“Residential Care Dilemma”

How do we greet the news in a recent press release that the Care Quality Commission plans to get tougher with the regulation of care homes?  A few years ago, I would have said “about time”, but now standing back from the problem I am not so sure this is the right way forward.

Older people and their relatives almost everywhere would confirm that residential care is very much seen as a choice of last resort.  Their own eyes and noses are the only quality assessment tool they need to know that most residential care is not up to a standard they would choose if there were a better and more importantly, affordable alternative.  For the lucky few there are some exceptionally good residential care homes with high standards of accommodation and qualified staff but this usually comes at premium fee rates.  New models of provision, such as extracare housing, are still relatively new and not available in most areas nor to the majority of people.

So we are left with most residential care homes acting as warehouses for older people – they keep people warm and fed but have no aspiration to give people any kind of quality of life.  Not surprisingly, even very frail older people are not keen to move in but nonetheless there are still queues at the door.  This is driven by the weight of demographics and the inability of individuals, their relatives and Social Services to cope with people at home, especially those with dementia.

So why don’t things change for the better, given that the customers certainly want better quality, the staff much prefer to work in a positive environment and Social Services and the Regulators want to see improvement?

At the heart of the problems is the fact that the financial model of residential care is flawed and the social care model is based on dependency.

In financial terms, since 1991 when the rules were changed and means tested assessment was introduced, Central Government has progressively starved Social Services of funding for social care.  Having been handed this poison chalice, Social Services have used their near monopoly purchasing power to dictate low fee levels, while simultaneously pushing up the care levels.  In fairness to them they have little alternative.

Small homes became less able to spend money on property upgrading or staff training and have been progressively squeezed out of the market.

In the meantime, corporate providers using the economies of scale, provided larger homes and grew rapidly in the decades between 1985 and 2005.  They were funded by bank borrowing “secured” by the promise of Government revenue and an endless supply of customers.  They also had impossible-to-achieve revenue returns, as debt was leveraged up to build more and more homes.

Now, many of the big residential care companies are on the verge of insolvency due to the combination of high gearing and artificially low fee income.  It is probably only the current low interest rates that keep them afloat.  Quite what the emergency rescue package would be for a large residential care provider going bust – nobody knows.  Hopefully the CQC have a contingency plan for this possibility.  I suppose theoretically they would be refinanced by further extending their debt.  This has already happened in several cases where “forced” mergers/acquisitions have taken place, but this cannot go on indefinitely.

It is this background of inadequate (but unlikely to improve) Government funding and a highly leveraged, financially precarious residential care provision that no doubt stays the hand of tougher regulation.  To close over 70 residential homes in the last 12 months sounds dramatic and indeed may well lead to an early death for many of the 700 residents who have been forced to move as a consequence.  However, closure of 0.3% of the 24,000 residential care homes will make very little impact on the quality of life of the hundreds of thousands of older people living in residential care.

I am not against tougher regulation nor arguing these few homes should not have been closed.  It is just that it fails to address the real issue which is the appalling quality of life which is offered to most elderly people living in residential care.  If CQC wish to have a substantial, strategic and long term impact on quality outcomes, it can’t be through increased regulation and more home closures.  Tighter regulation in itself only puts homes on the defensive and sets experienced regulatory staff on the opposite side of the quality debate to hard working and generally well intentioned care staff.  CQC in its own press release acknowledges that the final sanction of home closure inevitably hastens the deaths of many of the residents who are forced to move out.

So the Care Quality Commission sits on the horns of a great dilemma – in one open hand it has the aspiration to improve quality of life, and the other hand is a closed fist which holds the hammer of regulation.

The Department of Health needs to acknowledge that regulation has done very little to improve residential care in the last thirty years.  I was told by the Head of Regulation some years ago that their role was about compliance – well the evidence suggests that, that blinkered view hasn’t worked.  The brief of the Care Quality Commission needs to be re-focused.

The way ahead lies in the opposite direction to tougher regulation.  The CQC should champion good practice and facilitate learning and skills improvement throughout the residential and domiciliary care sector.  This approach is about preventative health care and support to encourage an active later life.  There is no shortage of residents, relatives and staff who would wish to travel this route.  The alternative only leads to dissatisfaction and distress.

If we do nothing, the tougher regulation road can only lead to crisis.  So enable the CQC turn around and walk the other way – take the high road of aspiration.

Don’t you agree inspiration is better than regulation?

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3 Responses to “Residential Care Dilemma”

  1. david freeman says:

    Residential Care dementia.
    You have struck a few chords with this Blog John: But I wonder if your ideals while correct are channelled in the right direction?
    I personally think one has to look again at old age through a different mirror. Gone are the social industries located in geographical areas of Great Britain, which during their time encouraged local communities and families to remain in close proximity to each other. Now the modern person of working age has had to migrate either within the UK, or abroad, and this to some effect has decimated the local social societies of yesteryear.
    From my personal experience of my grandparent’s and one great grand parent, their needs housing and welfare were dealt with by the extended family, and the whole family pitched in to provide as best as possible an economic platform that gave the elderly relative the way of life they wished.
    When as off today I and my sisters were asked to answer the call of my elderly mother life was a little complex? My mother was by then living on her own 82 years of age, in the family house (Which had been purchased with the thoughts of pension and care and well being provision). My mother of her own volition would not move as the house represented family memories and values of her life with our departed father. This made life difficult.
    We noticed with my mother living on her own she became dependent on visiting the local supermarket in the local shopping centre on a daily basis (7Seven days a week), and her visits became more frequent, and often duplicated during the day: Until in the end she was lost in the supermarket and taken home by a friend, and then for company she would telephone one of the family. No problem, but they the calls came late at night or during the night. Mum was getting senile dementia, and needed care. Mum went into a residential home for respite care: She was relieved she has servants and people around her 24 hours a day.
    As a family we had to take stock of the situation. Mums behaviour was becoming erratic. We had noticed some 3 years earlier on a family holiday with mum that she would not be satisfied to be left alone during the day and all ways like the company of one of the family members (Regardless of age-We had no one below the age of 7). At night being on holiday mum would wake up in the night and ask where we were- sitting on our bed and talking, she would then ask where was the toilet and then try the door to the apartment to make sure it was locked, and other erratic behaviour and then after going back to bed waking at 6 in the morning (daylight) and enquiring where was breakfast?
    When we talked as a family we realised we had a problem. Mum had expressed a true wish to stay with one of us four children and their family, but her behaviour would blight our own married and family relationships. We talked to mum after her respite care in the residential home, and she said she had enjoyed it, and felt very comfortable there. We were then as a family and my mum in particular offered a permanent place in the care home. We talked and talked to mum and mum agreed to move into the residential home. Which was in the locality of the family home (House). Thus it is still today and mum is happy with her carers’ (Servants) and friends.
    I have taken a long way around to explain much of the thinking of my wife and I. What we learnt from mum’s predicament was that it was company and the people around that she needed, and if she had let her memories of Dad and the house go since his death, then we may have been as a family to look at other means of old age housing, such as warden controlled housing, and other options available in the local area. My wife and I looked hard at our future-Our existing house was our means to care and welfare in our old age, and we realised if anything should happen to either of us we would need companionship, friends and care. We both came to the conclusion to move into a retirement village while we still both able and to take advantage of its philosophy and way of life, and start our new life together. This was very important to us: We had since we were first married moved around the UK remote from our base in Leeds, and I had travelled throughout my career so my friends were my work colleagues strewn all around the UK. Our immediate family were nearby still in the locality of our last family home, so we decided to move to the nearby retirement village.
    People friend’s companionship and care are to us most important after immediate family. But family must be free to do and live their lives as time goes on, and as they see it.
    That is the human side of ‘care in old age’. The next argument you provide on the blog site is economy of scale and the logical arguments of funding for care home providers. The green eyed devil of the $dollar is seen here and the requirement for more regulations. These discussions have to be seen through different mirrors.
    1 Take funding and social needs. Government funding and social needs in various localities should be a solvable problem, with the private and public sector coming together and working out a solution for the fabric of a facility with the opportunity to discuss the advantages of scale.
    2 Regulations. The private and public sector may have to consider ways of encouraging staff working together: Rather than a top heavy public sector, stipulating regulations, working conditions, staffing regimes, and levels of competency. This should all be to the benefit of the care/nursing home for the aging population, at an economic cost.
    3 Hospitalisation for the elderly may have to be revised as we all grow older, for those who become infirmed. There is a need for nursing homes: But the first provision should be affordable residential homes or ‘care in the home’ for those elderly people who are fit and mobile, but need social skills of friends and companionship.
    It great to talk, initially it cost less than inappropriate actions, and it may lead to a right and acceptable decision.

  2. John says:

    Thank you for sharing this storey of your family’s experience of dementia.
    It is one which will be familiar to a great many people. Coming to terms with the gradual decline of a loved-ones memory is a very difficult and heart rending process for everyone.

  3. david freeman says:

    Hi you readers of this blog! If you live in the Milton Keynes Catchment area, or have relatives in this area you may be interested in the current studies questionaires being asked by the Milton Keynes Borough Coucil Welfare and Communications team about the expenditure programme proposed for the next 25 years hence: With respect to care and dementia in old age in the MK Area. If you are interested it is worth following the case by ring MK Coucil Offices and talking to the Welfare and communications team for an update.

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