The Kingsmill Review: Taking Care

Regulation Social Care Staffing

Summary and recommendations of the independent report into working conditions in the Care Sector By Baroness Denise Kingsmill CBE.

Care matters. People receiving care need support to live comfortably and independently. Older and disabled people might need extra help to prepare meals and bathe, they might need a prompt to take vital medication, and they might need support with conditions such as Dementia and Alzheimer’s.

Care Work is in crisis. People who may be vulnerable are not being treated with the care and attention they deserve. All too often, their only source of support, Care Workers, are exhausted, unable to plan their own lives through insecure contracts, and unable to spend enough quality time with the person in receipt of care.

The role that Care plays in our society is vital. Care Workers deliver the support needed to people nearing the end of their lives, to disabled people, and to people with chronic illnesses. It enables them to live comfortably and in a dignified way. Care Workers need to be treated properly so that they can treat Care Recipients Users properly.

All too often during the course of this review, I’ve heard the words ‘I’m just a Care Worker’. How unfair it sounds. Care Workers often have to deal with complex feeding methods, use hoists for moving clients, dress wounds, administer medication, and provide vital emotional and domestic support for Care Recipients. It’s not a job for the faint-hearted and it’s certainly not ‘just a job’.

Care Workers are under-valued, under-paid and under-trained. They don’t have the status of Nurses.  They don’t have the status of Child-Minders. The sector is subject to weak regulation. We don’t know who they are, we don’t know what qualifications they hold and they are not registered with any professional body. This workforce of 1.8 million people in England is almost invisible.

The working conditions of Care Workers are among the worst of any in England. Their wages tend to be either National Minimum Wage or no more than 15% above that minimum. Frequently, even the National Minimum
Wage is ignored, with employers unlawfully refusing to pay Domiciliary Workers for the time to travel in between their clients. Many Care Workers don’t even know what hours they’ll be working from week to week – exploitative ‘Zero Hours Contracts’ play a huge role in the sector and destabilise workers’ lives.

Qualifications are patchy. The Care Quality Commission’s oversight of workforce issues is weak and the provision of training and education relies on a fragmented independent sector. Training varies considerably, with no real enforcement of a common framework for Care Workers. The workforce tends to be older women or migrant workers, who have few other employment options. Younger people are reluctant to enter the industry, as there is no career

The low status of Care Work and poor treatment of workers has led to a vicious downward spiral into one of the most difficult sectors for workers, with widespread exploitation. Turnover rates range from 20% to 30% per annum, a sign of difficult conditions and instability in the sector.

In this review we hope to highlight the low pay, poor status, inconsistent training, and weak regulation in the sector, the reasons for these conditions, and what can practically be achieved to improve standards for Care Workers. This is worthwhile and important work – too many caring and compassionate people are being forced out of the sector because of low wages, bad contracts, and a lack of training. We want real change for Care Workers.

When Care goes wrong, it can go badly wrong. The serious case of poor care and neglect last year at Orchid View shows that we need to value Care in the same way that we value Health. Workers need to be properly treated, trained and regulated.

Care for elderly and disabled people is a major issue for the mid-21st Century. We are all likely to live longer and a large number of us will require care in our final years. We would all wish to be cared for by staff who are valued, qualified, committed and treated properly by their employers and the State. The public purse, however, is tight – and increases in taxation are deeply unpopular.

As a result, the recommendations in this review fall into two categories: immediate changes that could be implemented within existing budget constraints, and long-term objectives that will require investment and extra funding. The most likely source of these additional monies would be the integration of the Health and Social Care budgets. Improving conditions for Care Workers and Care Recipients is a journey: we need to act now, but we need long-term change and to truly value Care as essential to the wellbeing of some of the most vulnerable people in society.


Care Workers carry out some of the most important work in society, caring for the sick, elderly and the disabled. Yet the Care Sector is in crisis. As well as the work being physically and emotionally demanding and often undertaken in
unsocial hours, there is evidence of widespread exploitation of workers. For example:

  • Studies suggest that between 160,000 and 220,000 Care Workers are unlawfully paid less than the National Minimum Wage. ( Hussein, S., Estimating Probabilities and Numbers of Direct Care Workers Paid under the National Minimum Wage in the UK: A Bayesian Approach, Social Care Workforce Periodical, issue 16 (December
    2011))  A HMRC investigation into 80 Care Providers found that almost half (47%) were not compliant with National Minimum Wage regulations
  • An estimated 307,000 Care Workers, or a fifth of the Adult Social Care Workforce, are on‘Zero Hours Contracts’, meaning they do not have stable hours each week or a stable income.
  • A fifth of Health and Social Care Apprentices receive no training at all. Nearly a third of Care Workers receive no regular ongoing training.
  • Over 41% of Care Workers do not receive specialised training to help deal with their client’s specific medical needs, such as dementia and stroke-related conditions

Exploitative working conditions for Care Workers mean that there is a risk that they will only be able to deliver a rushed, poor quality service. The pressure that 15 minute care slots places on them means they are unable to give the human interaction that Care Recipients desperately need. Excessive time pressures and low levels of training lead to mistakes and, in a minority of regrettable cases, abuse. Meanwhile low pay and exploitative working practices make it harder to attract, motivate or retain the workforce: turnover is 19% a year in Residential Care and 30% in Domiciliary Care, and a third of staff that leave do so within 12 months. The sector also struggles to attract young people: nearly half (45.6%) of employees are aged 46 or older.

These conditions make it difficult to attract ambitious and compassionate young people to the sector and have created a high dependence on low skilled, female and migrant workers who are particularly vulnerable to exploitation, due to their limited employment options.

In September 2013, Ed Miliband asked me to conduct a review into exploitation in the Care Sector. I was asked to examine what could be done to tackle exploitative working practices, and so improve the quality of care, within the existing care budget.

At the root of the immediate crisis is a crisis in funding, particularly since the deep cuts Local Authorities have had to absorb since 2010 and the context of increasing demand due to an ageing society. We have included long-term  objectives which  will require greater funding for the Care Sector. If we truly valued Care and Care Workers, we would help older and disabled people to reduce the need for potentially distressing hospital admissions.

However not all of the changes required in Care are about funding. We have evidence of a weak and fragmented regulatory environment, irresponsible procurement practices by Local Authorities, and poor workforce planning and management skills within Care Providers. The recommendations set out here focus on these issues, which could be addressed at little or no cost. Improvements could be possible in the sector through safeguards to support both
employers and employees to better coordinate and protect them from an unsustainable race to the bottom in wages and skills.

Policy recommendations

1. Introduce a Licence to Practice for Care Managers

  •  Care Workers need a stronger voice and greater status. The people who perform this essential task must receive fair compensation, reward and training for their efforts, and have their rights protected. Registration and legal training requirements for Care Workers are effective ways to raise standards in care and protect user rights. As a first step, Care Managers must be registered and have a Licence to Practice with a requirement to have a Level 5 Diploma in Leadership for Health and Social Care.
  • The Health and Care Professions Council (HCPC) currently operates a licensing system for Social Workers and a number of other professions. The licensing system includes Standards of Proficiency and a commitment to continuous professional development. We recommend the remit of the HCPC should be extended to Care Workers to protect them from exploitation. We believe that, eventually, all Care Workers should be registered and have a Licence to Practice. Care Workers are paid from the public purse; we need to know who they are and that they are properlyqualified. The Care Quality Commission (CQC) should have the power to prosecute providers who employ Care Managers/Workers without a licence.

2. Enforce the National Minimum Wage

  • The National Minimum Wage (NMW) must be a floor, not a ceiling. The CQC should  be required to monitor evidence of non-payment of the NMW. It should have an absolute requirement to refer cases where workers arebeing paid less than the legal minimum to the HMRC for investigation. The law should be changed to enable better information-sharing and joint-working between the HMRC and the CQC, as well as other relevant authorities.HMRC should be required to take a more proactive approach to enforcing the NMW.
  • Local Authorities must be required to perform due diligence to ensure that Care Workers are not being paid less than the National Minimum Wage. If evidence is found of nonpayment of the NMW and Local Authorities are found not to have performed appropriate due diligence, they would be jointly-liable.

3. Ban exploitative ‘Zero Hours Contracts’

  • An estimated 307,000 Care Workers are on ‘Zero Hours Contracts’. Many are on a compulsory basis and in some cases they are prevented from working for other employers. An independent review for the Labour Party recently set out new legal rights for employees on Zero Hours Contracts to ban employers from being able to force them to be available at all hours, insist they cannot work for anyone else, or cancel shifts at short notice without compensation. It also called for employees on ‘Zero Hours Contracts’ to be able to demand a fixed hours contract when they have worked regular hours over six months with the same employer, and to receive a fixed hours contract automatically when they have worked regular hours over a year – unless they decide to opt out.
  • If employers require a worker to be available for work but with no guarantee of providing work, I recommend that they should have to pay for this standby time. Good working relationships require reciprocity. Standby Contracts allow flexibility for employers and certainty for workers. This would remedy the uncertainty of ‘Zero Hours Contracts’ for workers, allowing them to plan and budget with a Standby Contract.

4. End 15 minute Care slots and introduce a Care Charter

  • The CQC should set standards for Local Authority procurement processes through a new Care Charter. This would ensure that commissioners drive best practice and hold Care Providers to the conditions they must meet to secure a contract. The goal should be to ensure that irresponsible procurement practices do not put pressure on providers to exploit workers and break the law. The CQC should be made responsible for ensuring that Local Authorities follow the principles of the Care Charter. Above all, this must include an end to 15 minute slots, which are associated with non-payment of the minimum wage and poor quality of care.

5. Improve training standards and progression

  • The Care Sector is suffering from weak and inconsistent training. Young people are not attracted to the industry, which is a concern for recruiting the next generation of Care Workers. The average age for a new starter is 35 years old. Skills for Care sets training standards for the Care Sector but adherence to these standards is voluntary and employers in the Care Sector lack the tools to ensure a level playing field. To tackle this problem Skills for Care should be reformed to strengthen the representation of employers and employees on its board. It should be given an explicit remit to tackle poor standards and raise levels of training, and particularly apprenticeships, in the sector.
  • A more strategic approach to skills funding would enable the sector to meet the new training standards within existing budgets.Labour has pledged to offer a ‘something-for something deal’ to employers. (The Labour Party, A revolution in apprenticeships: a something-for-something deal with employers (Labour’s Policy Review, 2013))  This will give employers, working collectively at sector level, more control over skills standards and the £1.5 billion apprenticeship budget, and in return ask that they work to increase the number of high quality apprenticeships in their sectors and supply chains. Skills for Care should negotiate with central government for more high quality apprentices in the Care Sector. The organisation should also look to:
    • Set a common training levy for employers to pool money that they each spend individually on care and give workers consistent training
    • Use the extra funding to invest in Group Training Associations in each area,providing tailored and high quality training provision for Care Providers
    • Licence training providers and identify poor training providers in the sector
    • Create example models for career progression from Care Worker to manager, with links to qualifications and pay

6. Improve oversight and regulation of working conditions

  • Oversight and enforcement of Care Providers needs to be improved to tackle exploitative work practices. The Care Quality Commission(CQC) is responsible for the regulation of all Health and Adult Social Care Providers in the UK. The CQC currently inspects most Care Homes and Domiciliary Care services at least once a year, and has the power to enter premises and remove records (The CQC was given these powers under sections 62 and 63 of the Health and Social Care 2008). This puts the CQC in a strong position to identify and monitor exploitation of Care Workers. Poor working conditions often go hand in hand with poor quality of care and abuse of Care Recipients. The remit of the CQC should be extended to protect Care Workers from exploitation, as well as their existing remit to ensure providers meet appropriate standards for care users.

A long term view for the sector

The ultimate objective is the professionalization of  Care Work. We believe that long-term changes in the  sector are needed to improve the status of Care  Workers, create opportunities for pay and  progression, and raise standards across the sector.  Some of these would involve financial investment,  and are therefore dependent on improvements in the  current funding situation.

Tackle low wages

  • Local Authorities should use the tendering of procurement contracts to encourage employers to pay the Living Wage. The experiences of  Southwark and Islington Council show that this can be done by reducing waste elsewhere, at no extra cost to central government.

A Licence to Practice for all Care Workers

  • All Care Workers should be registered and required to hold a Licence to Practice – with a particular focus on those contracted through personal budgets given the low levels of oversight of these workers. The register and Licence would be maintained by the HCPC; its role would also include sharing knowledge, promoting the status of Care Workers and protecting the public from unqualified workers. This should be completed within five years.

Create opportunities for progression

  • We believe the Care Workforce need to be more professionalised. In order to achieve this,significant improvements will be needed in the registration and training of Care Workers, with progression opportunities that are linked to qualifications and pay. National Minimum Training Standards and QCF Level 2 Diploma should be made compulsory for all Care Workers.
  • Skills for Care should develop higher-level apprenticeships linked to QCF levels 7 and 8, and Care Workers should be able to fast track into a specialist role or degree study, such as Nursing.

The full report is on the Your Britain website.