Nurses’ agencies and domiciliary care

Chris Payne reports on nurses’ agencies and domiciliary care in relation to the CQC’s Essential Standards of Quality and Safety.

Nurses’ agencies are included as one service type in a long list of community or integrated healthcare services (CHC). This list includes district nursing, health visiting, midwifery, school nursing and family planning clinics. In this respect they are distinct from domiciliary care, which is regulated as a separate service type (DCS).

In terms of classification all of this is logical, with the common denominator for nursing care being that all the services represented involve healthcare professionals, including nurses in one capacity or another.

Registration issues

In practice, registered nurses’ agencies provide similar services to domiciliary care, in that they offer care and support to people in their own homes. An analogy can be drawn with the two types of care home: one without nursing (CHN), the other providing nursing care (CHS).

The differences between the services provided by nurses’ and domiciliary care agencies can be explained with reference to the regulated activities that one or other is allowed to carry out in terms of their registration. Personal care is the main regulated activity of a domiciliary care service. Registered nurses’ agencies will also inevitably carry out personal care as well as nursing care, which is a separate regulated activity.

Some nurses’ agencies might also carry out activities involving “treatment of disease, disorder or injury”, which will be reflected in their registration. A domiciliary care service would not be registered to carry out this regulated activity because it would fall outside of its scope, though its care workers might still assist in some aspects, eg with a person’s medication. (See page 30 of the CQC’s Scope of Registration (August 2013), which lists examples of help with medication that does not count as “treatment of disease, disorder or injury”.)

“Nurses’ agency” is a confusing title since it covers not just service providers who must register with the CQC, but also employment agencies, which place nurses (and other medical staff) in suitable employment in hospitals, care homes with nursing, etc. Agencies that just place or supply people to health and care services are not required to register with the CQC, but are licensed to operate as any other employment agency.

Nevertheless it is evident that they, too, must develop their placement policies in line with CQC regulations, as the majority of agency workers will be employed in CQC-regulated services. Some agencies operate as both placement agencies and as registered providers.

The Scope of Registration guidance states: “the supply of nurses by an employment agency or employment business to another service provider is not a regulated activity”. Also an agency providing a recruitment or introductory service for individuals to select a suitable carer, whose services will be paid for privately or from a personal budget, is not deemed to be engaging in regulated activity. This last set of circumstances raises a question: must the carer then be registered with the CQC as someone who will be carrying out a regulated activity, ie personal or nursing care, even though directly employed by a private individual?

There is nothing in principle against an individual being registered with the CQC. By definition, a service provider can be an individual, partnership or an organisation, and therefore any of these potentially falls within the scope of registration. However, as with the employment of personal assistants generally, the answer is no. The Scope of Registration guidance states: “where a person makes a private arrangement and secures a nurse for his or her own care, under his or her direction, the service provided is exempt (from CQC registration), even if it did not involve an introductory agency or employment agency. This may include, for example, where an individual uses a personal budget or a self-pay arrangement”.

Who employs the carer is therefore of crucial importance. If an individual purchases the service from a nurses’ agency, which then remains responsible for the employment of the carer and the services that he or she provides, the agency must be CQC-registered. Registration would also be required where an individual nurse, although privately employed, carries out as a “sole provider” any of the regulated activities under the heading of “treatment of disease, disorder or injury”. This could occur, for example, where the nurse is responsible for treatments that would usually be carried out by registered healthcare service professionals and involve specialist training, eg administration of intravenous medication or even chemotherapy. Independent nurses providing a specialised nursing service in the context of private employment should always clarify their position with the CQC, which will consider the need for registration on a case-by-case basis.

Nursing care does not need to be registered as a separate activity, where it forms part of other activities that involve qualified nurses in some capacity, eg in the case of care homes with nursing or procedures carried out by community nurses, which are registered under “treatment of disease disorder or injury”. Also, because an activity is carried out by a qualified nurse does not mean that it has to be registered as nursing care. This occurs where a service might be provided by a range of qualified people including, but not exclusively, nurses. Likewise the care provided by a registered nurse in a non-nursing role would not be considered as nursing care, thereby requiring registration as nursing care.

Registered nurses’ agencies and domiciliary care compared

Putting the registration issues to one side, it can be seen that if the respective services of nurses’ agencies and domiciliary care providers are compared, more similarities than differences emerge. Both types of service are dedicated to providing care and support to individuals in their own homes. They will both be providing some level of personal care as defined by the legislation, with some variation according to the needs of the people receiving their services for additional nursing care.

It should be noted that not all of the care provided by nurses’ agencies is carried out by registered nurses. Nurses’ agencies might employ healthcare assistants, the equivalent of care workers, who provide much of the day-to-day care. They are able to do this provided that they are working under the direct or indirect supervision of a qualified nurse.

As described by the Scope of Registration, “Nursing care means any service provided by a nurse and involving: (a) the provision of care, or (b) the planning, supervision or delegation of the provision of care, other than any services, which, by their nature and the circumstances in which they are provided, do not need to be provided by a nurse.”

It might be thought that the second part of (b) is confusing in that it does not appear to follow logically from the first part, so is unnecessary. If an activity does not need to be provided by a nurse or under the supervision of a nurse then it is evidently not nursing care.

Overall, however, the definition follows the practice of nursing as applied, for example, in a hospital ward, where care is provided either directly by qualified nurses or by assistants who are not qualified nurses, but whose activities are controlled by nursing staff. Nurses or healthcare assistants also typically carry out activities that could be equally carried out by other than healthcare staff, for example, serving food — which arguably explains the second part of (b).

The key point is that nursing care as a regulated activity must be carried out by, or controlled by, nurses, whether as practised in a hospital or in a patient’s own home.

Nevertheless, it would seem that no sharp distinction can be made between many of the services provided by a nurses’ agency and those of a domiciliary care agency. The services of nurses’ agencies, like domiciliary care, can be purchased privately or through service commissioning, where they might substitute for traditional NHS community nursing. Many nurses’ agencies certainly offer services, including live-in services to people with long-term complex needs, for example, those with brain damage, stroke victims, and multiple sclerosis sufferers, and others who require equipment and procedures that need to be carried out by, or under the control of, trained nurses.

However, domiciliary care agencies also provide care to people with long-term needs and their staff are being increasingly expected, with training, to carry out procedures that, at one time, would only be carried out by nurses or healthcare assistants. An example of this is in the use of catheters. Also, they invariably provide services in situations where users are being visited by community nurses, thereby contributing to a wider care programme for those individuals who are also receiving nursing care. Many of the tasks carried out in these circumstances will thus be related to, and contribute to, the overall individual healthcare and support plan.

In the CQC’s Guidance about Compliance, several of the additional prompts for community health services are shared with domiciliary care and care homes, eg standards for end-of-life care. Many of the issues raised from the respective CQC inspections are also common to both service types. For example, this extract from a nurses’ agency report might appear equally in a domiciliary care service inspection report.

We also saw that the provider had sourced various training packages for care workers. These included assessments and care planning, person-centred care, risk assessing, record keeping, dementia care, mental capacity, safe moving and handling, nutrition and hydration, and death and dying.

The same report goes on to describe the agency’s approach to monitoring the quality of care.

The provider had also developed a care worker spot-check form. This included checking that carers were familiar with the person's needs and care plan, promoted people’s independence, privacy and dignity, offered choices, and listened to the person, as well as making correct records of the care given.

The emphasis on person-centred care is also one that would be expected from an inspection of an equivalent domiciliary care service.

Given what appears to be considerable overlap, it is hoped that the relationship between the two types of agency will be subject to fuller research and review as an important aspect of the integration of health and social care, which is to be actively promoted as a result of the forthcoming Care Act 2014. This, as the Care Bill, is currently going through its final parliamentary stages and will have a major impact on the future organisation and provision of health and social care services.