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The impact of legislative change on the independent, residential care sector

Stephen O'Kell

28 January 2002

The independent care sector is currently going through a period of great change, stimulated by legislation on the way that care is commissioned, provided and inspected.

In addition, difficulties recruiting and retaining staff are having a direct impact on homes' ability to provide adequate care for their clients.
This study identifies the key challenges facing the sector and makes recommendations on how they might best be addressed. The report includes a comprehensive literature review, together with a series of semi-structured interviews with national organisations, corporate providers, local and health authority registration and inspection units, and care homes.

It finds that the large number of overlapping government initiatives is causing concern and confusion. In addition, the independent care sector is no longer an attractive career option. Training was as a particular concern.
The study identifies a clear need, over the next few years, for interested parties to work together in order to improve care services for individual client groups. Without this, problems of recruitment, retention and training will remain a major issue within the independent care home sector.

Summary

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The independent care sector is currently going through a period of great change. These changes have been stimulated by a significant amount of legislation produced by the Government; this is expected to change the way that care is commissioned, provided and inspected, in the future. Stephen O'Kell, from the University of Portsmouth, has conducted this survey in order to highlight the current issues being faced by the independent care home sector. He found:

  • The large number of overlapping government initiatives currently being implemented is causing concern and confusion within the care sector.
  • The care sector is no longer attractive as a career option to many people. There are better jobs, offering more money, available in other occupational areas, especially within the commercial sector.
  • Extended care roles are being taken on by care support workers in some homes.
  • All the homes in this study were reluctant to transfer a resident to another care facility if his or her care needs change.
  • Most homes were very satisfied with the level and quality of community nursing services available to residents.
  • The independent care sector does not have the same access to training opportunities that are available to the public sector.
  • Few homes have reached the target of 50 per cent of care workers having achieved at least a level 2 NVQ in Care. Many care home owners felt that they have neither the time nor the resources to properly meet these standards.
  • The National Minimum Standards concentrate on structure and process within care homes. Consideration may need to be given to incorporating the outcomes of care into the inspection process.
  • Because the quality of assessment undertaken by care managers can be very variable, it is suggested that care home managers do their own formal or informal assessment on prospective residents before accepting them into the home.

Background

One of the key impacts of demographic change over the next few years is the fact that the number of individuals aged 85 years and over is set to at least triple by 2056. This is likely to lead to a boom in the independent care sector, starting in the near future.

In England, there is, currently, still an oversupply of long-term care beds in this sector, although this is likely to be eroded over the next couple of years. Also, profit margins are being squeezed; homes have had to become more efficient and offer a higher quality of care in order to maintain occupancy levels.

After extracting all the costs, a typical nursing home makes approximately 50p profit per bed per day (The private healthcare industry in the UK, Private Healthcare UK, 2000). Corporate providers achieve competitive advantage through economies of scale while the smaller scale home providers are having to 'service trim' to stay in business. This situation has led to the closure of many privately owned care homes and this trend is expected to continue. If the decline in the number of homes continues unchecked, it could lead to a very restricted choice of homes for clients in the future. In many parts of the country, there is already a great shortage of dementia care beds.

In some areas of the country, care home providers have threatened to boycott local authority placements because of the low fees on offer (Registered Homes & Services, 2001). Also, large numbers of clients continue to be transferred from nursing home care to (less expensive) residential home care so that local authorities can make savings.

This study reviewed the impact of the following legislation:

  • Modernising Social Services (1998)
  • Quality Strategy for Social Care (2000)
  • NHS Plan (2000)
  • National Service Framework for Older People (2001)
  • Care Standards Act (2001)
  • Health and Social Care Act (2001)

It found that the large number of overlapping government initiatives currently being implemented are causing concern and confusion within the care sector.

Accessing care home services

The National Service Framework for Older People and the Charter for Long-Term Care are expected to enable the NHS and local authorities to collaborate on the planning, resourcing and delivery of services for older people. The involvement of the independent care sector in the planning of local health and social care services is seen as essential for the delivery of high quality services to older people.

In this study, the majority opinion was that client needs assessments undertaken by care managers are not always accurate. Because the quality of assessment undertaken by care managers can be very variable, the author strongly suggests that care home managers do their own assessment on prospective residents before accepting them into the home.

There are two main problems with client needs assessment - the assessment process itself and eligibility criteria. The Department of Health has stated that it expects to see a single assessment process agreed for the health and social care of older people by April 2002. The Minimum Data Set Resident Assessment Instrument, which is currently being trialled by BUPA and Bristol University, appears to fit the bill.

All the homes included in this study were reluctant to transfer a resident to another care facility if his or her care needs change, because of the potential dangers to the resident's physical and mental health. Most homes were very satisfied with the level and quality of community nursing services available to individual residents. Some health authorities have established 'Elderly Liaison Teams' to provide advice, support and training to care homes.

However, care home residents and their relatives need clarification on precisely what care services are available and who has to pay for those services before admittance to a care home. In some areas, there was evidence that homes have to pay for primary care services and for the loan of NHS equipment, and these costs are then passed on to residents.

Care staff recruitment

The reality is that public services are no longer attractive as a career option to many people. There are better jobs, offering more money, available in other occupational areas, especially within the commercial sector. In one of the more affluent areas studied, people could earn more than £10 per hour for working behind a bar compared with an average £5 an hour for care work.

In order to minimise the shortages of care staff, the NHS Workforce Development Confederations are going to have to work collaboratively with Regional Training Forums and the independent care sector in developing integrated staff planning strategies that meet the needs of all participants in the care sector. Unfortunately, the staff shortages are expected to get worse before they start to get better, especially within the independent sector. This may require Registration and Inspection Units to be flexible in terms of their staffing requirements of homes, in the medium term.

It takes time, effort and resources to recruit, induct, supervise, provide training and pay the salaries of all members of staff. But this investment is essential if the employees are to provide high quality care and be successful members of the care team. The costs of not making such an investment leads to the care facility making a heavy commitment of management time to deal with the problems of poorly motivated staff, high sickness rates, poor care quality, unsatisfied clients and families, and increasing numbers of complaints. This all results in a care home developing a poor reputation and reduced profits, and can lead to problems when the home is inspected.

The homes in this study used a range of recruitment strategies to attract care staff of the right calibre, for example, free meals, private health and pension schemes, provision of staff accommodation. However, only one home in this study regularly used a skill/grade mix model to calculate staffing levels.

A number of issues were identified as affecting the recruitment of care support workers. In areas where there are still relatively high levels of unemployment and/or sizeable minority ethnic communities, there are individuals available who are willing to take on low paid work and, therefore, recruitment is not usually a problem. Also, it was found that rural homes usually experience more recruitment problems than those care homes based in towns.

The planned Code of Practice for care workers, together with the establishment of workforce registers, a Consultancy List and the Clearing House Initiative, when they are available, are likely to make the recruitment of care support workers easier. It will also enable employers to identify those individuals who should not be working with vulnerable people.

In addition, there are large shortages of nurses in most areas of the country. The Department of Health is investing £120 million on the recruitment of nurses. Although the record of such initiatives is not good, if the NHS recruitment drive is successful, it is likely to make the independent sector nurse recruitment problems even more acute.

Care staff retention

The study found that motivating staff appeared to be the best way to retain care staff. There was evidence that some care workers move on to other homes for little reason, for example, so that they can earn a few pence more per hour. This problem might be overcome if staff enjoyed their work more. In care homes, the major motivators were identified as:

  • A manager, owner, or matron who is 'employee friendly' and treats the care staff as valued and respected employees.
  • Homes that are a 'happy' place to work because there is an emphasis on good communications and teamwork.
  • Homes that assist staff to take up education and training opportunities.

There is an expectation that very little care will be designated as 'nursing care' in the new 'single care homes'. It is likely that home managers and Primary Care Groups will encourage extended care roles for care support workers. This will be even more important when a home employs no nurses and/or where there is a limit to the amount of health care support that NHS community nurses can provide for individual residents. It should be emphasised, though, that care support workers should not be allowed to work beyond their level of competence and that a qualified nurse who retains the accountability for the delivery of care, should supervise them (Guidelines for professional practice, United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1996).

The National Minimum Standards specify a range of issues that care homes need to address in relation to staff supervision and training. At the moment, though, few homes have reached the target of 50 per cent of care workers having achieved at least a level 2 NVQ in Care.

Many care home owners felt that they have neither the time nor the resources to properly meet these standards. In this study, in some homes, staff had all course fees and expenses paid and were allowed to undertake the course during work time. But other homes paid nothing towards course fees or expenses and expected staff to do the courses in their own time, even the statutory study days.

It is expected that continuous professional development (CPD) requirements will be introduced for those individuals registered with the Social Care Councils. This will bring them in line with the continuous professional development requirements for re-registration used by other care professions.

In terms of access to training opportunities, even if care homes can stimulate their care staff to undertake further study, they are likely to need outside help to solve the problems of involving the independent sector in local training needs analysis and in overcoming the problems of expensive course fees, limited access to academic libraries, etc.

The new occupational standards that have been developed for induction and foundation courses, registered manager awards, etc. will require a review of the NVQ in Care awards so that they can be integrated within the NVQ framework, as well as being stand-alone awards.

There was a general consensus in this study that a local review of available gerontological skills will be needed in each district to see how best to facilitate gerontological nurse specialist input into all care homes.

Registration and inspection

The Care Standards Act becomes effective from April 2002 and will establish wholesale reform of the registration and inspection of nursing homes and residential care homes:

  • Setting up the National Care Standards Commission to undertake the registration and inspection function of all care homes (including Part III accommodation).
  • Establishing the concept of a 'single care home'. The definition of a care home will become one that provides accommodation plus nursing or personal care.
  • Consulting on the final format of the National Minimum Standards that will form the basis for registration and inspection

Registration and inspection is currently in a state of flux. Care home owners are having to work towards implementing the National Minimum Standards. At the same time, many of the inspectors working for Registration and Inspection Units are applying for posts as regulators within the National Care Standards Commission and working towards the achievement of the national occupational standards that have been specified for regulators.

It is going to be a while before the regional and local offices of the National Care Standards Commission are established. In 2002 when these offices become operative, it will be interesting to see how well they are resourced and whether they can avoid the allegations of 'inconsistency' that have been leveled at Registration and Inspection Units within this study.

Some interviewees in this study felt that as the National Minimum Standards concentrated purely on structure and process issues, they did not improve on the Registered Homes Act standards. Linking the National Minimum Standards to the results of the Minimum Data Set Resident Assessment Instrument, which some care organisations are currently reviewing, may need to be considered so that the outcomes of care can be incorporated into the inspection process.

Conclusion

At the moment, the raft of legislation currently being implemented does not seem to have benefited care home residents, individual care homes, Registration and Inspection Units or commissioners of care. It will be interesting to see how well all the parties are able to work together over the next few years in order to improve the care services available to clients. In addition, it is not yet clear how far legislation will tackle the following problems:

  • funding shortages for long-term care;
  • the need for close collaboration between health and social care;
  • ensuring that there are enough residential homes and nursing homes;
  • ensuring consistency and excellence of care service delivery;
  • the need for intermediate care facilities in all parts of the country.

About the project

There were three components to the study: a literature review; semi-structured interviews with a purposive sample of national organisations and corporate providers of care homes; and semi-structured interviews with a random sample of local authority and health authority registration and inspection units, nursing homes, residential homes and dually registered homes.

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