioritise tasks]. 'Cos we have a care plan in each house we‟re stuck to that care plan. But if someone‟s needs have changed we‟re told to ring the office and they get the authorisation from social services then. (ONDom2, Care Coordinator and Care Worker, age 26, 5 yrs in post) Time constraints and developing relationships I don‟t feel we‟ve always enough time for to spend. Sometimes, if you‟ve a lot of service users to see in a day, you can‟t give them the time they need. And I think that‟s the biggest constraint. You are on a tight schedule because, you know, … Q: Is there any way you can get that changed in terms of asking for a longer visit or …? A: Well, it‟s not always … 'cos sometimes, you see the social workers assess the length of a visit on what they need doing, but sometimes they don‟t take into consideration that they might just want somebody to sit and chat to. (ONDom2, Care Coordinator and Care Worker, age 26, 5 yrs in post) Continuity of care You do build up, good relationships with some of your clients when you see them on a regular basis. So you see them, you know, getting better, you can see some getting worse. It is a rewarding job, that's why I do it. (ONDom2, Care Coordinator and Care Worker, age 26, 5 yrs in post) 'Cos we try and keep the same carer to the same service user. Keep it structured, which is a good thing. (ONDom2, Care Coordinator 1, age 54, 2 yrs in post) Part V. Recruitment and retention in the care sector: a case study approach 333 ing (see section V.1) and when there are issues related to too little time these seem to resolved with the LA. This could be the result of the good relationship between the LA and the provider, rated four out of five in our survey. Although managers expressed the view that there should be more time to sit with care users, in fact relationships are developing well in this case often at the discretion of the care worker. Fundamentally it would appear that care workers have more discretion than managers perceive them to have and the inherent autonomy in domiciliary care may mean that care workers are able to be more flexible and develop better relationships than the HR practices in theory would allow. As it is these aspects that are cited as the source of their job satisfaction, it is unsurprising they are willing to invest time and energy in building and deepening these relationships with users. A contrasting picture emerges in ONDom2 as care workers‟ experiences would appear to support manager perspectives. The lack of autonomy and reluctance to go beyond the care plan echoed the management perspective. This organisation had a high level of turnover and this combined with the unsupervised nature of domiciliary care work might be one possible reason why the provider did not encourage discretion if many of the care workers were new recruits and inexperienced. There was continuity of care but care workers reported time constraints on their freedom to spend time with users which was not recognised by managers. Electronic monitoring was not mentioned as a problem by the care workers specifically, but the tight schedules that they said did not allow time to talk to users might have been a result of this. It is also useful to contrast these care workers‟ experiences with those who worked for providers who reported different outcomes for care staff in terms of discretion and relationships with users. Box V.32 gives the perspectives of some care workers working for a provider in a partnership LA which sets KPIs relating to continuity of care. Box V.33 then looks at the perspectives of those working for a provider in a cost minimising authority where levels of discretion were reported to be high. We find that although the opportunities to develop good relationships were there only to some extent, the manager did encourage care workers to share ideas. In box V.32 extracts from interviews with care workers show that the emphasis on continuity of care at the LA and provider level is implemented in practice and shapes the care workers‟ experience of work. There are some limits on task autonomy but there were high levels of satisfaction expressed by those working for this provider. It was a low paying provider compared to other providers in RN but the care workers valued „being their own boss‟, being unsupervised and caring for regular service users. In terms of delivering good quality care, it would appear that care workers were able to do so because of the stress on continuity of care and their ability and confidence to use their discretion and go „beyond the care plan‟. Research with users shows that this kind of flexibility is valued by users (see section I.4) and a shift to outcome-based care can have the effect of sanctioning some of the discretionary behaviours care workers have been carrying out without little recognition in the past. Part V. Recruitment and retention in the care sector: a case study approach 334 Box V.32. Case study of RNDom1: care worker perspectives in a partnership LA that emphasises continuity of care Manager perspective: KPIs and incentive payments relating to continuity of care were built into contracting arrangements. This provider was also piloting outcome-based care for the LA which would move away from a task and time-oriented approach. The manager identified continuity of care as very important but reported that workers could only prioritise tasks and develop relationships to some extent. Outcome-based care was, however, providing more scope for care workers to exercise discretion over how to provide care . „Continuity of care is essential…It‟s one of our KPIs to the local authority, is continuity of care‟. (RNDom1, Manager) Care worker perspectives: Task discretion I go straight to the care plan and look at the tasks that are allocated, and then it‟s using a bit, working round commonsense, what is appropriate and what isn‟t, and just say „Is there anything else that you need me to do?‟ That‟s not perhaps on the care plan but within reason. (RNDom1, Care Worker 2, age 51, 2 yrs in post) Not being able to follow things through, if something needs to be done you have to hand back to the office. I‟d quite like it if I could phone up the social worker and speak to them myself, and that sort of business. Which I might be able to do soon if they let me be team leader. (RNDom1, Care Worker 3, age 50, 1 yr in post) Autonomy and relationships I like it because I‟m on my own and I‟ve got nobody breathing down my neck all the time and I just feel that, you know, you are, it sounds a bit clichéd, job satisfaction, rewarding (RNDom1, Care Worker 2, age 51, 2 yrs in post) (see Box V.18 for additional quotes) Continuity of care It‟s generally if you build up a relationship. When you‟ve got a regular service user, I do a lady that I go in to five mornings a week for an hour, and then I do an hour and a half with her doing her domestic, so it‟s continuity really. (RNDom1, Care Worker 2, age 51, 2 yrs in post) Outcome-based care There‟s a bit of both now because they‟re bringing in a different type of care plan where they can choose a little bit more of what they [the user] have, rather than a set one that we‟ve always had…..We make sure everything that we‟re supposed to be doing‟s done but there‟s loads of other jobs that we do and a lot of that‟s in our own time… Q: What kind of things? A: Go to post office for them and post letters, pick up shopping, papers, newspapers, fish and chips. (RNDom1, Care Worker 3, age 50, 1 yr in post) Part V. Recruitment and retention in the care sector: a case study approach 335 Box V. 33. Case study of ILHome1: care worker perspectives in a ‘high discretion’ provider in a cost minimising LA Manager perspective: The manager reported that staff were free to prioritise tasks and were able to develop good relationships to some extent, although she recognised this was often when they worked on other tasks. They were encouraged to share ideas with her and continuity of care was very important. „When I asked for ideas/suggestions at a meeting, they didn‟t say anything, but I asked them to write it down. We got some good suggestions, and when they were less shy, we got more. We try them out‟ (ILHome1, Manager) Care worker perspectives: Time constraints on tasks Sometimes you‟re, you know, obviously rushed off your feet and it can get quite hectic. (ILHome1, Care Worker 1, age 30, 1.15 months in post) They do [tasks] get done, just it is rushed a little bit. Like hoisting and things like that, and getting them all to their meals. (ILHome1, Care Worker 2, age 21, 6 months in post) Time constraints on developing relationships with users No, not always, they sometimes think you can spend all day with them, but realistically, you can‟t and sometimes they want it there and then – you learn to get out of that, you explain we have 42 residents and we can‟t possibly do that, especially if you have only five staff on. If it‟s full, it can be hard. (ILHome1, Care Worker 4, age 30, 6 yrs in post) Management support to exercise autonomy [ Q. (How much) Are you able to introduce new approaches on your own to improve the quality of care you provide? ] A. Well, it depends. I‟d ask the supervisor or [the manager] anyway, just to see what their opinion is. (ILHome1, Care Worker 2, age 21, 6 months in post) A. I would discuss this first with a supervisor. (ILHome1, Care Worker 4, age 30, 6 yrs in post) In the case study of ILHome1 there would appear to be some discrepancy between the management perspective and that of the care workers. The manager did not mention that staff shortages were affecting work organisation in contrast to the situation described by her staff although she did recognise that relationships often had to be developed while care workers were doing other tasks. However, the care workers identified problems when the service users wanted them to stop all other tasks and devote time specifically to their relationship needs. Care workers felt they could use their initiative but only if supported by management. Fundamentally, it would appear that, despite the manager‟s best intentions, time constraints Part V. Recruitment and retention in the care sector: a case study approach 336 were affecting the quality of care that staff were able to provide. Interestingly, although this group of workers experienced time constraints as a source of frustration, the care workers working in this provider cited pay as the aspect of work they were dissatisfied with and they linked it to the fact that the job was „very hard work‟. This would suggest that dissatisfaction with low pay can increase when work organisation and staff shortages mean care workers‟ experience their daily job as rushed and hectic. Part V. Recruitment and retention in the care sector: a case study approach 337 V.6. Care workers’ perspectives on training and development In this section we look specifically at how training and development practices of providers can affect recruitment and retention. This section will firstly give an overview of the level of qualifications attained by the sample of interviewees and identify any trends relating to the commissioning environment and type of provider. We then go on to discuss the care workers‟ views on training and their aspirations for development and promotion. These are discussed in relation to their effect on intentions to stay with their employer and in the sector. V.6.1 Experiences of training Levels of qualifications Table V.13 gives an overview of the NVQ levels of all of the interviewees across the case study providers. The share of interviewees with NVQ level 2 qualifications ranged from 53% in IDPs, 61% in care homes and 85% in LA providers. There were fewer differences in the shares with NVQ level 3, with 35% of those in IDPs, 34% of those in care homes and only 25% of those in LA providers with this qualification. Those working in LAs pursuing cost minimisation or mixed strategies were more likely to have NVQ levels 2 and 3, RN had the lowest number of staff with NVQ level 2. We found only one example of a more obvious relationship between commissioning strategy and level of training; the high proportion of NVQ level 3 trained staff in ILDom2 was the result of the block contract they had with the LA for hospital discharges that stipulated care staff working on this contract should be trained at this level. Table V.13 Qualification levels of interviewees NVQ2 Total Yes (%) Due to start (%) NVQ3 Yes NVQ4 Nursing qualification Yes UK Non-UK (%) Due to start (%) (%) (%) (%) Working in: Domiciliary 40 53 10 35 3 0 3 0 Care homes 38 61 8 34 5 5 3 8 LA providers 20 85 0 25 0 10 0 0 All provider types 98 62 7 33 3 4 2 3 ON 25 68 8 56 0 8 4 0 RN 22 55 5 27 0 5 5 5 IL 26 69 0 38 0 0 0 0 XD 25 56 16 8 12 4 0 8 By LA Part V. Recruitment and retention in the care sector: a case study approach 338 Experiences of training and links to retention Our interview data revealed that in general the new recruits and more established care staff reported positive experiences of training. Induction was perceived as useful by the majority of the sample, including both new recruits and stayers. Induction can be the first signal to an employee about the value the employer places on its workforce and can also provide the staff with a realistic introduction to what the job of a care worker involves, thereby the likelihood of staff quits where new recruits find the job to be different to expectations. Some of our case study organisations prided themselves on the training they gave and workers appreciated the opportunities this brought to help them do their job well (box V.34). Box V. 34. Positive experiences of training They do push us to learn more, which is good. And training wise we got all the training that we need. ...It‟s very helpful, yes they‟re all very helpful, all the training. Made us more confident in what we are doing. Like manual handling, we become more confident. With dementia training we become more confident about dealing with people with dementia. We get to understand them and we become better in the care that we are providing. (XDHome1, Care Worker 2, age 31, 6 months in post) Well the training is just absolutely brilliant. The best. It really, really is. It‟s all practical as well as theory. ….I think [the manager‟s] trying to encourage everybody to do the NVQ. Because it is interesting, you learn a lot from it. (XDHome1, Care Worker 4, age 32, 2 yrs in post) Well, I‟ve taken loads of courses. I‟ve taken a lot of courses in dementia. So I‟m really interested in dementia. Yes. I‟ve been lucky. I‟ve gone on a lot of courses. If I‟ve been interested in something, they found a course that will cover it. (XDLADP, Care Worker 3, age 52, 7 yrs in post) While low pay was rarely seen to be the fault of the employer, opportunities for training led care staff to think of the organisation they worked for as a „good employer‟. Box V.35 gives examples of care staff working for very low paying providers discussing the reasons why they value the training opportunities they have been given. These staff often had no or little opportunity for pay progression when they have completed training, so financial reward was not the motivator. Significantly, these workers had no or very few formal qualifications and valued the opportunity given by a sector that offers a rare opportunity for unqualified workers to gain a qualification. Box V. 35. Care workers and training: a chance to gain qualifications I did my NVQ 1. I did that in caring here. And that‟s about it really. I‟m gonna try do my NVQ2. I‟ve no qualifications with school. Just what knocks me back on that at the minute is like my reading and writing, so I‟m gonna try and get round, I was at college at one point doing it, it‟s only through me not going to secondary school through my accident. …And with me having my accident my confidence went….and I was a bit like behind with my reading and my writing and I didn‟t think that Part V. Recruitment and retention in the care sector: a case study approach 339 I could ever get the chance, and then [the manager] give me the chance and I loved it. (ONHome2, Care Worker 4, age 24, 6 months in post) I‟ve got my NVQ2, I‟m in the middle of doing my level three, I‟m also doing a safe medication course as well. Unfortunately I didn‟t get no GCSEs or anything at school. Well, I‟ve just, I started off as a carer and I‟ve worked my way up as a senior, and I think up to now that‟ll be like the highest I can get in this place here, but I wouldn‟t mind like going further up, like management or even owning my own home or something like that…. If I had the opportunity I would definitely take it, yeah. (ONHome2, Care Worker 2, age 26, 3 yrs in post) They do tend to give everybody a chance here, which is nice. They‟re not judgemental and they‟ll listen, 'cos I‟ve been here and been listened to, you know, so …And they do do a lot NVQ levels with the skills for life, English and Maths, so they‟re helping people that are perhaps from a disadvantage, do you know what I mean? (ONDom1, Care Worker 2, age 33, 6 months in post) Some care staff identified negative aspects of training, relating to the time it took and their lacked of basic reading and writing skills. However, more often any negative views about training related to it being too theoretical and class-based which fitted in with the positive accounts given above where training is valued because it can be put into practice (see box V.36). Box V. 36. Preferences for practical induction and training We did the training downstairs and it was just someone going over basically all the information about Plan and stuff like that….I found it a little bit useful, but I‟m the sort of person that learns from actually going out and doing the job and not sitting …. I mean the only time that she showed us a bit of information and we had to do it for ourselves is when we were learning to do the hoists and stuff like that. I preferred my shadowing, even though I didn‟t get to do much 'cos I‟m just observing, I still got to see it from that point of view. (RNDom2, Care Worker 2, age 24, 1 yr in post) I found the training, because I went straight into training, confusing. Because I‟d never done the job. It was alright the first day, that was interesting. But by the end of two weeks it was psh, psh, psh - going over my head. I hadn‟t been out in the field….I think it would have made more sense if you‟d have done a bit of training, gone out in the field, and shadowed, seen how things worked and progressed and you could slot what you‟ve just learnt into what you‟re seeing in practice. And then go back and do a bit more training. (XDLADP, Care Worker 2, age 55, 4 months in post) There were also many examples of staff who were happy with the training they received but who wanted more specialist training that was not related to meeting statutory regulations but related to the needs of specific users they cared for. In particular dementia training was mentioned by care staff as a form of training many would like the opportunity to have (see box V.37). The data across all case studies show that in general care staff valued the training on offer and this was particularly the case when they were able to train in areas that were relevant to the Part V. Recruitment and retention in the care sector: a case study approach 340 specific needs of users. When employers offered extensive training, care staff often came to define their employer as a „good employer‟. However, positive perceptions about training did not necessarily mean that care staff wanted to progress to more senior levels. Box V. 37. Learning opportunities that are user-led rather than regulation-led I‟d like to do both the Alzheimer‟s and the dementia, 'cos I have been to a few clients who have got that. (IL.Dom2, Care Worker 2, age 20, 3 weeks in post) There are other areas that I‟ve not been trained for that I would be interested in doing…..Alzheimer‟s and dementia and Parkinson‟s. And now we‟ve someone that‟s got MS and I‟m interested in that as well. So - and it all helps to understand. (XDLADP, Care Worker 4, age 58, 11 months in post) Then I‟ve had different individual training at certain houses, depending what the client needs. Some people you have to be trained to do certain tasks. We have a lady where she had a peg feed, where you feed her internally with liquid. I was taught how to do that. There‟s a lady who has liquid medicine. We have to be taught to do that. We‟re not allowed to just go and give liquids. We‟ve got to be trained. (XDLADP, Care Worker 1, age 50, 3 yrs in post) I‟d like, well, we do a dementia course but I‟d like to go further into it..More depth, you know, more understanding about it. (ONHome2, Care Worker 3, age 42, 2 yrs in post) I‟ve had medication training in the other place I used to work, had it all the time. But I‟d like dementia training especially, I think, because dementia, it‟s a thing everybody can suffer with, isn‟t it, quite a scary thing (RNHome1, Senior Care Worker, age 54, 6 months in post) V.6.2 Development and opportunities training Restricted career ladders have been identified as a reason why it is difficult to recruit and retain in the social care sector and the importance of linking training with career ladders has been identified. Because of the methodology used in the project, we are unable to say whether the lack of development and career opportunities have been deterring people from entry. However, in relation to retention we are able to look at whether the care staff we interviewed had aspirations to progress and if this shaped their intention to stay or quit working for their provider. We asked all care staff whether they would like to progress in the organisation. Thirty care workers out of 88 said they wanted to progress, 57 said they did not and one was unsure. There were no trends relating to type of provider or age, with older workers just as likely to want to progress as younger workers. Of those that wanted to progress, some interesting trends can be observed. Firstly, seven out of nine men wanted to progress; the two men who did not want to progress were in their 50s and 60s and said they were too old. For the men who wanted to progress, a lack of opportunities to do this was a reason to leave their employer in the future (see box V.38). Part V. Recruitment and retention in the care sector: a case study approach 341 However, as men made up a very small minority of our sample it is difficult to generalise and the attitudes of men in care work must be a key area of future research. Box V. 38. Development opportunities as a retention factor for men The only way that I can explain it is that I asked - because obviously I‟ve got an NVQ 2, I said to her [the manager] basically, everybody else is doing their NVQ 2, so I would like to do my NVQ 3. And [she] turned round and says, we don‟t let you do your NVQ 3 because we cannot promote you. That‟s not a good excuse really…obviously because of that reason I won‟t stay here. But yeah I would stay in social care. (XD.Dom2, Care Worker 2, age 32, 1 yr in post) I wanna do, I‟m thinking about doing my [NVQ] level four after Christmas, or I would really like to do my RMA [Registered manager‟s award].…I either wanna do like the manager‟s side or I‟d like to go to university and become a mental health nurse, so sort of like one of the two…..if I got to like a point within the home where I thought I‟m not gonna get any further, I would have a look around and if an opportunity come up then I would take it. (RNHome2, Care Worker 3, age 21, 3 months in post) Secondly, many who said they wanted to progress did so while anticipating barriers to doing so. While the lack of part-time positions in professional occupations has been highlighted as a barrier to women‟s progress, it would appear that in this female-dominated occupational group there is little room for part-time senior positions, or at least this is the perception of care workers (box V.39). Box. V.39. Obstacles to progression I became a senior, and that was hard work, but with my life the way it is with my young children, I decided that I couldn‟t keep the devotion up as a senior, so I went back down to being a carer, so I‟m doing that now….It‟s not a lot more work, it‟s just the company do put a little bit more pressure on you, because you‟re a senior. They think that you should - well they don‟t think, but they expect you to take calls on because you‟re a senior, they expect you to take the calls, and it‟s very, very it‟s quite hard. And with young kids I just found it too much. (XDDom1, Care Worker 2, age 37, 2 yrs in post) I think moving up to senior, it‟s just the hours that stop me doing that, because I can‟t work enough – I‟m not flexible you see. (ILHome1, Care Worker 4, age 30, 6 yrs in post) The reasons care workers reported for not wanting to progress were threefold; firstly the limited reward for a senior post that involved a lot more responsibility and stress; secondly the opinion that a senior role involved taking care workers away from the job of caring; and thirdly family responsibilities and circumstances that meant they could not work the hours required to do a senior role. Interestingly, some had been offered senior roles and declined Part V. Recruitment and retention in the care sector: a case study approach 342 them or had had them in the past but returned to a care worker post because they either felt it was too much work or preferred to be caring for users (box V.40). Box V.40. Care staff rejecting opportunities for progression I could. I was offered the job of a senior but I think, it‟s not even a pound extra an hour, so I will not take on the responsibility of this whole home for that sort of money. (RNHome2, Care Worker 2, age 56, 2 yrs in post) I was actually a senior carer, I was the first senior carer here, but all the responsibility of all the phones and all this I didn‟t want, so I chose to go back to be a carer because I enjoy the job, I love the job, you know, in the field, it‟s a totally different job. (ONDom1, Care Worker 3, age 49, 4 yrs in post) I suppose I could be a supervisor, but there‟s not that much, I could go to supervisor and I think that would be it. Yes, and no, the amount of work load and responsibility they have on them is a lot. I can see that because that‟s what my mum does. For a minute amount of money for the amount of responsibility, it‟s just not worth it. (ILHome1, Care Worker 3, age 23, 3 yrs in post) These comments (box V.40) shows that the increased responsibility associated with a senior role was difficult for many with families, especially when it was paid poorly and took care workers away from the direct care of service users. As we have seen, job satisfaction was largely derived from working with users. As such, the reluctance of some care workers to progress seems related to the perception that a more senior role would involve more paperwork and less caring (see Box V.41). It is also worth noting that there was very limited interest among the care workers we interviewed in taking up roles as personal assistants. Sixty-three care workers were asked whether they would be interested and of these 44 said they would not even consider it, while only ten said they were interested and a further four said possibly (five said they did not know). The majority of care staff expressed the view that they would not even consider a job as a personal assistant but ten of the 63 who were asked did say they might be interested. The minority of care workers who would consider it mentioned that one-on-one work of this kind could potentially be more rewarding and would also have the benefit of being less rushed than their current role. However, for the majority of care workers the one-on-one nature of the personal assistant role was not appealing. Many mentioned how it would be emotionally draining to care for only one user and many felt they would become too involved and be unable to cope. They identified aspects of their current jobs they would miss if they were to become a personal assistant, including opportunities to meet lots of different people, being able to move around autonomously and have the support of managers and colleagues. Some would not consider it because they wanted the „back-up‟ of management and working in a team and they also anticipated increased job insecurity in such a role if work was reliant on specific users. Part V. Recruitment and retention in the care sector: a case study approach 343 Box. V.41. Progression as a move away from hands-on caring It‟s not, it‟s more about paperwork at senior and medication. They do do care and that but I‟d rather be caring and more hands-on, definitely. (ONHome2, Care Worker 4, age 24, 6 months in post). I don‟t know if I would [like to progress], because then you don‟t get to do the care. See I like the care. (XDDom1, Senior Care Worker, age 42, 3 yrs in post). No. I do .. because the next level up from me would mean giving my care up, you see. The next level up from me is a coordinator, which is office based. So I do like being out on community, so for to move up I‟d have to have sort of reached that stage where I don‟t want to actually do hands-on any more, so to speak. (ONDom2, Senior Care Worker 2, age 36, 1 yr 6 months in post). I suppose if we went to … be senior carer or whatever, that entails an NVQ3, I don‟t wanna be in an office. I just don‟t. I don‟t, I wanna be on the floor. (ILLAHOME, Care Worker 2, age 49, 21 yrs in post). In summary, positive experiences of training may improve retention in the sense that care staff felt valued by their organisation. Crucially it was also another means to ensure they were providing good quality care to users, a key source of job satisfaction. Case-study data also revealed why a lack of career opportunities may not necessarily be a reason to leave the job or the sector. Care workers valued hands on caring and opportunities for progression typically represented a move away from this. Moreover, the more senior roles demanded very high responsibility with very limited improvements in pay. The examples of care staff that prized training in the low paying organisations shows the importance of recognising how employees can feel valued and supported by employers, even if in receipt of a low wage. However, we have shown this depends on the experiences and expectations of the particular care worker and we cannot assume this group is typical. For example, in order to expand the potential pool of applicants, for example to men or to women with more qualifications and career options, these potential new recruits might be less willing to make the trade off between opportunities to gain qualifications and low pay. If this is the case, the creation of senior posts that are both more rewarding financially and that do not involve such a leap away from care work, possibly involving more specialist care roles rather than only supervisory roles could help to make care work a more attractive opportunity for those who both wish to enter the sector to care but also to have opportunities to develop and progress. Part V. Recruitment and retention in the care sector: a case study approach 344 V.7 Summary and conclusions In section V.1 we compared the HR practices of providers across the case study LAs. This overview found variations among providers in the same LA as well as across LAs. The LA commissioning environment appears to have more influence on some aspects of HR practice more than others: for example pay and the nature of contracts offered to care workers were related to being in a higher fee paying LA, but the improvements were only marginal. In other aspects such as training and working time, firm level policies are even more significant with limited effects from the LA commissioning and contracting. Using case-study data to compare and contrast the practices put in place by the same national providers located in different LAs shows we find that the policies of national chains are playing a significant role in both shaping HR practices and in limiting the actual impact of favourable commissioning practices on employment terms and conditions. These findings suggest that the LA commissioning environment may be an enabler of better practice but there are variations between providers in the extent to which they respond to more favourable commissioning practices. Furthermore, although there is variation in practices across providers this variation is around a very low level of basic employment conditions and protections. Sections V.2 to V.6 explored the experiences and perspectives of care workers and identified a number of trends. The recruitment process in the social care sector is characterized by a high degree of informality, particularly in the independent sector. Care workers‟ informal experiences of caring in the home often lead them to want to do the job and care workers use family and social contacts and networks who are already working in the care sector to access information about the nature of jobs and vacancies. Employers are complicit in this informality and in some ways actively encourage it. Providers identify attitudinal qualities rather than formal skills as the most important factor when assessing the suitability of candidates and some national providers are trying to formalise the use of „word of mouth‟ recruitment by using voucher schemes which reward existing care staff with a bonus if they introduce a friend to the job. We found that just over half of interviewees anticipated that they would still be working for their current employer in five years time and 85% intended to stay working in the social care sector. Only 10% of care workers working for LADPs intended to leave their current employer. Of those who intended to leave their current employer, going to work for the NHS and/or undertaking nurse training were the reasons most often given. However, only 27% of interviewees said they definitely intended to leave. This may be considered unsurprising because the case study revealed high levels of job satisfaction. All 88 care workers enjoyed their work, in particular the rewarding nature of the job, helping others and relationships with service users were given as reasons for high levels of satisfaction. Care workers working for IDPs also mentioned the autonomy the job brings as a reason for enjoying the job. However, care workers also reported low satisfaction with pay. Fifty-six care workers out of 88 believed their pay to be unreasonable and there was particular dissatisfaction with the lack of travel pay and pay for unsocial hours. They also had concerns that the spread of electronic Part V. Recruitment and retention in the care sector: a case study approach 345 monitoring might reduce their total reward still further by restricting paid work time to time actually spent in people‟s houses rather than at work. In contrast those working for LAs expressed high levels of satisfaction with their pay, in part because they were aware of the poor conditions in the independent sector. Care workers were more satisfied with working time. Many had entered the sector because it offered convenient working time and 72 out of 88 care workers said their working hours matched their preferences, although care workers working for LADPs were less likely to work their preferred hours. Care workers who did not work hours that matched their preferences were more likely to intend to leave their current employer, although we cannot say whether this was a direct reason for their intention to leave. Care workers, especially new recruits, were working variable and unpredictable hours to cover shortages and holidays and the idiosyncratic nature of the hours worked by care workers was a key finding. Hours were highly fragmented and did not conform to standard family friendly working time and this had led some to defer entry into the sector in the past. While the care workers we interviewed were in general happy with their working hours, the hours suited care workers with very specific needs and circumstances who often needed to work locally. In general the new recruits and more established care staff reported positive experiences of training and the offer of training had attracted some into the sector. Opportunities for training led care staff to think of the organisation they worked for as a „good employer‟. Significantly, these workers had no or very few qualifications and they valued the opening for unqualified workers to gain a qualification. The provision of training and development opportunities appeared to be an important way in which providers could show care staff that they were valued. There were some contradictory findings relating to care workers‟ aspirations to progress. On the one hand the limited opportunities for progression were not perceived as a problem because many care workers said they did not want to progress, although this was not true for the small sample of men interviewed. However, one of the reasons the female care workers gave for not wanting to progress was that senior jobs involved far more extra responsibility for limited extra reward. Another important factor was that senior roles also involved taking them away from the hands-on care that was key to their job satisfaction. The findings on work organisation revealed some contradictory results. We particularly focused on care workers‟ opportunities to prioritise tasks to improve quality care and their opportunities to develop good relationships with service users. While some providers reported care workers had low discretion and also faced constraints in developing relationships, care workers accounts revealed care workers continue to use discretion despite some constraints in time and continue to be flexible and go „beyond contract‟. The extent of discretion varied by context. Thus a national provider operating in LAs that had put in place electronic monitoring was found not to offer much scope for discretion. However, a case study of a provider operating in an LA that had established KPIs relating to continuity of care for providers was found to allow care workers much more scope to go beyond contract. The opportunity to develop relationships with users allowed room for discretion and in this sense care work was not found to fit the standard classification of low paid, routine work. Part V. Recruitment and retention in the care sector: a case study approach 346 This finding that care workers do use discretion to improve the quality of care and develop relationships is important because research on users‟ perspectives shows that the attitudes of care workers and their relationships with care users are central to users‟ definitions of quality care. In particular care workers‟ willingness to be flexible and do jobs beyond those stipulated in the care plan are of particular importance alongside a caring attitude. This definition of good quality care fits into the definition of a good quality care job as defined by the care workers themselves. Those care workers who reported high job satisfaction referred to the importance of the relationships they developed with users.This fits with evidence from other studies ( see discussion in part I and TNS 2007). The importance of relationships to both care workers and users thus reveals a complementarity between user and care worker perspectives and between understandings of good quality jobs and good quality care. 347 VI. Research Findings and Conclusions In this final part of the report we return to our original research questions (see section I.5) and provide a summary of the findings. We conclude by using the insights gained from our nine empirical research questions and the three stages of the research project to address our final policy-related research question. That is, in the light of our findings, we consider the prospects for the recruitment and retention of an expanded and higher quality social care workforce in the future under current and emerging conditions and suggest where the key policy challenges may lie if these workforce objectives are to be realised. VI.1. The local authority commissioning environment 1. How do those in the local authorities responsible for commissioning and/or contracting make sense of the multiple, changing and potentially contradictory pressures on commissioning policy? Our qualitative interviews with key actors responsible for commissioning and contracting in the 14 selected local authorities (LAs) revealed the multiple and potentially conflicting influences on commissioning practices. Social care commissioning takes place within the wider local authority and is thereby influenced by the specific council‟s organisational and political environment. At the same time it is shaped by the longer term policy agendas for the development of social care. Approaches towards commissioning were found to be influenced by competing agendas, including on the one hand the need to support providers and develop the supply base and the imperative, on the other hand, to take costs out and control price, even in a context of pressures to drive up the quality of care delivered. Further competing agendas stemmed from whether commissioning would in the future continue to be dominated by LAs or either undertaken jointly with the NHS or devolved to users. While commissioning in all LAs was being pulled in competing directions, differences could be identified between LAs in both the preferred strategic approaches taken by their commissioners and in what they were actually doing to implement these approaches. In particular there were marked differences in the emphasis placed on developing partnerships with independent providers and in the emphasis placed on strategies to reduce costs. We classified LAs on the basis of both actual fee levels paid and on their commissioners‟ espoused views and policies on partnership to distinguish between three types of LAs: those that are partnership focused; those focused on cost minimisation; and those falling into a mixed category. This classification was found to have some resonances with the national user satisfaction scores as recorded by LAs, with the cost minimising LAs assessed by users as providing less good quality care than the partnership or mixed categories. The cost minimising category included LAs from different regions and labour market conditions, 348 indicating that their classification was a reflection of a particular policy stance by the LA rather than a reflection of other local conditions. However, the partnership category included mainly LAs that faced strong local labour market demand while the mixed category was also more mixed in characteristics. Some of the mixed category LAs topped the user satisfaction scores and in one case LA directly employed staff in a 3* rated unit provided a high share of domiciliary care services, suggesting perhaps that it is share of services outsourced as well as commissioning strategies towards the independent sector providers that may influence user satisfaction scores. While we have provided a categorisation of the commissioning and contracting strategies of the LAs, a triangulation of the various sources of information on LA strategies and approaches casts some doubts on the coherence, stability and long term sustainability of some of these apparent differences in commissioning and contracting stances. Above all there was a very high rate of change in commissioning policies, some of them implemented during the course of our project. This rate of change reflected both the changing commissioning environments and the recognition of potential contradictions between some of the LAs‟ objectives and their current commissioning approach. In some cases the problem was a perception that their policy was not working (higher prices for rural domiciliary providers were not being passed on to the workforce) or that their policy might lead to too high costs in the future (where uprating of fees was guaranteed in the contract as an indicator of partnership). In one LA the commissioners were planning to use new policy agendas such as personalisation to push through changes that they had found difficult to legitimize in the past, such as LA withdrawals from routine domiciliary care. Such double-edged policy initiatives created problems in developing stable and coherent classifications of the approach taken by the LA. Among the LA commissioners there was considerable awareness that following short term and budget driven competitive tendering was undermining the scope for long term strategic developments but cost pressures and rules on competition policy stood in the way of a more strategic approach. Furthermore, working with the NHS was identified by some as a means towards a more strategic approach but for others it had become a source of short term inconsistencies: for example, where the NHS in the locality created obstacles to policies of reducing admissions to residential homes or to developing quality rather than simply pricebased commissioning strategies. Past commissioning strategies were also hampering some LAs in developing current policies and practices. This particularly applied to those LAs that had effectively ended domiciliary care direct provision in the past. These LAs faced a large cost legacy in the form of TUPE transferred staff to independent providers but also lacked an inhouse facility to facilitate the development of re-ablement services and provide training support to local providers. Thus, although the LAs did adopt different commissioning strategies and approaches, these did not necessarily provide sufficiently stable and coherent signals for independent providers to have the confidence to use them as a basis to develop different approaches to managing the social care workforce. Even when a policy decision had been taken to provide a higher quality approach, there were concerns that this might leave them exposed to higher costs than other LAs which could prove difficult under future funding regimes. That is, the LAs were 349 not sufficiently autonomous from central government policy to be able to develop coherent and stable strategic approaches that would not be easily destabilised by changes in central government policy, as well as by other local policy decisions. 2. What are the variations and trends in the specific characteristics of LA commissioning and contracting practices, from price and contract to quality monitoring and provider relations? We found significant variation in the specific practices adopted by LAs with respect to commissioning and contracting, particularly in the case of domiciliary care, but these differences again were, as already suggested, subject to a high degree of change. The variations between LAs and the changes within LAs can be best analysed by taking commissioning of domiciliary care and care home placements separately. In domiciliary care the majority of service hours had already been outsourced in all LAs and there were further plans to outsource in six of the eleven where outsourcing was still below 90% of service hours. There were no plans to TUPE transfer LA staff and most LAs felt that this would not be cost effective. Moreover, most were planning to keep some inhouse provision and the high levels of outsourcing also coincided with a strong tendency towards greater specialisation within the remaining LA provision with only four still undertaking routine domiciliary care work. Nevertheless there were wide variations in the extent of involvement of the independent sector in specialist work (see table II.1). One of the major trends identified was a move away from block contracts towards a set of preferred providers, in part as a cost efficiency measure to reduce risks of paying for unused hours but also in preparation for the personalisation agenda. One LA described their new preferred provider systems as a „new block‟ contract, that is involving similar commitments to block but without minimum guaranteed hours. However, the trends were not uniform as five still used block contracts and two had recently moved to such contracts. These new preferred provider arrangements almost always included an increased use of national providers. The LAs‟ commissioning staff often expressed some concerns about the effect of the increased role for national providers but nevertheless still included more in their preferred provider list and in only a few LAs were concerns expressed about the need to maintain local agencies on the list particularly where they were associated with serving particular communities. All divided up their preferred providers or block contractors by geographical area but some used a number of providers per area while others used only one or a main and subsidiary providers. Many LA commissioners were concerned about the impact of personalisation on the survival of these arrangements which they saw as essential to reduce costs and keep travel time to a minimum. 350 Pricing strategies did vary between LAs with six setting a fixed fee per hour before the tender with all providers contracted at that rate while eight LAs fees varied by providers according to their tender price. The trend appeared to be more towards a fixed fee and in practice the variations between fees were limited even when they could vary in theory. Not only did the average fee paid to IDPs (excluding those with TUPE transferred LA staff) only range from £10.45 to £14.50 for 13 LAs but the range among providers within a locality rarely exceed £2 to £3. One LA was an exception on both counts with a range from £16 to £28. In addition to a trend towards a fixed fee there was a general trend towards a simple flat rate fee for whatever hours were worked (several had recently phased out higher fees for shorter visits and very few paid anything extra for unsocial hours or bank holidays) and also with limited or no differences by the needs of the user. Likewise fees were paid for service hours and not for travel time, although some allowed for higher prices from IDPs operating in rural areas. This simplification of the fee structure was driven by the interests of transaction costs at the LA level and the implications for wages and for incentives towards taking on more complex or more unsocial hours work for either the providers or the employed staff did not seem to be actively considered. Likewise the move towards use of electronic monitoring was primarily driven by the interest of reducing costs and ensuring clients received their full visits; the impact on the staff employed appeared not to be a prime consideration. While most LAs undertook some form of quality monitoring of IDPs, which also included some monitoring of HR practices, only two provided quality incentives for IDPs to either improve the quality of their care or the quality of their HR practices. Commissioning practices with respect to care homes tended to be primarily on a spot contract basis. Twelve of the 14 LAs still provided some residential home care inhouse and ten had some block purchase contracts with independent sector homes but most placements were spot contract with independent sector homes, usually according to the preferences of the user. LA commissioners were clearly aware that they had less ability to influence the behaviour of care home providers especially in those areas where a large share of clients were self funded. Variations in fees for residential care were much wider than for domiciliary care between LAs and reflected regional variations in housing costs, not just wage costs. However, the level of fees set also reflected political priorities. In some LAs there was an explicit commissioning strategy of setting a care home fee at a level where it would not be necessary for an LA funded client to pay any top-up fees unless they had a special room of some kind. In other LAs commissioners anticipated that most residents would be asked to pay top-up fees. Perhaps because of the difficulty of influencing care homes, more LAs had introduced quality enhancements for homes, with six currently offering quality premia and some others planning to introduce them. As with domiciliary care, many LAs were actively engaged in monitoring homes but fewer had developed their own quality frameworks for homes. However, where they were in place they had potentially more impact because they were linked to a qualitybased fee framework. 351 The selected LAs also were, for the most part, engaged in actively supporting independent sector providers through training partnerships. Nine had current partnerships with the independent sector and others supported training through opening up LA training to the independent sector. However, those that had outsourced all their domiciliary services were less likely to be engaged in training and in some cases LAs discontinued training provision when sources of central government money for training support dried up, thus providing another example where changes in central government policy may lead to rapid changes in LA policy. Although all LAs held forums with providers these were more common with IDPs than with homes. Moreover there was evidence of variations in activity within the forums in part linked to the tendency or otherwise for local providers to become organised and engaged in dialogue with the LA commissioning and contracting staff. 352 VI.2. Explaining the variety of HR policies and HR outcomes of providers 3. What is the current state of HR practices and outcomes in the sector? The need to map the current state of HR practices and outcomes arises largely out of the context of radical transformation in the organisation of social care services for the elderly, characterised by a near complete shift from local authority provision to independent private sector and voluntary sector provision. As a consequence, there are multiple forms of provider organisations currently engaged in delivering elderly care, of varying size, diverse ownership configurations (such as single establishments, local and national chains) and distinctive profit and not for profit business strategies. Moreover, without a guiding national framework for employment conditions and HR practices (as provided across much of the public sector through national framework agreements), there is enormous potential for variety and diversity in the quality of HR practices. To address the research questions about what factors influence HR practices and outcomes, therefore, this project constructed an original dataset on the characteristics, context, practices and outcomes of provider organisations – including domiciliary care providers, care homes and local authority inhouse providers of domiciliary care (referred to throughout this report as IDPs, homes and LADPs, respectively). An important contribution of our dataset is its incorporation of quality measures of a raft of HR practices and outcomes, encompassing recruitment, working time, pay and work organisation among others. The overall mapping of HR practices and HR outcomes presented in part III, and complemented by the case-study findings in part V, yielded the key finding that the quality of HR practices across the whole of the independent private sector is clustered at the poor end of the spectrum of potential HR policies and that there remain notable problems in recruitment and retention, despite much of the survey having been conducted after the start of the recession. Some systematic differences were found between homes and IDPs but the major differences in quality of HR practices were between the independent and the public sector, although voluntary sector providers offered better conditions than the private sector. However in our sample a high share of the volunaty providers were residential homes operating predominately with private clients rather than LA funded clients. The evidence suggests that there are significant problems of recruitment and retention in the independent sector. Although most providers judged recruitment to be relatively easy in the recession period, IDPs in particular faced difficulty meeting their needs with nearly 70% recording shortages for weekend and unsocial hours work. Much of the recruitment is informal although more so in homes than IDPs and LADPs ,and all tended to rely on recruiting workers with positive and friendly attitudes, with only LADPs placing importance on previous skills related to care work among job applicants. and IDPs were most likely to emphasise availability for early mornings, evenings and weekend work. Staff turnover averaged 24% for homes and 31% for IDPs. Homes were better at retaining new recruits but 22% of homes and 32% of IDPs had 353 lost more than half of their new recruits in the past year. Even excluding turnover among new recruits, turnover rates were still 22% for IDPs and 18% for homes. Responses to these problems by providers have been limited. Overall the independent sector provided a poor set of employment conditions, whatever the characteristics of the provider. Thus, the potential for variations in HR practices by type of provider were marginal within our dataset, although these could still, as we see later, make an impact on recruitment and retention outcomes. These poor conditions were particularly notable with respect to pay. Pay levels in the independent sector were clustered within a band for the most part no more than £1 above the then national minimum wage of £5.73 with limited opportunities for upgrading even for those who acquire NVQ qualifications at level 2 or even 3. The practice of uprating pay on a regular basis was not universal and in homes was more influenced by changes in the statutory national minimum wage while in IDPs the main factor was change in LA fee levels and profitability. Not only did we find basic pay levels to be low in the independent sector particularly among for profit organisations but we also found that other elements of the reward policy resulted in very low total pay for the length and scheduling of hours spent at work or in work related activities. Paying a premium for overtime was primarily confined to providers in the public sector, with most LADPs upholding this convention but only a quarter of homes and IDPs. Unsocial hours payments were either not made or were more a matter of pence than a significant proportion of the hourly wage. This lack of compensation for unsocial hours was particularly significant in a sector where almost all staff were involved in weekend work and many in early and late hours and night work. A significant share of providers also passed the upfront costs of entering work (such as CRB checks, uniforms and induction training) on to new recruits. Overall homes pay lower rates than IDPs and the IDPs in turn pay far lower rates than the LADPs. Moreover, there is no trade-off between pay and other benefits; LADPs pay the highest rates of pay and also pay for unsocial hours, travel time and upfront costs of entering work. The independent sector homes and IDPs pay low rates of pay and do not conform to good practices in these other areas of reward. Contractual arrangements were also found to be different between the public and the independent sector with evidence of a very strong employer-led model of flexibility among homes and especially among IDPs. The public sector LADPs had followed a standard approach to employment relationships by providing guaranteed hours to care workers while the bulk of IDPs offered zero hours contracts only. This seemed to provide IDP managers with a useful tool of workforce control enabling them to draw on a readily available pool of employees for the required schedule of hours but the result was that even staff who worked regularly full-time hours or longer and had been regularly employed for several years were given no employment or wage guarantees. In homes, care workers were more likely to be offered guaranteed hours and were also more likely to work full-time than in IDPs. In both homes and IDPs only a minority of providers claimed to be able to match hours with employee preferences all of the time. 354 With respect to working time the key difference in schedules was between domiciliary and homes rather than public versus independent sector. Working time schedules were very fragmented in domiciliary care and managers adopted a wide range of different solutions, involving either split shifts to allow for continuity of care or more consolidated shifts by banding together morning and dinner times and teas and evening care periods. In care homes, managers also struggled with care rotas that respected minimum staffing ratios, which seemed to vary between homes. Weekend working was extremely widespread in the sector with nearly three fifths of IDPs, seven in ten homes and nine in ten LADPs reporting that all their staff were engaged in regular weekend working. Opportunities to exercise discretion at work so as to improve the quality of care may be considered an indicator of both job quality and the quality of user care. Managers‟ responses indicate that there were more obstacles facing workers in IDPs than in homes. This is confirmed by our index measure of work organisation which is significantly worse for IDPs than homes (with LADPs in between). However, a similar share of both homes and IDPs (around a fifth) believed workers did not have sufficient time to develop better relationships with users. Two final areas of HR practices investigated concerned opportunities for development (such as through training and appraisals) and for performance management, including the expression of individual or collective voice. Although all providers were strongly engaged in training provision, including induction training and training to NVQ level 2, attainment of NVQ qualifications was higher in homes than in IDPs. More than half of homes and LADPs had more than 70% of care workers qualified to level 2 compared to only a third of IDPs. Nine in ten homes had already met the now abolished national target of having at least half the staff trained to level 2 compared to just two thirds of IDPs. The two key factors cited by managers in explaining failure to reach the target were high staff turnover and training related problems such as funding. Use of appraisals was frequent throughout the sector and most providers favoured soft over hard methods to improve performance, but poor performance, including absenteeism, had at times to be tolerated in four out of ten IDPs. While all LADPs had union recognition agreements, only 8% of IDPs and 15% of homes recognised unions. All providers held regular staff meetings, although IDPs were least likely to organise these on a frequent basis. 4. What role do provider characteristics play in shaping HR practices and outcomes? In our investigation of the impact of provider characteristics, including size, ownership, profit/not-for-profit status and CQC star rating, we deployed different descriptive and statistical methods. The first half of part IV presented the results of what are essentially multiple correlation tests that compare the differences in mean scores between our quality indices of HR practices and provider characteristics. Because correlations based on simple cross-tabulations may produce misleading results, we also applied multivariate regression analysis and presented these results in the second half of part IV. Thus while the cross- 355 tabulations offer a valuable guide to possible associations between variables, in this final part of the report we attribute greater weight to the evidence from the multivariate statistical models in pulling together the various results. The short answer to this fourth research question is that evidence for systematic differences by provider characteristics (other than between homes, IDPs and LADPs described above) was patchy. Drawing on both our cross tabulations of HR practices and our multivariate analyses we can summarise the effects as follows. Beginning with the size of provider (measured by numbers employed), we might expect larger homes and larger IDPs to design and implement better HR practices, drawing upon their better equipped HR teams, and to enjoy better HR outcomes. The findings, while mixed, do not support this argument. Among homes, it is clear that the larger the size the worse the quality index of pay levels (including minimum and normal rates of pay, premium payment for unsocial hours and pay for training) and the worse the overall summary index of HR practices. And among IDPs, larger organisations have a worse index of pay strategies, which covers HR practices of providing opportunities for pay improvement, career development and upfront costs of starting work. With regard to HR outcomes, larger homes and larger IDPs have worse recruitment and retention outcomes (measured on the basis of managers‟ views) and larger homes also experience a worse (quantitative) measure of staff turnover excluding new recruits. These are the main findings supported by the regression results. Other possible associations with organisational size are highlighted by the multiple correlation tests (Anovas). These suggest, for example, that smaller homes may have been more likely to offer better career opportunities, less likely to require regular weekend working and enjoyed better training outcomes than medium and large homes. Only one result suggests better practices among larger homes, namely, the greater use of appraisals. Among IDPs, the results are mixed: for example, larger IDPs had higher shares of staff working long hours and were less likely to pay for induction training, but on the other hand were more likely to offer time off for training and less likely to require weekend working (contrary to the result for homes). A second important distinguishing characteristic among providers is the form of ownership. We distinguished between national chain, local chain and single establishment. As with size, one might anticipate those providers that are members of national chains to be able to invest in better HR practices and enjoy better HR outcomes than local chain and, especially, single establishment providers. Again, however, the evidence does not support such an argument. Among homes the regression results suggest ownership type has no significant effect on HR practices; local chain homes appear to exert a positive influence on the quality index of pay levels but the effect is not statistically significant. HR outcomes among homes are influenced by ownership type, but it is single establishment homes, not chains, that enjoyed better performance, namely with respect to training outcomes and with respect to both quantitative measures of staff turnover (with and without new recruits). Among IDPs, local chain providers have a better index of pay strategies than national chain providers and this combines with better HR outcomes in the form of recruitment and retention and training; unlike homes there is no association with the quantitative measures of staff turnover. 356 Again, the multiple correlation tests are suggestive (although not fully substantiated) of other possible associations. The results are mixed. For example, national chain homes were less likely than single establishment homes to make unsocial hours payments and more likely than local chain homes to have staff working long hours. On the other hand, national chain homes were more likely than single homes to provide regular pay uprating and to pay the upfront costs of starting work, and national chain and single homes were more likely to allow for workers to exercise discretion than local chains. For IDPs, the correlation tests reveal very few effects of ownership type: like homes, national chain IDPs were more likely to have staff working long hours than local chains but on the other hand national and local chain IDPs were more likely to carry out staff appraisals than single IDPs. A third organisational characteristic we investigated is the star rating, from 1 to 3, assigned to the provider by the Care Quality Commission. While the overall variation of practices and outcomes was small, our analyses nevertheless attributed some broadly positive effects associated with a provider‟s star rating. Because the star rating may be interpreted as a performance outcome rather than an exogenous organisational characteristic (such as size of ownership type) we did not use this variable in our regression results. We did, however, explore its associations with HR practices and outcomes using the less sophisticated multiple correlation tests. These reveal the following. Compared with homes rated 1* and 2*, 3* homes paid significantly higher rates and were more likely to make unsocial hours payments. However, 3* homes had worse employee voice practices than 1* and 2* homes. Among IDPs, the net balance of effects was similarly positive with 3* IDPs more likely to pay for qualifications than 2* IDPs and less likely to have all staff working regular weekends than 1* IDPs, but less likely to pay for travel time and for paid breaks than 1* IDPs. A fourth characteristic is the profit status of the provider organisation – either for profit or not for profit. As might be expected, our regression results show quite clearly that not-for-profit providers offered significantly better quality HR practices than for-profit providers (both homes and IDPs) and not-for-profit homes also enjoyed lower levels of staff turnover than for-profit homes. This result is quite striking. The for-profit status of IDPs also emerges as the most statistically significant variable in shaping the summary index of HR practices and the index of pay strategies, and in both cases the effect is negative. Among homes, the for-profit status is strongly and negatively associated with the summary index of HR practices and the index of pay levels. Among homes, for-profit status is also significantly and negatively associated with turnover outcomes, with for-profit homes experiencing higher levels of staff turnover than not-for-profit homes. 5. What is the impact of the external policy and commissioning environment and the local labour market demand factors on HR practices? To explain the patterns of recruitment and retention of the social care workforce and the associated HR practices that we identified in the telephone survey of providers we investigated the differential effects of the type of LA commissioning context on the quality of HR practices in providers, distinguishing the level of fees paid for care services and the 357 partnership (or cost minimising) orientation of the LA. In addition, we explored the impact of varying local labour market conditions, drawing out two dimensions – the median level of female part-time pay in the local area and a composite index of labour demand, as described in part I. The results paint a complex picture of inter-related effects, but certain overall findings are clear: LA fee levels have a positive, albeit weak, association with good HR practices, especially pay practices and working time practices; the partnership orientation of LAs has mixed effects on the quality of pay practices for homes but significant positive effects on both pay practices and the overall quality of HR practices for IDPs; the level of local labour market demand positively influences the quality of pay levels, pay strategies and HR practices, especially for homes; In more detail, our results are as follows. With regard to the role of LA fee levels, three findings deserve highlighting. First, the level of fees paid by an LA positively influenced the quality of pay practices of providers. With regard to actual pay levels, the relationship was positive but relatively weak: an additional £1 in fees translated into just 19p (IDPs) and 14p (homes) extra for a care worker‟s hourly pay. The regression results only identified a significant effect of LA fees on pay levels for homes, not for IDPs. This is an important result since it both confirms to some extent managers‟ views that their ability to set pay was constrained by the level of LA fees but it also clearly shows that there was only limited willingness among the independent sector homes and IDPs to raise pay. Other pay practices were also positively associated with high fee paying LAs, including the practice of paying a premium for unsocial hours working among both homes and IDPs. A further important result is that both homes and IDPs in high fee paying LAs (compared to those in medium and low fee LAs) were more likely to reward care workers with additional pay for acquiring qualifications. Relatedly, the results of multivariate tests show that the level of LA fees was positively associated with our summary index of pay strategies for IDPs, which includes practices of pay upgrade opportunities, payment of upfront costs of starting work and internal career opportunities. A second set of findings shows that LA fee levels also influenced the quality of working time practices, although not in a consistently positive direction. For homes, weekend working was less commonly required of all staff in high fee paying LAs compared to low fee paying LAs. But long hours working in homes (hours per day and/or days per week) was in fact more likely in high fee LAs than in medium and low fee areas. For IDPs, high and medium fee LAs were positively associated with the practice of giving workers time off for training compared to low fee paying LAs. Thirdly, LA fee levels appear to have a counter-intuitive association with the quality of practices that shape work organisation. Homes in low fee paying LAs score higher on measures of discretion at work than homes in high fee paying LAs; the results specifically refer to the index measure of work organisation that captures the likelihood that care workers exercised acquired skills, had the freedom to organise tasks to improve care quality and 358 enjoyed opportunities to exchange ideas with other colleagues. It is not clear why such opportunities would be more prevalent in homes paid low fees by the commissioning LA. For IDPs the results point to a non-linear association with LA fees; the aggregate index measure of work organisation is positively associated with both low fee and high fee paying LAs; the same result applies to the sub-index measure of time discretion. However, the multivariate regression results do not identify a significant role for LA fee levels in shaping work organisation. Other factors aside from the LA commissioning context would appear to matter in determining workers‟ opportunity to exercise discretion at work. Our categorisation of LAs according to commissioning orientation suggests there is a broadly positive association between partnership approaches and the quality of pay and HR practices for IDPs (confirmed by the multivariate regression results) but for homes the statistical evidence is rather mixed. For homes, the practices of paying a premium for unsocial hours and providing opportunities for pay improvements were more likely in partnership LAs. Also, statistical (anova) tests suggest that pay levels in homes were significantly higher in partnership LAs than in mixed and cost minimising LAs. However, the regression results in contrast identify a negative association (albeit not strongly statistically significant); it is therefore difficult to draw a firm conclusion about the impact of partnership LAs on pay levels in homes. For IDPs, our index measures of pay levels and pay strategies are both highest in partnership LAs and the significance of this positive association is confirmed by our regression results. A contrary finding for homes, however, suggests that cost minimising LAs are more likely to be associated with the practice of paying for training than partnership and mixed LAs. In common with the relationship with level of fees, partnership LAs were associated with a lower tendency for homes to require weekend working among care workers (compared to mixed LAs). Yet, similar to the fee levels again, the association with long hours working in homes was contrary to expectations with long hours and/or long days less likely in mixed LAs. For IDPs, the partnership orientation had one significant association with working time practices, namely that IDPs in cost minimising LAs were most likely to expect care workers to tolerate changes in hours or location at short notice. A counter-intuitive result for homes was that cost minimising LAs were associated with better quality employee development and voice practices. With regard to local labour market conditions our findings point to a strong tendency of providers to respond to strong labour market conditions by improving their HR practices. The implications for the current period are therefore that all providers may be less likely to improve the quality of HR practices as labour markets have slackened. For homes, our index measures of quality of pay levels, working time and the summary of HR practices were all positively associated with strong demand areas. For IDPs, several results follow those for homes, including positive associations with quality of pay levels, payment for unsocial hours and a lesser requirement of staff to work weekends. As with LA commissioning practices, the association with work organisation measures was counter-intuitive for both homes and IDPs. The regressions results confirm the general direction of the statistical (anova) tests. In particular, it is the level of female part-time pay in the locality that drives the quality of pay 359 strategies among IDPs (including opportunities for pay improvement and payment of upfront staff costs) and for homes while the level of female part-time pay is strongly and positively associated with the summary index of HR practices, it is the summary measure of local labour demand that drives the quality of pay strategies. 6. The evidence presented in parts III and IV is complemented by the case-study findings presented in part V. These case studies revealed variations among providers in the same LA as well as across LAs. The LA commissioning environment appears to have more influence on some aspects of HR practice more than others: for example pay and the nature of contracts offered to care workers were related to being in a higher fee paying LA, but the improvements were only marginal. In other aspects such as training and working time, firm level policies are even more significant with limited effects from the LA commissioning. Using case-study data to compare and contrast the practices put in place by the same national providers located in different LAs shows that the policies of national chains are playing a significant role in both shaping HR practices and in limiting the actual impact of favourable commissioning practices on employment terms and conditions. These findings suggest that the LA commissioning environment may be an enabler of better practice but there are variations between providers in the extent to which they respond to more favourable commissioning practices. Furthermore, although there is variation in practices across providers this variation is around a very low level of basic employment conditions and protections. However, national providers in keeping pay levels relatively similar in LAs offering very different fee levels may either be securing a high profit rate on their investments in high paying areas or may be using these profits to offset losses in low fee paying areas; that is there may be cross subsidies between the high and low fee paying LAs. What is the combined impact of HR practices, environmental conditions and organisational characteristics on the quality of recruitment and retention outcomes? Using a combination of statistical techniques we interrogated the multiple internal and external effects described above on four inter-related measures of recruitment and retention outcomes that drew on both qualitative and quantitative measures from the telephone survey dataset. Given the different challenges facing IDPs and homes, we consider the main headline results for each separately. We find that retention in IDPs,was more clearly related than in homes to interactions between the key external influences of commissioning and contracting practices and labour demand conditions with the internal HR practices of providers, as specified in our analytical framework. Thus we find evidence of a strong positive association between the quality of pay strategies pursued by IDPs with both the level of LA fees and the level of female part-time pay in the local area. While the statistical analyses only demonstrate a significant association, we believe it is highly likely that these external conditions acted as a trigger for better pay strategies among IDPs. The regression results demonstrate that these same better pay strategies not only have value for the care workers (more opportunities for pay uprating and premium payments for weekend working), but also are effective in reducing staff turnover; 360 the result holds for the two quantitative measures of staff turnover (for all care workers and for all excluding new recruits). These results hold even with the relatively low range of pay levels provided by the independent sector providers in our study based on a rather low rate of pay increases in response to higher LA fee levels, and even with the rather high levels of staff turnover found for the independent sector providers. The implication is that with either more favourable commissioning and contracting practices or more responsiveness of providers to fee levels, further improvements in turnover rates could be anticipated. Better practices in managing working time in IDPs are also positively associated with better recruitment and retention outcomes, both with regard to our qualitative measure (drawing on managers‟ perceptions) and with regard to our quantitative measure, at least with respect to the practice of providing time off for training. Importantly, these positive associations, which trace the linkages between external conditions, internal HR practices and recruitment and retention outcomes, are contingent upon certain organisational characteristics. Larger IDPs, holding all other factors constant, are more likely to experience worse recruitment and retention outcomes (on two of the three measures) and local chain IDPs experience better recruitment and retention outcomes than national chains according to our qualitative measure. For homes, the findings point to a different set of possible causal relationships. There is a direct association between lower staff turnover on the two quantitative measures of staff turnover and more emphasis on the HR recruitment practice of recognising the value of skills, qualifications and care experience in the selection of new recruits. We saw in part III that this practice is not very common among homes (or IDPs, although it is among LADPs); while most homes valued the desirability of skills and experience very few believed such attributes were necessary to do the job. This result therefore illustrates the potential pay-off in terms of reduced staff turnover for those managers who do attribute greater value to experiences of informal and formal caring, acquired qualifications and past training among job applicants. The practice in homes of not requiring care workers to regularly work weekends is also associated with lower staff turnover (on one measure). This is an important result given the statistical association between this particular HR practice and the LA commissioning environment as noted above; namely, that homes in high fee paying, partnership LAs are less likely to require regular weekend working. One measure of labour demand – the level of female part-time pay in the locality – is negatively associated with the quantitative measure of total staff turnover. Again, this is especially significant given the strong positive association between this indicator of labour demand and the overall summary measure of the quality of HR practices in homes. The particular organisational characteristics of homes also play a role. The size of homes has the same association with recruitment and retention as we found for IDPs – that is, larger homes have worse recruitment and retention outcomes - but the contingency effect of ownership type is different with single establishment homes faring better. A fourth outcome measure reflects the effectiveness of providers in developing a skilled care workforce, estimated by combining data on the share of workers with NVQ level 2 and managers‟ ambitions to meet a 50% target. The results for IDPs and homes are similar in the 361 cross tabulations of training outcomes by the indicator of strong, medium, weak labour demand that combines information on local pay and employment/unemployment rates for women. In areas of strong labour demand both IDPs and homes have worse measures of training outcomes. However, when in the regression analysis we separate out pay levels from employment/ unemployment conditions we find it is strong local labour demand that reduces training outcomes for IDPs but the level of female part-time pay that has this effect for homes. This last result may be surprising given the association of high female part-time pay in the area with reduce staff turnover and better overall HR practices although the impact on staff turnover is only found of the overall measure for homes and for only for turnover excluding new recruits for IDPs. One interpretation of this result is that higher job mobility in strong labour demand areas, whether through poaching or staff quits in search of better job opportunities, may make it difficult for managers to keep up with training new recruits. 362 VI.3. Recruitment and retention from a care worker and user perspective 7. What factors shape the recruitment of care workers? The case studies identified a number of factors that shape recruitment into the sector. Firstly, the personal motivations and experiences of care workers reveal the „pull‟ factors into care jobs. In particular, informal experiences of caring in the home for elderly relatives and/or children had often led to a commitment and desire to care for others and do meaningful work and these intrinsic features of the job are an important explanation as to why people enter the sector. Other features of the job that are shaped by HR practices more directly, such as training opportunities and convenient working time, were also found to be important influences on decisions to enter the sector. Secondly, the recruitment process was characterised by a high degree of informality which was also a trend indicated by the telephone survey. The informality of the process led to an important role for social networks; many care workers entered the sector by word-of-mouth recruitment. This informality was found to provide advantages from both the employer and employee perspective. From an employee perspective the informality of the recruitment process allowed them to make use of social networks which not only provided information on job opportunities but also provided encouragement to enter. This encouragement came not only through factual information about the work but the care workers in their social networks were often clearly passionate about their work. From an employer perspective this form of recruitment was useful in selecting workers who already had some knowledge of what care work entailed and were therefore less likely perhaps to quit at an early stage due to misconceptions over the nature of the work. This may account for employers‟ tendency at the recruitment stage to emphasise informal caring experiences and attitudes, in contrast to formal skills and qualifications. Moreover, word of mouth recruitment also provided a useful way of recruiting some younger workers, often younger family members of existing care workers. These benefits were being increasingly recognised by employers, including national providers, who were trying to capitalise on the potential of informal word-of-mouth recruitment methods by using bonus voucher schemes to encourage existing care workers to introduce friends and family into the sector. 8. What factors influence the retention of care workers? Our case study research revealed that just over half of the care workers we interviewed anticipated that they would still be working for their current employer in five years time and 88% intended to be still working in the sector. While we are unable to show whether this long-term commitment will lead to high levels of retention in practice, what it did reveal is the relatively high level of job satisfaction experienced by care workers. This satisfaction was found across the cases studies located in different LAs and representing different types of 363 providers. Job satisfaction related to the rewarding nature of the job and the opportunity to help and care for others. Also, for workers engaged in domiciliary work, job satisfaction also related to the opportunities provided by the nature of the work for autonomy and discretion. This high satisfaction with the job was found alongside revealed low satisfaction with key HR practices, in particular pay practices. Two thirds of care workers reported that they felt their pay was unreasonable for the work they did and the lack of travel pay and payment for unsocial hours were key areas of dissatisfaction. A further concern was that the spread of electronic monitoring might reduce total reward still further by restricting paid work time to time actually spent in people‟s houses rather than at work. In contrast all those employed by LAs expressed a high level of satisfaction with pay. Importantly their knowledge that the independent sector often did not pay for travel and unsocial hours shaped their satisfaction with their own pay and benefits. The reported high job satisfaction and commitment to the work, despite dissatisfaction with pay, could suggest that care workers become what England (2005) has described as „prisoners of love‟; that is, they become trapped in low paid work due to their engagement with and concern for their clients. Retention of care staff thus relies to a great extent on altruistic motivations and the intrinsic rewards of the job. However, while we have presented strong evidence of such motivations among current care staff, it is notable that most of these staff had previously worked in low paid, low skilled jobs in sectors such as retail, hospitality, administration, and factory work. These jobs were low paid and often described as monotonous. Care workers contrasted the monotony of other jobs with their experiences of care work which they found to be both more challenging and more rewarding. The limited opportunities available to unqualified workers mean many will accept low pay in exchange for interesting work because the opportunity to have both is not considered as an available option. Thus these findings should be put into the context of care workers‟ educational backgrounds, work histories and expectations about wages. The negative effects on employee morale of low wages and other poor employment conditions may be greater if the recruitment network for social care were to widen to groups with either more positive past experiences of employment or with a currently wider range of alternative employment options or career choices. Certain bundles of HR practices proved to be important in understanding why care workers seemed to accept low pay and intended to stay. Our case study findings show that satisfaction with working time and training opportunities meant that some of the high levels of satisfaction and commitment to the sector were indeed because of the HR practices in place. The majority of the care workers we interviewed worked hours that matched their preferences and there is no doubt that care workers valued this aspect of the job and that this is a key factor in retention. Another way of showing this effect is that those care workers who were not working the hours that matched their preferences were more likely to express an intention to leave. However, those satisfied with their hours had often been able to negotiate specific schedules that fitted their own particular needs and which were not necessarily even typical of the organisation they worked for. These working time schedules would thus either not be attractive to the majority of potential recruits, or alternatively represented specific 364 arrangements –for example not working weekends- that could not be generalised to all staff due to the service demands on the organisation. Training opportunities provided another example of an HR practice that could help with retention. Although many of the training opportunities on offer in the sector were often a direct result of statutory regulation, they were also valued by care workers as many had experienced few opportunities to gain qualifications in the past. Even though the majority did not have aspirations to progress, opportunities for training made them feel valued by their employer and care workers felt committed to their employer because of this. In general, we also found no evidence of the so-called „supermarket effect‟ where care workers leave the sector for better paying, less demanding jobs in the retail sector. Rather, it was the „pull‟ of the NHS and nurse training that were the reasons most often given for intentions to leave. The better terms and conditions of employment in the NHS mean that when care workers stated they intended to leave for a job in the NHS, pay is likely to be a factor shaping this choice. 9. Is care workers‟ job commitment influenced by the nature of the job and does it involve trade-offs between „bad‟ and „good‟ aspects of the job? The overwhelming reason for high job satisfaction and commitment expressed by the interviewed care workers related to the nature of the work and in particular the opportunities to help people, work with the elderly and build relationships with service users. This represents an example of complementarity between user-centred services and employeecentred work organisation. Research on older people‟s definition of quality care has shown the importance that users attach to „process outcomes‟, such as feeling valued and respected, being treated as an individual, and being cared for by staff that demonstrate a caring motivation (Francis and Netten 2004, Glendinning et al. 2008). Our case study research has revealed that the opportunity to focus on these aspects of the job is central to the high levels of job satisfaction and commitment to care work reported by care workers. The ability to develop good relationships with service users was a defining aspect of job quality as well as a defining aspect of service quality. However, evidence about the nature of work organisation and whether this facilitated good quality care and good quality jobs was at times contradictory. Care workers‟ accounts reveal higher levels of discretion than reported to us by management in the telephone survey. In some cases the LA commissioning environment enabled this, as for example in the local authority RN where key performance indicators relating to continuity of care were set. In other cases it could prohibit this, for example with the use of electronic monitoring. However, in many cases it was simply the way care workers managed the boundaries between commissioned tasks and user expectations that was key to their high levels of job satisfaction and to good quality service. This was often despite the formal system of work organisation in place rather than because of it. 365 The opportunity to develop relationships with users allowed room for discretion and in this sense care work does not fit the standard classification of low paid, routine work. As suggested above, some care workers appear to be making trade-offs between these „good‟ aspects of the job and the „bad‟ aspects of the job, in particular low pay. Yet it may be the case that low pay is only accepted because other dimensions of HR practice are in place that accommodate care workers‟ specific needs. For example, care workers in our case studies were generally satisfied with their working hours and training opportunities. And while prospects for promotion are usually identified as a „good‟ aspect of a job, the importance attached to this feature depends on the aspirations of the workforce. Because many of the care workers did not in fact have aspirations to progress, the limited career opportunities on offer were not identified as a particularly „bad‟ aspect of the job for many of those interviewed. However, this lack of aspiration was also shaped by the poor additional rewards for senior status within social care coupled with a requirement to take more responsibility but reduce involvement in hands on care. Whether this group is typical in the trade-offs it makes will be discussed in the next section. It also needs to be recognised that care workers working for different types of providers may be making different types of trade-offs. For care workers working for LADPs, pay and benefits were a „good‟ aspect of the job but they faced less flexibility in terms of hours as this group were less likely to work hours that matched their personal preferences. For this group working time could be described as the „bad‟ aspect of the job but was accepted because of the relatively good pay and benefits on offer, especially when compared to those on offer in the independent sector. 366 VI.4. Prospects for recruitment and retention under expanding demand: the policy issues The final research question explored relates to the context in which this research was funded, namely the expectation of increased demand for the social care workforce, in relation to both quantity and quality. We draw on evidence from each stage of the research and from each of the above eight questions to ask: 10. What are the prospects of meeting current and future increased demands for a social care workforce under present conditions - that is, without major changes in commissioning arrangements, the policies of provider organisations and the conditions of employment? The evidence across all stages of this research project suggests that while the current arrangements are just about delivering the current level of commissioned services, the model of delivery of social care for the elderly is in a fragile state. There is positive evidence that providers are achieving adequate levels of recruitment, albeit supplemented by recruitment of migrants and with clear shortages in some key areas. But providers of all types are experiencing relatively high levels of staff turnover and significant problems in achieving and retaining a trained workforce, particularly in domiciliary care. The sector is also very reliant both on the easing of recruitment conditions in the recession, and on a workforce that for a variety of reasons has accepted to work under poor employment conditions, primarily because of the intrinsic rewards associated with the work. The sustainability of even this quantity and level of service would be even more in doubt in normal labour market demand conditions but there was little evidence, whatever the conditions, that the sector was in position to realise aims in relation to expansion in quantity of service, improvements in quality of service or the delivery of long term strategic change. This last aim includes both movement towards a more holistic and integrated approach to the delivery of social care for the elderly and towards a more user-centred service which does not put in jeopardy the development and stability of an effective supply side of both providers and social care workers. It is also clear from all stages of the project, that while LA commissioning and contracting, provider HR practices and the experiences of care workers all play a part in shaping the current quality and level of delivery, the impact of each of these elements cannot be looked at in isolation. Thus, LA commissioning sets the general set of conditions for both providers and the workforce operating in the independent sector of social care and must bear considerable responsibility, together with central government, for the current state of the sector and its ability to deliver on the three aims of expansion, improved quality and strategic change. Nevertheless, our research also demonstrates that, where LAs do take the initiative to develop a more favourable commissioning environment for better social care delivery, the 367 opportunities offered to providers to enhance their HR practices and improve recruitment and retention are not necessarily taken up. Good LA commissioning practice is thus a necessary rather than a sufficient condition for improvements in HR practices and in HR outcomes in the sector. There is also a need to consider the strategies and policies of the providers themselves. Providers may not be keen, unless pushed by commissioning or other regulatory practices, to improve employment conditions for care staff. This reluctance may be reasonably based upon concerns over the future, given the rapidly changing and uncertain policy, budgetary and labour market context. However, they may also be regarded as too ready to take as much advantage as they can of their committed workforce by, for example failing to offer guaranteed hours even to staff working regular full-time or even longer hours, in part because the zero hours contracts makes it easier for them to demand flexibility in the number and timing of hours from their staff. Particularly significant here are the policies and strategies of the increasingly dominant national chains whose perspectives extend beyond the immediate LA and may be relatively unaffected by any specific initiatives in commissioning that are pursued only at a local level. Finally, we also need to bring in the attitudes and experiences of both current and potential care workers. Here again some potential contradictions in possible strategies for change within social care may be identified. The factors that have led the current social care workforce both to enter and to stay in social care, and to develop a relatively strong commitment to care work, cannot necessarily be built upon to expand the pool of recruits to social care or to develop a higher quality workforce, measured in conventional terms of accredited skills and qualifications and formal career ladders. There appear to be two main sources of supply into care work as presently organised; those who come into care work as a result of social networks involved in care, or their own experience of informal care; and those who have found social care to be an opportunity for more satisfying work compared to other more routinised and less meaningful jobs to which they have access. Both groups also often fall into the category of those who have had limited previous opportunities for training and development. A further factor in retention has been the recruitment of very local staff with specific needs for particular hours schedules. Working time arrangements in domiciliary care are far from employee friendly in any conventional sense; they involve variable hours at unsocial times and also frequently unpaid breaks and split shifts. However, individual employees, and primarily those located in the immediate area, may find either that these hours fit their specific circumstances or that they are able to negotiate specific schedules within the range available that suit their current needs. All these factors may tend to reinforce commitment of the existing staff, but operate against the expansion of the pool of recruits as staff may have to be brought in from wider geographical areas, and to be attracted from groups who have a wider range of alternative jobs and training and development opportunities. If providers model their recruitment and retention strategy on what currently makes for the most committed care workers, they may not realise the need for a strategic change to recruitment, work organisation, employment conditions and career opportunities if the available pool of recruits to social care is to be expanded. 368 Although the factors that may inhibit recruitment and retention in social care are interlinked, in order to clarify the policy implications of these findings we will consider these first under three main and relatively separate headings – commissioning and contracting, HR practices of providers and the organisation of work and careers - before returning to the need for a more integrated approach. We focus here primarily on improvements that may be needed within the current framework for commissioning social care. We address later the significance of our findings for the move to personal budgets. Commissioning and contracting practices If the objective of commissioning is to set the conditions for expansion, quality enhancement and/or driving long term strategic change then there is a need to address four main problems. The first is that budgetary constraints appear to be the overwhelming influence on actual LA commissioning practices. Even though many people in LAs involved in commissioning are very aware of the need to foster and develop the supply side, they are often unable to put these concerns into practice, or to do so only in marginal ways, through additional training support or limited quality uplifts to otherwise very tight fee payments. A second and related problem is that commissioning practice is variable across both space and time; LAs are making different compromises between competing agendas and are thus sending out mixed messages to key national actors such as national chains. However, within a particular LA the policy and practices are also subject to rapid changes, such that the consistency of the message even at the local level may not be strong. Third, short term needs largely take priority over longer term strategic developments, not only in relation to fostering the local supply structure but also in developing strategic partnerships with other services such as health and housing or in developing new ways of commissioning including outcome based commissioning where users have more input into the composition and quality of services delivered. The priority to the short term reflects both of the first two problems, that is the immediate imperative of the budget and the changing political balances across competing agendas. Movements to outcome-based care may also run counter to budget imperatives to introduce electronic monitoring to take costs out of the service However, the focus on the short term is also an outcome of practical problems that LAs encounter when they engage in more strategic developments. In working together with health on elderly care, problems arise because of the potential dominance of health in the partnership or because of the difficulties of working across two public bodes with different views, for example, on the benefits of fair commissioning and with different budget constraints, different regional or geographical boundaries and different processes of intra-organisational restructuring. The fourth problem is that LAs are not paying sufficient attention to the employment consequences of their commissioning practices. In many respects LAs hide behind the notion of business to business contracting to evade the responsibility that they must share for employment practices in the sector; as our evidence shows, employment practices are not only poor, but in some areas may even be on the margin of legality. Nevertheless LAs consider the issue of payment of travel time between clients to be an issue for the independent providers 369 even though they fail to include payments for travel time in their commissioning, except in the margin above the national minimum wage in their fees for one hour of care. Likewise no specific provision is made for training time and the decisions to simplify fee structures in the interests of minimising transaction costs carry with them the implications that wages are unlikely to be higher for work involving more skill and intensity of care or for work outside of standard working hours - whether overtime or unsocial hours. LAs are increasing their monitoring of providers‟ HR practices but are treating the meeting of quality thresholds more as an additional requirement on providers and not as an indicator of what elements of their own commissioning and contracting practices may need to change. HR practices of providers The evidence presented in the report suggests that by and large providers in social care do not deliver even the basic guarantees to employees associated with an employment relationship, rather than a casual employment contract. Thus within the domiciliary care sector, in particular, staff cannot expect to be given any guarantees of hours or wages, they are not necessarily paid for all the time they spend at work, receive at most limited compensation for working unsocial, flexible and long hours and are unlikely to be rewarded more than a few pence per hour for additional skills and experience. Even those taking positions of responsibility can expect an uplift of no more than £1 an hour at most. Many of these conditions appear to follow directly from LA commissioning practices, but even when LAs offer more favourable commissioning and contracting most of the benefits are not passed to employees. National providers are developing some company-wide policies but are continuing to fix pay and other conditions at a local level. However, this approach seems to be more about ensuring that a national scale does not price them out of work in some low paying LAs than a means of upward adjustments of wages. Some of our results suggest that it is only when local labour market conditions push turnover rates above acceptable levels that providers may be dragged into providing what many would regard as basic employment conditions and guarantees. One area where providers have developed HR practices beyond the basics is in training, where most care workers felt they were offered training beyond what they had experienced in other low paid jobs. One issue for the future is whether the removal of the training target from CQC care standards will have an adverse impact on future training provision. The other main area of good HR practice where providers appear to do more than is required of them statutorily is in relation to efforts to fit working time schedules to staff preferences. The extent of this accommodation may be exaggerated as various comments by managers referred to accommodating within the constraints of their very specific needs to deliver care in short chunks throughout the day and evening or to provide 24/7 care as in the case of homes. Nevertheless, the efforts made to accommodate their preferences were valued by the staff in the case studies and this suggests that this is one way in which the local managers may aim to recruit and retain staff within the limits of the overall poor employment conditions. It may be worth noting that managers‟ ability to juggle schedules to offer staff hours that fit their needs may be further constrained under personal budgets as one of the benefits of personal budgets is held to be the opportunity 370 to users to have more choice and control over their care. How this may affect the working time arrangements for care staff has not been widely debated. Overall we found little evidence of a more strategic approach towards recruitment and retention; reliance on word-of-mouth recruitment and offering flexibility to match individual circumstances in working hours may be a means of securing a stable workforce under current conditions but these approaches set limits to the extent to which providers can develop ambitions to expand or upskill the workforce. The overall policy conclusions must be that providers cannot be simply trusted to respond to more favourable commissioning and contracting and to improve employment conditions or to develop longer term strategic approaches without some specific incentives or constraints. This suggests that improvements are likely to require regulatory development – just as, for example, the improved level of the national minimum wage and the move to 28 days paid holiday have probably done most to improve conditions in this sector in the 2000s. It also suggests that improved employment conditions need to be built into LA commissioning and contracting strategies, but these requirements need to be funded by the LAs rather than simply added in as an additional requirement without the complications taken into account in the commissioning and contracting price. Another issue that needs to be considered is the possibility of developing longer term partnership approaches with local providers; currently there is a lot of discussion of partnerships but these are contingent on future competitive tenders. Current partners or preferred providers may be encouraged to improve quality and invest in their workforce in line with an LA‟s quality framework but they have no guarantee that at the next tender they will not be rejected on the basis of too high prices. Such risks may be even greater for providers who may be encouraged to develop a more strategic approach to the recruitment and development of the workforce by offering not only better employment conditions but also perhaps more training and development opportunities and more extended career ladders. Such strategic turns require a long lead in and a stable and favourable commissioning environment, conditions that are unlikely to prevail under current arrangements. The organisation of work and careers The case studies revealed the current reliance on a workforce with specific characteristics that is, a largely female workforce with low qualifications, social and family networks with links to the sector, very locally based and with very specific working time preferences. This group was also found to have high levels of job satisfaction linked to their unrewarding work experiences in the past as well as the nature of their present job. While this group of women are a reliable workforce, provider practices and employment conditions that can appeal beyond this group need to be put in place. However, a number of obstacles currently prohibit this. 371 Firstly, if the sector is to expand and appeal to under-represented groups, such as men or indeed women with higher levels of qualifications, there are limits to how far the sector can rely on localised recruitment practices that are predicated on informality. This will only access a certain pool of female recruits, often those with no or low-level educational attainment who are looking for work where low-level qualifications are not a barrier to entry. Moreover, this pool of workers is contracting as the educational levels of women rise. Secondly, it would appear that for too long the sector has relied on workers being „prisoners of love‟, willing to accept low wages because of the intrinsic rewards of doing meaningful work. While workers with few qualifications and limited opportunities may be willing to accept such a trade-off, if the sector is to expand it may not be able to find new pools of potential recruits willing to do so, quite apart from the social justice question as to whether committed workers should be rewarded with lower pay. Furthermore, it is a trade-off that cannot be made until people enter the sector in the first place and we do not know how many people are deterred from entering because of the low pay levels on offer. This is exacerbated by the better pay and opportunities on offer in inhouse local authority services and in the NHS. The „pull‟ of the NHS and nurse training were the reasons most often given by care workers for intentions to leave. Thirdly, while workers were generally satisfied with their hours, the case study research revealed the idiosyncratic nature of the hours worked by care workers. The hours were unpredictable and variable, fragmented across the day, and did not fit standard notions of family friendly flexible working. The hours suited care workers with very specific needs and circumstances who often needed to work locally. This sort of working time would not constitute flexible working to many and because legislation has ensured that more standard notions of family friendly flexible time are now available in many organisations, the sector cannot rely on its image as „flexible‟ as a way to expand the sector in the future. Thus, to expand the quantity of recruits and provide a more diverse workforce that may also have the capacity for further quality improvements there are clear needs to: i) go beyond the informality of recruitment and to recruit across wider segments both geographically and by gender, age, ethnicity and qualifications; ii) to stop taking for granted that the nature of the work will compensate for poor working conditions and provide terms and conditions that are at least comparable to the main competitors such as the NHS; iii) provide for more stable and guaranteed hours at work, albeit still with opportunities to tailor working hours to preferences and circumstances of the staff. However, at the same time there could be strategies that build on the positive aspects of the work, as revealed by our case study research, in developing systems of work organisation on the one hand and career structures on the other. Four elements in such a strategy can be identified. First, and above all, there needs to be scope built into the organisation of care work that enables and encourages staff to develop relationships with users. This is a key factor in 372 explaining high levels of satisfaction in the job and is key to both retention of staff and good quality of care. The intrinsic features of the job, caring for the elderly and doing meaningful work, bring high levels of job satisfaction and work organisation that supports this should be part of providers‟ recruitment and retention strategy as well as part of their remit to provide quality care. Any changes relating to work organisation need to be put in place with the consultation of care workers and users as this is an area of HR practice where quality service and quality jobs complement each other. At present this aspect of the work may be developed more through the discretionary action of care workers than through it being an objective in the design and organisation of work; if the high levels of satisfaction that we uncovered are to be the basis for further development of the quantity and quality of the care workforce, we would suggest that such activities need to be explicitly allowed for and rewarded in the job. The commissioning environment and provider responses to this must build on the strengths of the sector by offering interesting and rewarding jobs that are meaningful and allow time for care workers and service users to develop relationships and be flexible in their approach to care. This will improve both recruitment and retention and the quality service for users. The second point follows from the first and that is that the use of electronic monitoring needs to be carefully assessed and the benefits of improved data and reduced transaction costs and direct care costs for LAs weighed against the possible loss of opportunities for delivery of high quality care, with consequences for recruitment and retention as well as for the users of care. A third element that provides a positive base for further development is the generally positive attitude of care workers to opportunities to training and to acquiring qualifications. This proved particularly appealing to those who had, for example, been made redundant late in life and wanted to start a new career and to younger workers who had not gained qualifications in education. This may suggest that social care should develop an eclectic approach to recruitment, providing opportunities for those who have missed out on earlier chances for education and training while also raising the overall profile of social care as a career choice by offering opportunities for training and development. Finally social care needs to develop more opportunities to progress which do not take the more senior and experienced care workers away from hands on care. This could involve combining hands on care work with supervisory and mentoring roles or providing more opportunities to move into re-ablement work at higher wage levels. Current specialisations of LAs in the higher skilled work may be restricting those opportunities as LA departments may not be recruiting as they reduce in size. As this problem eases through natural wastage it may be important to encourage transfer from the more routine work into more specialised areas as a means of retaining staff within the sector and providing them with both more rewards for experience and new challenges. Opportunities to progress may prove to be particularly important to recruit and retain men, on the basis of the small sample we interviewed. However, this also means that it is even more necessary to create a range of career opportunities as otherwise the relatively few men in the sector may be found occupying most of the higher level positions if they are more active in bargaining for quick progression. 373 Summary of key policy recommendations. The key policy recommendations to achieve better recruitment and retention outcomes include the following. Stronger partnership arrangements are needed with providers, either at LA level or through a national system of care commissioning, involving increased obligations on both sides. Longer term guarantees of contracts or of preferred provider status need to offered to enable providers to make a step change in their employment practices ( but these arrangements should be designed to foster and not reduce the diversity of supply). LAs or a national care commission should promote better and reasonable employment conditions through both better resourcing and more stringent requirements on providers to meet higher HR standards. Attention also needs to be paid to maintaining or improving the intrinsic rewards from the work, potentially calling into question the practice of fragmented commissioning of care packages, backed up by electronic monitoring. Likewise there needs to be a more partnership approach to developing working time arrangements that meet both user and care worker needs, perhaps by moving away from the fragmentation of care commissioning by task and narrow time periods. These recommendations should together provide the environment in which providers can start to extend their recruitment pool and begin to attract and retain staff beyond the immediate vicinity and to provide both better employment conditions and more opportunities for advancement within social care work. Attention should also be paid to how to facilitate the development of high quality reablement and specialist services to ensure that users are not unnecessarily placed in residential care. The delivery of specialised and short term care could require consideration of a return to more guaranteed employment conditions and higher paid employment, possibly within the public sector or under more stable and higher paying contracts with specialist providers. The further development of specialist services could also provide the important missing elements of opportunities for care workers to progress without loss of involvement in hands on care. Implications of our findings in the context of the move to personalisation There are several ways in which our findings would support a move towards a more user centred system of care as a means of recruiting and retaining a larger and more skilled social care workforce. In particular, to the extent that this offered care workers more opportunities for developing relationships with users and more opportunities to exercise discretion in the ways in which they provided care, then this change in direction could promote the intrinsic value of the work and enhance retention. However, these benefits may not necessarily be achieved under current proposals for the mode of implementing personalisation. This applies in particular if the proposals result in the user being the direct employer. In this latter scenario even the above listed potential benefits of enhanced discretion and more opportunity to form relationships would not necessarily be realised as the dual role of the user as the person 374 receiving the care and the employer of the care giver could inhibit the formation of a good relationship. Care workers mentioned concerns about the lack of back up from managers in their decisions on care provision, about their discomfort at the idea of being paid by the user and about the potential problems of how they would be able to cope with a user who was difficult or aggressive. An important concern is how work would be scheduled and organised without the role of the intermediary, the employer; this was a critical factor in care workers‟ job satisfaction. Although opportunities to schedule care to meet their own needs is an important positive attraction of personalisation for users, it is not clear how the difficult trade-offs between the ideal time for a care visit and the competing demands from many users would be met. The scheduling problem in principle could be eased by care workers caring for only one or a smaller number of users but this would increase the need to expand the available workforce and reduce the possibility of the job providing for full-time employment for those in need of a full salary. Care workers we interviewed were concerned that caring for only one user might prove less fulfilling compared to their current involvement with many users or might lead them to be too involved, making it difficult to retain some distance from the user. They were also concerned about job security if a user were to die or to move into residential care. The ending of the job with the loss of a user could also enhance the risk of loss of skilled workers to the sector as a whole; when workers are displaced from employment there is no guarantee that they will confine their job search to the same field of work and having just been made unemployed they might be unwilling to risk this happening a second time by entering into another contract with an individual user. Beyond these concerns over the move to directly employed personal assistants, our research also pointed to a number of more institutional and budgetary concerns over personalisation as currently proposed. Those most commonly raised by providers related to the poaching of their staff and the increased difficulty in securing payment for services. For LAs the most common concerns were over the impact on costs, the possibility that users would choose not to purchase the more expensive re-ablement services, even though their long term costs of care might then increase, and the problems user choice posed for organising care provision by geographical area to minimise travel time and guarantee supply. The general uncertainty over the future role of LAs and providers in the provision of services was also inhibiting more strategic thinking and development, particularly with respect to integration with health. Finally there was the problem of adding to the existing ambiguity over who had the responsibility to provide training. Under personalisation three sets of agents might be involved- the LA, the provider (if the PA were hired through an agency) and the user who might be asked to pay for the training or the time spent training. In general it seems unlikely in a sector where public funding inevitably shapes the market that strategic aims will be achieved, or even the current quality and quantity of care maintained, without some continued planning of provision at either LA or national level. If policies are not put in place to enable strategic developments to be maintained and strengthened, the outcome could be moves away from re-ablement and care in the users‟ homes and back to the more expensive and less desired outcome of residential care. 375 There thus seems to be an urgent need for further consideration of the appropriate modes of implementing greater user choice in social care. Greater clarity is needed in the future roles of LAs and existing providers in acting as commissioners, brokers or intermediaries with the users and detailed consideration needs to be given to appropriate forms of employment relationships and employment organisation in a caring profession. More clearly needs to be done to enable users to have more say over how and when their care is delivered but there is little evidence that the full consequences for the employment relationship of a move towards directly employed personal assistants or even personal budgets have been considered. A comprehensive study of the experiences of personal assistants is urgently required, together with more policy thinking on how care staff are to be provided with adequate training and some form of employment security under the new budget holding arrangements. Towards a rebalancing of the care debate A key premise of this research has been that, in order for the quality of care to be maintained and enhanced, it is vital to do more to recruit and retain skilled and committed care workers. What has been missing in current debates over social care is any serious consideration of employment. While there has rightly been an increased recognition that the voice of the care user needs to be heard more, the voice of the care worker is still silent when one examines the main policy debates and documents. The consequence is that the implications of social care policies, whether towards competitive outsourcing or user-centred care delivery, for the quality of employment relationships in social care are often ignored or hidden. This is a surprising feature of public policy in this service area where the quality of care cannot be divorced from the quality and commitment of the person delivering the care. Thus, whatever direction social care policy moves in, we would argue for the need to give greater consideration to the employment arrangements that could be reasonably expected to deliver the committed and skilled workforce that the care users in turn deserve and need. 376 Appendix I.A. Appendix part I I.A1. Social Care Workforce Project -Telephone interview including common questions and specific questions for domiciliary care providers and for care homes Because of the importance of recruitment and retention for care providers we are carrying out this survey in an effort to find out what is happening in the sector what you think about the current situation and how it could be improved. 1. General information 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 1.10 1.11 1.12 1.13 1.14 1.15 Agency name ……………………………………………… Interviewee Name ……………………………………………………… Position ……………………………………………… (If unable to find out in advance) Number of branches/offices ……… Which LAs does this branch hold contracts with? What proportion of your service users are local authority funded? Do you do any work for the NHS? YES NO If yes What kind of work is this? (e.g. intermediate care) CARE HOMES ONLY What percentage of your beds are currently vacant? Who is responsible for HR issues on a day to day basis? Do you have a specialist human resources manager or department If yes, where located? What support do they provide? (e.g. grievance and disciplinary) Do you have a formal recognition agreement with any trade union? YES NO If yes, which? ADVANCE 1.A How many staff do you employ? a) This branch b) Total (if applicable) 1.B How many of the staff at this branch are care workers? 1.C How many of your care staff are permanent ……..temporary……… external agency workers ……….? 1.D What proportion of hours are done under a) block b) spot contracts? 1.E Do you collect figures on staff absenteeism? YES / NO 1.F (If yes) How is this measured What is the rate of absenteeism? 377 2. Recruitment and retention of care workers Now we would like to ask you some questions about recruitment and retention of care workers. ADVANCE 2.A What proportion of your staff are under 30 ……………………………….. over 50 ……………………………….. over 60 ……………………………….. Female ……………………………….. White British ……………………………….. White other ……………………………….. Black or Asian ……………………………….. Over the past twelve months How many new starters have you recruited?............... How many are still with you?.......................................... How many other staff have left?...................................... What proportion of your staff have been with you over 2 years?.................. And over 5 years? …………………………………………... NOTE If the agency/branch opened in the last 5 years please state date it opened and the share of staff who have been with you since that date 2.B Date………………………. 2.1 2.2 2.3 2.4 2.5 Share of staff …………………………. Are you happy with the composition of your workforce? YES NO If NO, would you prefer to have Tick relevant box more younger employees more older employees more men more women a more ethnically diverse profile Which of the following applies to you? Tick relevant box a)We currently have the right number of staff b) We currently have more staff than we need. c) We currently have fewer staff than we need If c), how many more staff would you be keen to take on? How easy or difficult is it to recruit care staff? Tick relevant box 1. Very difficult 2. Quite difficult 3. Neither difficult nor easy 4. Quite easy 5. Very easy 378 2.6 2.7 Has this changed since the summer of 2008? If it is difficult to recruit, what are the main reasons? (No prompt). Tick relevant boxes Local competitors (e.g. new supermarkets) Higher (or lower) wages elsewhere Changing nature of care work Working time schedules Transport costs High (low) local unemployment Other – please specify 2.8 Are there any specific shortages (for night work, weekend work etc. or other specific shortages)? Tick relevant box Night Weekend Other specific shortages ADVANCE 2.C What methods do you normally use to fill vacancies? Tick relevant boxes Use Tick all that apply Most effective Pick one only Word-of-mouth recommendations from existing staff or others List of interested applicants Schools, colleges Jobcentre Plus Other agencies Press advertising (local, regional or professional press) Notice in office or shop window Internal advertisement Fee charging, private employment agency, Any other way? (Please specify) ……………………………………………… 2.D Which of the following do you normally use as part of the recruitment process? Tick if normally used Formal job descriptions and person specifications Application form CV Initial telephone screening References Extra info If yes Requires full work history? If yes Before or after 379 Formal interview Informal interview Aptitude testing interview? If yes With whom? IF yes With whom? IF yes – At interview At induction? 2.E Which of the following factors do you consider a) necessary b) desirable c) most important when recruiting care workers? Necessary Desirable Most Tick relevant boxes (Tick all (Tick all important that apply) that (tick one apply) only) Availability for early starts or evening work Availability for weekend work Recommended by another employee Skills related to care work Experience of caring for family member or friend Formal experience of care work (e.g.care home, other home/agency) Qualifications - NVQ2 or above in care Positive attitude/ friendly nature Ability to drive Own transport Lives locally Other (please specify) 2.9 Is it easy for you to meet your recruitment criteria? YES NO If no, what are the main reasons? (prompt using questions below): Appropriate availability to match our service needs Appropriate skills Appropriate age range Who already have appropriate experience/qualifications Who are willing to gain appropriate qualifications With appropriate attitude (friendly nature, motivated, positive attitude) Who live locally. 2.10 What is the most frequent reason you find an applicant unsuitable for a care job? …………………………………………………………………………………… 2.11 Do you turn down staff who would, in your view, be acceptable care workers? VERY OFTEN OFTEN OCCASIONALLY ALMOST NEVER NEVER 2.12 Do you find that you are taking on staff who do not have as many of the desirable qualities as you would like? 380 VERY OFTEN OFTEN OCCASIONALLY ALMOST NEVER NEVER 2.13 If unable to recruit staff locally do you Tick relevant boxes extend recruitment efforts to surrounding areas attempt a more national recruitment drive use other agencies contact agencies/intermediaries who are seeking work for migrant workers recruit abroad directly yourself? 2.14 Approximately how many migrant workers (defined as living in the UK for less than two years) do you have working for you? ………………………………………………………………………………………… 2.15 What are the two most common nationalities? ………………………………………………………………………………………… 2.16 In the past two years approximately how many staff have you failed to recruit due to a) delays with CRB checks b) failure to pass CRB checks? 2.17 Do you consider staff turnover to be VERY HIGH? QUITE HIGH ABOUT RIGHT/ACCEPTABLE QUITE LOW VERY LOW 2.18 What are the main reasons for staff care workers leaving? (No prompt) Tick relevant boxes Work for another care provider Work for the NHS Work for the Local Authority Work in a different sector More convenient working time Better pay Full-time education Nurse training Not suitable, dismissal Family responsibilities Other 2.19 Do you normally recruit senior care workers/team leaders/supervisors/managers from within your existing staff or externally? 381 3. Pay 3.1 What is the range of hourly rates of pay for care staff (minimum/average/maximum)? 3.2 DOMCARE ONLY Are there different rates of pay for personal care and domestic work? (If yes, what?) 3.3 DOMCARE ONLY (If applicable) Are there different rates of pay for those providing intermediate care? 3.4 How do these rates compare with other domiciliary care providers in the area? LOWER ABOUT THE SAME HIGHER 3.5 If there is more than one pay rate used, what are the main reasons for differences in pay rates (give details of pay rates): (PROMPT FOR THOSE NOT MENTIONED - CAN I JUST CHECK ARE THERE ANY DIFFERENCES IN PAY RELATED TO AGE, EXPERIENCE , …. Age Experience (including special probation rate) Qualification Weekend work Night work Length of Service/increments Other (please specify) 3.6 Is there a regular upgrading of pay? 3.7 What are the main factors influencing pay upgrading? (PROMPT FOR THOSE NOT MENTIONED) Change in NMW Performance Related Completion of qualifications Incremental salary scales Commissioning price Employee‟s request Profitability Other 3.8 DOMCARE ONLY How do you compensate for travel costs/travel time? (NO PROMPT) Included in hourly rate Supplement – flat rate Supplement - percentage Higher rate for call lasting under an hour Mileage allowance Reimbursement of petrol costs Re-imbursement of public transport costs Other 3.9 Do you provide uniforms? YES NO 3.10 (If yes) are staff required to pay for them? 3.11 Do you pay for CRB checks? YES NO 3.12 (If no) does that cause a significant drop out among those applying for vacancies (apart from any other pay issues)? 3.13 CARE HOMES ONLY Do any service users make extra financial payments? 382 4. Organisation of Work Work Scheduling 4.1 DOMCARE ONLY What are the hours of care provision? 4.2 DOMCARE ONLY How important is it to organise working hours to provide continuity of care (1-5 scale)? 4.3 DOMCARE ONLY How important is it to organise working hours to fit employees‟ circumstances (scale 1-5)? 4.4 DOMCARE ONLY What kind of contracts do you offer for care staff? Zero hours only – percentage of staff Guaranteed hours - percentage of staff 4.5 In practice, what percentage of staff work: under 16 hours 16-30 hours over 30 hours over 45 hours? 4.6 What is the maximum number of days a week that care staff work? 4.7 How many care staff occasionally/regularly work weekends? 4.8 DOMCARE ONLY Do care workers work alone or in pairs? 4.9 DOMCARE ONLY What is the minimum/average length of visit? Are visit lengths tightly defined? 4.10 How is working time organised? 4.11 DOMCARE ONLY Is there a minimum length of a work period? 4.12 Do staff work: continuous shifts split shifts (morning shift and evening shift on same day) Permanent early shift Permanent late shift 4.13 DOMCARE ONLY Excluding travel time, what happens if there is a gap between service users? Prompt: Unpaid break (only paid for contact hours) Paid break 4.14 DOMCARE ONLY (If applicable) Are there different working time arrangements for care workers providing intermediate care? 4.15 CARE HOMES ONLY Do all staff work some weekends? Or are there weekend/weekday only schedules? 4.16 If there is a need for additional hours do you: Ask existing staff to work extra hours Use external agencies Subcontract to other care providers? 4.17 DOMCARE ONLY How easy is it to find staff willing to work additional hours? What about at short notice (2-3 days notice) or very short notice (the same day)? 4.18 Are care workers ever paid overtime premia? YES NO 4.19 If yes, does this apply to all staff or only those contracted to work a certain number of hours per week. If so, how many hours? 383 4.20 Are your care staff able to get work schedules that match their preferences for particular hours? Tick relevant box All of the time (1) Most of the time (2) Some of the time (3) Occasionally (4) Rarely (5). 4.21 CARE HOMES ONLY Do you have minimum staffing levels YES NO 4.22 CARE HOMES ONLY If yes, what are they? Communication 4.23 Do you hold staff meetings? YES NO 4.24 {If yes) How frequently? 4.25 Do you carry out attitude/ staff satisfaction surveys? (If yes) Can we have a copy? Performance 4.26 How is performance (of staff) monitored? 4.27 User surveys by care provider User surveys by LA Visits by supervisors Observation Electronic monitoring Other (please specify) What are the most common problems of poor performance that you encounter? Absenteeism Timekeeping Skimping on time or services provided to service users Complaints from service users (over attitude, competence, completion of tasks etc. Other (please specify) 4.28 What has been the most effective way you have found of dealing with problems of poor performance? Disciplinary action Loss of wages Training Electronic monitoring Other (specify) 384 4.29 Do you carry out staff appraisals? YES NO 4.30 (If yes) How often? Who carries these out? 4.31 Do recruitment difficulties mean that you are sometimes forced to put up with some problems of poor performance? 4.32 Do your staff have opportunities to improve their performance in any of the following ways: Yes To some No Don‟t know Tick relevant boxes extent Having enough time to carry out the work to a high standard Having the opportunity to put into practice the training/qualifications they have gained Being free to prioritise and carry out tasks in ways that they feel will improve the quality of care? Having the opportunity to spend time talking to service users Being encouraged to exchange ideas with other carers of new ways of working/best practice 4.33 Would you expect workers to tolerate any of the following as part of their job (tick all that apply)? Regularly Occasionally Never Working longer than scheduled due to unanticipated needs of service users Variations in hours or location at short notice Working in very unsanitary conditions Working with aggressive service users (due to dementia etc.) Working alone late at night (after 10 pm) 4.34 Do you consider rates of staff absenteeism to be: VERY HIGH QUITE HIGH ACCEPTABLE QUITE LOW VERY LOW 5. Training and Development 5.1 Describe the induction training offered to new recruits: How long is induction? Is it offered by yourselves, LA, other external body? Who pays for the induction? Are staff paid for attending induction training? 5.2 For new staff who already have experience of care work, approximately how long does it normally take before they are able to do their job as well as employees already working here? : 1) One week or less, 2) More than one week, up to one month, 3) More than one month, up to six months, 4) More than six months, up to one year, 5) More than one year 385 5.3 How do you identify training needs? (prompt if necessary) Appraisal Employee request ADVANCE 5.A What training courses are offered to staff? Compulsory Optional Health and Safety Food hygiene Service user handling Use of equipment Infection control First aid Medication management Dementia care Diabetes care Loss and depression in elders Parkinson‟s care NVQ 2 Others (please specify) 5.4 Refer to grid on advance information sheet - Who organises the training? (e.g. employer, LA, other external body). Where the LA organises the training: Where other…. Who delivers the training? Who delivers the training? Is training devised specifically for providers? Is training devised specifically for providers? Is it provided free of charge? Is it provided free of charge? If it is not free, who pays the course fee? If it is not free, who pays the course fee? 5.5 Are staff paid for time spent training? 5.6 Do they get time off from care duties to attend or do they attend outside their normal working hours? 5.7 Does this apply to all courses? (Prompt – optional courses). 5.8 Does the local authority provide help with access to funding for training? 5.9 How many care staff have the following formal qualifications? NVQ2 NVQ3/4 nursing qualifications other relevant qualifications? (Check – if any staff have NVQ3/4 or nursing qualifications are they employed as care workers or in more professional/management jobs? 5.10 DOMCARE ONLY If agency provides intermediate care (Q1.6) Do staff providing intermediate care need extra qualifications? 5.11 If yes, what qualifications? 5.12 How likely are you to meet the 50% NVQ2 target? Already met/ will meet soon/ experiencing difficulties. (Check with CSCI) 386 5.13 5.14 5.15 If not yet met, what factors make it difficult to meet this target: NO prompt. staff turnover staff motivation pressure of work (e.g. scheduling, fatigue) other Do any staff need to have NVQ3? YES NO (If yes) Are they recruited externally or internally trained? 6. Relationship with NAMED LA (Prompt – remind interviewee that their answers will be treated confidentially) 6.1 How would you describe your relationship with NAMED LA (1-5 scale) 6.2 What is the main problem, if any, you have you experienced in your dealings with the LA? Obtain from the LA interview/questionnaire whether LA organises a providers’ forum and how often it meets. If it does: 6.3 How frequently do you attend? (always, mostly, occasionally, never). 6.4 How useful is the forum on a five point scale? (1-5) 6.5 How much importance does the NAMED LA place on providers‟ HR practices in the tendering process? 6.6 What monitoring if any does the LA undertake itself or does it rely on CSCI? 7. Policy and regulatory environment 7.1 How satisfied are you with the CSCI‟s a) set of quality standards b) system of quality ranking? (1-5 scale) 7.2 Star rating: Do you consider your own ranking to be fair? ADVANCE –DOM ONLY 7.A Which of the following quality care standards do you find most challenging? (Tick up to 4) Care needs individually assessed Service users treated with respect, valued and right to privacy upheld Policies and procedures on medication and health related activities protect service users Health, safety and welfare of service users is promoted and protected The risk of accidents and harm happening to service users and staff is minimised Service users are protected from abuse, neglect and self harm The well-being, health and security of service users is protected by the agency‟s policies and procedures on the recruitment and selection of staff Service users know that staff are appropriately trained to meet their personal care needs Service users know and benefit from having staff who are supervised and whose performance is appraised regularly Service users receive a consistent, well-managed and planned service Service users, relatives and representatives are confident that their complaints will be listened to, taken seriously and acted upon 387 ADVANCE: CARE HOMES ONLY 7.A Which of the following quality care standards do you find most challenging? (Tick up to 4) No service user moves into the home without having his/her needs assessed and assured that these will be met Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home Service users‟ health, personal and social care needs are set out in an individual plan of care Service users‟ health care needs are fully met Service users, where appropriate, are responsible for their own medication and protected by the home‟s policies and procedures for dealing with medicines Service users feel they are treated with respect and their right to privacy upheld Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs Service users maintain contact with family/friends/representatives and the local community as they wish Service users are helped to exercise choice and control over their lives Service users receive a wholesome, appealing balanced diet and pleasing surroundings at times convenient to them Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon Service users are protected from abuse Service users live in a safe, well maintained environment The home is clean, pleasant and hygienic Service users‟ needs are met by the numbers and skill mix of staff Service users are in safe hands at all times Service users are supported and protected by the home‟s recruitment policy and practices Staff are trained and competent to do their jobs Service users live in a home run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully The home is run in the best interests of service users Service users‟ financial interests are safeguarded The health, safety and welfare of service users and staff are promoted and protected 7.3 What change, if any, would you most like to see in the inspection/regulatory system? 7.4 What, if any changes in the LA‟s commissioning/contracting arrangements would do most to assist you in recruiting and retaining a stable and motivated social care workforce? Prompts: 388 Improvements in commissioning price Variations in price by type of service and time of delivery Higher guaranteed volume of work More scope to determine how care is delivered (e.g. commissioning in hours not minutes) More integrated approach by LA to care provision More time per service user Other? 7.5 What changes to HR policies/practices would do most to improve recruitment and retention, and have you implemented any of these changes in your organisation in order to improve recruitment and retention? HR policies that Have implemented Tick relevant boxes (prompt) would do most to improve R and R Improved opportunities for training Pay increases Recognition of variations in service time of day/weekends/ type of care /skill etc Improved opportunities for internal promotion Flexible hours/hours to suit Improved Non-pay benefits More scope for care workers to exercise discretion over how to provide care Any other? 7.6 DOMCARE ONLY What problems/opportunities do you anticipate as a result of an increase in direct payments and individual budgets? 7.7 Do you have any concerns that proposed new regulations limiting non EU migrants will affect your ability to recruit sufficient or sufficiently skilled care staff? 8. Further information (If interviewee unable to answer any of the questions) Could we get back to you for the answer to this question? We will be selecting a small number of providers interviewed for more in-depth case study research. This will involve researchers visiting the organisation to interview a sample of care workers. If you are chosen would you be willing to take part in this? Would it be possible for some of your staff to attend a focus group to discuss issues for the case studies? 389 Appendix Table I.A1. Classifying female demand conditions in the selected LAs Female employment rate in relation to average for Great Britain 69.4a a Female unemployment rate in relation to Great Britain average female unemployment rate of 6.1b Share of women who are inactive but wanting a job compared to Great Britain average of 6.6c Classification of female employment conditions based on columns 1-3d Female parttime hourly earnings relative to Great Britain average f AH M L M 5 M ON L M M 3 L RT L M M 3 M RN H M M 5 H UY M M L 4 L AD M H M 3 L AW L H L 3 H IL L H H 2 L OM L H M 2 L XD H L M 6 H HD M M L 5 M TE L H H 2 L LK H L L 6 M RD M M M 4 M H=2.2 to 7.9 %points above GB average, M=0.6 to 1.3 % points below GB average L= 3.4 to 10.3 % points below GB average 2008 b H=1.4 to 3.2 %points above GB average, M=0.7 below to 0.9 %points above GB average L= 1.6 to 7.9 % points below GB average 2008 c H=2.6 %points above GB average, M=0.3 below to 1 %point above GB average L= 1.2 to 3.4 % points below GB average 2008 d Scores computed as 3,2,1 H, M, L column 1 plus average of scores on columns 2 and 3 where 1,2,3 correspond to H,M,L. f H=£1.13 to £2.97 above GB average, M=-1p below to 43p above GB average L= -78p below to £-1.91 below GB average (2009) Source: LFS on NOMIS for 2008, Ashe table 2009 8.6a for part-time earnings 390 Figure I.A1. Strong, medium and weak labour demand conditions Female employment conditions – low to high High pay Medium pay 2 3 IL, OM, TE AW 4 Note: RT ON, AD RD UY 5 RN AH,HD 6 XD LK Weak demand: white Medium demand: light grey Strong demand: dark grey Low pay 391 IV.A. Appendix part IV IV.A1. Technical notes explaining the standardised dataset - Indicators, subindices and indices The analysis in part IV of the report draws on a standardised dataset that we constructed from the telephone survey general data set. Four principles guided the construction of the standardised dataset, as follows. i) Selection of providers: inclusion of providers on the basis of no less than 10% missing values from the list of standardised indicators - resulted in the selection of 102 out of 105 providers from the full sample of independent sector providers. ii) Selection of indicators: inclusion of indicators for use with the standardised data set on the basis of a) their potential for explaining variations in HR practices and outcomes and b) having less than 10% missing values (after elimination of providers with more than 10% missing as in i) above) iii) Construction of sub-indices: designed in order to group together indicators that measure similar dimensions to HR practices iv) Construction of indices: designed to provide overall summary measures of HR practices in a particular HR domain. The following tables provide details of the various indicators, sub-indices and indices, along with a note referencing the table or figure in the report that provides descriptive statistics. 392 Appendix Table IV.A1. HR practice indicators, sub-indices and Xindices: standardised data set. HR practice indicators Description and range of scores For data distributions see tables in part III Sub-indices (unweighted average of the component indicators) X indices (unweighted average of the component sub-indices) IP1 Pay level (minimum) Very low = 0; Low = 0.25; Medium = 0.50; High = 0.75; Pay (normal) Verylevel high= 1 Very low = 0; Low = 0.25; Medium= 0.50;High = 0.75;Very high = 1Regular uprating of pay Table III.14 and Fig. III.11 Table III.15, Table III.41and Fig. III.12 SIPAYLEVEL INDEX OF PAY LEVELS Table III.19 SIPAYUPGRADE XPAYLEVELS Table III.16 Fig.III.16 SIPAYUNSOCIAL IP2 IP3 No, or not regular = 0; Yes = 1 IP8 IP9 IP10 Extra pay for weekend work No= Yes= Extra0;pay for1 night work No = 0; Yes = 1 overtime premia for extra hours No = 0; Yes = 1 IP14 Payment of staff for time spent training No = 0; Some courses=0.5; all = 1 Table III.20 SIPAYTRAIN IP13 Payment of staff for attending induction training No =0; Partly/ Reimbursed after specified time in post = 0.5; Yes = 1 Pay for CRB checks No (+staff pay but reimbursed if stay) = 0; 50/50 = 0.5; Yes (+but staff reimburse if leave time) = 1uniforms) = 1 Pay for uniforms Yes =within 0; Nospecified (or only for extra Table III.22 SIPAYTR AIN Table III.21 SIPAYUPFRONT Table III.21 Table III.14 and III.15 SIPAYIMP IP11 IP12 IP4 IP5 Pay upgrade opportunities (normal pay minus minimum pay) zero= 0; 1p-20p = 0.25; 21p-40p Differences in pay rates£1byorreason = 0.50; 41p-99p = 0.75; over =1of experience or incremental scales? No = 0; Yes = 1 SIPAYUPFRONT INDEX OF PAY STRATEGIES XPAYSTRAT Table III.16 392 393 IP6 IP15 IHR1 IHR2 IHR3 Differences in pay rates by reason of qualification? No = 0; Yes = 1to become senior care workers Opportunities No seniors = 0; Externally only = 0.33; Both internally and externally = 0.67; Internally only =1 Recognition agreement with trade unions (Q109) No = 0; Yes = 1 Frequency of staff meetings Less frequently than once a year = 0; Between once every three months and once a year = 0.33; Between once every month and every three months =satisfaction 0.67; Everysurveys month or more frequently = 1 Staff attitude/staff Table III.16 Table III.5 SIPAYOPPCAR Fig III.35 SIEMPVOICE EMPLOYEE DEVELOPMENT INDEX Table III.46 XEMPDEV Fig.III.35 No = 0; Yes = 1 IHR4 IHR5 Frequently of appraisals? No appraisal =0; Less frequently than annual= 0.2; once a year =0.4; every six months to once a year =0.6; every 3 to 6 months= 0.8; More frequentlyofthan 3 months=1 Identification training needs Table III.41 SIEMPAPP Table III.41 No system = 0; Employee request = 0.5; appraisal alone or appraisal plus employee request = 1 IRC1 IRC3 IRT5 IWT3 IWT4 IWT5 Formality of recruitment Word of mouth recommendations=0; Other agencies/ internet/ open days/any other way or notice in shop window=0.5; Press advertising or job centre qualifications plus=1 Importance placed on skills, or experience in recruitment: score of 0=0; a score of 1-4=0.5; a score of 5-8=1 Role of push factors in staff quits one or more push factors=0; no push factors=1 Work schedules that fit staff preferences for particular hours? Occasionally/some of the time = 0; Most of the time =0.5; All of the time = 1 Percentage of staff regularly working weekends? 100 percent = 0; Less than 100 percent = 1 Availability for weekend work as recruitment requirement Table III.4 SIRECRUITPR Table III.7 and fig. III.5 Table III.15 SIRECRSELEC INDEX OF RECRUITMENT AND RETENTION PRACTICES SIRECRETEN XRRPRACT Fig. III.21 SIWTSTFFPREF Fig. III.20 SIWTWEND Fig.III.4 WORKING TIME INDEX XWT 393 394 Yes = 0; No = 1 IWT6 IWT8 IWT9 IWO1 IWO2 IWO3 IWO4 IWO5 Maximum number of days that care staff work 7 = 0; 6 = 0.5; 5 or less = 1 Share of staff working over 45 hours Over 6 percent = 0; 1-5 percent = 0.5; Less than 1 percent = 1 Table III.24 SIWTLHOURS Time off from care duties to attend training? No = 0 Sometimes = 0.5 Yes = 1 Time to carry out the work to a high standard No = 0 To some extent = 0.5; Yes = 1 Opportunities to develop good relationships with service users No = 0; To some extent = 0.5 Yes = 1 Opportunity to put into practice their training/ qualifications No = 0; To some extent = 0.5;Yes = 1 Freedom to prioritise and carry out tasks in ways to improve the quality of care Encouragement exchange No = 0; To some to extent = 0.5; ideas Yes = with 1 other carers of new ways of working/best practice No = 0; To some extent = 0.5 Yes = 1 Table III.20 SIWTTOFFTRAIN Table III.45 SIWOTIME Table III.23, and fig. III.19 and fig. III.27 Table III.45 Table III.45 WORK ORGANIZATION INDEX XWO SIWODISCRET Table III.45 Table III.45 Note: index of all HR practices is called-XHRPRACT and is the result of the average of XPAYLEVELS, XPAYSTRAT, XEMPDEV, XRRPRACT, XWT, and XWO 394 395 Appendix Table IV.A2. HR outcome indicators, sub-indices and Xindices: standardised data set HR outcome indicators Description and range of scores For data distributions see tables in part III Sub-indices SITRAINSKILDEV (unweighted average of the component indicators) IOUT1 Percentage with NVQ2 (Q194) <46 %= 0 46–55 %= 0.33 56-69% = 0.67 >69%= 1 Table III.36 and fig.III.28 IOUT2 Likelihood of meeting the 50 percent NVQ2 target Experiencing difficulties = 0 Will meet soon = 0.5 Already met = 1 Fig. III.29 IRC5 Difficulty in recruiting care workers very difficult=0 quite difficult =0.25 neutral=0.5 quite easy=0.75 very easy=1 Fig. III.1 IRC7 Staff shortages in particular areas Yes=0 No=1 Staff turnover considered to be: very high=0 quite high=0.25 about right=0.5 quite low=0.75 very low=1 Table III.3 Fig. III.7 SITO Absenteeism among care staff considered to be: very high=0 quite high=0.25 acceptable =0.5 quite low=0.75 very low=1 Fig. III.34 SIABSENT IRT1 IRT6 X indices (unweighted average of the component sub-indices) TRAINING/SKILL DEVELOPMENT OUTCOME INDEX XTRAINSKILDEV SIRECDIFF INDEX OF R&R OUTCOMES XRROUTCOMES 395 396 Appendix Table IV.A3. HR practice indicators: non standardised data set. HR practice Indicators (excluded from standardised data set due to too high missing variables) Description and range of scores For data distributions see tables in part III IP7 Pay levels compared to other agencies/homes Lower = 0; About the same = 0.5; Higher = 1 Most effective method of dealing with poor performance? Disciplinary only = 0; „Soft‟ measures plus disciplinary = 0.5; Training and „soft‟ measures only =1; Not addressed IOUT3 Do you have the Investors in People Award? No = 0 Yes = 1 Fig. III.31 HR practice indicators specific to domiciliary care Description and range of scores For data distributions see tables in part III IPDOM1 Compensate for travel costs/travel time No extra pay = 0; Mileage or reimbursement = 0.5; Supplement or higher rate for short call = 1 Fig. III.15 IHRDOM1 Performance monitored by electronic monitoring Yes = 0; No = 1 Domiciliary care workers expected to tolerate variation in hours or location at short notice Yes = 0; Occasionally = 0.5; Never = 1 Fig. III.32 Paid break between service users No = 0; Yes = 1 Minimum length of a work period (QDO149a)? No minimum = 0; One hour or less = 0.5; More than one hour = 1 Fig. III.24 Important attached to organising working hours to fit employees’ circumstances very unimportant/ unimportant/neutral = 0; important = 0.5; very important = 1 Minimum length of a visit No min/15-29 minutes = 0; 30 minutes = 0.5; More than 30 minutes = 1 Staff required to work alone late at night Yes = 0 Occasionally = 0.5 Never = 1 Table III.26 Contracts offered to care staff All zero hours = 0 mix zero and guaranteed hours = 0.5 all guaranteed hours = 1 Fig. III.18 IHR7 IWTDOM1 IWTDOM2 IWTDOM3 IWTDOM4 IWTDOM5 IWTDOM6 IWTDOM7 Table III.42, Fig. III.22 Fig. III.23 Fig. III.23 Table III.32 396 397 Appendix Table IV.A4. HR outcome indicators: non standardised data set HR outcome Indicators (excluded from standardised data set due to too high missing variables) Description and range of scores For data distributions see tables in part III IRT2 Share of new starters in the last 12 months that have been retained less than 70%=0; 70-99%=0.5; 100%=1 Fig. III.8 IRT3 Overall level of staff turnover in the last 12 months 30%+=0; 10-29%=0.33; 1-9% =0.67; 0%=1 Staff turnover excluding new recruits (as a percentage of staff 12 months previously) >30%=0; 20-29%=0.33; 10– 19%= 0.67; 0-10%=1 Fig. III.10 IRT9 Fig III.9 397 398 IV.A.2. Descriptive statistics for indicators, sub-indices and indices from the standardised dataset Table IV.A5. HR practices by size Homes All SIPAYLEVEL Pay levels 0.33 SIPAYUPGRADE Regular upgrading of pay 0.91 0.91 0.91 0.93 0.78 0.79 0.79 0.75 SIPAYUNSOCIAL Pay for unsocial hours 0.28 0.31 0.30 0.19 0.44 0.40 0.46 0.45 SIPAYTRAIN Pay for training 0.91 0.91 0.90 0.95 0.79 0.77 XPAYLEVELS Index of pay levels 0.61 0.61 0.61 0.60 0.63 0.93** (L) 0.65 0.63 0.65** (VSS) 0.59 SIPAYIMP Opportunities for pay improvement 0.44 0.44 0.38 0.52 0.46 0.43 0.51 0.40 SIPAYOPPCAR Opportunities for career 0.78 0.77 0.88 0.82 0.72 Payment of upfront costs 0.83 0.86 0.64** (VS) 0.85 0.81 SIPAYUPFRONT 0.92** (ML) 0.76 0.67 0.77 0.67 0.58 XPAYSTRAT Index of pay strategies 0.68 0.71 0.67 0.67 0.65 0.69 0.67 0.57 SIEMPVOICE Employee voice practices 0.50 0.49 0.47 0.57 0.54 0.50 0.56 0.54 SIEMPAPP Employee appraisal 0.65 0.66 0.60 0.68 0.61 Index of employee development practices Formality of recruitment process 0.58 0.57 0.59 0.55 0.62 0.57 0.58 0.63 0.75** (S) 0.66** (S) 0.55 0.64 XEMPDEV 0.57** (ML) 0.52** (ML) 0.55 0.72 0.77 0.71 0.69 Selection by skills, qualifications or experience Role of push factors in staff quits 0.58 0.54 0.64 0.55 0.62 0.63 0.67 0.69 0.68 0.64 0.54 0.50** (L) 0.57 0.63 0.75** (VSS) 0.33 Recruitment and retention practices index. Work schedules that fit staff preferences 0.61 0.62 0.62 0.58 0.63 0.61 0.65 0.59 0.64 0.59 0.71 0.57 0.61 0.65 0.63 0.55 SIRECRUITPR SIRECRSELEC SIRECRETEN XRRPRACT SIWTSTFFPREF Small 0.33 Medium & Large 0.35 All 0.50 IDPs Very Small& Medium Small 0.49 0.50 Very small 0.31 Large 0.53 398 399 SIWTWEND Weekend working 0.29 0.35 0.41** (S) 0.77 0.32 0.31 0.58 0.30 0.77 0.17** (ML) 0.84 SIWTLHOURS Long hours/long weeks 0.80 0.73 0.59 0.62 0.70 SIWTTOFFTRAIN Time off for training 0.87 0.94 0.84 0.82 0.86 0.96 0.83 0.85 XWT Index of working time practices 0.65 0.66 0.64 0.64 0.63 0.63 0.66 0.60 SIWOTIME Time discretion at work 0.96 0.97 0.95 0.96 0.83 0.79 0.88 0.79 SIWODISCRET Task discretion at work 0.93 0.96 0.94 0.88 0.84 0.85 0.83 0.86 XWO Index of work organisation practices 0.95 0.96 0.95 0.92 0.84 0.82 0.85 0.83 XHRPRACT Overall index of HR practices 0.68 0.69 0.67 0.68 0.66 0.66 0.67 0.64 Table IV.A6. HR outcomes by size Homes All Very small Small Medium & Large All IDPs Very Medium small & small 0.37 0.45 Large SIRECDIFF Recruitment difficulties 0.69 0.56 0.76 0.72 0.38 SITO Perceptions of staff turnover 0.72 0.72 0.82 0.55 0.52 0.45 0.61 0.40 SIABSENT Perceptions of absenteeism 0.63 0.66 0.70 0.48 0.46 0.52 0.47 0.40 XRROUTCOMES Index of recruitment and retention outcomes Index of training outcome 0.68 0.64** 0.76** 0.58** 0.45 0.44 0.51 0.34 (ML) (ML) (VS &S) 0.87 0.84 0.70 0.63 0.67 0.69 0.44 XTRAINSKILDEV 0.81 0.24 399 Table IV.A7. HR practices by ownership 400 All Homes Local National chain chain SIPAYLEVEL SIPAYUPGRADE Pay levels Regular upgrading of pay 0.33 0.91 0.36 0.93 SIPAYUNSOCIAL Pay for unsocial hours 0.28 0.31 SIPAYTRAIN XPAYLEVELS SIPAYIMP SIPAYOPPCAR SIPAYUPFRONT Pay for training Index of pay levels Opportunities for pay improvement Opportunities for career Payment of upfront costs 0.91 0.61 0.44 0.78 0.83 XPAYSTRAT SIEMPVOICE SIEMPAPP XEMPDEV SIRECRUITPR SIRECRSELEC 0.68 0.50 0.65 0.58 0.58 0.58 SIRECRETEN XRRPRACT SIWTSTFFPREF SIWTWEND SIWTLHOURS Index of pay strategies Employee voice practices Employee appraisal Index of employee development practices Formality of recruitment process Selection by skills, qualifications or experience Role of push factors in staff quits Recruitment and retention practices index Work schedules that fit staff preferences Weekend working Long hours/long weeks 0.95 0.64 0.41 0.76 0.80* (N) 0.66 0.53 0.64 0.59 0.68 0.54 0.37 1.00* (S) 0.17** (S) 0.92 0.61 0.45 0.70 0.93**,* (S, L) 0.69 0.50 0.66 0.58 0.57 0.62 SIWTTOFFTRAIN XWT SIWOTIME Time off for training Index of working time practices Time discretion at work 0.87 0.65 0.96 SIWODISCRET XWO Task discretion at work Index of work organisation practices 0.93 0.95 XHRPRACT Overall index of HR practices 0.68 0.57 0.60 0.57 0.44 0.89* (N) 0.86 0.69 0.91**,* (S,N) 0.89 0.90**,* (S,N) 0.68 0.72 0.64 0.67 0.24 0.71* (L) 0.83 0.61 0.99* (N) 0.93 0.96* (L) 0.68 0.67 0.61 0.64 0.29 0.80 IDPs Local National chain chain Single home All Single home 0.27 0.83* (N) 0.35** (N) 0.89 0.58 0.44 0.87 0.76** (N) 0.69 0.49 0.64 0.57 0.51 0.58 0.50 0.78 0.49 0.80 0.49 0.76 0.55 0.82 0.44 0.37 0.45 0.48 0.79 0.63 0.46 0.81 0.67 0.93 0.64 0.52 0.87 0.72 0.76 0.62 0.45 0.82 0.65 0.73 0.64 0.45 0.76 0.69 0.65 0.54 0.64 0.59 0.72 0.62 0.70 0.56 0.59 0.57 0.55 0.55 0.64 0.57 0.65 0.61 0.72 0.62 0.64 0.44 0.65 0.55 0.86 0.68 0.70 0.60 0.65 0.23 0.81 0.54 0.63 0.61 0.32 0.73 0.60 0.57 0.64 0.37 0.59 0.52 0.62 0.68 0.45 0.70 0.55 0.70 0.67 0.12 0.58 0.90 0.65 0.98 0.86 0.63 0.83 0.95 0.64 0.85 0.82 0.66 0.85 0.75 0.53 0.75 0.96 0.97** (L) 0.68 0.84 0.84 0.83 0.84 0.82 0.84 0.91 0.83 0.66 0.65 0.66 0.67 400 401 Table IV.A8. HR outcomes by ownership All Homes Local National chain chain Single home All IDPs Local National chain chain Single home SIRECDIFF Recruitment difficulties 0.69 0.67 0.74 0.65 0.38 0.46 0.38 0.28 SITO Perceptions of staff turnover 0.72 0.68 0.69 0.76 0.52 0.58 0.49 0.52 SIABSENT Perceptions of absenteeism 0.63 0.66 0.58 0.65 0.46 0.53 0.41 0.55 XRROUTCOMES Index of recruitment and retention outcomes 0.68 0.67 0.67 0.69 0.45 0.52 0.43 0.45 XTRAINSKILDEV Index of training outcome 0.81 0.77* (S) 0.71** (S) 0.93**,* (N,L) 0.63 0.86* (N) 0.56* (L) 0.60 401 402 Table IV.A9. HR practices by star ratings Homes IDPs All 1* 2* 3* All 1* 2* 3* 0.19* (3*) 0.88 0.13** (3*) 0.91 0.52** (3*) 0.36 0.67 0.83 0.62** (3*) 0.58** (3*) 0.66 0.62 0.27 0.58 0.34 0.50 0.44 0.51 0.50 0.90 0.24** (3*) 0.91 0.60* (3*) 0.42 0.77 0.80 0.66** (3*) 0.55** (3*) 0.67 0.61 0.77 0.60 0.39* (1*) 0.96 0.46** (1*,2*) 0.92 0.68**,* (1*,2*) 0.53 0.87 0.90 0.77** (1*,2*) 0.35** (1*,2*) 0.58 0.47 0.31 0.54 0.78 0.44 0.67 0.39 0.82 0.44 0.70 0.47 0.79 0.63 0.71 0.55 0.78 0.64 0.85 0.63 0.46 0.81 0.67 0.65 0.58 0.72 0.69 0.67 0.40 0.80 0.66 0.62 0.60 0.90 0.70 0.73 0.54 0.57 0.55 0.49 0.64 0.59 0.72 0.62 0.78 0.68 0.70 0.50 0.61 0.58 0.73 0.65 0.65 0.57 0.67 0.60 0.63 0.49** (2*) 0.63 0.21 0.78 0.88 0.62 0.61 0.66** (1*) 0.60 0.28 0.82 0.85 0.64 0.85 0.57 0.54 0.63 0.50 0.57 0.56 0.65 0.50 0.59 0.73 0.37 0.74 0.88 0.68 0.61 0.32 0.73 0.86 0.63 0.63 0.38 0.64 0.93 0.65 0.60 0.50 0.65 0.90 0.66 0.60 0.50 0.65 0.90 0.66 SIPAYLEVEL Pay levels 0.33 SIPAYUPGRADE SIPAYUNSOCIAL Regular upgrading of pay Pay for unsocial hours 0.91 0.28 SIPAYTRAIN XPAYLEVELS Pay for training Index of pay levels 0.91 0.61 SIPAYIMP SIPAYOPPCAR SIPAYUPFRONT XPAYSTRAT Opportunities for pay improvement Opportunities for career Payment of upfront costs Index of pay strategies 0.44 0.78 0.83 0.68 SIEMPVOICE Employee voice practices 0.50 SIEMPAPP XEMPDEV SIRECRUITPR SIRECRSELEC 0.65 0.58 0.58 0.58 SIRECRETEN XRRPRACT Employee appraisal Index of employee development practices Formality of recruitment process Selection by skills, qualifications or experience Role of push factors in staff quits Recruitment and retention practices index SIWTSTFFPREF SIWTWEND SIWTLHOURS SIWTTOFFTRAIN XWT Work schedules that fit staff preferences Weekend working Long hours/long weeks Time off for training Index of working time practices 0.64 0.29 0.80 0.87 0.65 0.67 0.61 402 403 SIWOTIME SIWODISCRET XWO XHRPRACT Time discretion at work Task discretion at work Index of work organisation practices Overall index of HR practices 0.96 0.93 0.95 0.68 1.00 0.94 0.97 0.64 0.94 0.93 0.94 0.68 0.98 0.92 0.95 0.69 0.83 0.84 0.84 0.66 0.96 0.83 0.90 0.65 0.79 0.84 0.81 0.66 0.90 0.87 0.88 0.68 Table IV.A10. HR outcomes by star ratings Homes IDPs All 1* 2* 3* All 1* 2* 3* SIRECDIFF Recruitment difficulties 0.69 0.68 0.69 0.68 0.38 0.54 0.38 0.26 SITO Perceptions of staff turnover 0.72 0.69 0.72 0.73 0.52 0.46 0.54 0.45 SIABSENT Perceptions of absenteeism 0.63 0.66 0.61 0.65 0.46 0.42 0.48 0.43 XRROUTCOMES Index of recruitment and retention outcomes 0.68 0.67 0.67 0.69 XTRAINSKILDEV Index of training outcome 0.81 0.83 0.79 0.85 0.45 0.63 0.47 0.65 0.47 0.65 0.38 0.55 403 404 Table IV.A11. HR practices by LA commissioning practice All SIPAYLEVEL Pay levels 0.33 Homes Partnership Mixed LAs LAs IDPs Partnership Mixed LAs LAs Cost Minimising LAs All Cost Minimising LAs 0.50 0.55 0.48 0.45 0.44** 0.27** 0.24** (M C) (P) (P) 0.83 0.15** 0.93 0.31 0.78 0.44 0.82 0.52 0.88 0.40 0.58 0.37 0.79 0.74 0.83 0.81 SIPAYUPGRADE SIPAYUNSOCIAL Regular upgrading of pay Pay for unsocial hours 0.91 0.28 0.98 0.37** (M) (P) SIPAYTRAIN Pay for training 0.91 0.89** 0.89** 0.98** (C) (C) (M P) 0.67** 0.54** 0.61 0.63 0.66 0.64 0.55 (M) (P) 0.54** 0.41 0.33** 0.46 0.55 0.43 0.36 0.81 0.67 0.65 0.54 0.64 0.59 0.85 0.66 0.68 0.54 0.68 0.61 0.79 0.72 0.65 0.56 0.63 0.60 0.78 0.65 0.60 0.52 0.58 0.55 XPAYLEVELS SIPAYIMP SIPAYOPPCAR SIPAYUPFRONT XPAYSTRAT SIEMPVOICE SIEMPAPP XEMPDEV SIRECRUITPR SIRECRSELEC SIRECRETEN XRRPRACT SIWTSTFFPREF SIWTWEND Index of pay levels Opportunities for pay improvement Opportunities for career Payment of upfront costs Index of pay strategies Employee voice practices Employee appraisal Index of employee development practices Formality of recruitment process Selection by skills, qualifications or experience Role of push factors in staff quits Recruitment and retention practices index. Work schedules that fit staff preferences Weekend working 0.61 0.44 (C) 0.78 0.83 0.68 0.50 0.65 0.58 (P) 0.77 0.84 0.72 0.46 0.63 0.55* 0.81 0.80 0.67 0.49 0.61 0.55* 0.76 0.85 0.65 0.59 0.72 0.66* (c) (c) (M P) 0.58 0.51 0.62 0.51 0.72 0.70 0.83 0.60 0.58 0.58 0.53 0.68 0.62 0.62 0.59 0.67 0.67 0.57 0.78 0.57 0.54 0.64 0.50 0.42 0.61 0.55 0.64 0.59 0.63 0.65 0.64 0.56 0.64 0.58 0.67 0.69 0.63 0.59 0.66 0.67 0.29 0.46** 0.12** 0.27 0.38 0.37 0.31 0.48 404 405 SIWTLHOURS SIWTTOFFTRAIN XWT SIWOTIME SIWODISCRET XWO XHRPRACT Long hours/long weeks Time off for training Index of working time practices Time discretion at work Task discretion at work Index of work organisation practices Overall index of HR practices (M) (P) 0.71** 0.93** 0.74** (M) (P C) (M) 0.93** 0.75**,* 0.93* (M) (P,C) (M) 0.65 0.67 0.62 0.96 0.93 0.95 0.98 0.90 0.94 0.68 0.69 0.80 0.87 0.64 0.63 0.63 0.67 0.90 0.98 0.81 0.88 0.66 0.64 0.64 0.60 0.67 0.97 0.95 0.96 0.93 0.94 0.93 0.83 0.84 0.84 0.84 0.88 0.86 0.88 0.81 0.84 0.75 0.82 0.78 0.66 0.68 0.66 0.68** 0.66 0.62** (C ) (P) P, M, C used to indicate difference from partnership, mixed and cost minimising LAs respectively Table IV.A12. HR outcomes by LA commissioning practice All SIRECDIFF Recruitment difficulties 0.69 SITO SIABSENT XRROUTCOMES Perceptions of staff turnover Perceptions of absenteeism Index of recruitment and retention outcomes Index of training outcome 0.72 0.63 0.68 XTRAINSKILDEV 0.81 Homes Partnership Mixed LAs LAs 0.60* (C) 0.78 0.66 0.68 0.70 0.68 0.64 0.67 Cost Minimising LAs 0.80* (P) 0.68 0.57 0.68 0.75** (M) 0.94** (P C) 0.73** (M) IDPs Mixed LAs All Partnership LAs 0.38 0.36 0.38 Cost Minimising LAs 0.39 0.52 0.46 0.45 0.58 0.44 0.46 0.48 0.47 0.45 0.44 0.50 0.44 0.63 0.55 0.73 0.63 H, M, L used to indicate difference from high, medium and low fee paying LAs respectively 405 406 Table IV.A13. HR practices by LA fee level All SIPAYLEVEL Pay levels 0.33 SIPAYUPGRADE SIPAYUNSOCIAL Regular upgrading of pay Pay for unsocial hours 0.91 0.28 SIPAYTRAIN XPAYLEVELS Pay for training Index of pay levels 0.91 0.61 SIPAYIMP Opportunities for pay improvement 0.44 SIPAYOPPCAR SIPAYUPFRONT XPAYSTRAT SIEMPVOICE SIEMPAPP XEMPDEV SIRECRUITPR SIRECRSELEC SIRECRETEN XRRPRACT SIWTSTFFPREF SIWTWEND Opportunities for career Payment of upfront costs Index of pay strategies Employee voice practices Employee appraisal Index of employee development practices Formality of recruitment process Selection by skills, qualifications or experience Role of push factors in staff quits Recruitment and retention practices index. Work schedules that fit staff preferences Weekend working 0.78 0.83 0.68 0.50 0.65 0.58 0.58 0.58 0.67 0.61 0.64 0.29 SIWTLHOURS Long hours/long weeks 0.80 SIWTTOFFTRAIN XWT SIWOTIME Time off for training Index of working time practices Time discretion at work 0.87 0.65 0.96 Homes Low fees Medium fees 0.20** 0.34 (H) 0.83 1.00 0.25 0.13** (H) 0.93 0.88 0.55** 0.59 (H) 0.37** 0.38 (H) 0.81 0.77 0.79 0.82 0.66 0.66 0.52 0.57 0.68 0.64 0.60 0.60 0.50 0.72 0.57 0.51 0.61 0.60 0.56 0.61 0.68 0.60 0.17* 0.23 (H) 0.84** 0.95** (H) (H) 0.89 0.75 0.65 0.63 0.94 0.98 High fees 0.47** (L) 0.97 0.39** (M) 0.91 0.69** (L) 0.55** (L) 0.75 0.88 0.73 0.45 0.62 0.53 0.59 0.64 0.79 0.67 0.61 0.46* (L) 0.66** (M L) 0.89 0.66 0.97 All fees 0.38 IDPs Low fees Medium fees 0.54 0.57 High fees 0.50 0.80 0.36 0.75 0.40 0.80 0.58 0.78 0.44 0.85 0.60 0.74 0.61 0.78 0.68 0.79 0.63 0.26 0.57 0.52 0.46 0.80 0.70 0.59 0.55 0.54 0.54 0.71 0.57 0.40 0.56 0.67 0.29 0.82 0.65 0.68 0.52 0.69 0.60 0.74 0.63 0.60 0.65 0.60 0.49 0.82 0.69 0.68 0.56 0.67 0.62 0.70 0.67 0.60 0.66 0.63 0.31 0.81 0.67 0.65 0.54 0.64 0.59 0.72 0.62 0.54 0.63 0.63 0.38 0.63 0.66 0.62 0.64 0.73 0.58 0.92 0.98 0.68 0.70 0.97 0.63 0.92 0.90 0.64 0.83 406 407 SIWODISCRET Task discretion at work 0.93 0.93 0.95 0.96** (H) 0.95 XWO Index of work organisation practices XHRPRACT Overall index of HR practices 0.82 0.81 0.91 0.84 0.95 0.89** (L) 0.93 0.87 0.67 0.70 0.66 0.75* (M) 0.62** (H) 0.91**,* (L,H) 0.70 0.84** (M) 0.66** (L) 0.68 0.66 H, M, L used to indicate difference from high, medium and low fee paying LAs respectively Table IV.A14. HR outcomes by LA fee level SIRECDIFF SITO Recruitment difficulties Perceptions of staff turnover SIABSENT XRROUTCOMES Perceptions of absenteeism Index of recruitment and retention outcomes Index of training outcome XTRAINSKILDEV All fee level 0.69 0.72 Low fees 0.75 0.69 Homes Medium fees 0.64 0.65 0.63 0.68 0.63 0.69 0.81 0.86** (P) High fees All fees 0.64 0.78 0.38 0.52 0.55 0.61 0.67 0.70 0.46 0.45 0.95** (P) 0.68** (M L) 0.63 IDPs Low fees Medium fees 0.38 0.39 0.37** 0.60** (M) (L) 0.43 0.54 0.39 0.51 0.71 0.67 High fees 0.35 0.55 0.40 0.43 0.49 H, M, L used to indicate difference from high, medium and low fee paying LAs respectively 407 408 Table IV.A15. HR practices by labour demand level Homes All IDPs Strong demand 0.46**,* (W,M) 0.98** (W) 0.40** (W) 0.92 Medium demand 0.31* (S) 1.00** (W) 0.31 0.94 Weak demand 0.20** (S) 0.79** (S M) 0.12** (S) 0.89 0.64** (W) 0.39 All Strong demand 0.56** (W) 0.82 Medium demand 0.56** (W) 0.75 Weak demand 0.38** (S M) 0.75 0.79 0.56** (M W) 0.73 0.31** (S) 0.81 0.38 (S) 0.84 0.50** (S,M) 0.38 0.63 0.67 0.61 0.59 0.46 0.48 0.56 0.36 SIPAYLEVEL Pay levels 0.33 SIPAYUPGRADE 0.91 SIPAYUNSOCIAL Regular upgrading of pay Pay for unsocial hours SIPAYTRAIN Pay for training 0.91 XPAYLEVELS Index of pay levels 0.61 SIPAYIMP Opportunities for pay improvement Opportunities for career Payment of upfront costs Index of pay strategies 0.44 0.69** (W) 0.52 0.78 0.75 0.83 0.79 0.81 0.80 0.72 0.90 0.83 0.85 0.85 0.79 0.67 0.69 0.59 0.72 0.68 0.71 0.69 0.65 0.65 0.66 0.63 0.66 Employee voice practices Employee appraisal 0.50 0.51 0.54 0.47 0.54 0.53 0.53 0.56 0.65 0.63 0.73 0.61 0.64 0.62 0.60 0.69 Index of employee development practices Formality of recruitment process 0.58 0.57 0.64 0.54 0.59 0.57 0.56 0.63 0.58 0.62 0.52 0.56 0.72 0.70 0.77 0.70 SIPAYOPPCAR SIPAYUPFRONT XPAYSTRAT SIEMPVOICE SIEMPAPP XEMPDEV SIRECRUITPR 0.28 0.50 0.78 0.44 408 409 SIRECRSELEC 0.58 0.62 0.51 0.58 0.62 0.62 0.63 0.63 0.67 0.71 0.67 0.63 0.54 0.64 0.58 0.38 0.61 0.65 0.57 0.59 0.63 0.65 0.66 0.57 0.64 0.59 0.63 0.69 0.38 0.45 0.48 0.20 Long hours/long weeks 0.80 0.64 0.64 0.66 0.63 SIWTTOFFTRAIN Time off for training 0.87 0.90 0.95 0.96 0.78 XWT Index of working time practices Time discretion at work Task discretion at work Index of work organisation practices Overall index of HR practices 0.65 0.64 0.66 0.68 0.57 0.98 0.72** (S) 0.06** (S M) 0.87** (S) 0.76** (S) 0.60* (S) 0.96 0.63 SIWTLHOURS 0.57** (W) 0.48** (W) 0.73** (W) 0.93** (W) 0.68* (W) 0.95 0.63 SIWTWEND Selection by skills, qualifications or experience Role of push factors in staff quits Recruitment and retention practices index Work schedules that fit staff preferences Weekend working 0.83 0.96** (S) 0.97* (S) 0.69** (S) 0.97** (S) 0.97** (S) 0.64** (S) 0.84 0.88** (M) 0.86 0.63** (S W) 0.82 0.92** (M) 0.83 0.87** (M) 0.68 0.72** (S W) 0.64 0.88** (M) 0.65 SIRECRETEN XRRPRACT SIWTSTFFPREF SIWOTIME SIWODISCRET XWO XHRPRACT 0.29 0.96 0.93 0.95 0.68 0.87** (M W) 0.91**,* (W,M) 0.70** (M W) 0.33** (W) 0.80 0.92 0.67 0.84 0.66 S, M, W used to indicate difference from strong, medium and weak labour market demand areas respectively 409 410 Table IV.A16. HR outcomes by labour market conditions Homes IDPs All Strong demand Medium demand Weak demand All Strong demand Medium demand Weak demand SIRECDIFF Recruitment difficulties 0.69 0.70 0.67 0.69 0.38 0.36 0.38 0.40 SITO Perceptions of staff turnover 0.72 0.76 0.65 0.71 0.52 0.52 0.50 0.52 SIABSENT Perceptions of absenteeism 0.63 0.67 0.54 0.64 0.46 XRROUTCOMES Index of recruitment and retention outcomes Index of training outcome 0.68 0.71 0.62 0.68 0.45 0.43* (M) 0.44 0.63**,* (W,S) 0.50 0.39** (M) 0.43 0.81 0.72** (W) 0.76* (W) 0.94**,* (S,M) 0.63 0.46**.* (W, M) 0.73* (S) 0.78** (S) XTRAINSKILDEV 410 411 IV.A3. Technical notes on our presentation of results from the multivariate statistical analysis For all our regression analyses we used the backwards method. This method works by beginning with an examination of the combined effect of all independent variables on the dependent variable. Then in a series of steps, the independent variables that offer the weakest explanatory value are removed and a new analysis is performed. As with other regression methods, the final results provide coefficients for each independent variable that signify the degree to which each one, when combined with the others, contributes to predicting the dependent variable. We have considerably simplified the results generated from our regression analysis and therefore wish to provide a brief explanation of the format of tables used in the report. Each table of results adopts the following general form43: Effects of environmental factors and organisational characteristics on different indices of HR practices for homes b. X HRPRACT Coefficient Significance LA fee levels 0.24 * Single establishment 0.17 Private for profit -0.46 i) With LA fees Etc. Coefficient Significance Female part-time pay 0.17 n.s. n.s. Single establishment 0.12 n.s. *** Private for profit -0.47 *** ii) With labour demand Etc. Note: OLS regression, sample 52 (homes) and 50 (IDPs). Adjusted R 2 of 0.32 (model i), 0.31 (model ii). Since the backwards regression method removes those independent variables that are weakest in terms of their predictive power, the tables do not list all the independent variables that were included in the first step but rather those that remain in the nth step, selected because it has best predictive power as estimated by the adjusted R2. For each table, the title clarifies the nature of the relationship being tested and identifies the independent variables and the dependent variable, in this case the summary X index HR practices. The independent, explanatory variables are listed in the left-hand column. The column „coefficients‟ presents the estimated effects of each variable on the outcome or dependent variable. In all tables we use the standardised (beta) coefficients. Because the dependent variables used are measured on a continuous 0-1 scale the interpretation of coefficients is relatively straight forward. In the above example using the first model that includes the LA fee variable (and excludes the labour demand variable) the results suggest 43 We borrow here from the style and explanation of statistical results presented in Gallie et al. (1998). 411 412 that for every unit increase in standard deviation of LA fees, holding all other factors constant, the X index HRpractices increases by 0.24 times a standard deviation. For dichotomous variables, such as Single establishment and Private for profit, the coefficient refers to the effect on the dependent variable compared to the reference variable; in this case, National chain and Voluntary not for profit, respectively. For example, the results generate a negative standardised coefficient for the variable Private for profit, which means that compared to Voluntary for profit homes there is negative impact on the dependent variable X HRPRACT, again holding all other factors constant. The importance of each variable is estimated by applying a t-statistic to measure the statistical significance. To simplify the presentation the tables only present the result that is derived from the t-statistics following a „starring‟ convention. A single * indicates a minimum 90% confidence level (p < 0.1), ** indicates a 95% confidence level (p < 0.05) and *** a 99% confidence level (p < 0.01). The abbreviation n.s. means the result is not statistically significant. Estimates of the adjusted R2 (the coefficient of determination) and sample size are provided in the notes to each table. The R2 shows the proportion of variability explained by the variables included in the model and for our regression method varies from 0 to 1. In the above example, the first model had an adjusted R2 of 0.32, which means that the predictors account for 32% of the variation of the index X HRpractices. The results presented in part IV are confined to those where the independent variables in a particular model offer relatively strong explanatory value. We therefore exclude from the text all results where neither the R2 nor the adjusted R2 exceeds 0.2. The one exception is for the model that explores the effects on the index X Paylevels for IDPs, which has an adjusted R2 of 0.11 (with LA fees) and 0.12 (with labour demand), since we wished to compare the results with those for homes where the models produce a higher value R2. 412 413 IV.A4. Description of variables for regression analyses The following tables list the independent and dependent variables used in the regressions presented in section IV.5.1 and IV.5.2. Table IV.A17. Variables in regressions investigating indices of HR practices Dependent variables Independent variables Notes XHRPRACT XPAYLEVELS XPAYSTRAT XRRPRACT XEMPDEV XWT XWO LA Partnership LA fees levels % dependency on LA Local labour demand Female part-time pay Size Ownership (3 categories): national chain local chain single establishment Private sector/ Voluntary sector Partnership = 3, Mixed = 2, Cost minimisers = 1 For homes only Range of 2-6 Median level of earnings (£) in local area Converted into 2 dummies: Dummy1 (Local chain= 1; others= 0) Dummy2 (Single establishment= 1; others=0) Dummy (Private = 1; Voluntary= 0) Table IV.A18. Variables in regressions investigating the HR outcomes XRROUTCOMES and XTRAINSKILDEV Dependent variables Independent variables XRROUTCOMES XTRAINSKILDEV XHRPRACT XPAYLEVELS XPAYSTRAT XRRPRACT XEMPDEV XWT XWO LA Partnership LA fees levels % dependency on LA Local labour demand Female part-time pay Size Ownership (3 categories): national chain local chain single establishment Private sector/ Voluntary sector Notes Partnership = 3, Mixed = 2, Cost minimisers = 1 For homes only Range of 2-6 Median level of earnings (£) in local area Converted into 2 dummies: Dummy1 (Local chain= 1; others= 0) Dummy2 (Single establishment= 1; others=0) Dummy (Private = 1; Voluntary= 0) 413 414 Table IV.A19. Variables in regressions investigating the HR outcomes RT3 and RT9 Dependent variables Independent variables RT3 P2 RT9 P3 Notes P4 P8 P11 HR1 HR4 HR5 HR7 IRC1 RC3 WT3 WT4 WT9 PDOM1 Only for IDPs WTDOM2 Only for IDPs WTDOM4 Only for IDPs WTDOM7 Only for IDPs LA Partnership Partnership = 3 Mixed = 2 Cost minimisers = 1 LA fees levels % dependency on LA For homes only Local labour demand Range of 2-6 Female part-time pay Median level of earnings (£) in local area Size Ownership (3 categories): national chain local chain single establishment Private sector/ Voluntary sector Converted into 2 dummies: Dummy1 (Local chain= 1; others= 0) Dummy2 (Single establishment= 1; others=0) Dummy (Private = 1; Voluntary= 0) 414 415 IV.A5. Detailed results of selected regression models The following results serve to accompany summary tables presented in Part IV section 5.3. For the staff turnover measures, RT3 and RT9, we have used the logarithm of the actual turnover rate, which means that the higher the measure the higher the level of staff turnover and the worse the HR outcome. Table IV.A20. The effects of environmental factors, organisational characteristics and HR practices on measures of staff turnover for IDPs a. Overall staff turnover (RT3) Model i: With LA fees Coefficient Significance Code IP3 IP4 IP11 IHR1 IRC1 IRC3 IWT9 Female part-time pay Regular uprating of pay Pay uprating opportunities Pay for CRB checks Recognition agreement with trade unions Use of formal recruitment methods Skills and qualifications desirable among job applicants Time off from care duties to attend training Model ii: With labour demand Coefficient Significance -0.26 0.47 -0.42 0.39 -0.40 ** *** *** *** *** -0.26 0.47 -0.42 0.39 -0.40 ** *** *** *** *** 0.40 *** 0.40 *** -0.23 * -0.23 * -0.20 * -0.20 * Note: OLS regression, sample 37 (IDPs). Adjusted R2 of 0.62 (model i), 0.62 (model ii). b. Staff turnover excluding new recruits (RT9) Model i: With LA fees Coefficient Significance Code IP3 IP4 IP8 IP11 IHR1 IRC1 IWT9 IWTDOM4 IWTDOM7 Partnership Size Regular uprating of pay Pay uprating opportunities Payment for weekend work Pay for CRB checks Recognition agreement with trade unions Use of formal recruitment methods Time off from care duties to attend training Work schedules that fit staff preferences Offering guaranteed hours contracts Model ii: With labour demand Coefficient Significance 0.46 0.24 0.28 -0.58 -0.35 0.43 -0.72 *** * ** *** ** *** *** 0.59 0.33 --0.61 -0.43 0.39 -0.75 *** ** -*** *** *** *** 0.63 *** 0.70 *** -0.30 ** -0.27 ** 0.26 ** 0.34 ** 0.34 ** 0.43 ** Note: OLS regression, sample 37 (IDPs). Adjusted R2 of 0.62 (model i), 0.56 (model ii). 415 416 Table IV.A21. The effects of environmental factors, organisational characteristics and HR practices on measures of staff turnover for homes a. Overall staff turnover (RT3) Model i: With LA fees Coefficient Significance Code IRC3 Female part-time pay Single establishment Private for profit Skills and qualifications desirable among job applicants -0.34 -0.26 0.23 -0.33 ** * * ** Model ii: With labour demand Coefficient Significance -0.34 -0.26 0.23 -0.33 ** * * ** Note: OLS regression, sample 45 (homes). Adjusted R2 of 0.19 (model i), 0.19 (model ii). b. Staff turnover excluding new recruits (RT9) Model i: With LA fees Code IRC3 IWT4 Single establishment Private for profit Skills and qualifications desirable among job applicants % of staff who regularly work weekends Model ii: With labour demand Coefficient Significance Coefficient Significance -0.28 0.24 -0.26 * * * -0.28 0.24 -0.26 * * * -0.28 * -0.28 * Note: OLS regression, sample 45 (homes). Adjusted R2 of 0.18 (model i), 0.18 (model ii). 416 417 V.A. Appendix part V Table V.A1. Simplified identifier codes for case study organisations Code in telephone survey XD XD.HN.4 XD.H.5 XD.D.1 XD.D.3 XD.DIH.1 Case study code for Part V XD XDHome1 XDHome2 XDDom1 XDDom2 XDLADP RN RN RN.H.3 RN.H.1 RN.D.1 RN.D.2 RN.DIH.1 RNHome1 RNHome2 RNDom1 RNDom2 RNLADP ON ON.HN.1 ON.H.2 ON.D.1 ON.D.3 ON.DIH.1 ON ONHome1 ONHome2 ONDom1 ONDom2 ONLADP IL IL IL.H.4 IL.H.3 IL.HIH.1 IL.D.1 IL.D.2 ILHome1 ILHome2 ILLAHome ILDom1 ILDom2 Table V.A2. Job positions of case study interviewees Position of interviewees Roles involving direct care work Care Worker Care Worker with Supervisory Role Care Coordinator and Care Worker Line Manager / Senior Car Worker Roles involving organising/supporting care work Care Coordinator Nurse with supervisory role Service Manager Line Manager/Coordinator All Female Male Migrant Workers 69 14 3 2 62 13 2 2 7 1 1 6 5 2 2 1 5 2 2 1 1 417 418 Table V.A3. Working Hours of Case Study Interviewees by LA XD RN ON IL All LAs Domiciliary workers per LA 10.0 20.0 60.0 10.0 Care homes workers per LA 0.0 40.0 60.0 0.0 LA providers workers per LA 0.0 40.0 60.0 0.0 All providers workers per LA 4.0 32.0 60.0 4.0 No. of respondents Under 16 hrs 16-30 hours 30-45 hours Over 45 hours 10 11.1 22.2 44.4 22.2 10 0.0 37.5 50.0 12.5 5 0.0 60.0 40.0 0.0 25 4.5 36.4 45.5 13.6 No. of respondents Under 16 hrs 16-30 hours 30-45 hours Over 45 hours 9 0.0 20.0 60.0 20.0 8 10.0 20.0 70.0 0.0 5 0.0 100.0 0.0 0.0 22 4.0 36.0 52.0 8.0 No. of respondents Under 16 hrs 16-30 hours 30-45 hours Over 45 hours 10 0.0 18.2 63.6 18.2 10 0.0 20.0 70.0 10.0 5 0.0 80.0 20.0 0.0 25 0.0 30.8 57.7 11.5 No. of respondents Under 16 hrs 16-30 hours 30-45 hours Over 45 hours 11 5.0 20.0 57.5 17.5 10 2.6 28.9 63.2 5.3 5 0.0 70.0 30.0 0.0 26 3.1 33.7 54.1 9.2 Total respondents 40 38 20 98 Under 16 hrs 16-30 hours 30-45 hours Over 45 hours 418 419 Bibliography Akerlof, G. and Yellen, J. 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