Eleanore Robinson

Put some va-va-voom into migrant worker retention

Visa restrictions on care workers bringing their dependents into the UK, along with more stringent Home Office regulations, has already begun to bite into the burgeoning migrant social care workforce.

So, with fewer workers expected to come into the country, what can care home operators do to retain the ones who make the journey here?

One key thing is to ensure that newly-arrived workers have a driving licence. Many arrive with an international driving licence, which lasts for around a year, after which workers will be required to pass the UK test.

Charles Taylor, director at Taylor and Taylor Care Group, explained: “Most of the time we have found that as an employer you need to be quite proactive about that.”

His nursing home group has offered low interest loans on some occasions to pay for lessons. Taylor said: “You need to have a plan or at least have a discussion with the person about it.”

He added that despite seeing the number of applicants per position drop from between 40 to 50 to 20 to 30 since the rule change in March, most vacancies are still being filled.

However, Taylor said that the biggest change he has seen is that the Home Office has added a number of bureaucratic barriers to bringing in overseas recruits.

For example, to get one person in from overseas, his business had to send details of the other 82 workers that it employs from overseas as part of the process.

Taylor explained: “The Home Office has put in soft rules to make it more difficult for employers to put us off bringing in so many people.”

Part of the reason for this is to get social care providers to take on people who have already arrived in the UK, but have either lost their jobs or had nefarious employers that didn’t exist.

Historically, another issue facing overseas workers is formal childcare, although this situation is expected to get better after the universal offer of 15 hours per week for children aged above nine months was introduced in September.

Another barrier can be access to accommodation, particularly in rural areas, with some operators leasing houses for their staff as part of the package.

Help is also needed with the cost of living in the UK, which can be higher than in other countries, and for the need to buy much warmer clothing than they routinely might bring.

Navigating public services such as paying council tax or even opening a bank account, can be helped by pairing a new recruit up with a “buddy” care worker who has already been through the process.

This can also help overcome cultural and language barriers and help build up confidence when talking to care home residents, Taylor said.

“With that in place they are much more likely to succeed and stick with you”, he said.

UK social care employers have become very dependent on foreign workers.

According to The State of the Adult Social Care Sector and Workforce in England report, published this month (October) by Skills for Care, an estimated 105,000 people started direct care roles in the independent sector having arrived in the UK during 2023/24.

Some 20,500 headed to homes with nursing, while residential homes brought in 16,500 overseas workers in 2023/24, with overseas workers now accounting for 28 per cent registered nurse posts, 26 per cent of care workers, 23 per cent of senior care workers, and 6 per cent of manager roles.

However, in the second quarter of this year (Apr-Jun 2024) Skills for Care notes a “substantial decrease” in this workforce in the three months to June 2024, with only 8,000 people joining the workforce, compared to last year’s average of 26,000 per quarter.

For those planning overseas recruitment, it’s worth noting that the migrant workforce is more likely to be younger than the average UK workers, with an average age of just over 34 years. They are also more likely to be male, making up almost three in ten overseas workers coming to the UK, compared to their 21 per cent share of the domestic social care workforce.

By origin country, Nigeria tops the dataset at over one in five of this workforce, followed by India (17 per cent) and Zimbabwe (8 per cent), according to the figures.

Care Home Management: October 2024

Chief medic warns of stiff future competition for social care workers

There is going to be “stiff competition” for social care workers in the future.

That was the stark warning issued by Chief Medical Officer Professor Chris Whitty, speaking at a recent Nuffield Trust summit.

In his presentation, he warned that providing support for people in old age was going to be an increasing challenge, and he warned that almost certainly providers will not be able to “buy their way out of trouble”.

He added that the problem would be particularly acute in rural and coastal areas, where the population is ageing faster than in other areas, and where the younger workforce is most sparse. Urging care providers to act now, he said: “These trends are not a guess – they are a certainty, and we need to be taking a serious run-up at them.”

Care homes are often built in affluent areas, but local affordability can force local people to seek out higher paid work. In rural areas, young people also tend to head to the cities for work, leaving gaps in the available workforce. As a result, care home providers have had to do some thinking “outside the box” to secure their care workforce.

At Bracebridge Care, some homes put on buses to transport people to work in these areas.

Another tactic is to actively recruit older workers, as well as those with previous careers, for example, in the Armed Forces, or to offer part-time work and flexible hours. This can be particularly beneficial to those using public transport to come to work.

At LDC Care Company, as there are military bases nearby, the company has found good take-up for care roles from military wives and spouses. It has also found success among local men, as unusually for social care, 55 per cent of LDC’s workforce are men. Having good ambassadors for the company can help, said Lara Bywater, director at LDC Care Company.

At Stow Healthcare, key factors in reducing the their vacancy rate from more than 7 per cent to 1.6 per cent have included employing a recruitment manager as well as looking overseas. Savings in agency staff wages have covered the manager’s wages, says Ruth French, operations director at Stow Healthcare.

The advice from Melanie Weatherley, chair of the Lincolnshire Care Association, is to embed your care home in the community. “From nursery, bring them into your care home so when they are looking for work experience, they will come to your care home,” she said.

LDC’s Bywater added: “It is about making people feel valued, welcome and safe, with the opportunity for future training and all the lovely stuff that people can get involved in while working for us.”

Care Home Management: June 2024

Southwark charter has positive effect on care home recruitment and retention

Two years ago, the London Borough of Southwark launched its voluntary Residential Care Charter outlining the expected standards for care home providers that signed up to it.

Since then, six homes have joined the initiative, representing 86 per cent of the borough’s residents currently living in care homes.

Developed in conjunction with Unison, the terms of the charter include paying all staff the London Living Wage (LLW), as well as covering the time needed to carry out a handover between shifts.

In addition, training must be offered for free and during working hours, and zero-hour contracts must not be used in place of a permanent one unless requested by a member of staff.

In return for signing up to this, care home providers receive a financial uplift from the council to fund the gap in pay for staff who are not already paid the LLW.

These payments are then monitored by the council via a spreadsheet of costs from providers.

Southwark Cabinet Member for Health and Wellbeing Cllr Evelyn Akoto said the Charter had been “really well received”, despite a few issues around communication and monitoring.

She said: “It is a no-brainer in making sure the terms and conditions are adequate. It is about a safe environment for care workers and those they are looking after, recognising the really important work that care workers do. It is also a business as well as an ethical case. It’s about making the business more attractive and creating an environment where staff want to work.”

Camberwell Lodge Care and Nursing Home, owned by Country Court Care (pictured), is one of the homes that signed up to the charter.

The home provides nursing care, residential care, dementia care and short-term respite care for up to 98 people. Home manager Lauren Gordon said that the staff benefits ramp up morale in the home and support recruitment and retention. She said: “People are more willing to pick up shifts, even unsociable shifts, which has a positive impact on the residents’ wellbeing, given that there are healthier staffing levels.”

Southwark has set itself a target of all care providers to be signed up by 2026, citing early successes from the scheme: a staff survey by Agincare – which took over four care homes in the borough from Anchor last year – found that 100 per cent of workers were happy working there.

Cllr Akoto said: “I do believe the care charter is a major factor in this. This is an example of how well the charter is working.”

However, the success of the scheme has meant that some care providers who operate across London are concerned that staff and services could migrate to Southwark due to the better conditions.

Cllr Akoto said that “there needs to be consistency across London” to prevent a postcode lottery.

She added: “I enjoy the fact and I’m proud we are a frontrunner, especially towards driving up standards of care. If we can do it, everyone else can do it.

“Our door is always open to anyone who would like to speak about it. I think this is something that we all need to do.”

Care Home Management: February 2024

Care providers count the costs of the incoming National Minimum Wage

Chancellor Jeremy Hunt announced in his 2023 Autumn Statement that the National Minimum Wage (NMW) would increase by 9.8 per cent to £11.44 per hour from next April for workers aged 21 and over.

The increase was based on the recommendation of the Low Pay Commission, which said that in “large low-paying sectors”, including social care, employers’ ability to pass on the increased costs is “highly constrained”.

According to LaingBuisson’s Care Cost Benchmarks model, the increase will add £49 per week to average staff costs for nursing care and £53 per week for residential care.

Furthermore, it calculated that care providers will require an average fee increase of around 5 per cent to compensate for this factor alone.

While care organisations have welcomed the move, they have also raised concerns about how care providers would absorb the costs.

The National Care Forum said that the uplift would be a vital boost to care workers’ income. However, it does not address the “fundamental lack of appropriate pay, terms and conditions for those working in this sector”.

Care England added that the care sector’s ability to adjust wages was “extremely limited” as around 60 per cent of care providers fees are determined by local authorities and the NHS.

The effect on service users of a lack of investment in social care has also been raised by the Association of Directors of Adult Social Services (ADASS).

Its president Beverley Tarka said that many older and disabled people will not now get timely care, support and safeguards.

For care providers almost exclusively relying on public funding for fees, this lack of investment is worrying.

Rachael Dodgson, chief executive of specialist care provider Dimensions, said that it would be talking with local authorities about uplifts in the new year.

She said: “We will be relying on local authorities to give us those increases. The increase to National Minimum Wage is really welcome. The gap between the National Minimum Wage and National Living Wage is closing.

Dodgson added that in her experience local authorities want to fund as much as they can but there is not much left to cut from their budgets to pay for this and they are reliant on central government for extra funding.

“There has to be some recognition of that. Central government has to support local authorities.”

Of course, it is not just those on the lowest salaries who benefit from increases in the minimum wage. Those in more senior roles, such as assistant managers and managers, also expect wage differentials to be maintained.

Dodgson said: “It is also all those things you need to factor into it too.”

Dimensions has a workforce petition called Save Our Social Care, calling for support worker pay to be a minimum at NHS band 3 as there is some consistency across those roles.

Dodgson said that, as the NMW increase applies to all sectors, wages in areas such as retail and hospitality will also be going up, meaning social care workers have just as much incentive to leave to work in these industries as they do now.  

She explained: “We still can’t compete with hospitality and retail over pay. That is why our workforce petition is calling for social care to benefit from different rates of pay.

“From our perspective, until there is some differential between social care and these other sectors, it is not going to help as much as we need it to.

With government tightening immigration restrictions, no longer allowing overseas workers to bring dependents with them, the number of foreign workers in social care is expected to fall.

This will make recruiting and retaining a domestic workforce even more crucial for care providers.

Skills for Care found in its recent annual State of the Adult Social Care Sector and Workforce in England that being paid more than the NMW was one of the reasons people stayed in social care.

Dimensions is a Real Living Wage employer and Dodgson said doing this has “made a difference to vacancies in the sector”.

Care Home Management: December 2023

The rise of modern slavery in care

Modern slavery in becoming more and more prevalent in the social care workforce.

The CQC reported double the rise in referrals for modern slavery abuses across the health and care sectors in 2022 than the previous year.

In addition, the number of potential victims working in social care calling Unseen’s Modern Slavery Helpline leaped from 63 in 2021 to 708 in 2022, due to a combination of the Covid pandemic and Brexit, the charity said. 

Unseen director Justine Carter explained that the tightening of regulations to work in the NHS had led people in other countries to look at the care sector as a way of coming into the UK to carry out similar work. The charity’s concerns have been highlighted in a recent report.

Carter said: “Quite often they are agency workers. We have had some instances where people are being recruited in their home country and being told ‘there is a job for you’.

“We have also got instances where people are starting to work when they are on a particular visa within the UK. That might be a student visa where someone is allowed to work a certain number of hours a week, then they might work outside their visa requirements. These elements can create an environment where people become more exploited.”

Carter added that, while there might be the odd rogue recruitment agency, normally it is a rogue individual within a recruitment agency or a third party who organises access to workers for a recruitment agency.

She said: “Where there is a need for workers and they are readily available, rogue actors will look at where the least resistance is for getting these people in.”

Workers most likely to report exploitation come from India, Zimbabwe or Nigeria, according to the Unseen analysis.
The rise in cases in modern slavery is seen by employment lawyers as within the context of an increased reliance on international recruitment, agency staff and other outsourcing options to address the ongoing recruitment and retention challenges”.

Legal director at law firm Bevan Brittan Louise Mansfield said: “From an immigration perspective, where providers are granted a sponsor licence there is an ongoing duty to ensure that migrant workers are not being exploited. UK Visas & Immigration (UKVI) can conduct an audit at any time.”

Non-compliance with licence terms can result in the licence being suspended or, even, revoked.

She added that employing illegal workers is a criminal offence that can lead to a civil penalty or, even, a custodial sentence.

Health and safety regulators can also be called in.  

For these reasons, Unseen’s Carter urges providers to do due diligence on the staffing agencies they use.

When new workers join, providers should make sure they have got their own mobile phone, give details to contact their next of kin with their address, and have not got people turning up with the same details.

Red flags of exploitation can include concerns that the employee is at work outside of their allotted hours, excessive tiredness or stress, never bringing or buying food items when at work, and regular transport to and from work.  

If a provider does suspect a worker could be a victim of modern slavery, employers can seek legal advice about how to report the concerns to the Home Office via the available channels.

Bevan Brittan’s Mansfield said: “Providers should however be discreet and, whilst they may offer support to any potential victims, they must also make sure they do not do anything that could make the victim’s situation worse.”

Providers who have concerns about the welfare of one or more of their workers can call the Modern Slavery Helpline on 08000 121 700 in confidence.  

Antislavery charity Unseen is now in preliminary discussions with CQC about jointly raising awareness of modern slavery and improving regulatory powers.  

A Department of Business and Trade spokesperson added: “The Employment Agency Standards Inspectorate and Gangmaster Labour Abuse Authority work with organisations to take action against businesses who have unethical and illegal employment practices.”

Care Home Management: June 2023

Creating career paths

While women make up the lion’s share of the social care workforce, the gender balance in frontline roles fails to translate when it comes to senior management.

According to Skills for Care data, the adult social care workforce comprised 82% of workers identifying as female, compared to 48% in the economically active population. However, these workers were less likely to be in management roles (79%), especially in senior man- agement roles (68%), compared to direct care giving roles (83%).

So why, like many other industries, is social care not harnessing the skills and experience of front-line workers by promoting or recruiting more women to senior management?

Traditional views on gender roles are one of the barriers for women moving up into senior management, which is still seen by many as a male domain.

‘From my experience, the vast majority of men that we interview, they say they don’t want to cook, they don’t want to provide personal care. They don’t feel that’s their role, so they tend to go more for a management position,’ said Upward Care operations director Natasha Streeter.

Streeter herself made the journey from deputy manager at the specialist and housing with care operator. ‘I started with Upward Care in 2014 as a deputy manager. Then I progressed through to manager, to operations manager and now operations director.

‘I was very fortunate in that I was given support to do that because I couldn’t have developed without the training and without the support from my managers,’ she said.

‘I think across the sector it would be really useful because some people do think you can’t employ this male as he isn’t going to want to do this or you can’t employ this female because she’s got three children at home so she is not going to be able to commit to this.’

Streeter added it was really important management keep an open mind when employing somebody and look at how they can develop that person, understand what their ambitions are, what their passion is, why they want to do the role, and continue to give everybody, regardless of male or female, opportunities.

She said Upward Care tries to develop everybody and offer the same opportunities to develop regardless of male or female. ‘I think it is important in any organisation to give opportunities to everybody,’ Streeter said.

A large proportion of women in senior management roles have built their own care business.

This is highlighted in this month’s CM Meets... with Helen Davies-Parsons, who is founder and chief executive of Dorms Care Communities.

Elsewhere, Melanie Weatherley, chief executive of homecare agency Walnut Care, said there are some strong female role models in social care but often these women are entrepreneurs so there is a limit to what they become. In addition, she said women set up care organisations because they want to make a difference rather than create a huge business.

Weatherley explained: ‘You probably don’t want to get to the stage where you are a huge corporate because you are not engaged with what is going on anymore.’

She added the very largest organisations don’t attract women in social care. ‘When large corporates bring in senior managers from outside the sector, they seem to be all men and I don’t know why,’ she added. ‘Why wouldn’t being chief operating officer at a large domiciliary care company not be attractive to a woman who is a chief operating officer somewhere else?

‘There are some really successful medium-sized companies run by women who deliver a fabulous service, deliver a pretty healthy profit, but they probably have no inclination to take that to a corporate, mega size. But you do get lots of middle managers in the biggest corporates who are female.’

She argued there are lots of women in senior care organisations in large corporations who have come through by being nurses or therapists but are not very visible. ‘If there are any women, they are hidden’, Weatherley said. ‘We can’t see them. They don’t come to anything.’

Streeter agreed it was important for females to see other women in senior roles as it can be quite stereotyped that they stay at home or just come in and provide personal care while men stay in the office. ‘It is important that everyone can see what everyone can achieve.’

Key to this is training and development.

Upward Care tailors staff development, both male and female, to the individual employee and their ambitions. ‘It is really important that everyone has the same goal in terms of wanting their staff to develop,’ Streeter said. ‘We do everything we can to fulfil these ambitions.’

Weatherley agreed, pointing out that creating a clear career path for workers is critical in achieving more of a gender balance at all levels. ‘There is no career path in care so maybe that is why we don’t have as many males at the bottom.’

This was because workers had to be quite a way up the career ladder before they had any status and a lot of people come into the sector without a formal education, she said.

Furthermore, providers don’t have much spare money to support people’s careers, and, if they do train people to a higher role, that person might want more money or want to leave. ‘There is something fundamentally wrong with the way working in the sector is seen as a career. If you are an entrepreneur you can set your own business up, you can do those things but there is a limit as you are no longer an entrepreneur, you are a corporate manager,’ Weatherley said.

One solution that could make a difference, like nursing, is for care work to be registered as a profession.

‘If you look at nursing, pre- and post-registration, it is an entirely different role with an entirely different view,’ Weatherley said. ‘I can’t imagine in my lifetime that the care workforce is going to get registered as it is too big and too complicated. But maybe if you register your first level of qualification.’

So, can there be a registered social care practitioner? ‘Unless it is seen as the profession that it is, there isn’t going to be a career path,’ she added. ‘Care will not be reflective of its front-line work- force as we will tend to parachute people in and they tend to be men.’

She said there was also a need for some kind of mentoring structure so women can talk to others who had made the journey into senior management before them.

Bringing together women already in senior management roles to mentor those who aspire to be, as happens in other industries, could help more fe- males on the journey to senior management.

Another option would be for women working in social care senior management to share their experiences and forge links. ‘The couple of dozen most go-getting entrepreneurial women all know each other but I’m not sure any of those know...who is the quality director from Barchester. We are different animals with different interests but maybe if we are going to do something for women coming through, we need to be as prominent as each other,’ Weatherley said.

‘We are probably leaving a lot of women in care underdeveloped and that is wrong.’

Care Markets: June 2023

Missing a trick

As social care providers struggle to fill vacancies, there is one pool of largely untapped potential care workers who could significantly boost workforce numbers – men.

According to Skills for Care figures, the adult social care workforce is made up of around 82% of female workers. However, there were proportionally more males in senior roles than front line jobs, so the proportion of male workers actually providing care is likely to be even lower.

So how can care providers tap into this half of the population to attract them into social care jobs, challenging the traditional view that caring is ‘women’s work’?

According to Oonagh Smyth, chief executive of Skills for Care, these traditional values, the portrayal of care work in the media as being low paid and low skilled, and a lack of awareness of opportunities in the sector among male school leavers is holding back recruitment of this group of people.

Its research, however, has found it is easier to attract older men with some experience of social care. However, when there is a personal care element, service users would rather have it carried out by a woman than a man, Smyth said.

‘Some providers will tell us that they have a high number of applications from men, but they can’t staff the packages because some people who draw on care and support don’t want to be supported by men,’ said Smyth, speaking on BBC Radio 4.

Despite this there are proportionally more men working with working age adults than with older people.

West Midlands-based Upward Care offers both supported living and housing with care services. It employs 15 male care workers in its supported living services in Solihull.

Recruitment manager and safeguard- ing lead Andy Dennehy said it was hard to recruit male employees because of the traditional role of men being the main provider for the family. ‘Care work will not give you that. Coming into care you are on the minimum wage,’ he said. ‘Our young male care workers are people coming into work for the first time. It’s their first job. They just want to go to football and have a drink with their mates. They live at home with mum and dad.

‘However, what we have done to recruit more males, from our adverts on Indeed you will see we develop staff. There is career progression within Upward Care.

‘With us a male care worker who is thinking of a career can become a senior support worker, team leader, then become deputy manager and ultimately manager of a service.’

‘They know that they can progress and when they have done so they have stayed with us.’

One Upward Care worker has been with the provider for eight and half years and a few others have stayed for more than five years.

Operations manager Natasha Streeter said having male carers was really beneficial to the tenant’s daily lives. ‘The male tenants, they relate to them really well. They are exceptional support staff. They take them to the gym, talk to them about all the things they want to discuss that they wouldn’t want to discuss with a female,’ she said.

However, Streeter added that some of the male care workers were reluctant to carry out personal care tasks. Furthermore, the provider had struggled to employ male care workers in Upward Care’s extra care setting.

Dennehy explained: ‘The majority of tenants there are female and want people of their own age and experiences caring for them. They want older females, but the majority of the staff team are younger females.

‘We tried to increase the number of male care workers as we have male tenants. We would like more male carers.’

He said social media, particular Facebook, was good for recruiting young men, as photos and video can capture the more fun moments of working in care.

Housing with care and care home operator Anchor has seen a 7% rise in male applicants from its ‘Men in Care’ campaign, which also used social media to target this group.

Anchor’s equality, diversity and inclusion manager Teagan Robinson-Bell said: ‘We use positive action campaigns to target men who are in the job market, whether passively or actively looking for a new role.

‘We use strong imagery and messaging to drive the campaign in places such as Facebook where we know majority of target demographic are active.’

Robinson-Bell said the campaign challenged what it meant to work in care and tried to rebuff the idea that care roles are for women. ‘We focused on the responsibilities of the role and transferrable skills from other jobs,’ she said.

Homecare agency Visiting Angels North Surrey has four male care workers recruited through a combination of referrals and using the job centre.

Co-owner Chris James said these workers tended to want to work more hours than their female counterparts with one employee working 40 hours per week and another working 30 hours. ‘What we have found with the men is, they just had more availability. So that is what men can do. We get a lot of school mums, available between nine and three,’ he said.

‘The great advantage with men is that they can often work when other people can’t. It is these sorts of things, companionship, things over a long period that can work. There are no restrictions, they can go wherever they want.’

James said male care workers would do the calls at eight o’clock in the morning and at night. ‘We are at the top end of the market. We are giving clients what they want. We are not sending people, we are matching clients with a caregiver,’ he added.

‘What we have found is when the male caregiver is seeing a male client, they are particularly appreciative.’

However, the high-end agency has had a couple of calls when the wife of the service user has also become ill, she no longer wants a man to come so they have had to switch over care workers.

James said: ‘There is a situation where work can go against them. We are still
at the point where the vast majority of ladies don’t want a man doing personal care with them.’

He said the agency would always like one or two more male workers but would not have enough work to take more than that.

However, with Skills for Care estimating that on any given day there are 165,000 vacancies in social care, and an extra 480,000 people will be needed to work in the sector by 2035, it is going to imperative to draw more men into the workforce.

Dennehy said: ‘There are so many young males in the country on benefits. If they were aware of the joy and happiness of working in social care, it would be brilliant for us.

‘It’s making people aware that it is not care ‒ minimum wage, it is care ‒ enjoyment, that it is an exciting and active role.’

Robinson-Bell added: ‘Studies show that gender diverse teams not only perform better but make better decisions and are more change-ready which is very important for Anchor, as we’re always evolving.

‘We want to have cognitive diversity and we know the best way to achieve this is to have people from all backgrounds as colleagues.’

Care Markets: May 2023

Bargaining Arrangements

With Scottish health and social care secretary Humza Yousaf succeeding Nicola Sturgeon as First Minister, plans for a National Care Service are set to be looked at again. Under the plans championed by Yousaf, Scottish ministers would be able to transfer social care responsibility from local authorities to a new national service. It would also pave the way for full sectoral bargaining on workforce wages, which is where agreements would be negotiated to cover the whole sector.

Scottish mental health minister Kevin Stewart told the Scottish parliament at the end of January: ‘The 2017 Labour Force Survey indicated 19% of social care workers have their pay and conditions affected by agreements between employer and trade unions.

‘The National Care Service will provide for full sectoral bargaining and therefore lead to greater equalisation of pay and terms and conditions across the whole of the social care workforce.

‘By rewarding and valuing the workforce fairly, we will deliver the best possible service for the people of Scotland and make the sector fit for the future and more attractive to people coming into the profession.’

However, the vote on a National Care Service Bill has been postponed until the end of June to allow the parliament’s health, social care and sport committee to scrutinize plans more closely.

This follows its contents being severely criticised, with trade union Unite walking away from the negotiating table and the Royal College of Nursing accusing the Scottish government of not properly engaging with stakeholders, including social care staff, to develop the plans before taking forward the primary legislation.

Yousaf himself has said he would be prepared to overhaul the plans, but it is not clear if full sectoral bargaining is one of the areas he would be prepared to compromise on.

Scottish Care deputy chief executive Karen Hedge told CMUK reform was needed but the current bill is not necessarily the right path. ‘Part of the challenge that we have is that the bill is in uniterated form, so we don’t really know where we are headed with it,’ she said.

While there were recommendations taken from Derek Feeley’s Independent Review of Adult Social Care in Scotland, Scottish Care does not think the legislation reflects this. Hedge said there was a ‘peculiarity around the question of sectoral bargaining’ as rates are currently set either through the Scottish living wage recommendation or through national care home contracts. For care at home, it is set through tenders as there are limitations on what people can offer in terms of rates of pay.

She said: ‘In sectoral bargaining, one of the challenges we have at the moment is the proposition is not sectoral bargaining, as it doesn’t include local authority-owned care provision.

‘From my perspective you are going to end up with a two-tier system where there is bargaining from local authorities and there is bargaining for charities, organisations, employee-owned organisations at the end of which you might end up with two different results. And I don’t think that is ethically sound.’

Hedge added there was also a question as to whether the Scottish government and Convention of Scottish Local Authorities (COSLA) would honour a rate of pay that is higher than in local author- ity-owned provision. ‘For me it has to be sectoral bargaining as a whole otherwise you are undermining the system given that the rate of pay is already set by the government,’ she said.

COSLA has been critical of the bill, arguing it does not address issues around the workforce and around sustainability. What is missing is investment, it said.

A source close to the local authority representative body told CMUK that, while the National Care Service will have sectoral bargaining, it will not be easy.

In the independent sector there are around 2,000 individual employees, some of which will be unionised, some of which will not. The source said: ‘Our focus needs to be on investment in the system around fair work. The uplifts haven’t been sufficient.’

According to trade union Unison, proposals for full sectoral bargaining is nothing new, with the recommendation, which the Scottish government has accepted, being suggested as far back as 2017.

‘A rate would be set which all employers, regardless of sector, would be expected to pay. That was way before that bill was contemplated,’ said Unison policy officer Stephen Low. ‘The things that are going to happen or that have been entrenched for a long time that could potentially deliver improvements for workforce in care started before the bill and could be progressed separately to the bill. If the bill never happened, they would not be impacted on.’

The trade union is also concerned local authorities no longer providing care services would lead up to 75,000 workers being TUPE’d across to other organisations.

This could create a two-tier system, particularly in terms of pensions, with the third sector potentially facing serious workforce problems trying to offer all their staff the same benefits, it argued.

The biggest challenge is the social care workforce is not visible or valued, Hedge pointed out.

While sectoral bargaining could enhance the value of social care work, there also could be some unintended consequences, she said. ‘One of the risks we have, and we saw this with the nurses, is coming up with what that agreed rate of pay will be’, she explained. ‘It was only last week that nurses were sent the letter agreeing the uplift for 22/23, two weeks before the end of that financial year.

‘If you are in business, you need to project across that year, what your income is and know what to charge, if you know how much you have to pay your staff.

‘For most of our care at home providers and care home providers, 89% of their costs are workforce related, so it is a massive proportion of costs.

‘If there was so much delay from bargaining arrangements, it might be they find themselves in a situation where they have not charged enough and haven’t had that income to back date that payment.

‘So, I think there are a lot of financial risks that could happen as a result of sectoral bargaining if timescales aren’t met.’

Hedge said if the situation with the nursing agreements was replicated across the entire workforce, there would be a risk of providers closing down.

She added providers also needed to know how much to bill private clients as they would be paying the staff working with them the same rate.

If Yousaf is prepared to go back to the negotiating table, Scottish Care would like to see the bill extending the human rights-based approach to care and support recommended in the Feeley report to people in care homes.

It also wants to understand more what a care board is and what it is likely to do as there are concerns there is a risk of duplication with integrated joint boards, which link health and social care.

Low added: ‘In terms of delivering improvements for the workforce, the bill doesn’t touch on them, so it is completely irrelevant.’

He argued national workforce standards being set and a degree of national training, including planning for training, and the promotion of social care as a job should be enhanced instead.

The new First Minister has a lot of work to do between now and the end of June to get everyone in the social care sector on board with the National Care Service Bill.

Care Markets: April 2023

Having a voice

Forty-two integrated care systems (ICSs) were created by the government in July, with the aim of bringing all stakeholders in health and community care together in a way their predecessors did not. Under the ICSs, and the integrated care boards (ICBs) formed to replace clinical commissioning groups, an end to silos was promised with health, social care, housing and education services working together.

Explaining the concept while giving evidence to the House of Commons health and social care select committee, social care minister Helen Whately said: ‘The thing that I see as different about integrated care systems and the institutions within them is the extent to which they are bottom up.

‘While we have 42 integrated care systems and integrated care boards and a framework that has been put in place by legislation, it was very much driven by parts of the system saying that was what they wanted.

‘It is a framework that allows a significant amount of local variation.’

But seven months on, social care providers are reporting they are not being involved or consulted by the local ICSs, with contact being described as ‘patchy’ at best.

Instead of being the desired ‘bottom up’ model, a top-down version is pre- dominant with the NHS taking the reins, according to social care representative bodies.

Care England chief executive Professor Martin Green said ICSs are dominated by the NHS, which considers having a local authority director of adult social care on the ICB all the representation that social care needs. ‘We are now starting to see some ICBs not engaging with social care,’ he said.

Senior policy, research and projects officer at the National Care Forum (NCF) Nathan Jones, agreed. ‘I think we are at the point now where it is very clear to us that social care providers are not being engaged properly at the top level.’ However, he said when this is mentioned to the boards, there is defensiveness because they think they are engaging. NCF members disagree.

Jones added: ‘It is that NHS mindset of command and control in many ways. There are attempts to shift that culture, but when you have got that direction from above, pressure from above and in other parts of the system to discharge people, the focus becomes I can pay you money to do what I need to do rather than let’s have a discussion about why four weeks doesn’t work to get someone out of hospital, rehabilitated and back to their homes. What needs to be put in place to make that more effective?’

Whately acknowledged there was a problem while giving evidence to the committee. ‘There is a local authority voice on ICBs, yet I know from conversations with providers that local authorities can be seen to a greater or lesser extent as the voice of social care, because local authorities are the commissioner but generally not the provider.

‘There are some very interesting examples where ICBs and integrated care partnerships (ICPs) have gone further in having a care provider voice in the room as well. I do not mean to call on Bristol so much, but when I was there I had a meeting that involved the acute trust, ICB representatives and a care provider representative, and that was a valuable part of the conversation,’ she said.

‘It is an example of how integrated care systems can look around and learn from what other places are doing. The benefits of having a strong care provider voice in the room, as well as the local authority, are really important.’

Social care having a voice is critical to ICSs delivering their goals of dealing with population health problems and wider wellbeing, and focusing more on pre- vention and community work, including social care, housing and mental health services. However, stakeholders are reporting that in the seven months the ICSs have existed, the entire focus has been on discharging people from hospital.

Jones said: ‘We are just focusing very narrowly on care homes for over 65s or domiciliary care for over 65s. What about all the stuff about helping people before they get to the point of needing an NHS in- tervention? What about people of working age with learning disabilities or autism or people with less needs than that just to stop their health deteriorating?’

Furthermore, social care is not just about protecting people’s health. It is about allowing people to live really good lives and enabling that. ‘I don’t think system leaders view ICSs as the means to facilitate that’, Jones added.

ICBs are currently submitting integrated care strategies to NHS England. These will be five-year plans that get reviewed every year.

Jones said: ‘If we don’t have social care at that table, if we are not ensuring that voice is fed in, then we are going to have some problems here.’

In response, the Care Provider’s Alliance (CPA) is lobbying the Department of Health and Social Care trying to produce some guidance for ICSs on including social care.

‘Within CPA, I think we are all on the same page about needing to have as close to mandated representation as possible’, he said. ‘That is not to say some ICSs will not engage with the care associations. It just doesn’t seem like much progress has been made on that front.

‘The problem is, the rebuttal that comes back, from ICSs and local authorities, is “if we have to mandate for you, we have to mandate for everyone”. Our view is this is not the case. If you are really focused on getting discharge to work, the key things that are blocking your system is social care. Why would you not want to speak to us? It seems like a false argument to us.’

CPA is also putting on a series of webinars for the sector and ICS leadership to try to make them understand what social care is and the importance of its role in delivering the ICSs’ objectives.

However, many in the sector believe education is not enough – a cultural change is needed.

Professor Green said ICSs were the latest in a ‘well-worn path’ trodden by primary care trusts and joint wellbeing boards before them.

He said: ‘I do not see any chance of it changing. Every time the government goes down the route of changing the structure. The cause is the culture.’

Jones added: ‘That whole culture piece is the reason that we are asking for mandated representation because the culture in so many places means that social care does not get a voice.

‘It is not that we are not optimistic, we are just frustrated that the obvious things aren’t being done as we would hope for it to happen.’

One cause for optimism is a review conducted by Patricia Hewitt, former secretary of state for health and chair of Norfolk and Waveney ICB.

While the terms of reference of the review does not extend to social care’s role within ICSs, there have been elements of social care in the different workstreams used to gather evidence.

NCF has been on those calls and social care providers have spoken to her directly and the review is due to be published on 15 March, the day before the Spring Budget.

Jones said: ‘We are just waiting with bated breath to see what’s in that final report. I think people are nervous that we are just going to see an NHS-focused thing again. I think that’s our concern.’

Care Markets: March 2023

Route to recruitment

With increasing challenges around recruiting local staff and the relaxation of visa requirements for care workers in 2020, providers are increasingly looking overseas to fix workforce shortages. Some are using innovative methods, such as forging links with immigrant communities in the UK and using connections both home and abroad to recruit staff.

Lancashire-based Clifton Homecare started employing overseas workers in January 2021 and has recruited 12 permanent staff to date, with ten recruits still on the payroll.

The homecare agency started this journey after being approached by a potential employee from the Philippines whose sister lived in the local area.

After checking her references, some significant investigation into the process, Clifton obtained its sponsorship licence in November 2020.

All those recruited are friends and family of current employees and are interviewed virtually. All references, police checks and UK DBS’ are completed ahead of their arrival, and all employees must complete their IELTS examination, pass their care certificate and hold a driving licence.

Managing director Caroline Cosh told CMUK she foresaw the recruitment challenges coming as the UK economy reopened after Covid-19 restrictions were eased and decided to plan ahead.

To successfully recruit she said providers needed to explore the potential challenges and seeking a way of managing those challenges before they even arise, so when they do arise you have a plan. For example, using a DBS provider that would complete a check on workers from outside the UK.

‘You need to be organised with it and need to try be one step ahead, if not two,’ she said.

Oxfordshire-based Taylor and Taylor, which operates three nursing homes in the area, has been recruiting senior care staff from overseas for the past 20 years, bringing in upwards of 200 nurses.

When the health and care worker visa was introduced in August 2020, the provider decided to recruit overseas employees to care roles that it could not fill locally.

Managing director Charles Taylor said: ‘We had to find another source. We were already using short-term agency workers to fill shifts and that is not sustainable long term.’

The senior workers Taylor and Taylor have recruited over the years form part of the local Indian community, which now helps new workers coming from overseas get settled.

Taylor said: ‘We now donate to that group, we talk to that group on a semi-regular basis, and because of that we get a lot of workers. They are all from a number of towns in the same part of In- dia. They know we are a decent employer – we are not going to abuse our position as sponsors – that has helped us bring people over that have some connection to our existing workers.’

Furthermore, one of the nursing home group’s former employee has set up a recruitment agency in India, which sources the candidates for the provider and arrange flights and local accommodation.

Taylor said it normally takes up to two- and-a-half months to get a new worker to the UK, so they tend to over-recruit for positions, assuming that there is going to be some staff turnover. He said: ‘By the time they are here, we will have the jobs for them.’

Simon Newton, recruitment lead at Rushcliffe Care Group, said its business would not have been able to grow without overseas recruitment. He said: ‘It hasn’t just been about the number of recruits welcomed into the team but the investment in them that has seen us be able to train and develop staff into highly skilled and knowledgeable health and social care workers which helped us to be
able to support and care for our service users.

‘Through working in partnership with our trusted overseas partner we have been able to grow and develop the business at rate that might not have otherwise been possible. We are lucky to have not only seen our own growth but that of some the recruits that have joined us. Many have been with us for a number of years, and we have seen their careers grow and develop alongside us.’

Rushcliffe has been working with an agency partner based in the Philippines for a number of years, holding interviews virtually and making sure they comply with immigration laws.

Newton added: ‘We are lucky enough to have our own staff that are very knowledgeable in this area, along with the support of our agency.

‘Before our new staff members arrive, we help to secure housing for them, and help with things like setting up bank accounts and settling into the local areas. We pride ourselves and the support we offer to our newest team members and see the going “the extra mile” with them as a real reason the overseas recruitment has been so successful for us.

‘Rushcliffe helps to cover the costs for many things when the new recruits come over that other companies and agencies might not. It can be a big investment, but the commitment shown has always benefitted us.’

The immigration process is one of the biggest challenges when recruiting from overseas, particularly dealings with the UK Home Office.

‘They are almost a law unto themselves because of the sentiment in the country. It is almost like the system is set up to trip you up,’ Taylor said. ‘You can lose your licence over a small problem in paperwork. The Home Office decides if it is right or it is wrong. There is nowhere you can go to appeal the decision.’

Cosh said Clifton Homecare has also experienced delays with the Home Office when certificates of sponsorship are requested, with her local MP helping expedite this process.

She added finding secure and safe short-term accommodation in a timely manner that is ready for arrival but not too far ahead so recruits are paying for this before entering the country could also be problematic.

Supporting overseas workers through to the first six months of employment; checking they are well housed, have everything they require to live comfortably and support with their job roles, was one of the key lessons Clifton has learned.

Alongside support to settle in, Taylor said extra training was needed within the workplace to overcome language and cultural barriers. He said: ‘You do have to put in more effort with training to create those connections because they are not as natural.’

Newton added supporting overseas staff at the start had led to high retention rates at Rushcliffe Care.

He said: ‘A very high percentage of the recruits stay with us for a number of years, with many able to develop to senior roles. We firmly believe that by being committed to our overseas staff from the start this is reciprocated from the recruits. Many look to settle down and bring family members over.’

The benefits extend to service users with Clifton Homecare clients giving ‘incredibly positive’ feedback about the overseas workers during a recent survey.

‘I think what helped with that was the open lines of communication. We communicated with them six months prior to recruiting,’ Cosh said.

This was in the form of newsletters, introducing members of staff, sending a biography of them and inviting some clients in to talk to them when they first arrived.

Cosh added: ‘I would do it again tomorrow. We have no plans to recruit more staff but, as the need arises, we will go back down that route.’

Care Markets: February 2023

Unable to respond

This summer a report by government education watchdog Ofsted found the Covid pandemic has exacerbated long-standing staffing challenges in children’s social care. This has led to children living in unregistered homes or in places where their needs are not met, the report concluded.

Ofsted chief inspector Amanda Spielman said at the time: ‘Children’s social care has been plagued by workforce challenges for some time. But we have seen these issues accelerate in recent years, with more social workers moving to agency contracts, and residential workers leaving the sector entirely.

‘As a result, too many children, with increasingly complex needs, are not getting the help they need. A workforce strategy and improved support for disabled children and those with mental health needs, and their families are more urgent than ever.’

A Children’s Home Association (CHA) survey conducted in February and March found half of its members were not able to operate at normal staffing levels, with about a third operating at 70% or less capacity.

Members reported recruitment was more difficult than it had ever been and had little confidence it would be resolved.

CHA highlighted the challenges at a roundtable with the Local Government Association and the Department for Education earlier this year.

‘We have had zero support so far from government. Lots of talk but no actual tangibles so that has been really frustrating,’ said CHA deputy chief executive Mark Kerr. He said requests for children’s social care to be added to the skilled worker shortage occupation list to recruit from overseas had been refused.

In addition, the regulation of 16-plus accommodation next year is expected to further exacerbate the situation. ‘They are going to take more from our sector,’ Kerr said. ‘It is holding back the sector to be able to respond to local authority placements which are so desperately needed.’

Like adult social care, many people are leaving the sector for better paid jobs in retail and hospitality, with the cost of living impacting retention. Kerr added: ‘If you are struggling to pay your bills and you can solve that by changing jobs, you might have to do that.’

The vast majority of children’s homes providers are locked into local authority contracts, meaning they have very little flexibility to increase worker’s wages.

A Local Government Association (LGA) spokesperson said: ‘We are aware that children’s homes have been unable to open, or have had to reduce capacity due to staff shortages’.

Staff shortages have led to some care groups having to take a large number of placements offline.

Kerr said: ‘I think for a lot of the established providers, from that point on it has meant any plans to expand or create new provision have been paused because they couldn’t staff what they had.’

While Kerr said that situation had now stabilised, he added a lot of the provision coming online is from new providers.

Those that are opening new homes are having to increase the salaries and CHA estimates next year £25,000 would be the core salary for residential care staff.

‘If you are giving that to new staff, you have to give that to existing staff and then that pulls up all other different staffing levels,’ Kerr added.

In response to this challenging environment, residential care and fostering provider CareTech has been investing in initiatives such as local and targeted recruitment campaigns, including a Young People Strategy.

Nigel Taylor, group head of learning and development at CareTech said: ‘We are working in partnership with schools, colleges and organisations like Youth Employment UK, Careers & Enterprise Company and the 5% club to identify potential career pathways for young people.

‘Apprenticeship schemes for people of all ages have provided opportunities for staff to grow their knowledge and experience, and over 5% of CareTech staff are doing apprenticeships.’

The operator has also created a career pathway within the group and has launched a management development and leaders coaching programme to source their own managers within the organisation.

Taylor added: ‘We want people to have high expectations and aspirations for a career in the care sector. We also know that upskilling our staff benefits them and the people they support.’

Recruitment and retention problems are not limited to junior staff. The workforce challenges are also acute at management level.

Kerr said managers’ salaries had gone up by up to 20% as there is a shortage here too. ‘We have seen examples of recruitment companies sending around CVs of really good experienced managers but they are commanding £70,000.’

CHA is launching a national recruitment campaign in mid-January to improve the perception of residential children’s care as a ‘valid vocation’, highlighting the experiences of those working in the sector already.

Kerr explained: ‘A large proportion of the public don’t know what goes on in children’s homes.’

‘There are great opportunities for progression. There is no reason why you couldn’t come in and start working in a children’s home. If you got your head down to do your qualifications, in two or two-and-a-half years you could be a registered manager earning £50,000.’

The poor perception of the sector is a barrier to attracting new workers, according to the LGA, which said the national narrative around children’s social workers ‘urgently needs to change.’

A spokesperson explained: ‘This is difficult, highly skilled work, yet too often children’s social workers do not receive the respect and recognition that they deserve in the media.

‘When tragedies happen, children’s social workers can find themselves vilified in the national press and facing threats to their safety. Not only is this unacceptable, but it drives good people from the profession and prevents others from joining.’

CareTech agreed that more stakeholders could support the sector in portraying a career in care more positively.

Taylor said: ‘We need the media, providers and the general public to help us challenge the stigma of promoting care as low-skill, low-paid roles. Working in care is a professional, highly skilled job, and we advocate for professionalising the status of care workers, so they receive the recognition and status they deserve.’

LGA also called on the government to address the current shortfall in funding for children’s social care and invest in new pathways to bring people into the profession, as well as to tackle the current challenges posed by some social work agencies which are ‘driving up costs while hampering councils’ ability to provide the best possible support for children in care’.

A Department for Education spokesperson said: ‘Our Frontline and Step Up programmes have trained more than 3,900 new social workers since 2010, but we recognise the pressure on children’s services, which is why we are providing councils with £4.8bn in new grant funding over the spending review period to 2025, to help maintain vital frontline services, including children’s social care and children’s homes.

‘This funding will create additional provision in children’s homes for children and young people in their area.

‘Ahead of next year’s publication of our bold reform plans to fundamentally improve children’s social care, we are working closely with the sector to make sure future services build on the strong evidence base we have developed over the past ten years.’

Care Markets: December 2022/January 2023

Developing Supply

More than ten years after Winterbourne View, the government has unveiled its latest strategy to reduce the number of people with autism and learning disabilities in inpatient settings.

Building the right support action plan, published in July, carries forward the commitment in the NHS long term plan to close 50% of inpatient beds by March 2024. It comes after the 2015 target outlined in Transforming care for people with learning disabilities to close 30-50% of beds by 2019 did not happen.

A core part of this new plan is to strengthen community support so people with learning disabilities and autism can leave institutional care and, crucially, do not return.

According to the latest NHS Digital figures, there were 1,965 people with learning disabilities or autism in inpatient settings. Of this number, 1,110 had been in hospital for over two years.

Mencap head of policy Dan Scorer said: ‘Recent months have shown modest falls, around 20‒30, which is of course welcome, but the general trajectory is we are not on course to meet that target of closing 50% of beds by March 2024. ‘One of the huge questions is around the community support services, which are desperately needed to prevent both further admissions and for people to be able to come back home.’

Scorer said the two biggest reasons why the target is not achievable are lack of social care support and a shortage of supported living housing. He explained: ‘The question is how to make a fundamental difference to social care and specialist skilled services in the community and how will it bring new housing options on board? We don’t see convincing answers to either of those or how progress is going to be monitored and who is going to be accountable if there is a lack of progress.’

Chief executive of Dimensions Rachael Dodgson said there were good things
in the plan. These include making sure health support professionals are trained, making it easier to access community support and funding, increasing the amount of housing options, and the delivery boards ‘should have some teeth’ to monitor progress, she said.

‘I think there is some stuff in there which should make a difference. It should reduce the numbers but there needs to be proper community support services available,’ Dodgson said. ‘Without that proper funding into community settings, there’s not going to be places for people to go and live.

‘The workforce challenges are adding to that, because to discharge people into the community you need quite large staff teams, you need consistent and skilled teams and the current workforce pressure isn’t helping with that.

‘Social care has been under the cosh for years and the latest Skills for Care data shows a 52% increase in vacancies from last year. It is difficult for the sector to support the people already within it needing a service, never mind the people who need to move into it as well. I think that is a real difficulty.’

Scorer said: ‘It makes the work Skills for Care does in terms of training and developing the workforce even more urgent.’

He said people coming out of assessment centres are often traumatised and coming off misprescribed anti-psychotic medication and adjusting to life outside of an institution. ‘Staff teams need a lot of support and need to be resilient in supporting that person through that journey.’

He added the right pay and career progression is not there yet to be able to recruit and retain staff. Dodgson agreed saying the sector needed ‘proper funding’ to be able to pay people at a good rate and have parity with the NHS.

The Department of Health and Social Care would not comment on what it is doing to boost the workforce working within supported living settings.

However, a spokesperson said ‘tens of thousands of extra staff’ had joined the workforce since visa changes were introduced and it was ‘investing £15m to boost the international recruitment of care workers’.

In addition, forthcoming changes to the Mental Health Act mean it can no longer be used to detain people with learning disabilities and autism.

Dodgson said this would mean even more community settings would be needed for people to move into. ‘There really has to be a focus on that from our perspective,’ she said. ‘For people, the accommodation has to be right. Often people need quite specialist housing in terms of the robustness of the environment and where it is.’

Senior director of care at Christie & Co Simon Harvey said many care operators in his home county of Cornwall were having to accommodate people in the most deprived areas.

Here property is more available but is not the healthiest environment for people leaving institutional care, he argued. ‘It is probably the same across the country,’ Harvey added.

CQC noted in its latest State of Care report it was seeing increasing registration requests for large-scale services, often situated apart from local communities that could ‘have a negative impact of the quality of outcomes for people living there’ rather than small-scale housing.

According to the report: ‘A substantial proportion of applications we receive are refused based on inappropriate models of care or the applicant’s poor understanding of how the model should be delivered.

‘We have found that often providers do not recognise the importance of being part of the local community and the value of feeling at home in their wider environment.’

Harvey said planning is also an issue in terms of the bigger units. He added local authorities have a certain number of houses in multiple occupation (HMO) that they will commit to a certain area and there are areas where they will not allow any more HMO licences.

Furthermore, in some areas, student housing, which could have been used as HMO, is being converted back into big family properties. ‘That has limited the number of these properties that are available,’ Harvey said.

He added reaching out to landlords, who often are not aware of opportunities with supported living providers, could lead to sourcing new accommodation.

‘No-one really knows what a supported living accommodation is as most of them are not badged.

‘I understand why but, therefore, it’s not as well-known in the wider community. I think profile is something that would make a difference,’ Harvey said. Mencap wants to see a government strategy for people with learning disabilities and autism based on what housing is needed and where, and making funding available for local areas to develop the necessary housing supply.

Scorer said: ‘The action plan bandies around huge multi-billion-pound numbers for housing and money that has been made available.

‘What we are trying to do is find out how much of that is actually going to be available for the job of housing for people coming out of inpatient settings and people living in the community now.’

Dodgson agreed it was difficult to track if the funding is being used in the right way.

She said: ‘There needs to be a better way of looking at the money being used on inpatient care, on crisis support and things that are happening at post-discharge care and looking at that over a period of time and really tracking that to understand what the NHS is paying and what are local authorities paying.’

Care Markets: November 2022

FIT FOR THE FUTURE

Mixed  tenure schemes are becoming more prevalent in the private retirement housing market, driven by demand from both consumers and investors. Research published by property consultants Knight Frank found last year some 25% of the £1.4bn invested in the market was for rental projects.

Furthermore, two-thirds of private operators are currently offering rental as a tenure option, either alongside leasehold properties or as fully build to rent platforms.

Head of the seniors housing consultancy team at Knight Frank Lauren Harwood told CMUK: ‘There has always been a large proportion of stock that has been rented but it has been affordable for social rent. It is not a new concept it is just how we are perceiving it and the reasons why this has come about.’

She explained in the last ten years more institutional investors had come into the sector, particularly in the private and integrated retirement community part of the market.

This has led to a desire to diversify and a shift to more urban and larger developments. ‘I think it is really interesting. We have seen an increase in rental but we have also seen other options coming through, like more shared ownership and rent before you buy, which are tools being used to widen the market and affordability and to also give the tenant flexibility,’ Harwood said.

Prime examples of this diversification are AXA-based Retirement Villages Group, which is committing 40% of pipeline units to rental, and Inspired Villages, backed by Legal & General and the NatWest Group Pension Fund, offer- ing tenure-blind choices, with every unit available to buy or rent.

Inspired Villages chief executive Jamie Bunce said older people should be given the choice over how they want to live. ‘We looked at it that we should align with our customer as best we possibly can,’ he said.

As its investors are social impact funds, they were very keen on offering more choice.

Bunce said: ‘Our investors very much want to see a product that is fit for the future. In that case it is a matter if somebody chooses or wants to rent, that they can, and they can have the choice of where they want to rent.

This includes allowing residents to choose whether they want to rent or buy a particular property. This decision can also be changed at a later date, for example, if a resident wanted to rent for a period before deciding to buy the property or vice versa.

Bunce said there was strong take up of units at the start of the year but slowed down in Q2. Inspired Villages is now looking at how to showcase the offer for the rest of the year.

Of the seven schemes Inspired Villages operates, three are fully sold out and now going through resales.

Bunce added a typical scheme would be 20-25% of apartments rented as the estate matures, but that could change in time. ‘In many ways we are following what people’s sentiment is,’ he said. ‘We are there to help to support these decisions as they come forward and then see how the take-up happens.

‘We do see a predominance of smaller apartments for rental, predominantly single females in this case at the moment. But we are ready to flex with it on a person-by-person basis.

‘We are seeing baby boomers coming through with enquiries now. It is the first year we have seen this,’ he added.

The operator is looking closely at how people consider their capital and income and make it work for them, as are many of its competitors.

Tenure diversity is a good thing as not everyone wants the same thing, according to Michael Voges, chief executive of Associated Retirement Community Operators. He explained: ‘Rental is likely to be interesting for a number of groups, for those that are older. If you are 88 and your health isn’t the best it can make total sense.

‘In many ways I think it is an evolution offering that option and that’s a good thing.’

Voges added an operator’s business model needs to be set up to support rentals. ‘For people like Inspired it works because they can say what the price is, and they are responsible for the life-cycle costs of the scheme anyway as they charge a deferred management fee (DMF).’

When individual apartments are bought for rent in a leasehold scheme, there could be legal problems if a developer wants to refurbish the scheme, as it would have to negotiate any updates with all the residents.

Of the 5,500 rental units in the private market, which equates to around 1% of stock according to Knight Frank, the majority are ‘pepper-potted’ within a leasehold scheme with 10‒15 units to rent and the rest to buy.

One industry insider said often this was a fall-back for apartments that have failed to sell. They said many mixed-tenure schemes are still the result of business models that ‘aren’t quite right’.

For those developers who do get their business models right, they can expect to see strong demand from both investors and older people.

Harwood said: ‘We are seeing a lot of demand and seeing the schemes fill up and we are seeing that flexibility does work. People are realising that maybe they don’t have to sell the family home or certainly not straight away.

‘We are seeing more and more demand from investors with the problem being a lack of platform.’

She said, from an investment perspective, adopting mixed tenure helps accelerate absorption rates and widens the target market.

Voges said institutional investors want the income from both DMF and rent. ‘Investors want to park their money and they think rental is a steady investment stream,’ he said.

‘What I keep saying is you can’t let the customer proposition be dictated by the capital structure behind it.

‘Mixed tenure is good if it is part of diversifying your offer and responding to customers’ needs.’

Inspired Villages, according to Bunce, can be agnostic about mixed tenure because their funders like both DMF and rental income streams.

He said: ‘Investors are very interested in rental. In conversations with our investors we say, “surely we should be driving with what the customer wants and where they want to live”. We realise that not everybody has that flexibility, but we do and we are going to ensure we make the most of that.’

There are, however, limits to how much the rental model in the private residential housing sector could grow as the majority of older people want to reduce their outgoings and have been homeowners for most of their lives so want to continue with that level of security.

Growth projections range from a quarter to a third of the private market being made up of rental units in the future.

‘Rental is on the cards and it is opening up those urban locations and allowing the market to widen up,’ Harwood said. ‘We do think that rental will accelerate at a very fast rate. We are projecting that 114% growth in the number of private rental units to about 11,500 by 2026.’

CARE MARKETS UK: SEPTEMBER 2022

Southwark ‘supplement’ aims to boost retention and standards

A new pilot programme outlining the expected standards for care home residents in the London Borough of Southwark starts this month (April).

The voluntary Residential Care Charter, which has been developed in conjunction with Unison, also covers minimum standards for care home workers, including paying all staff the London Living Wage (LLW).

Workers should also be paid for the time needed to carry out a handover between shifts, training must be offered for free and delivered in work time, according to the charter.

Finally, the charter stipulates that zero-hour contracts must not be used in place of a permanent one unless requested by that member of staff.

In return for adhering to these measures, providers will receive a financial uplift from the council.

The “Southwark Supplement” is a separate agreement with care home providers, which allows the council to fund the gap in pay for staff who are not already paid the LLW.

This will be monitored by the council’s contract team during the year-long pilot, Southwark said.

If successful among residential care homes, it will roll it out to other settings the following year.

Director of commissioning for children’s and adults’ services at Southwark Council Genette Laws said the charter was born out of residents wanting more than just a focus on the terms and conditions of the workforce.

Laws said: “During our consultation with residents and their families, we asked what was important to them in terms of living in a care home.

“Their expectations are reflected in the Charter, including around residents and families meeting with staff, families being able to visit their loved ones, and clearer timelines for managing complaints.”

During the pandemic, the council used fortnightly Care Home Forum meetings, which are attended by care home managers, to talk about the Charter and seek their views. 

Laws added: “The care home managers broadly welcomed the ideas. The most frequent question asked was how care homes would fulfil paying the LLW commitment if the council did not pay for all the residents in the care homes. 

“We want our residents to continue to have choice about where they want to live and receive care, so we had to come up with a novel way to ensure that the LLW was paid directly to all staff regardless of whether they were supporting a resident funded by the council.

“We are piloting an approach where we pay care home staff a Southwark Supplement so all staff in care homes are paid at least the LLW.

Laws added that the council has received expressions of interest from around a fifth of homes in the borough so far.

This includes residential and nursing homes, and homes that support older people and working age adults.

The charter came about after Southwark approached Unison about helping it draw up a set of standards.

The trade union has developed its own charter for residential care, but it didn’t take off as it’s a lot harder for councils to influence residential care due to the prevalence of private payers and a mix of people from different local authority areas, explained assistant national officer Matt Egan.

He said: “Councils were not really keen to intervene and change or influence the provision of residential or nursing care.

“So, it is really good that Southwark are taking this step to influence the standards of care in their residential settings.”

Egan added that Unison was very keen to see how the charter works in practice and the trade union is hopeful that it will have a sizable impact.

He said: “We are going to try to promote what Southwark has done among our branches and getting them to take the example to their corresponding council officers. And we will be very keen to see how it goes in the borough itself.”

Laws added that the council hopes the charterwill provide residents and families with clarity about what they can expect from a care home, support residents to experience safe and high quality care, and let the care home staff know that both the council and their employer value what they do and how they do it. 

She said: “In practical terms, we hope to see an increase in care home staff retention, a reduction in staff turnover; and a stabilisation of homes being rated Good or Outstanding in the borough.”

Care Home Management: April 2022

Retirement living fills gap left by care home acuity, says Santhem

Hallmark Care Homes has become the latest care home operator to move into the retirement living space with its offshoot Santhem Residences. 

Launching its first development in Shenfield, Essex, Hallmark joins a number of care home operators developing retirement communities. 

This market is backed by polices at both local and national level promoting the creation of more retirement communities and the Government announcing plans to launch an older people’s housing taskforce as part of its Levelling Up strategy. 

A recent Knight Frank report published this month (February) found that 2021 spending by institutional investors was £1.4bn, breaking previous records. 

All the signs are there for this part of the social care sector to take off, but could it become a threat to existing care homes in terms of competition for residents? 

Retirement communities actually complement care homes, argued Michael Voges, executive director of Associated Retirement Community Operators (ARCO) the representative body for much of this sector. 

He explained that demand was being driven by more and more people living longer with co-morbidities and massive cohort of people born in 1946 who have just turned 75/76 which is where entry to retirement communities typically starts. 

Furthermore, in the past 30 years both nursing and residential care homes have moved up the acuity scale, taking in residents who need more complex care. 

Voges said: “There is nothing really anymore to provide for people who have some care needs but don’t have a huge amount of care needs.

“So for some of those care providers they are seeing there is an opportunity and this is a kind of extension of what we used to do.”

“There are many care operators who come to us and say this would not replace care homes but ‘complements what I do very well’ and it’s an important strand of that wider picture. 

Hallmark chair and Santhem chief executive Avnish Goyal described it as a “natural extension of providing high-quality hospitality and lifestyle choices as well as outstanding care and wellbeing”. 

He said” “It fits because we focus on the delivery of outstanding retirement care and wellbeing and by diversifying our portfolio, we expand the range of retirement living services. 

“More and more older people would like to live in retirement communities as more of them become available and prove to become a new standard. 

“There is more choice available, therefore, the retirement living offer will improve further over time.  

“We want to continue providing the quality we are known for by offering new and improved lifestyle choices for older people.”

Goyal said Santhem hopes to attract local people to live in the communities who “want to have a certain quality of life upon their retirement” by creating communities that “focus on providing enjoyable independent living exclusively for the over 65s”. 

Anchor, which already operates retirement communities, recently entered a joint venture with McCarthy Stone to develop an initial five sites. 

The partnership, which will see McCarthy Stone manage the retirement living properties while Anchor runs the extra care housing on site, expects to have its first two sites open by the end of the year. 

Anchor’s director of new business Charles Taylor explained that there was an under-supply of “truly affordable for all retirement communities”. 

He said: “The changing needs of our ageing society mean that demand for specialist housing and care is strong and is continuing to grow across all price points. 

“The partnership aims to tackle these challenges now by efficiently producing more homes where people love living in later life while driving more affordability and choice within the sector. 

“The partnership is also helping to reach our target of delivering 5,700 homes over the next 10 years.” 

There are, however, planning and regulatory barriers holding the sector back, largely because it is not clear where retirement communities fall on the social care spectrum. 

Taylor added: “Development is often difficult and expensive due in part to a lack of support and policy within the planning system. This is holding back investment in the sector despite proven need and demand. 

“We welcome the Government’s commitment to supported and specialist housing as part of the Social Care White Paper and are calling on the Government to ensure that the new planning reforms include changes which encourage local authorities to include older people’s housing in their Local Plans.”

 Care Home Management: February 2022

Dementia care goes Dutch

Richmond Villages Willaston has become the first large-scale social care setting to use the Dutch Hogeweyk model.

The facility comprises a ground floor ‘dementia village’ with six households of up to six people, each with their own front door. On the floor above there is a traditional 35-bed care home.

Within each self-contained apartment, residents with mild-to-moderate dementia are encouraged to carry out daily tasks such as cooking or laundry with the assistance of only one member of staff, known as the ‘homemaker’.

Much as they would at home, apartment residents can go outside by themselves in enclosed private patios to do some gardening, and inside, as many household activities as they want. 

The traditional care home is there if required

Richmond Villages Managing Director Philippa Fieldhouse explained: “The idea is we can look after them at the different stages.”

In its two months of operation, the Hogeweyk approach to providing has had a “hugely positive” impact on its residents with dementia, Fieldhouse said. “Individuals are coming back to what their families recognise as a person. It does not feel like a care home. It is just like going into someone’s house.”

She adds that homemakers make a real difference as it looks like they are assisting rather than running the environment.

But could this model become the standard for caring for people with severe dementia in the UK?

Richmond Villages, which is owned by Bupa, decided to take this approach following a visit to the Netherlands see the Hogeweyk model in action.

Here it has been established for several years and residents are reported as feeling less stressed, have less problem behaviour and need less medication.

Frank van Dillen of DVA Dementia Village Associates, who was the main architect of the Hogeweyk project, said: “In general small-scale dementia care is far more beneficial than old fashioned nursing homes.”

He said the model was a different way of thinking by placing together like-minded people with the same background. For instance, residents who lived in a large city like London would be comfortable living in a high-rise block and be placed with people with whom they had shared interests.

Van Dillen added: “It is a human approach, not a medical approach. It is not hospital but hospitality. It is long term care.”

Existing care homes could be converted to create these smaller scale settings, but as the built environment is crucial, the traditional care home model would need to be significantly transformed to suit the needs of the residents in that area. “It is a complete package”, van Dillen explained.

Of course, implementing the model ultimately comes at a huge initial outlay on the property or land, which would ordinarily be recouped in the fees charged.

However, learnings from the Hogeweyk experience in the Netherlands suggests that you can provide these services within the same budgets as a care home, as you can make savings in other areas, for example, the number of staff needed on site.  

Fieldhouse agreed, saying that, while the costs were higher in terms of setting up the village, there were savings as one homemaker looks after the whole household and they have acoustic monitoring at night.  

“The investment really does pay off”, she said. 
But how can this model be replicated across the UK, which has an ageing care home stock that is being updated slowly and where larger, traditional dementia care homes make more economic sense?

Property consultants Knight Frank said that converting smaller-scale nursing homes to the Hogeweyk model would not be viable due to the significant amount of land needed to create the village.

Healthcare team associate Mandip Bhogal said: “We are aware of developers and operators incorporating this concept within their forthcoming schemes, albeit a very small number of developers and operators.

“The key constraints are around scarcity of suitable sites and the viability of the concept from a development perspective.

“There also needs to be a higher degree of awareness of the Hogeweyk model within the UK.

“We think that any government incentives towards such schemes would be much welcomed by developers in the UK, given the that projected number of people suffering from dementia is to increase to 1.3m by 2028.”

Care Home Management: June 2021

A trusted Approach

With NHS waiting times reaching record levels, alleviating the problem of delayed transfers of care has never been more important.

NHS figures show that November to February is the busiest time of year for hospitals, with more than 20% of admissions from A&E taking place last December and January. And the problem looks set to intensify this winter once more.

The Department for Health and Social Care has allocated £6.4bn through the Better Care Fund to projects that join up health and social care services to ensure a smooth and timely pathway out of hospital.

One of these vanguards was the introduction of a trusted assessor at Lincoln City Hospital. This person would assess patients on behalf of care home providers in Lincolnshire to ensure they could be discharged into an appropriate social care setting.

The fund pays the salary of the trusted assessor, but they report to Lincolnshire Care Association (LinCA). Such has been the success of this scheme in the county, they are now starting to assess patients for homecare services.

But this has thrown up its own unique challenges. Chair of LinCA and chief executive officer of homecare provider Walnut Care, Melanie Weatherley, said there is often a delay in transfers of care into people’s homes as there is not enough capacity to deliver the amount of care social workers prescribe on discharge.

‘It is totally new and we are just not used to people with this level of complexity going in and out of hospital.’ She said Walnut Care had received assessments for people and initially could not offer them care. But when it looked deeper into what care was actually needed, rather than what they were prescribed, they were able to take the person rather than having to recruit someone specifically to look after that patient.

She explained: ‘The trusted assessor challenges the (standard) package at two people, four times a day because often you don’t need all of that.”

With state-funded care packages she said it could be problematic as providers would have to challenge the person commissioning the care to ensure it was deliverable. She explained: ‘There is a difference between being medically fit and my care staff being able to manage them. And this is very new because a few years ago, they wouldn’t have been going home.

‘They would have been going into a care home. And as we move people with more complex needs home, we do need to think “you are not just going in to wash and dress them”.

‘It is having someone there who under- stands and isn’t driven by the fact there are 42 other people there who also need an assessment.

‘My view is, if it gets three people a day home, two days before they would have done previously, it helps. In the winter, when the care homes are under stress,

it makes a bigger difference as often the care home manager or homecare manager can’t get to the hospital for a week.’

Assessing self-funded homecare packages, however, is very similar to doing the same for care home beds. Because they are on site, they can assess patients straight after a care home bed or homecare service is offered. Otherwise the managers must drive to the hospital to do it.

Weatherley said: ‘The way we describe it is imagine you have a deputy manager for your care home who lives in a cupboard in the hospital. It is really that simple. But it breaks down the barriers between the care home and the hospital sector because the care home sector can help to solve the hospital’s problem rather than being seen as the root cause of the problem.’

Furthermore, the patient needs to be able to trust what the assessor is telling them. Just having one person makes that easier, Weatherley said. ‘What we are finding on the homecare side is, they might not get the person home faster but they reduce the chances of them bouncing back in because the care fails because of the difference in reality and the expectation.

‘We recommend that a trusted assessor is someone who has been a care home manager or deputy and either is or has been recently a nurse. Then they’ve got both sides.

‘It builds up the trust between the care homes and the hospitals so if things are really bad, you have not got the confrontational relationship which you can have sometimes. They definitely make a difference is the feedback I get from the hospital.’

Kate Sayles, discharge lead for United Lincolnshire Hospital Trust, confirmed this saying the trusted assessors had helped to reduce patient’s length of stay in hospital as they can assess them on behalf of the care provider as soon as the patient is medically fit and able to return home, instead of waiting for the operator to come in and do their own assessment.
She said: ‘This in turn ensures no unnecessary delays and is fundamental to a patient’s health and wellbeing.’

One body who will be watching LinCA’s progress closely is the Healthy London Partnership, which has been working with the Havering Care Association to establish a trusted assessor for care homes within Barking, Havering and Redbridge University Hospitals Trust. However, they are not at the stage to use the trusted assessor for homecare services just yet.

Jane Sproat, ageing well senior manager at Healthy London, explained it was important not to rush the process of setting up this system. ‘You need to be brave in trying something new. It is really about the relationships. You need to take time to make sure you are speaking the same language and encourage care providers to come forward and get them involved in this work.

‘One of the things that we sometimes forget in health is we do not always have the solution. We are now seeing some real differences.’

Sproat added the trusted assessor was only one part of a raft of measures such as NHSmail and Care Pulse designed to aid communication between health and social care providers.

Like Weatherley, she said the trusted assessor has helped change the per- ception that care homes are part of the problem to them being the solution. Such is its success in this London borough, only one of the 68 discharges carried out by the trusted assessor was refused by care providers.

She explained: ‘Trusted assessors by themselves won’t solve the problems of delayed transfers of care but there is a huge potential there to save bed days.’

Using a trusted assessor does offer potential opportunities for homecare operators, which policy director at the UK Homecare Association Colin Angel agreed with, but only when used appropriately.

As well as reducing patients’ time in hospital, it also offers homecare providers a degree of a consistency in the assessments they receive from acute trusts from someone who understands the local social care market.

‘However, trusted assessment isn’t a panacea: it won’t reduce the time people spend in hospital if the real problem is a lack of available care workers to provide the necessary support’, he warned.

Angel added: ‘It is fundamental that “trusted assessment” is just that: trusted. Care providers joining existing schemes should be reassured that they are confident in the assessment process and they should be involved directly in the creation of new schemes. ‘There is no obligation for a provider to accept or use a trusted assessment scheme in which they are not confident.’

Care Markets: January 2020

Mind the gap!

A gender pay gap exists in residential care. According to one report published earlier this year, male employees earn on average 11.8 per cent more than their female counterparts, compared to the national average gender pay gap of 17.9 per cent. 

Tim Kellett, director of Paydata, which carried out the research, said the difference in salaries could be attributed to the fact that men and women tend to do different jobs in residential care. Men are more likely to be on the service side, for example, in driving jobs, whereas the vast majority of care assistants were women. Kellett explained: “There are so many people being paid at the National Living Wage, so there is no inequality around the largest proportion of the workforce.”

At a senior management level, however, Paydata did not find any gender pay gap and there was no marked difference between for-profit and not-for-profit providers. Kellett believes this is because of the robust salary structure in place in care.

What’s more, he says that care organisations are becoming increasingly focused on avoiding accusations of unfair pay: 89 per cent of those taking part in the research said they were now monitoring the situation. Kellett said: “They have thousands of employees and get people saying, ‘how are we as an employer?’” Focus becomes extra sharp because there is a high concentration of people in a small number of jobs, he explained.

One care provider taking the pay gap seriously is the Orders of St John Care Trust (OSJCT). HR director Sue Lane said that while they operated a policy of equal pay for equal roles, men in the organisation tend to earn more than women because they tend to occupy the more highly-paid roles, for example, in finance and other corporate functions. Women within the organisation tend to take up the front line care roles. Lane admitted: “We need to look at matching gender balance in the homes. [Care] should not just be seen as a career for women. We need to broadcast more that care is a career for both genders.” 

To ensure that all staff are given career development opportunities, OSJCT supports career progression of its care home workers and talent development. She said: “We are giving people the understanding that there are career opportunities and promoting people with potential. That might start to realign the gender imbalance. But it is something that we need to do as a sector. It is where we have got to invest and spend more.” 

In a recent survey OSJCT said that more women were taking up senior management positions at the company. 

Traditionally, care roles have been adopted by women wanting to fit work around running a home, says National Care Association chair Nadra Ahmed, and they have had low pay expectations. With women dominating the frontline care workforce, this can make the gender pay gap seem wider than it needs to be.

Ahmed believes that it will take pressure from the ground up – from ambitious women themselves – to force companies to properly address the gender pay gap. Equally, care workers need to consider actually how easy career progression is when most care operators (84 per cent) are small to medium enterprises (SMEs). 

But things are starting to change, she thinks, particularly among the smaller operators. Ahmed said: “At a local level it is more representative; there are more women CEOs.” However, a bigger issue, she warns, is the lack of recognition of front line care as a profession. She said: “I worry about where the role models are in the sector. We have got to promote care as a career of choice and professionalise it, so we are not always being held up as the example of a minimum wage sector. 

“Social care does have to speak a bit louder that a lot of leaders on the coalface are women.”

Care Home Management: October 2019

The rise and rise of self-pay fees

As local authority care home fees remain frozen in many areas, the prices paid by self-funding residents are sharply rising year-on-year.

According to analysis of LaingBuisson figures published by magazine Which? this spring, the largest increases in nursing home fees for self-paying clients in the past year were in the North East of England (11.3 per cent) and Yorkshire and Humberside (10.9 per cent). 

Westward Care operates three care homes in Leeds with a predominantly self-paying clientele, which managing director Peter Hodkinson says is partly being driven by a lack of state-funded provision in the area. 

Hodkinson, who is also chairman of Leeds Care Association, says state-funded care now accounts for 42 per cent of beds in the city. “The number is still growing but the market place is changing,” he said. “The gap is because councils have been unable to keep up with what is a fair and affordable, even for state-funded care, and they are slipping behind year-on-year.”

Care England chief executive Professor Martin Green also acknowledges the growing mismatch between private and LA fees across the country as “local authorities are abusing their position by refusing to pay the true costs of care.”

Few nursing homes in Leeds now offer state-funded dementia beds as the fees being paid are too low, Hodkinson said. However, while a lack of state-funded beds is increasing the proportion of self-paying clients, it is the customers themselves who are setting fee rates by demanding extra, non-care services. 

“Somebody who can afford to pay, will pay, supported by their families”, Hodkinson added. “Families, whose parents might be of modest means, say: ‘We’ve done well in life so I want the best room, with a minibar and wet room as we will pay the difference’.” He added that a cost of care exercise carried out by Westward Care a few years ago found that for some services, fees increased by as much as 28 per cent. 

Alongside the East of England (7.7 per cent), the lowest increases in nursing home fees for self-pay funders were in London (8.6 per cent) and the South East (7.9 per cent), which boasts the lion’s share of self-paying homes.

Research conducted by Berkley Care Group on its portfolio of five care homes, four of which are based in London and in the South East, found that cost was not the most important factor when residents chose to live there. Chief executive Seamus Halton said: “What we have found in the areas we operate in is that price is probably the least important consideration coming into our homes.” 

For example, when it opened a home in Oxford and set fees at £1,200 per week, people questioned why it was so cheap when the average price in the area was £1,300. Furthermore, a spring offer of £1,100 per week for its Warwick facility was not taken up at all. (Warwick is the company’s only home outside London and the South East where rates are usually between £1,300 and £1,600.)

Halton explained: “There is an expectation that in a quality care home, prices start at £1,300 even as far out as Warwickshire. That is becoming very much the norm for the top-end homes. You have to price below £1,000 to have an impact on occupancy.

“In London, with a dearth of beds, you are almost getting to a point where you can charge what you like. In our Hillingdon and Bexley Heath homes we can charge £1,700 – £1,800 per week and customers don’t blink.”

He said that by providing a fully all-inclusive offering, which extends to residents’ family and friends eating for free in its bistro, bar and private dining and even spa treatments, was a more important factor than price. Halton said: “That is perceived as being worth more than it probably is.”

Halton added: “The South East is going to become competitive because that is where all the activity is; where everyone wants to be, so it is inevitable there will be a softening on price.”

Professor Green, however, argued that the disconnect in fees between state-funded and self-paying care will continue until the Government puts more money into the social care system.

Care Home Management: August 2019

Supporting staff through change

With Four Seasons Health Care entering administration and then being put up for sale, its 20,000 staff in its 250 homes face an uncertain future.

Stress levels for many social care workers are already at a critical level; a seismic shift in their workplace, such as the collapse of their employer, their care home being put up for sale or that dreaded word “restructuring”, can lead to some staff unable to cope. 

As well as impacting staff, it can also affect everyone in the care home if that person is no longer able to come into work. So how can providers help their employees during these difficult times? 

A Social Workers Union (SWU) survey last August reported that social care has among the highest levels of stress sickness absence of all employment sectors in the country. Levels of presenteeism (coming into work despite being so ill it would be better to stay at home) were also rising.  

John McGowan, general secretary at SWU, believes it is crucial that staff are able to access support during these times of change. He said: “You need a general management structure who know how their staff are doing. They need to be making sure they have access to training and future development. They need to be making sure they can progress.”

A spokesman for Four Seasons said they understood that it was crucial for staff to be supported in their work at this time. He said:  “We have made it a priority to ensure that all of our managers and care home staff are aware that nothing will change for them as the sale process continues, and we have maintained open lines of communication to management to ensure any concerns raised by our colleagues are dealt with promptly.”

Even if the day-to-day job doesn’t alter during this process, the uncertainty surrounding the future of an organisation can lead to high levels of stress. Anchor Trust’s merger with housing association Hanover last December affected around 10,000 workers in 1,700 locations. Anchor Hanover chief executive Jane Ashcroft acknowledged that, as well as being an exciting opportunity for both organisations, it was an unsettling time for staff, so it was important that colleagues were supported through the process.

Managers in both organisations received briefing packs and there was a dedicated email address for staff to pose questions to management. An internal social media platform, Workplace by Facebook, was also rolled out, allowing staff to post comments and pictures, ask questions and watch live broadcasts. Employees were involved in creating the branding of the new organisation. This helped foster a sense community, Ashcroft said.

Furthermore, before the merger completed, a new set of values were developed. She said: “A huge amount of work goes into a merger. But the formal completion of a merger is just the beginning in many ways, as teams get into the detail of how to integrate a variety of different systems, processes and ways of working. Having a shared set of values up front has really helped with that.”

Ensuring values have a key role to play in any deal is essential to reassuring staff during this period of change, John McGowan said. “It is about working with companies that have a good staff ethos, not just bums on seats”, he said. He argued that issues such as the professionalisation of staff should be set down in contracts when operators change hands.

Constant communication is key to keeping stress levels to a minimum during any time of change. When integrating more than 100 Bupa homes in 2017, HC-One held roadshows with 600 managers and key stakeholders around the country. On the first day of transfer of services, HC-One held a teleconference, set up helplines and sent out more than 300 bunches of flowers to staff. 

Ashcroft added: “Communication was, and continues to be, a key priority. When we announced that Anchor and Hanover were in merger talks, we were keen to explain the rationale and the benefits to both colleagues and customers. We published our business plan soon after the merger so that people could see how the merger enables us to grow and achieve more together.”

Care Home Management: June 2019

THE WATFORD GAP

While flourishing in the south east of England, private retirement villages providing care have yet to take off in the north. Apart from a handful located in pockets of affluence, most notably in parts of Yorkshire and Cheshire, where house prices are a similar level to the cost of acquiring a two-bedroom apart- ment in a development, this type of care facility has yet to take off. But demand for these types of services across the country is strong, so could this be an opportunity missed?

While there are retirement villages for private clients, where residents buy a property on the development, in the region, few offer care services. Those that do tend to be at the top end of the market. Demand is met at the other end of the spectrum by charities offering extra care housing for the most disadvan- taged older members of society.

There is no doubt that the demand for these services is there. Knight Frank’s recent report UK Retirement Living Comes of Age suggests a need for three million retirement living properties to house the number of people aged over 65 that would consider downsizing. This is based on the assumption that 25% of over-65’s in their existing homes would consider downsizing into some form of specialist retirement living.

Furthermore, the private retirement living market has expanded from 2% of total stock in the 1970s to almost a quarter of retirement stock at present, Knight Frank found. Since 2000, private units have accounted for 54% of all new units delivered annually.

So why is development in the north lagging behind?

Director of healthcare investment (alternatives) at JLL, Phil Schmid, explained that people at both ends of the socio-economic spectrum can afford to have their care needs covered either through paying privately or being supported by the state.

‘In the middle is not covered. There is no option other to remain in your own home until it becomes a burden and you have to move into residential care.’

One successful development is Middleton Hall Retirement Village, just outside Darlington, County Durham, which offers apartments and bungalows in its rural scheme, alongside a spa and a residen- tial care home.

Managing director Jeremy Walford said: ‘The issue is not so much the lower property prices, as land is also less expensive, but the lower rates of property price inflation and risk of property prices going down. This makes the ‘event fee’ model (where fees of upwards of 10% are charged on selling the property) less marketable. Consequently, the importance of making an ongoing profit from the retirement village services is key. In the case of Middleton Hall, this means providing high-quality care services.

‘We funded most of our development through bank debt as we had an existing care business to generate profit. In our model, we also made a development profit for the leasehold developments that reassured the bank that we could comfortably repay the debt.

‘There are advantages of operating in the north in terms of employment – Middleton Hall benefits from having charming, enthusiastic and friendly staff, all locally recruited. We also operate a wide range of services – in effect we offer a US style CCRC (Continuing Care Retirement Community) model that I believe is key. I cannot overemphasise the importance of quality though – it is critical for housing with care (ARCO regis- tered schemes) to differentiate ourselves from standalone retirement housing and care homes.’

Walford added that, while there was an advantage in being relatively unique and without true competition, the lack of awareness of retirement villages does provide a marketing challenge, as the number of self-funding clients was far smaller in its catchment area. But, he argued, with the right business model there was an opportunity for growth.

Audley Villages operates two villages in Harrogate and Ilkley and is developing a further site in Scarcroft, all within reach of Yorkshire’s most affluent areas. Also catering for people at the highest end of the socio-economic spectrum in the re- gion, these developments boast access to fine dining, swimming pools as well as on-site care services.

Chief executive Nick Sanderson explained: ‘They are all in what is called the Golden Triangle where affluence levels and therefore property prices are much higher than average. However, that does not discount going into new areas in the north.’

Audley is currently in negotiations to develop sites in the north under its new mid-market brand Mayfield, with an announcement expected next year.

Sanderson said: ‘Our Mayfield develop- ments will be more city centre and more urban. We can make them work in the north where house prices are lower.

‘Housing with care relies on home ownership and 77% of over 65s are home owners. In 90% of these cases, they are debt free so they have sole control of their homes. If they are in a low value area, the costs of a retirement village will need to be less. But in the north land costs are cheaper and building costs slightly less and, taking into account minimum wage, services cost less.

‘If you make it bigger with 250 apart- ments, it brings down the costs. I think it is a massive opportunity.’

So why are not more providers doing the same? Sanderson explained that housing with care ‘falls in a hole’ between housebuilders and care providers, with the former wanting to construct a village and then walk away and the latter not interested in getting involved in the development side.

‘Another thing is we need customers to demand services’, he added. ‘That will be the biggest driver. Once we start and we make it successful, then other people will follow.’

Executive director of ARCO, the representative body for housing with care providers, Michael Voges, agreed that mid-market schemes could be a potential solution to unlock the housing with care market in the north.

He said: ‘Larger scale building brings down the initial costs. It is probably going to be six months to a year before we see this model becoming increasingly popular.’

Voges argued that another factor that could drive the development of retirement villages in the north is the current shift among operators from a development model, where residents pay the costs up front, to more of an operational income model, whereby costs are recouped at the end of life through event fees. This means older people who are asset rich but cash poor can be offered fixed prices for services while they are resident in the village, without having to worry about future hikes in the cost which they may not have the disposable income to afford.

‘It is not about affordability, it is a liquidity issue’, he explained. ‘It is about how to operate incomes that will unlock the property market in the north.’

Schmid, went further saying a greater reliance on shared ownership as well as event fees could unlock the market.

He said: ‘It is tough when sales are reliant on property prices. But longer-term money is moving into the sector driven by income. People are starting to look at the sector.’

He said more clarification around event fees could attract new investors. ‘The beauty of the sector is there is a demand all over the country.

‘Because there are still risks in the space, they need to see high levels of returns. If they [the risks] are removed, it will allow them to grow more. It is not just the preserve of the South East.’

CARE MARKETS: OCTOBER 2018

Opening doors for LGBT

Imagine entering a care home and being unable reveal your sexuality, talk about past relationships, and be scared of the prejudices of staff and fellow residents.

This is often the experience of people from the lesbian, gay, bisexual and transgender (LBGT) community, who can find themselves forced back ‘into the closet’ when entering care for fear of being bullied or harassed. But initiatives are emerging to ensure that care homes are a place that members of this community feel comfortable being themselves.

Up to 6 per cent of the population identifies as being lesbian, gay, bisexual or other: statistically, this means most care homes will have at least one LGBT resident.

In June, Opening Doors London, which campaigns for LGBT rights, launched its Pride in Care quality standard. Care homes participating in the scheme can expect to achieve the required standard within a year at a cost of £2,000, and can display the Pride in Care kitemark for three years.

The kitemark is being piloted with three organisations: a care home group with 5,000+ beds, a mid-size operator and a small domiciliary care agency.  

The process includes reviewing all policies and procedures and staff carrying out an online survey to flag-up any concerns. Jim Glennon, who helped develop the standard, says: “The online training is to help people understand what it is like to be 80 years old and gay. It gives us a sense of if they have read the material they have been given. The final step is to visit a home and talk to three staff members and at least a few clients”.

Feeling safe and secure is a top priority for the LGBT people, according to Glennon. And, best practice involves ensuring anti-harassment policies for staff and residents are clearly displayed. “Things need to be concrete”, he said, noting that high staff turnover in care homes can create gaps in LGBT policy induction or training. 

Speaking at the launch of the Pride in Care standard, Care England chief executive Martin Green said: “When people get old, other people forget there is a life and identity behind them. We have got to move towards a personalised approach to care. That is central to delivering high quality care.” 

Already some operators have grasped the commercial potential of personalised LGBT care. Sanjay Dhrona, managing director at The Close Care Home in Abingdon, Oxfordshire, is developing a LGBT-friendly care home. He expects the purpose-built home to open in Didcot at the end of next year, where everything, including the suppliers, will be chosen for their LGBT values.

Dhrona, who is gay himself, said: “A lot of people want to make diverse and inclusive homes but care homes can be scary places for LGBT people.

“We want to create a space where it is a very diverse community. It all depends on the culture of the business. We would like to have an open culture. It’s a home that can accommodate residents who can identify anywhere along the spectrum. It is about the awareness in the training. We do not sell bedrooms, we sell care that focuses on the individual.”

He believes that a gay man at the head of the care home group will set the tone but great leadership notwithstanding – the Close Care Home has won multiple awards, including a 2018 Care Home Award – there will be challenges in the day-to-day running. For example, dementia may cause an otherwise liberal person to adopt conservative attitudes from a previous time, for example, when being gay was illegal.

Unlike other LGBT exclusive developments – Tonic Housing is planning an LGBT care village in London and Manchester City Council has announced plans to develop an extra care scheme exclusively for LGBT residents – the new Close care home will be a mix of members from the LGBT community and heterosexual residents. Dhrona believes that LGBT-friendly homes should not be seen as niche as homes, for example, for Jewish people. He says: “I think the LGBT community is integrated into everyday life. I would not want to go into a home that was niche. We are going to make sure we explain that we are offering support and training for the community. It is saying it is normal. We want people to buy into what a great community looks like.” 

CARE HOME MANAGEMENT: JUly 2018