Comparing models of housing with care for later life
A study of seven different housing with care schemes for older people in England.
A growing number of housing schemes for older people combine independent living with relatively high levels of care. However, there are questions about what, if any, model works best for older people. The authors examine how different models of housing with care address the needs of older people.
The longitudinal study compares seven different housing with care schemes, including ‘village’ style and smaller schemes operated by a range of provider organisations in different locations. It considers:
- what makes schemes distinctive;
- services and resources; and
- how different needs for housing, care and support are balanced.
Interest is growing in the role of housing schemes for older people that combine independent living with relatively high levels of care. This comparative study of seven schemes in England examines different models of housing with care for older people.
- There appeared to be no single dominant model of housing with care that was most effective. The combination of independence and security offered by all schemes appeared to be highly attractive to older people from a range of backgrounds.
- Schemes developed in partnership between housing associations and local statutory sector services were more likely to be responding to local needs and shortfall in existing services. Independent providers were able to exercise more autonomy.
- The profile of residents was different in each scheme, reflecting entry criteria operated by the managing organisations. This allowed communities of people with similar life experiences and backgrounds to develop.
- The size of schemes did not appear to influence the levels of care that could be offered, but did affect the variety and range of facilities and amenities available to residents. Larger schemes appeared to offer some social advantages.
- Location and design features were important influences on how schemes operated and on residents' daily lives, particularly the size of each dwelling. Accommodation that was very small impacted on residents' lifestyle, and had implications for care delivery. Greater emphasis is needed on 'space for living'.
- The housing needs of older people entering such schemes should not be underestimated. For residents, the 'housing' element of housing with care schemes was not a secondary consideration.
- Informal support from family or volunteers was often integral to the functioning of schemes and the well-being of individual residents.
- Not all care and support needs could be met within the schemes, especially if people had dementia-type illnesses or challenging behaviours.
Reflecting concerns about how the housing, care and support needs of the growing number of older people will be met, there is much interest in the role of housing schemes for older people that combine independent living with care. However, there is no single blueprint for housing with care schemes. Provider organisations across the statutory, not-for-profit and private sectors have undertaken various new developments or remodelled existing schemes, often taking quite different approaches to type of tenure, care services and provision of amenities and facilities. This study set out to explore a number of different models of housing with care for later life, and to examine 'what works best?' from the perspective of a number of key stakeholders, including provider organisations, residents and on-site staff.
What makes schemes distinctive?
Although all the schemes in the study were selected because they were apparently operating very similar services, a number of key factors made the schemes distinctive. However, no single model appeared to be dominant in terms of effectiveness.
Managing organisations and partnership working
Schemes developed in partnership between housing associations and the local statutory sector were more likely to be responding to local needs and shortfall in existing services. Independent providers were able to exercise more autonomy, and their practice could potentially be more innovative.
Staff and organisational attitudes were also linked to a sense of community or belonging. A stable staff group across all elements of provision – care, catering, maintenance – enhanced residents' sense of community and security.
In all cases, residents could not just choose to live in the schemes. They had to meet various entry criteria, which were different for all the schemes participating in the study. From the perspective of the managing organisations, eligibility criteria were essential to ensure that the needs of residents who came into the schemes matched the level of care services on offer. From the perspective of residents, this element of selection was not unwelcome.
Two of the participating schemes were 'villages', the larger one being home to more than 300 people. The size of schemes did not appear to influence the levels of care that could be offered, although larger schemes were able to offer a wider range of facilities and amenities. Larger schemes also appeared to offer some social advantages to residents. For example, larger schemes had a wider range of social clubs and interest groups, and men – always in the minority in these settings – were particularly likely to benefit.
Location and design
The design of individual dwellings and overall scheme layout were as crucial to maintaining residents' independence and quality of life as the provision of care and support services. For both individual accommodation and shared spaces, the focus of design appeared to be on wheelchair access. However, other types of impairment, for example sensory or cognitive, appeared to be less well understood or addressed in design terms.
The location of the schemes varied from city centre to more rural. Those living in schemes in more isolated locations could feel cut off. Obviously, city centre locations allowed easy access to local services and facilities. However, people with disabilities could also be isolated in more central locations as they were less able to get out.
Meeting different needs
Much of the discourse around housing with care has focused on care needs and care services. This study showed that the actual housing needs of older people should not be a secondary consideration. Many residents were primarily seeking a secure, accessible, affordable place in which to live in later life.
"I would still love to be there [previous home], but it was second floor, and no lift, and the steps were getting harder and harder knee-wise, and I've got a pace-maker, so you know, I had to look ahead." (Resident in one of the participating schemes)
In terms of levels of care needs, decisions as to whether residents could be cared for in particular settings were made on an individual basis. These decisions often depended very much on the capacity not just of the housing with care scheme but also of other local partners to provide a package of services. Although most of the schemes could support people who were becoming confused or forgetful, only one could provide care for people with more challenging and difficult behaviours, and this was within the care home element of the scheme. With regard to end-of-life care, some participating schemes could offer this, but usually within an on-site care home.
In schemes where volunteers were active, they provided invaluable and often indispensable assistance to residents in a number of different areas such as benefits advice, bereavement counselling, transport, shopping and visiting.
Costs and affordability
Charges for services varied across the different schemes. However, the charges made to residents were not inconsiderable, and schemes could be expensive places to live. On the whole, residents felt that housing with care provided value for money, and many believed that it was a cheaper option than other alternatives, with the added advantages of independence and security.
Perspectives of residents
Across all schemes, residents spoke about the combination of independence and security that the housing with care scheme offered them. Independence was linked with privacy and having their own accommodation (however small), with the option of participating in the community within the scheme and the wider community outside, as and when they chose. The sense of security was not just derived from knowing that help was available from care staff, but also appeared to reflect a range of concerns. These included being alone and therefore more vulnerable, lack of confidence in services outside (particularly home maintenance), security of tenure and fear of crime.
From the perspective of the majority of residents involved in the study, age-segregated living offered a number of advantages over living 'in the community'. Notably, these advantages were a sense of security and, for some, sanctuary in an environment that focused on the needs and preferences of older people, and from where they could engage with the wider community on their own terms. There were concerns about gossip and rumour, however. Residents noted in particular the need to keep personal financial affairs private. Considerable friction could be generated when some residents were in receipt of state benefits and others were not.
Engaging with the wider community
One major criticism of housing with care is that older people are segregated from the wider community. However, the study found little evidence that residents were disengaged from the wider community, and many were conscious of the need to maintain existing social networks and activities. Part of the remit of some schemes was to provide facilities that could be shared with the wider community. In some instances, schemes were reliant on the additional income that could be generated by hiring or sharing facilities. Opening the schemes to others was not always welcomed by residents, who had a great sense of ownership of the schemes where they lived. They had strong views about the extent to which other people could use community facilities.
Greater clarity is needed on the part of healthcare providers about exactly what housing with care schemes can provide and how community health services can best work with scheme providers, notably to provide community nursing and GP services, particularly out-of-hours services. Where schemes had elements of primary care provision on site (for example, a regular GP surgery), there were obvious benefits to residents and to staff.
Space standards need to be as generous as possible, with adequate space for living and careful thought given to the smaller design details. They also need to take account of future requirements for equipment or adaptations, and for space to allow care assistance to be given. A balance is required between meeting current and future needs and aspirations, particularly in the use of assistive technologies. The overriding messages seemed to be that technologies need to be simple and robust.
Given many residents' needs for low-level support, above what is formally offered within housing with care schemes, providers could seek opportunities to work with the voluntary sector to develop and support a range of voluntary activity.
There are tensions around the capacity of housing with care schemes to accommodate individuals with high levels of care needs while remaining true to the concept of promoting independence in later life. The capacity of schemes to provide care for chronic life-limiting conditions and increasing needs for care is questionable. This study suggests that housing with care cannot at present easily support people with dementia-type illnesses or challenging behaviours. Unless such schemes are able to offer services that take account of the specific needs of people with dementia, the requirement for alternative accommodation will need be addressed. End-of-life care is an area of practice that could also usefully be further explored.
About the project
This longitudinal study looked at seven different schemes in England operated by a range of organisations, including housing associations working in partnership with local authorities, and charitable trusts. Visits were made to all schemes in 2005, and second visits in 2006. Baseline data was collected, and interviews and focus groups were held with residents, managers and frontline staff. More than 150 residents participated in the project.