Risks and value of the care home market

Torbay Council wishes to influence the size and shape of its residential care home market for older people, desiring an expansion of alternatives to residential care in the future. The remaining care homes will provide more specialist services for people with complex needs and dementia. The project developed a multidimensional analysis to provide a view about the quality and viability of providers required in the future, to inform a market strategy for Torbay. This case study forms part of our productivity experts resource.

Efficiency and income generation

The challenge

Torbay has approximately 50 per cent more older people than the England average. Older people in Torbay are around a third more likely to reside in a care home than for England as a whole. Furthermore, these care homes are smaller, on average, than the rest of England.

Torbay Council (through its NHS partners as part of an integrated care model) currently purchases around 42 per cent of Torbay care homes with nursing capacity and 30 per cent of care homes without nursing capacity. Other local authorities also pay for care home placements in Torbay and Torbay ‘competes’ against these authorities when seeking placements. In addition care home places are purchased by individuals funding themselves. Nursing home provision is slightly below the England average. The area, also known as the English Riviera, is considered an attractive place for older people to retire to, partly accounting for the relatively high proportion of older people resident in the area, as well as in the residential care home population.

As part of a well-established model of integrated care Torbay, in common with national policy and sector trends, is developing alternatives to bed-based care including: developing housing for later life; more resilient community and voluntary support networks; an enabling approach to formal homecare; and assistive technology. It is anticipated this will lead to reduced reliance on residential care homes. There are a number of initiatives in place or being developed to support this shift (see section below on How the new approach is being sustained).

Torbay Council considers that the needs of a significant proportion of those people currently residing in a care home could have potentially been met through other community-based services. It is looking to expand alternatives to care homes with nursing such as all age extra care schemes, supported living, shared lives, specialist domiciliary care, aids, adaptations and assistive technology, as well as an expansion of floating support. Consequently the number of care home beds required in Torbay in future may fall as these alternative options are developed and/or expanded. It is of course recognised that some people may still wish to privately purchase care home beds, nonetheless alternatives should be available to all of the older people population.

Torbay’s strategic vision is the care homes of the future that cater to older people in Torbay will be more likely to provide nursing care than at present. There will be fewer care homes without nursing and those remaining will provide specialist services for people with complex needs and dementia. These homes will ideally be able to house at least 50 people to ensure financial sustainability and be rated good or outstanding by CQC. People under 65 will only be placed in care homes without nursing in exceptional circumstances.

Of the nearly 90 care homes that operate in Torbay, 60 primarily support older people (46 residential and 14 nursing). The remaining homes specialise in providing support to people with learning disabilities or mental health conditions (which can of course include older people as well). Unsurprisingly given the small size of the typical care home in Torbay, there are few large providers operating in the area. 44 homes (50 per cent), are independently owned, single-site businesses. A further 17 (20 per cent), are part of a ‘group’ with four or less homes. Only four homes (5 per cent) are part of a business with 20 or more sites. Many of the care homes are not purpose built and have premises that may not be suitable for development in the future.

The solution

With Torbay staff, the Institute of Public Care (IPC) drew up a long list of factors that had the potential to influence the quality, stability, value and general health of care homes. In looking at the care home market we were mindful of not only homes that are delivering a good service now, but also how viable they are over the next period of time. There are a wide range of factors that influence the quality and viability of care homes, examples of which are given in the table below. There is also an interplay between these factors.

Factors that influence viability of homes

  • size
  • number of self-funders
  • occupancy levels
  • staffing
  • levels of debt
  • requirement to make a profit
  • cost of building maintenance
  • factors that influence the quality of homes

Factors that influence quality of homes

  • manager and staff training
  • understanding of role/culture
  • turnover
  • organisational ethos and the individualisation of care
  • premises
  • price.

Factors that influence the viability and quality of homes are not always easy to measure. For example, whilst the culture and leadership of staff in a care home is key to the quality of the service there is no simple way to measure this. Likewise different care home providers can work to very different business models. The long list was reduced to a shorter list influenced by likely:

  • insight that could be gained e.g. some measures are more useful than others
  • cost/benefit of resource to collect
  • availability of data e.g. from NHS partners, CQC, etc. that are a mixture of performance, financial, staffing and quality measures.

The impact

The analysis has enabled us to look at where current provision is weakest and strongest, and therefore where to focus our efforts. The project brought clarity and focus to the further development of our model of integrated care, as well as a deeper understanding of the current complexity of the market and the challenges faced (see also section below on Lessons learned).

How the new approach is being sustained

The Productivity Expert’s work is closely linked to the ongoing development of alternative provision and crucially, conversations with all providers. Further work is required to improve demand modelling and projections in order to determine to what extent current care home provision will meet anticipated demand and aspirations. The work indicated some of the changes required within the care home market including, the need for a smaller number of sustainable homes with specialist provision for people with more complex needs such as, those on ventilators, people with dementia and brain injury, as well as changes to the built environment and the types of skills and standards that may need to be developed.

The initial findings from the work with IPC were presented to Torbay care homes in November 2018 (via a face-to-face event and subsequent cascade of information). The feedback from this engagement event was useful in informing the development of the draft strategy, ‘Integrated Care – The Shape of Adult Social Care in Torbay 2019-2029.’ This strategy, together with our Market Position Statement, is intended to stimulate partnership and delivery with the independent sector, to achieve the market change required to deliver the vision for resilient adult care and support in Torbay. This draft document has been shared with all care homes in Torbay and we plan to engage all local health and social care providers in developing it over the coming months.

In undertaking the work with IPC and the market engagement with care homes, a number of parallel or follow-on projects/activities have taken place or are planned for the future. Some examples of these are summarised below.

A Torbay Care Charter has been developed by people living in care homes. Facilitated by local artists they developed a set of principles that were important to them e.g. purpose and meaning; community and belonging; health and wellbeing; and respect. These principles are what we would expect good care homes to be supporting their residents to achieve.

The Care Homes Leadership Programme aims to build on the successes of the charter project by bringing creative practitioners together with care home staff, to deliver inspirational professional leadership development.

We have identified just over £1million investment as a transformation fund for care homes to support the change in the market to meet shifting demand. We are therefore, inviting expressions of interest for funding from homes willing to work together in close partnership to meet the specialist needs of people with dementia, making best use of skills, buildings and other resources.

Creation of a Torbay Care Homes Partnership Board to: strengthen partnerships, joint working and information sharing between commissioners and providers; develop a shared understanding of the challenges (current and future) faced by the Torbay care homes market and address these together with innovative solutions; care homes providers are able to influence future commissioning direction and co-produce models of care (both within care homes and other settings); and ultimately improve health and wellbeing outcomes for residents and staff.

Working with Devon County Council on their Risk and Sufficiency Tool, as part of wider engagement with LGA/ADASS around their emerging Markets and Modelling Project.

An expansion of the Quality Assurance and Improvement Team and the Care Homes Education and Support Team to assist care homes in implementing improvement plans and to work with care homes to develop staff skills in positive behaviour management and working with people with dementia.

We have also developed a new care home fees model for clients over 65 and are exploring options for our approach to under 65 clients.

Lessons learned

Collection and use of data

Local authorities face an ongoing question of how best to use data to inform decision making. The project made us question whether all the data reports that are generated within the authority (or its NHS partners) are necessary, and what it is that we should be analysing on a regular basis or less frequently. If our staff are responding to a high volume of ‘ad hoc’ data queries, is that information that we should be looking at more regularly? Do we have the skills and the time to look properly at what we do have and use it to inform our thinking and planning?

Software systems are not always configured to enable reporting at provider level, posing challenges when seeking to better understand the wider market. Following the work undertaken by the IPC and ourselves, we have identified improved reporting procedures such that commissioners now have a better understanding of detailed parts of the market. So whilst the overall numbers of clients were known, the detailed and improved analysis has provided information on where there is apparent growth in service demands, which had not been previously identified. Work is now being undertaken that will identify reasons as to why this growth has taken place, and the analysis should result in improved services and future reductions in expenditure.

Furthermore, no common provider identifier is used (e.g. CQC’s location ID) making it time consuming to, for example, cross reference performance monitoring data with finance data. Despite some challenges in collecting the data in Torbay, IPC regards arrangements and current practice in Torbay as being relatively good. For example, the CHRIS system, built by Torbay staff at relatively low cost, that provides an overview of vacancies, placements and other core information by care home.

Conducting the analysis also revealed valuable lessons about the data that the authority captures. Like most LAs we collect the information required by government, we have our financial and placement data and we have a series of one-off responses to queries. However, this does not always give us the full performance and quality information we require to make policy changes. It also illustrated to us the need to bring health and social care data together (as part of our integrated care system), if we are to judge the ability of homes to promote well-being.

Savings

The IPC work has helped inform our ongoing interactions with care homes.

Whilst the original submission for the grant LGA funding identified current placements being 80 per cent at banded rates, 2018/19 saw a significant fall in this percentage largely due to the homes not always accepting our fees. In addition, some instability in our domiciliary care market during this period, with some care packages being transferred between home care providers, meant that more clients were placed in residential care than was originally planned, impacting on anticipated savings.

However, during the year our NHS partner has been able to work with care homes to achieve anticipated savings from costs, which it would otherwise have had to incur.

Firstly, working with the Over 65 care home market, a new funding model has been developed and agreed that will improve the sector’s financial base, but at the same time ensure more clients are placed on banded rates rather than “ad-hoc”, more expensive rates. As part of the planning process following the exercise to re-establish a fees model for residential and nursing care home placements, it was recognised (as noted above) that the percentage of clients on banded fees had fallen below the 80 per cent level. It was recognised that setting a target of achieving 85 per cent of clients on banded fees would result in a breakeven position (after allowing for clients who fell below the banding fee). Furthermore, by setting a challenging but achievable target of 90 per cent of clients in banded fees, this would result in savings of £100k per annum initially and would rise as more people were accepted on banded fees. The 85 per cent target has been set for 2019/20 and the 90 per cent target will be set for 2020/21.

Following the work on over 65s, we are now turning our attention to under 65 care fees and placements, to develop better funding models in this segment of our market.

Secondly, we worked with one large home dealing with specialist care clients and through financial analysis and support was able to put the home on a more stable footing. It is estimated that this will save the NHS Trust approximately £0.2m, compared to if the clients had been placed in other homes out of area. Similarly, working with a supported living/residential home the NHS Trust was able to get the business on a sounder financial basis going forward and ensure that the home will be able to keep clients in the locality, rather than have to move them away to secure but remote accommodation also out of area.

Thirdly, working with another care home provider, we have been able to support the company such that it has been able to reduce its running costs by some £10k per month, providing a more stable foundation for future growth.

The IPC analysis also reinforced the need for us to produce and implement a business case for the development of further extra care housing. If approved, this will result in more placements into extra care housing as opposed to residential care, with reduced ongoing costs to our health and care system and improved quality of life for individuals. A new extra care scheme of 78 units (when completed in 2022) could offer potential savings of £600k per annum (when compared to placements into residential care).

Longer term, further savings will accrue as our NHS integrated care trust is able to use the information gained to address market issues. It is anticipated that the trust will be able to work further with homes to offer alternative care to reduce cost pressures. Some of these savings will not emerge in the short-term and it is anticipated aspects of these will come through in 2021/22.

Wider questions about our health and care system

This work has generated questions about the wider health and social care environment in Torbay, and the factors that influence demand for health and social care services. For example:

  • Are care homes responding in the best way to incidents and emergencies?
  • Do all care homes, particularly residential care homes, have sufficient and equal access to local health professionals?
  • Are individuals being discharged from hospital at the right time and with sufficient support on their return to the care home?

The suitability of current care home premises/configuration in the future is a major factor when looking at the future viability of our current provision.

There is significant variability in the needs profile of residents in otherwise comparable homes. For example, some homes have a mix of nursing, residential and intermediate care clients. Likewise some clients in residential care homes could be in nursing homes but they are not classified as such. Our reflection on this is that there may be a gap in the market for clients with complex social care and nursing needs who can be too complex for residential care homes, but are not considered sufficiently severe for nursing care homes (and associated funding).

The effect of a care home on an individual’s wellbeing can only begin to be understood if a full view of that individual’s needs, abilities and potential is captured on entry (rehabilitative/strengths-based approach). Whilst metrics are relatively well developed to understand the impact of domiciliary care for individuals, a more fatalistic view is often taken for those entering care homes. Therefore, whilst we believe that the development of alternatives to care home placements is vital and their performance well measured, we also need to ensure that care homes do not simply become ‘care repositories.’ If we believe that care homes can work in a strengths-based way and offer a positive quality of life for residents, then we need to further develop our thinking on how we can evidence (and incentivise) this.