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Care at Home - A Guide for People Using the Service


Orkney Health and Care Partnership is committed to providing flexible, responsive and good quality Care at Home Services, which reflect individual need and preferences, and encourage people to live as independently as possible in their own home, as well as to support carers in their caring role.

Orkney Health and Care’s Vision is:

To make a real difference to the lives of the people living in Orkney by improving their health and social wellbeing, and delivering high quality services closer to home.

The vision statement for the Health and Community Care Services is:

‘We aim to work together to promote independence and self-management by providing tailored services at home, or in a homely setting that supports people to feel as physically and emotionally well as they can be. People who use our services will experience safe, effective, person-centered, responsive and timely care that is barrier free.’

Aims and objectives of the services

Orkney Health and Care Partnership Care at Home Services aim to apply the following objectives to all service provision.

That people should:

The rights of carers are recognised and they will be supported in their role. Carers can receive both an assessment and services in their own right, if appropriate.

What the service provides

Care at Home Service provides support and assistance 365 days a year with:

Personal care includes:

Domestic support is defined as:

Light domestic tasks linked to Personal Care and Meal Preparation e.g. tidy bathroom, tidy kitchen, washing dishes.

Night support

Where support is required during the night. A visit can be planned with our Night Support service.

What the service does not provide

There are a number of things home carers cannot do such as those listed below (this list is not exhaustive):

Who do we provide services for?

Services can be provided to anyone 18 years and over who has had an assessment of their needs completed and requires assistance with daily living within their home.

Applying for Care at Home services

You or your representative can apply for support from the Care at Home Service by contacting the Duty Worker for Orkney Health and Care directly (phone numbers are at the back of the booklet), or by asking your GP or health professional to make the referral.

A Social Worker or a member of the assessment team will arrange to visit you at a time convenient to you.

You can have someone else present if you wish, for example, a member of your family, or a friend or carer.

The role of the Social Worker will be to:

What does the service cost?

A charge may be applied for the service you receive. This charge will be determined by the outcome of a Financial Assessment.

For people over the age of 65, all personal care and meal preparation is free. However, non-personal care (domestic tasks such as housework, dish washing, or laundry) is potentially chargeable.

Financial Assessment

The Social Worker/Care Manager will complete a Financial Assessment with you. The charge for the service will be calculated on the current hourly rate for the service, the amount of income you receive and the level of savings you have.

You may not know what your exact charge will be before the service commences but the Social Worker/Care Manager will discuss this with you so that you should have a broad idea of the level of charge you are likely to pay.

If you choose not to disclose your financial details you may be liable to pay the maximum hourly rate for the service.

Setting up your service

Following a referral from your Social Worker, your allocated Social Care Co-ordinator will contact you to arrange a meeting. This meeting will be to discuss an appropriate support package for you as well as to complete and sign the necessary paperwork prior to your care and support commencing.

These documents include:

Personal Support Plan

Your Personal Support Plan will be developed with you and your Social Care Co-ordinator. It will identify those tasks that home carers will undertake to help ensure that you can live as safely and as independently at home for as long as possible.

The plan will include personal information about you such as next of kin with their contact details. It will also include the names and contact details of any others who support you such as a family member, Community Nurse, and your Care Manager. Your wishes on how you want your support to be delivered by your carers will also be included so that we can provide you with the best possible service we can.

A brief Personal History is often a very good way of ‘breaking the ice’ to help carers get to know you a little from the start of your service. If you choose to share some relevant aspects of your life to create a little Personal History we will include this in your Support Plan. This can help carers build a positive working relationship with you as well as to deliver a more person-centred service for you.

The Home Care Service uses an electronic system to monitor carer visits to your home and you will be asked if a tag can be placed discretely in your home to enable carers to tag in and out. Your Social Care Coordinator will describe this to you in more detail.

At the end of every visit your carers will record what they have done in a daily communication sheet and, where appropriate, any additional relevant information that may need to be conveyed to their colleagues who visit after them.

Where your medication is being administered by home carers a separate Medication Folder will be put in place. The ordering, re-ordering and collection of your medication will not be undertaken by a home carer and the person(s) responsible for doing so will be identified and their contact details recorded in your Support Plan.

Withdrawing your service

Orkney Health and Care Partnership has a legal obligation not only to you but also to our employees. While your needs are very important to us the Council has a duty to protect employees and we reserve the right to withdraw a service if employees are put at unnecessary or unacceptable risk.

Violence and aggression

If staff are subjected to repeat incidents of violence or aggression, you and/or your family will be advised of the procedures which apply.

Your care needs will be formally reviewed and your service may be at risk of being withdrawn.

If you are likely to be at risk without a service we will use the appropriate legal procedures to make sure that we fulfil our obligations to you and our staff.

You will be advised, in writing of the outcome of any review and decisions taken.

Suspending your service

If you go away on holiday, to stay with family or if you need to go into hospital or respite your service can be suspended until you return home. In these cases you must contact the duty Social Care Co-ordinator with the dates that you plan to be away. As soon as you can before you return you would need to contact the Social Care Coordination team to inform them of your intended return and when you need your service to restart. Following any suspension of your service we will do our best to restart your service with the home carers that you are familiar with. If for any reason the service is suspended beyond a six week period we will ask your Social Worker for a re-assessment of your needs in case there has been change.

Ending your service

You can end the service at any time if you feel you no longer require it. It is helpful to let us know in advance.

If you decide to cancel the service, we will contact you to find out the reason and where possible to make sure that stopping the service won’t leave you at risk.


There is an initial Review at the end of the first six weeks of service and thereafter Reviews are planned to take place every six months. One of these may include an Annual Review with your Social Worker or Care Manager, however Reviews can take place more frequently if your needs are complex and/or change. Reviews are a continuation of the assessment process to ensure that the support you are receiving continues to meet your needs, to allow you to remain as independent as possible.

This does mean that your service can change, or be reduced or increased according to your changing needs.

You can be supported at your review by a family member/representative and/or advocate.

Care at Home staff involved in delivering your service will also be asked for feedback on a regular basis to ensure your needs continue to be met.

If at your review it is determined that you no longer need the service/s we will agree with you when the service/s will end.

Care at home staff

We will ensure that the Care at Home staff (Home Carers) allocated to provide your service will have the necessary skills, competencies and experience to meet your specific needs.

All of our home carers work with what we call the ‘re-ablement ethos’. What this means in practice is that home carers will work with you to support you do things for yourself, and where there are tasks that you cannot do for yourself your home carer will do those things for you. Our goal is to help you maintain as good a quality of life as possible through being as independent as you can be.

Your service will be delivered by a small team of trained carers to ensure continuity and reliability in the provision of your service. When a team member is on holiday or off sick the service will aim to provide a continuity of cover through the use of one or both of our peripatetic teams. Where circumstances dictate that either your care or the times of your visit has to change a member of our Home Care Organiser team will give you as much notice as possible of that change.

All Home Carers are issued with photographic identity cards.

For protection we encourage you to request any caller to provide proof of identity before admitting them to your home.


Your visits are monitored electronically either by using your landline to call a specific Free-phone number. The use of your landline is only likely when we use one of our relief carers to support you, where a mobile signal is very poor or non-existent or when a carer’s mobile phone breaks down. The call should only take a few seconds and is completely free. The iConnect system requires carers tagging in and out using their work mobile phon. To enable this you will be asked if tag can be placed discreetly in your home, usually close to the door your carer will enter and leave your home. Both of these confirmation systems ensures that your visit is being provided within the agreed time frame and that it lasts for the length of time that is necessary to deliver your support. It also ensures that no visits are missed.

This system is linked to the billing process to ensure you are charged correctly so it is very important that confirmation of visits recorded accurately.
If you do not have a phone line this should be discussed with your Social Worker/Care Manager or the person who completes your Single Shared Assessment with you.

Gifts and loans

You are requested to refrain from giving gifts or loans in cash or kind to Care at Home staff.

Home Carers are instructed not to accept gifts or loans from people using the service.

If there are any queries regarding gifts and loans, please contact your Social Care Coordinator.

Access to your property

In some circumstances we are aware that our staff will be required to use a key to access your property.

Key safes may be available through the Care and Repair Service and they can be contacted on 01856873369 and will also fit in a convenient location outside your home.

Your privacy is important and carers will only enter those parts of your home for which you give them permission.


You and / or your representative will be asked to sign the necessary documentation to confirm the service you will receive. In signing the various documents it is implicit that you are giving your consent for Orkney Health and Care’s Care at Home Service to provide you with their home care service including, where appropriate, the administration of your medication.

It is very important that your Support Plan folder and your Medication folder are retained safely within your home in order to provide each carer with the information they need to provide you with a consistent quality of service that continues to meet your needs. These folders are your property serving as a point of reference for you and all Home Care staff visiting you.

Health and Safety legislation

Risk Assessment

The Health and Safety Legislation requires that a risk assessment of all work activities be completed to ensure the health and safety of its employees, and the people for whom we provide a service.

Health and Safety Regulations require all Orkney Islands Council employees to report any accidents or incidents they have within their workplace. The workplace in this instance will be your home or property. You will be fully involved in the risk assessment process and the outcome and any actions required will be fully discussed with you. These will be recorded in writing and you will be given a copy of this.

All accidents/incidents will be recorded and we will seek to establish what caused the accident, and more importantly, what will prevent any recurrence of the accident.

We ask that service users assist us where they can; in ensuring that risk assessments and/or investigations are carried out and control measures agreed.


If equipment is needed to help you move or transfer between rooms this should be in place before staff will be able to help you. To use or install equipment it might be necessary to move furniture etc. to allow space for staff to work safely.


The Smoking, Health and Social Care (Scotland) Act 2005 came into effect on 26 March 2006.

To help us protect our employees from the effects of passive smoking we would ask that you do not smoke during the time our employees are present in your home.

In addition, if you know when our employees are due to visit your home, we would ask that you do not smoke one hour before the visit.

Where persistent heavy smoking that may adversely affects the health and wellbeing of staff continues your service provision will be reviewed and may be withdrawn until a resolution is found.

Home Carers will not smoke during their visits.

Pest Control

Where any concerns are raised by our carers regarding infestation of any kind that places your and their safety and wellbeing at risk we ask that you deal appropriately with the issue as soon as you are made aware of it. Should the concerns continue we may withdraw your carers until the issue is resolved.

Force Majeure

The Orkney Health and Care, Care at Home Service shall not be held liable for failure to provide a service due to events or circumstances beyond it’s reasonable control including fire, flood, storms, snow, war, acts of terrorism, labour disputes, compliance with the law etc.

Quality Assurance

Ensuring that you receive services of the highest quality is important to us. Your service will be monitored closely to ensure that you are satisfied that the services you receive continue to meet your needs.

Your Social Care Coordinator will, with your consent, undertake a minimum of one annual visit whilst your Home Carers are supporting you to undertake an observation of their practice to ensure that they are carrying out their tasks appropriately and professionally.

Your Social Care Coordinator will arrange to meet with you twice per year to review how well your support is being provided and to ensure it continues to meet your needs.

If you have any concerns at all about your service the office can be contacted at any time between 07:00 and 22:00.

Each year a confidential Satisfaction Survey will be sent out to randomly selected service users of whom you may be one. A similar survey will also be sent to randomly selected family/friend/carer seeking their comments on the quality of service you are being provided with. All people who use The Care at Home Service as well as those who are family/friend/carer will be informed of the results of the survey and any actions taken as a result of comments/suggestions made.

Regulation and inspection

The Social Care Social Work Improvement Scotland (more commonly known as the Care Inspectorate) is a national organisation set up to regulate and inspect all Scottish Care Services.

The Care Inspectorate will inspect all Care at Home services to make sure that we are meeting the standards and regulations.

You have the right to be involved in the Care Inspectorate inspection process if you wish.

Please discuss this with your Social Care Coordinator if you wish to take up this opportunity.

You are also able to have access to the Service’s most recent Care Inspectorate Inspection Report, and copies can be requested or found on the Care Inspectorate website (available from the 'Related Sites' section of this page.

Comments, complaints and suggestions


We would welcome your comments if your service is going well or you feel you have suggestions that could make improvements to your service. Please see next page for Care at Home Service contact details.


If you have a complaint about any aspect of your service that we have been unable to address or where you or your representative have a complaint but felt unable to contact the service directly, you can make a formal complaint by using the Representations and Complaints Procedure. You should contact:

You also have the right to raise a concern directly with the Care Inspectorate. The address of the local office is:

The Care Inspectorate, East Bank, East Road, Kirkwall, KW15 1LX.

Telephone: 01856870535.

Contacting Us

Home Care Office

Orkney Health and Care, School Place, Kirkwall, Orkney, KW15 1NY.

Telephone 01856873535.

Need more information?

If you would like further information please contact Home Care Support or provide us with your name and address if you would like further information sent to you.


Related Sites

School Place, Kirkwall, Orkney, KW15 1NY

Telephone: 01856 873535

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