Care Tiers

Overview of Care Tiers

CARE TIERS

Overview

Service User needs vary widely for different Service Users. Table 2 categorises the Services into four different Care Tiers of increasing specialism.
Care Tiers 1 and 2 describe non-specialist Domiciliary Care and Care Tier 3 describes specialist Domiciliary Care. The term "specialist" refers to the clinical complexity of the care. Every Service User will receive individual, person-centred care at each Care Tier.
The Provider will agree to deliver a care package that is within the scope of the services that the Provider can deliver. This can be within one or more Care Tiers. Providers are not required to deliver care at every Care Tier.
The appropriate Care Tier or combination of Care Tiers will be decided by the Commissioner, informed by input from the MDT and the Provider.

CARE TIER 1: NON-SPECIALIST CARE

Overview

Care Tier 1:

  • provides support and enablement for Service Users with significant needs around the personal activities of daily living, potentially including mobility, nutrition, hygiene and personal safety;
  • includes Personal Care;
  • excludes Nursing Care or Delegated Nursing Tasks (DNTs) carried out by the Care Worker. Service Users may have Nursing Care needs that are met by other members of the care team; and
  • provides support and assistance to Service Users in a way that encourages and maximises independence.

Care Workers
In Care Tier 1 Care Workers will:

  • have or will be working towards The Care Certificate5 or equivalent qualification standards (e.g. Level 2 Diploma in Health and Social Care6), and will comply with the National Minimum Training Standards7 and the Common Induction Standards8.

Activities
Care Tier 1 activities can include but are not limited to:

  • supporting Service Users to get up/go to bed and get dressed/undressed;
  • supporting Service Users to wash, shower or bath including washing of hair and oral hygiene;
  • supporting Service Users with their toilet/continence requirements;
  • helping Service Users to eat their food or take a drink;
  • assisting Service Users to make a safe transfer or to mobilise. Service Users will have some ability to weight bear or move independently;
  • assisting and facilitating Service Users to take medication. Service Users will not be passive in taking medication, and will have the cognitive capacity to manage their medication and to direct the Care Worker. Tier 1 does not include medicine administration; this is included in Tier 2;
  • supporting Service Users’ social care needs including social interaction and some domestic activities. Domestic activities will be specifically and exclusively for the Service User and may include but are not limited to light housework, preparing meals, washing up after meal preparation, laundry and shopping;
  • working towards maintaining a safe environment for Service Users, respecting Service User and family preferences;
  • recognising changing mental, physical and emotional needs, and reporting appropriately; and
  • EOLC, where appropriate EOLC will be delivered in partnership with specialist palliative care teams, GPs and other healthcare professionals to identify the support and resources required to meet Service Users’ needs and to anticipate changes in their condition. The Provider will follow Guidance on Care of Dying People.

CARE TIER 2: NON-SPECIALIST CARE

Overview

Care Tier 2:

  • incorporates all components of Care Tier 1;
  • includes anticipating Service Users’ needs and responding to dynamic needs that may not be directly communicated by Service Users;
  • excludes administration of an intravenous (IV) antibiotic or other drug requiring training in reconstitution, mathematical calculation, or titration; and
  • includes greater identification and management of risks compared to Care Tier 1.

Care Workers
In Care Tier 2 Care Workers will:

  • have additional competencies, skills, experience or training (e.g. health and social care qualifications9, continuing professional development qualifications10, National Occupational Standards11, or the Level 3 Diploma in Health and Social care12); and
  • take on further responsibility compared to Care Tier 1. In Care Tier 2 Care Workers can complete DNTs where they are deemed competent, have received the necessary training, and appropriate supervision is agreed.

Activities
Care Tier 2 activities include but are not limited to:

  • observation and monitoring of skin including pressure areas;
  • continence care, which requires monitoring to minimise risks, for example care associated with urinary catheters, double incontinence, chronic urinary tract infections and/or the management of constipation;
  • supervised feeding where there may be a risk of aspiration. Care will be delivered in line with SALT guidance;
  • care for Service Users receiving nutritional support through feeding tubes (such as PEG, RIG, NG) delegated by an appropriate registered health care professional (e.g. a district nurse);
  • transferring and mobilising Service Users, where Service Users are unable to weight bear and are unable to assist or cooperate with transfers and/or repositioning;
  • careful positioning where Service Users are unable to cooperate and there is loss of muscle tone, pain on movement, or a risk of physical harm;
  • care for Service Users with involuntary spasms or contractures placing them or others at risk;
  • administration of medication. Care Tier 2 Care Workers have a greater responsibility for delivering medication and have a more active role compared with Care Tier 1 Care Workers. Care Tier 2 Care Workers administer medication as per the Service User’s prescription instructions or the Service User’s MAR (Medicines Administration Record). Medication is not delivered under the direct instruction of the Service User, as per Care Tier 1. All details of the medication administration will be recorded;
  • administration of prescribed insulin that has been dispensed via an insulin pen, where Service Users cannot do this themselves;
  • non-invasive ventilation, including sleep masks and cough assist machines;
  • caring for Service Users with Behaviour that Challenges, where the Risk Assessment document indicates a pattern of behaviour that can be managed by appropriately skilled Care Workers and planned interventions;
  • care for Service Users who are unable to assess basic risks even with supervision, prompting or assistance, due to cognitive impairment, and who are dependent on others to anticipate their basic needs and to protect them from harm, neglect or health deterioration; and
  • care for Service Users who are unable to communicate reliably their needs at any time and in any way, even when all practicable steps to assist them have been taken. Service Users have to have most of their needs anticipated because of their inability to communicate them.

CARE TIER 3: SPECIALIST CARE

Overview

Care Tier 3:

  • incorporates Care Tiers 1 and 2;
  • applies for Service Users with a combination of conditions and disabilities. The conditions or disabilities will be severe or in the advanced stages; and
  • may require the Provider to have a greater role in developing the care package. The Provider may be required to share specialist expertise with the Commissioner to enable Service Users specific specialist needs to be fully understood and met. The Provider’s role in developing the care package may include assisting the Commissioner with the assessment of Service Users needs, and with the development of the Personalised Care Plan (hereafter referred to as the Care Plan).

Care Workers
In Care Tier 3 Care Workers will:

  • have additional competencies, skills, experience or training (e.g. health and social care qualifications, continuing professional development qualifications, National Occupational Standards, or the Level 3 Diploma in Health and Social care); and
  • take on further responsibility than Tiers 1 and 2, with a greater emphasis on DNTs.

Activities
Care Tier 3 activities include but are not limited to:

  • oral suctioning;
  • care for Service Users with ventilator dependency;
  • care for Service Users with a tracheostomy requiring suctioning where the Service User is unable to manage this themselves;
  • care for Service Users at risk of autonomic dysreflexia;
  • administration of medication through feeding tubes (such as PEG, RIG, NG);
  • care for Service Users with altered states of consciousness (ASC) that occur on most days, do not respond to preventative treatment, and result in a severe risk of harm; and
  • care for Service Users with Behaviour that Challenges, where the behaviour is of a severity and/or frequency and/or unpredictability that presents an immediate and serious risk to self, others or property. The risks are so serious that they require access to an immediate and skilled response at all times for safe care.