Introducing the Care Certificate Evaluation: Innovative practice

Although investment in staff development is a prerequisite for high-quality and innovative care, the training needs of front line care staff involved in direct care have often been neglected, particularly within dementia care provision. The Care Certificate, which was fully launched in England in April 2015, has aimed to redress this neglect by providing a consistent and transferable approach to the training of the front line health and social care workforce. This article describes the early stages of an 18-month evaluation of the Care Certificate and its implementation funded by the Department of Health Policy Research Programme.


Introduction
Health care assistants and social care support workers play an increasingly key role in front line care provision. Not only are they usually the first point of contact for those in receipt of care, delivering around twice as much care as registered nurses, but they also perform many of the complex roles formerly undertaken by these nurses (Unison, 2016). Furthermore, they are growing in number with over 300,000 new workers entering the health and social care support workforce each year (Department of Health, 2013). Due to demographic trends towards an ageing population, these numbers are likely to progressively increase. Thus, the All Party Parliamentary Group (2009) estimates that the number of people in the UK with dementia will reach almost one million by 2021 and that many will be reliant on the support of front line care staff. Policy makers within the UK have responded to these challenges with national strategies such as the National Dementia Strategy, aiming to improve the delivery of good-quality person-centred care (Department of Health, 2009). In spite of these developments, front line practice is still characterised by inconsistency both in terms of the role and identity of care workers (Unison, 2016) and in the common adoption of depersonalised and task-centred approaches to the care they provide (Department of Health, 2013). This 'implementation gap' has often been attributed to inadequacies in the quality and quantity of training for the front line care workforce (All Party Parliamentary Group on Dementia, 2009Dementia, , 2014. In recognition of these inadequacies and precipitated by a public enquiry into care at Mid Staffordshire NHS Foundation Trust (Francis Report, 2013), increased attention has recently been given to the training needs of the front line care workforce by policy makers. This culminated in the Cavendish Review (Department of Health, 2013) which found that care staff often lacked clarity in their role and felt undervalued and underutilised with negative implications for the care they provided. The review called for the introduction of a Certificate of Fundamental Care -now called the 'Care Certificate' and recommended that all new health care assistants and social care support workers should achieve the Care Certificate before working unsupervised. The Care Certificate, which was piloted over 29 sites during 2014 (Allan, Thompson, Filsak, & Ellis, 2014), sets out 15 fundamental skills, knowledge and behaviours that are required to provide safe, effective and compassionate care (see Box 1). As such, it aims to provide a consistent approach to staff training and induction, improvee the quality of care provided and promote better training provision and career development pathways within care organisations.
Although not mandatory, as from April 2015, it is now expected to form part of training for new recruits to care organisations in England with the Prime Minister's challenge on dementia suggesting that all newly appointed care staff should undertake this training (Department of Health, 2015). On average, this training should take 12 weeks to complete and cover 15 fundamental topics in health and social care (Allan et al., 2014). However, since its implementation, a number of issues have emerged which were not addressed in the pilot study. For instance, the extent of variation in the implementation of the Care Certificate, potential barriers and incentives to implementation, how delivery methods differ and how possession of the Care Certificate, which should be transferable between employers, affects staff mobility. It is the purpose of an ongoing project called 'Evaluating the Care Certificate: a cross sector solution to assure fundamental skills in caring' (ECCert), which is funded by the Department of Health Policy Research Programme, to address these and other questions and to assess how successfully this training innovation meets its objectives.

Evaluation methodology
The ECCert study takes a two-stage mixed methods approach. Stage 1 consists of a stratified sample of 400 primary and secondary care organisations in England. These organisations have been randomly selected from the Care Quality Commission database and stratified by region (North, Midlands and South) and care setting (health care, social care and domiciliary care). Survey respondents are staff who have responsibility for care staff training or induction. The survey aims to: • Quantify and explore patterns of uptake across different care settings.
• Assess the wider impact on training provision offered by care organisations.
• Develop a taxonomy of approaches to implementation.
In stage 2, subject to ethical approval, case study visits of nine of these care organisations will be conducted in order to gain a more in-depth insight into the implementation and effectiveness of the Care Certificate. Participants interviewed at this stage will include representatives from workforce development and management as well as front line care staff. The aims of this stage are to: • Investigate the experiences of carers who have completed the Care Certificate.
• Evaluate the impact of the Care Certificate on carer practice and patient experience. • Identify the characteristics of successful implementation and explore the barriers and facilitators to its achievement.
Also explored through a series of focus groups will be the views and perspectives of care receivers and unpaid carers on the principles of the Care Certificate and on front line care more generally. Project outputs will include interim and final reports, articles published in peer-reviewed journals and practitioner publications, presentations at national conferences and meetings and leaflets and posters summarising the findings in plain English.

Discussion
The better utilisation of front line care workers can promote high-quality care, create better career pathways and reap savings through increased efficiency (Allan et al., 2014). The Care Certificate and its role in demonstrating a given level of skill and knowledge has been implemented as one route to achieving this goal (Department of Health, 2013, 2015. Nevertheless, although the initial evaluation of 29 Care Certificate pilot sites (Allan et al., 2014) found that its content met with little disagreement, its delivery was left to employers, leading to potential inconsistencies in its implementation. A representative picture of this adoption by providers of adult health and social care is therefore needed in order to understand whether a truly national standard is being achieved and whether the Care Certificate is having the desired effect on the confidence and skills of the workforce. A further challenge for this enquiry is the need to embrace both health and social care workforces, within a mixed market of care and in different settings and contexts. For example, whereas larger and longer established providers are likely to have considerable experience of workforce development and to have existing plans, resources and roles to support this, other organisations may face particular obstacles to adopting the Care Certificate. These issues need to be identified and understood in order to maximise the adoption and impact of the Care Certificate across the whole health and social care workforce.
Also in need of identification are the barriers and facilitators which may be encountered in the process of knowledge utilisation. For even when training is provided it may not go on to impact upon the quality of care provision (McCabe, Davidson, & George, 2007) due to the influence of contextual factors on this process. Thus, staffing levels and the care environment more generally, as well as training, all help to determine the type and quality of care provided by front line staff. For example, high levels of staff turnover (Department of Health, 2013) can 'dilute' levels of skill within care organisations and reduce employer incentives to invest in staff training with subsequent implications for workforce efficiency (Bowers, 2008). It can also prevent care workers from getting to know clients, thus undermining person-centredness and continuity of care. This is particularly an issue for those working with people with dementia who are often unable to fully express their own needs and preferences and is exacerbated by the potential diversity of these needs and the increasing scale of care organisations (Argyle, 2012).

Conclusion
In recognition of shortcomings in front line care provision, relevant policy developments have been recommended or implemented for support staff. One example has been the introduction of the Care Certificate for front line care staff which, since April 2015, has formed a part of the training for new recruits to care organisations in England. Its general aims have been to, not only improve standards of care, but also promote consistency and transferability in the training provided. While the Care Certificate was rigorously piloted prior to its full introduction, a number of questions in need of further investigation have subsequently emerged. It is the purpose of the ongoing study described here to investigate these issues in order to optimise the implementation of the Care Certificate with potentially positive implications for care organisations, care workers and those in receipt of this care.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial supportfor the research, authorship, and/or publication of this article: This study is funded by the Department of Health Policy Research Programme, Project Reference Number PR-R14-0915-12004