Can the Care Sector meet fast-rising demand
More care homes are needed to meet demand. But can the care sector cope?
People are living longer than ever before. And that’s a good thing – but it also means that more care homes are needed to cater for a rising ageing population.
There are around 16,700 care homes in the UK, around 70 per cent of them residential, according to Care Home UK, with nearly half a million people living in them.
The job of overseeing the sector has, since 2009, fallen to the Care Quality Commission (CQC), established by government to regulate and inspect health and social care providers in England.
But this regulatory body is itself in trouble. In May the government said it would undertake a review of operational effectiveness of the CQC. And when even the staff don’t rate the organisation they work for, and the CEO steps down suddenly, you know things need to change.
The effectiveness of the CQC was a major talking point at The Business Magazine’s roundtable on the care sector held at law firm Herrington Carmichael’s Farnborough offices.
ROUNDTABLE PARTICIPANTS
Moderator: Nicky Godding, Editor, The Business Magazine
- Graeme Black, Partner in the Private Wealth and Inheritance Team at Herrington Carmichael
- Mark Chapman, Partner in the Commercial Regulatory team at Herrington Carmichael
- Jane Connery, founder and director, Care Campaign for the Vulnerable (CCFTV)
- Katrina Douglas, CEO, Oxlabs
- Liz Hailey, Partner and Head of Real Estate at Herrington Carmichael
- Richard Henshaw, Head of Healthcare for alternative lender ThinCats
- Matthew Lea, Partner specialising in technology and healthcare at Herrington Carmichael
- Melissa McGee, Managing Director of architecture practice Carless + Adams
- Brijesh Patel, Managing Director for care home operator DMP Healthcare
- Paul Robinson, Corporate Director, Metro Bank
- Usof Shah, Senior Solicitor in the immigration team at Herrington Carmichael
- Ravi Sodha, Director at care home operator ACI Care
In November 2023 the CQC began to roll out the Single Assessment Framework to help simplify and improve the care home assessment process.
Mark Chapman, Partner in the Commercial Regulatory team at Herrington Carmichael, said: “Staff feedback in a CQC survey from earlier this year, didn’t make for positive reading.
“It’s not achieving what it set out to achieve. Among other things, care home operators are concerned that new ratings are affected by poor scores carried over from previous inspections which don’t fairly reflect improvements made. What really needs to happen is that CQC reviews should be more frequent.
“The feedback I get from the sector is that there are fewer on-site visits.”
Ravi Sodha, director at ACI Care which owns and operates four care homes across the South Coast and Midlands, expressed his frustration.
“The CQC seems to be in a constant state of reorganisation,” he said. “The Single Assessment Framework was supposed to be quick and nimble, but a home can wait years for a reassessment. And there will be homes that are no longer adequate but are still rated ‘good’ or ‘outstanding’ because they were when inspected years ago. And some which are still rated ‘inadequate’ or ‘requires improvement’ have received major improvements and must wait 12-24 months to receive a CQC visit to upgrade their rating.”
A positive CQC assessment gives confidence to residents, their families and care home staff who feel a sense of pride in their place of work.
Brijesh Patel, Managing Director for DMP Healthcare, which operates 10 care homes in and around London, said: “A poor rating affects morale and the care home’s reputation. And there are further ramifications. It can impact on the ability of a care home operator to raise finance to make further improvements or expand.
“We’re a relatively large care home group and can absorb the cost of improvements, but for small operators who may only have one or two care homes, it can be a big issue because having invested in improvements, without an updated CQC rating they could struggle to attract private fee-payers and have to rely on local authorities to keep up occupancy levels.”
Jane Connery is founder and director for Care Campaign for the Vulnerable (CCFTV), which supports families and care home residents – particularly those with dementia. “The CQC’s outdated ratings don’t always reflect the day-to-day running of a care service,” she said. “I’ve visited ones with an outstanding rating but have safeguarding issues, and ones which the CQC have previously said require improvement but are well run. The CQC is reactive, not proactive as it should be.”
Richard Henshaw, Head of Healthcare for alternative lender ThinCats said that lenders into the sector are well aware of CQC shortcomings. “I have to judge the competency of the operator, and part of that judgement will be based on a home’s ratings.
“If I’m looking at a transaction on a home that was last inspected in 2019 which then required improvement, how can I assess it? If it’s full and the local authority don’t have a problem with it, then we take that into account.”
Brijesh added: “Our local authorities visit regularly and are probably better at regulating care operators than the regulators themselves, because they’re part of the local community and know whether a care home is good or not.”
Using technology to keep older people at home safely for longer
Care homes aren’t the only solution for our ageing population. Many people want to remain in their homes, but can this be done safely?
Yes, says Katrina Douglas, CEO of Oxlabs which is developing an in-home monitoring system to safeguard the wellbeing of the elderly, enabling them to stay in their homes for longer. But what are the ethical and privacy issues around using technology to monitor people in their homes?
“Our product, “habita™”, sits in the home and monitors the environment for a period of a few weeks, including heat, light, sound, movement and so on. It essentially learns the habits of the individual and their environment and can give two alerts – emergency and wellbeing,” she explained. “If anything has changed – maybe no movement has been detected for a while, or the temperature’s changed, the family are alerted and can check in.
“We are totally transparent about what data we collect, how and where it’s used and stored so that it remains private. The data we collect is completely anonymised and cannot be attributed to any individual. We compress and encrypt all data on the habitaHub before transmitting it to the cloud for processing.”
This 24/7 monitoring could be seen as controversial, but Katrina points out that habita™ does not use cameras. It uses AI to learn and build a profile of the user’s daily activity and lifestyle.
However, such individual monitoring can’t be done in a care home. Working on behalf of vulnerable adults in homes, Jane does see the need for video monitoring – from bitter personal experience.
“My mother had dementia and was abused in a care home, so this is a personal journey for me. It’s not just about installing a camera, but about working with experts. We partner with Care Protect, a safety and monitoring company that uses cameras which support care providers to help deliver consistent high-quality health and social care.
“It’s not a spying tool, it’s there to support carers as well as residents.”
Graeme Black, Partner in the Private Wealth and Inheritance Team at Herrington Carmichael agreed that video monitoring works for both parties. “Video monitoring can help families monitor the care their relative is receiving. It also gives carers comfort and protects them because there can be abuse from residents to staff.
“I also look at social services reports on a care home on behalf of clients which often gives more up to date and relevant information than an CQC report.”
Brijesh has been using CCTV in his homes for more than a decade. “The staff know it’s there and feel comfortable with it. More recently the CQC has instigated a formal process that a care home must follow before it can be installed, and that’s probably a good thing.
The challenges of staffing a care home
Attracting good quality care home staff has long been a challenge for operators. And things got more complicated after Brexit. Since March this year only employers registered with the CQC can sponsor care workers in England, who can no longer bring their dependents with them.
Usof Shah is a Senior Solicitor at Herrington Carmichael working with the immigration team.
He said: “This presents a significant challenge for care operators, who depend heavily on migrant workers to fill many of these roles. They now face the dual challenges of increased salary demands to qualify for skilled worker visas and the need to persuade migrant workers to relocate to the UK without their dependents.”
Interestingly, some care homes have found other solutions to their staffing problems. Brijesh and Ravi both highlighted the fact that some people furloughed during Covid moved to work in the care sector, and some nurses who felt burned out in the NHS have pivoted to working in nursing homes. The pay can be better and the hours not so long.
Lower UK job growth is also likely to benefit the care sector. “With fewer jobs available, there will always be jobs in care,” added Ravi. “And it’s not just in a front-line work. There are many other jobs in this sector – management, housekeeping, working as a chef.”
Brijesh added: “Where we used to really struggle to recruit good quality chefs, with so many pubs and restaurants closing, it’s got easier. And from a chef’s point of view, they enjoy much better hours, giving them an improved work/life balance.”
There are good career opportunities for those who want to seize them, added Ravi.
“We are happy to sponsor workers from overseas and some of them are exceptional. For example, in my experience Filipinos in particular are hardworking and really, really want to deliver good quality of care.”
Jayne agreed the importance of employing quality staff: “My worry is that care homes need to use a reputable agency.”
Brijesh added: “We’re now recruiting small clusters of people, three or four at a time, so that we can support them with accommodation, travel needs and integration in the first months after their arrival.”
Usof warned that care homes must ensure compliance with their licence when recruiting overseas workers. “With the Home Office making more visits to care homes, it’s important they maintain a high level of compliance because licences can be revoked. This would impact a care home’s ability to sponsor migrant workers and potentially lead to the curtailment of existing sponsored workers’ visas,” he said.
Can technology reduce costs and free up more frontline nursing staff?
Herrington Carmichael’s Matthew Lea considered whether deploying tech monitoring equipment could safely reduce a care home’s running costs.
“With running costs high, should care homes be looking at rolling out technology which could free up nurses and care home staff to spend more time interacting with residents? I have worked with care homes which have adopted some diagnostic technologies. These can be safely used by a senior healthcare assistant rather than a nurse, who can then work elsewhere in the home.”
Ravi warned that the CQC might not allow this. “They are often fixated on numbers of people rather than need. The other issue is the investment cost needed to buy and roll out the right technology, which many care homes don’t have.”
Melissa McGee is Managing Director of Carless + Adams, an architectural practice that solely specialises in the design of care homes, dementia care homes and integrated retirement communities. She warned about taking the human element out of caring.
“Technology shouldn’t replace people. Yes, it can be more efficient – for example, self-scanning is more efficient in supermarkets, but some shoppers will always choose to chat with the person in the kiosk.
“There are some parts of care that can be improved by using the right technology which prioritises people’s dignity and wellbeing. For instance, there’s software that can detect someone getting out of bed a minute before they wake. It’s about being proactive, not reactive. Fundamentally care is a distress purchase. Our biggest battle is to switch that and make it a positive choice so that someone can continue to live the life they want with the right support around them, whether that’s human or technology.”
Old buildings and the need to build more care homes
Many care homes are in old buildings, which have been adapted with varying degrees of success.
Half of the bedrooms in current care home stock don’t have wet rooms or even a sink. But the CQC has a problem – if it closes a home down then there’s nowhere for the residents to go.
Melissa said: “Last year the government was striving for 50,000 new care beds. The sector was only able to deliver 8,000.”
Liz Hailey, Partner and Head of Real Estate at Herrington Carmichael, said the UK has the oldest stock of care homes in Europe, and the government has no real solution to that.
“Last September the government indicated that it would withdraw the requirements for some of the energy improvements it had demanded, but this will only be a temporary fix. Older people are rightly more demanding than they used to be and expect good facilities.”
There is funding for new care homes, but it comes at a cost to residents. To make a new care home financially viable, operators may face doubling the fees – which will then make it out of reach of many but the most wealthy.
Paul Robinson, Corporate Director in Metro Bank’s Healthcare Division, said: “We are funding new care homes. These tend to be being built by existing operators adding more to their portfolios. As a lender, we look at the debt serviceability from their existing homes while they are building a new one. And yes, it is a challenge.”
Ultimately, for all roundtable participants, successful later life living is about choice.
Melissa added: “Regardless of wealth, everyone should have a choice in whatever they do, and that includes care. There is great luxury care, and the local authorities will support those on minimum income. But, at the moment, the middle market for care homes just isn’t catered for.”
Developers want to build where the private money is, where land is expensive and construction workers more difficult to find.
Ravi said: “I know some people who’ve bought land and secured planning for a care home but can’t get anyone to build it because it’s too expensive.”
Liz added: “And it can take so long to get planning permission that in the intervening period local demand changes and a developer will apply for change of use to build residential.”
Richard concurred with this: “Few lenders will look at small elderly care homes anymore, because there’s just no margin of safety. One of our considerations is of longevity of asset – will the asset still be there in 20 years when the loan ends.”
Matthew added: “These are private businesses and if an asset can’t be funded, it won’t be bought or built.”
But each lending opportunity should be looked on by its own particular merits.
Paul said: “We have lent to a first-time buyer on a 22-bed care home. While he hadn’t got experience in the sector, he had lots of business experience and was prepared to put plenty of equity into it. The home had been running for a long time with an experienced manager in place who was prepared to stay.”
The above roundtable, produced in partnership with The Business Magazine and Herrington Carmichael, is the fourth in a series of roundtables with the previous three events focusing on hospitality, construction and financial services.
