The following are some of Mike Short's investigations into the Social Care sector, including reproductions of Mike's editorials in the specialist press.

CSI investigates the awarding of Outstanding ratings to care homes for older people, and asks what is Outstanding, but more importantly – WHERE IS IT?

Like most words in the English language “Outstanding” can mean different things.

For starters it reminds me of an old joke that was recently re-posted on Facebook.

“I had a letter from the HMRC today saying that my self-assessment tax return was OUTSTANDING. This really pleased me, although to be honest I cannot remember sending one.”

The other definition of Outstanding of course is exceptionally good, and in the Care Sector the term is used by the CQC as the highest rating possible from their inspections. The national association Care England has an Outstanding Society where members who enjoy this plaudit for one or more of their homes, can share best practices.

Recently Carterwood published a report that said that care homes for older people with an outstanding rating charged an average 20.6% premium for self-funding clients. Whether local authorities are willing to pay such a premium was not recorded.

Many industry commentators have written about what Outstanding is and a number of suppliers offer assistance to care providers to attain such a rating.

In this investigation CSI breaks down exactly how many Outstanding care homes there are in England, their size and care sector – residential, nursing, dementia, but more importantly,(having done the research already I know how interesting this is), where they are.

Across England there are around currently 420 care homes for older people with an outstanding rating, so around one in every 24 homes.

When is an Outstanding rating awarded?

As most of you will know a CQC inspection rates a location across five categories Safe, Effective, Caring, Responsive and Well-led, as either Outstanding, Good, Requires Improvement and Inadequate. The same as for the Overall rating. To get an overall Outstanding rating the home needs at least two of the five categories to be Outstanding, and the remainder, Good.

Only 19 homes (4.5%) got Outstanding in all five categories with over 60% of these top performers coming from just 4 local authorities – 3 from Nottinghamshire and 2 each from Bournemouth Poole & Dorset, Oxfordshire, and West Sussex.

Half of all homes boasting Outstanding achieved this with just two out of five categories at this level, the remaining three ratings being Good.

How do Care Homes perform by Sector?

As can be seen from the chart above, nursing homes, both with and without dementia, perform better than residential homes, achieving 48% of all Outstanding ratings, whilst accounting for just 40% of all homes.

Does size matter?

It certainly appears to when it comes to being Outstanding. The chart above shows that smaller to medium homes account for 58% of all homes, but only 48% of Outstanding homes. The larger homes, 41 beds or more account for 41% of homes but 52% of all Outstanding ratings.

What about the various business sectors?

I thought the best way to comment on the table above was to leave it to Liz Jones, Policy Director for the National Care Forum, "the leading voice for not-for-profit care providers", "Valuable insight here, as ever, from CSI Market Intelligence with an analysis of the outstanding ratings by the CQC. Delighted to see the strong showing from the NFP sector here, with the finding that while our sector accounts for just under 14% of all care homes for older people, the Not For Profit sector has a 20% share of all Outstanding ratings - #HereToCare!"

So where exactly are these Outstanding Care Homes?

And so to my headline question. Where is Outstanding?

I have noticed a polarisation of Outstanding care homes into small geographical areas I have delved deeper and looked at variances at regional, local authority and town / city level.

Outstanding at a Regional level

The regional picture is pretty clear. The biggest winners are South West and East of England with a 7% and 6% higher share respectively for Outstandings compared to their total share of homes in the regions.

The biggest losers are the North West, West Midlands and Yorkshire and Humberside have respectively, a 5%, 4% and 3% lower share of Outstandings than they do share of homes.

Outstanding Homes by Local Authority

At Local Authority level I discovered that 12 out of 150 had between 2.5 and 6.4 times the national average percentage shares of Outstanding care homes, which means just 8% of all LAs provided 25% of all Outstanding ratings.

The map below shows these clusters of Outstanding homes that make up the 25% share. Apologies that the map only goues up to Leeds, but no Local Authorites north of this line are in the top 8%.


Top of the tree was Kensington and Chelsea, with two out of their seven homes rated Outstanding. Their great performance is so different to other London boroughs. They are followed by South Gloucestershire who have 10 out of 41 inspected care homes being rated Outstanding which is five and a half times the national average.

At the bottom, 42 Local Authorities cannot boast a single Outstanding rating out of 1,150 care homes that have been inspected. Nearly half of these (19) are London authorities, and 6 are in the North West making up a total of 60% of the national picture between them.

This second map shows the Local Authorities without an Outstanding home.

So does my town have an Outstanding home?

A little over 1,200 towns or cites in England have a care home, but only 250 can boast an Outstanding home – so around 950 (nearly four out of five) do not have any! The largest city without an Outstanding is Sheffield, nearly 100 homes but not one top rating.

Many other towns with lots of homes but no Outstanding ratings include The Wirral, Chesterfield, Weston Super Mare, Oldham, Huddersfield, Torquay, Hove (near Brighton), and Gloucester (this is interesting at the town is close to South Gloucestershire that was at the top of the list of Outstanding performers)

Ignoring towns with just a few care homes, top of the Outstanding charts include Sidmouth and Seaton, who are just 10 miles apart and who have a total of 10 out of 19 homes that are Outstanding – that is 53%, or 12 times the national average.

But (I hear you say) it’s all about money isn’t it?

To a certain extent it is, when it comes to the percentage of self-funders within any local authority.

The top 12 local authorities share of self-funders is much in line with the national average as forecast by Laing and Buisson and included in the CMA final market report in 2019. The 42 without an Outstanding averaged about 60% of the national forecasts, but the sample did include some local authorities that enjoyed above average levels.

And as far as local authority contributions, which we know vary greatly across the country, there was little difference between those at the top and those at the bottom. Using the latest iBCF data for 2018/19 the average contributions were basically in line with national averages across both samples.

So a decent share of self-funding income does help with attaining Outstanding, and conversely low levels affect that same attainment. But local authorities varying contributions is less of a factor, albeit a low contribution aligned to a low share of self-funders will have an impact.

So why are we getting this geographical polarisation?

The cynic may well say that an Outstanding rather than Good rating is down to the subjective attitude of inspectors working this area, but this would totally undermine the massive efforts being put in by care groups and individual homes to up their game, and also one would believe that the CQC has measures in place to control this.

So could it be that having a local competitor that is Outstanding, inspires others to attain this standard?

For a few years in my home town of Worthing we had just one care home with an Outstanding rating, but in the last 12 months or so three more have been added to that roll of honour.

In Blackpool, out of the six Outstanding homes that make up 12% of all the homes in the city, four belong to one provider, and this situation is repeated across the country in other Outstanding hotspots.

And finally – are we getting more Outstanding?

I am pleased to say we are, as we have grown from 2.8% outstanding in October 2018, to 3.8% in October 2019, and a year later we are up around 4.5%.

And it could be higher, as the number of CQC inspections in 2020 have dropped due to Covid-19, and those that have been undertaken since April have focused on homes where the CQC had concerns with homes rated Requires Improvement or Inadequate.

Around one fifth of current Outstanding care homes had their inspections published in 2020, and of these only a third already had an Outstanding rating. This means that about two thirds improved, predominantly from Good, but three homes were promoted from Requires Improvement, and on four occasions it was the first inspection, so well done to all of you.

So to summarise:

• Across England there are around currently 420 care homes for older people with an outstanding rating, so around one in every 24 homes.
• Only 19 homes (4.5%) got Outstanding in all five categories
• Half of all homes boasting Outstanding achieved just two out of five categories at this level, the remaining three ratings being Good.
• Nursing homes, both with and without dementia, perform better than residential homes
• Smaller to medium homes account for 58% of all homes, but only 48% of Outstanding homes.
• Larger homes, 41 beds or more account for 41% of homes but 52% with Outstanding ratings.
• Whilst accounting for just under 14% of all care homes for older people, the Not For Profit sector has a 20% share of all Outstanding ratings
• The biggest regional winners are South West and East of England sharing a 13% increase in share compared to the number of homes in the regions.
• The biggest regional losers are the North West, West Midlands and Yorkshire and Humber, losing 12% share between them. Just 12 (8% of all) LAs provided 25% of all Outstanding ratings.
• 42 Local Authorities cannot boast a single Outstanding rating
• Around 1,200 towns or cites in England have a care home, but only 250 can boast an Outstanding home – so around 950 (nearly four out of five) do not have any
• A decent share of self-funding income helps with attaining Outstanding, and conversely low levels affect that same attainment. But the local authorities varying contributions is less of a factor
• The share of Outstanding care homes has grown from 2.8% outstanding in October 2018, to 3.8% in October 2019, and a year later we are up around 4.5%.

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Earlier this year Editor Tim Probert asked if I would analyse what happened in the care home market during COVID-19 and put together an editorial for publication in one of the Autumn’s Care Home Environment magazines.

Well this is the editorial, but at the time of asking I think both of us thought it would as report saying, “this is what happened, now onwards and (hopefully) upwards”.

Even as I am writing in September things are changing on a daily basis, and the Government’s mis-management, specifically with regard to regular testing in care homes, policy U-Turns and with lockdown being eased and once again tightened, and above all their unmet promise to “fix social care” - it means that we are all still in turmoil.

We are all extremely worried about how a second spike of the Virus will continue to affect those operating, working and living in care homes going into the colder Winter months, not to mention the ability of relatives, like myself to eventually visit their loved ones.

As the virus, arguments and lobbying continues, I have looked at what has been happening within this market sector with regard to openings, closures and changes of ownerships both in the first quarter of 2020 (Pre-COVID) and the subsequent “COVID months” between April and August.

Obviously, openings and changes of ownership do not happen overnight, but by measuring what did occur we can estimate to some extent what pent up activity is likely to occur if and when the COVID dust settles.

Just to put in place a starting point and context of where we were at the start of 2020, the number of care home beds in England had shrunk by around 10,000 (2.5%) over 5 years due to higher levels of closures than openings, whilst the 75 plus population, that accounts for around 90% of all care home beds, has grown by around nearly half a million (11%) during that same period. That same age group will grow by a further 19% by 2025, and so a reversal in current trends is essential.

As CSI has repeatedly cited, supply levels across the country vary greatly. Areas of high supply have up to 150 beds per thousand population aged 75 plus, but as low as 26 beds per thousand where supply is low – so a 6 times variance.

So current supply levels are decreasing on a national basis and on a local basis are in a mess.

A Great Start to The Year

First the good news. 2020 started with promise, as care home openings during the first quarter were up by 79% year on year, with an 83% increase on the number of new beds.

Then comes lockdown, and things stalled or even stopped as developers, investors, lenders, sellers, and buyers had to stop and take a deep breath.

From a 79% year on year increase prior to lockdown, openings during the “COVID months” dropped by 8% year on year. Without COVID 19, and if the year on year increase had continued from quarter one, there would have been an extra 50 new homes and a much needed 3,000 new beds.

There were 49 different providers across the 55 openings, with over a third of them as new providers – welcome to the sector guys!

There were four groups who between them made up about a fifth of all openings. The author did contact them for a comment on how they have fared filling the new beds but has had no responses to date in this respect – I imagine it will have been a slow process.

But at least closures are down, that’s good isn’t it?

In the first quarter closures were up by 2% year on year, but the number of beds lost actually dropped by 19%.

And from April onwards closures dropped even further by 31% year on year.

This is probably due to the fact that homes that may have been thinking closure was imminent have found themselves committed to continue as they shield their vulnerable clients from the outside World, and are hopefully buoyed by whatever got through to them from the £4.3 billion of extra funding the Government gave to local authorities to help with public services, of which £600 million was ringfenced for social care.

Now in September there is a second spike in new COVID-19 cases, albeit deaths are very much down on the initial crisis, and the age profile of those testing positive in younger, but lockdown restrictions on social gatherings have once again be tightened, and there are still no guidelines as to visiting care homes.

This could well mean that strict shielding within care homes will continue through what will be the harder Winter months. Should this be the case a further tranche of money will be needed to support those homes who would otherwise have to close.

The Net Effect of Openings and Closures

Over recent years I have used the rule of thumb that for every care home that opens, two have closed. In 2020 it is more like two openings for three closures, and with the new homes being larger, by the end of August we lost 365 beds compared to 1,850 in the same period in 2019.

The COVID-19 Effect on Occupancy Levels

Based on the information available from various sources I have had a shot at the change in occupancy levels in care homes between April and the end of August.(See Table 1)

The generally recognised average occupancy levels across residential and nursing homes is around 90%, so 360,000 of the approximate 400,000 care home beds in homes registered for older people are filled.

The CMA Care Homes Market Study 2017 estimated 41% of care home beds were taken up by self-funders, with the remaining 59% local authority funded.

According to the ONS there have were around 66,000 deaths in care homes between April and August , including 14,683 attributed to COVID-19, and so without any re-admissions the care home population would have dropped below 300,000 an average 73% occupancy level.

According to CQC estimates in June there has been a reduction in the number of re-admissions to around 35% of last year for self-funders, and 72% of those funded by local authorities. When you multiply these percentages by the Nuffield Trust’s average admissions for every 100,000 population aged 65 plus in 2018/19, we can see that new admissions are much lower than those lost through deaths during the same period.

If this is accurate then occupancy levels will be down from 90% in April to 76% at the end of August, meaning homes will be missing the weekly income from around 55,000 residents or a reduction of 15%, which is a massive financial loss of income against already tight, and probably now negative, margins.

Knight Frank research published in September stated that they believe occupancy levels have more recently recovered to just above 80%, but still well below the pre-COVID levels.

But of course this is average. Supply levels and therefore occupancy levels will vary greatly on a local basis. And of course, there has not been a flat line COVID-19 death rate in all homes, with many not experiencing any deaths (although still tarred with the same brush with regard to new admissions) whilst other homes will have lost much higher than the average number of residents.

The CQC recently declined to report on COVID-19 deaths by home for commercial and confidentiality reasons, although they are quite happy to publicly brandish these same commercial ventures as anything between Outstanding and Inadequate via their inspections.

There is of course a longer term worry, and that is with regard to future capacity expectations for care homes in England. Should the existing concerns as to the safety of, and accessibility to loved ones within a care home continue, admission rates will stay low.

However there are somewhere between two thirds and three quarters of care home residents who are living with dementia at various levels of dependency.

It is difficult to know what other environment could properly manage a person’s dementia once it has reached a certain level of dependency, but it could well be that people with earlier stages of dementia that would previously been moved into a care home, may well be cared for longer in the community, which could reduce the care home population greatly.

Before COVID-19 some dementia care homes I have spoken to have told me that the level of dependency of newer admissions seems to be getting higher, so there is already a trend in this respect.

But at current rates the dementia population looked after in a care home is due to grow by around 16% over the next 5 years, and due to high mortality rates within that age group, the true growth of dementia means that by around 2027 the dementia population will be made up of people who have not been diagnosed as yet. So even if there is a shift from care homes to community care the dementia population within care homes will still be massive.

Above all this is of course is the hope that a cure for dementia, or a way of slowing its development, will come as soon as possible. Dementia is a massive influencer of the care home sector.

New Investment in existing homes

In addition to openings being well up year on year during the first quarter of 2020, sales and purchases were looking good as well, with a 3% increase in activities year on year.

It is not surprising to see that this activity reduced, falling by around 12% year on year between April and August, as many impending deals will have stalled or even stopped.

Within this reduction around half of all the deals that were completed in this period were sales of the Four Seasons brand from its administrators.

The largest purchasers included Roseberry Care Centres, whose 13 purchases has increased their portfolio to 29 locations, predominantly in the North of England. Their purchases were from small groups, mostly in administration.

Barchester Healthcare Group added eleven homes to their group through the purchase of Four Seasons locations through their Barchester Hellens company.

Barchester also added four new homes through openings, and so are by a length the most progressive care group during this period.

Marton Care added ten homes through procurement, nine of which were from Four Seasons, which brought their total portfolio up to 14 homes. Marton Care are connected to the Burlington Care Group who have a further 17 homes.

Richard Hoggart, Owner and CEO at Burlington Care & Marton Care Homes said about the purchases, “the staff teams, residents and families have been so welcoming with us as we acquired these Marton homes. We have ensured the staff teams remained employed and already commenced our upgrades and investments.”

Conclusion

It is obviously an insensitive thing to say but it seems that COVID-19 has come at the wrong time for the care home market.

It is difficult to know if without the pandemic the Government would have been true to its word to “fix social care”. BREXIT is raising its head again and there always seems to be something that diverts attention from social care reforms.

Once again, this editorial is being updated as it is being written, as Matt Hancock, Secretary of State for Health and Social Care has said that whilst work had started on Social Care Reform, he would not give any idea as to when it would be delivered.

In the conclusion of the newly published report Beyond COVID: New thinking on the future of adult social care, the Social Care Institute for Excellence (SCIE) say “Now is the time for bold action to transform social care for decades to come. After nearly 20 years of underfunding it is time to call time on austerity. The adult social care system needs a long-term funding settlement; one that is simpler, fairer and helps tackle the fundamental inequalities which exist in society.”

So what are my thoughts on what will happen post COVID-19, whenever that is as far as safe access to care homes is concerned?

Care home closures will increase drastically, the level of increase dependent on whether a further tranche of extra financial support is provided through local authorities. Additionally many owners may well say enough is enough.

New care homes will stay low until an acceptable Social Care Reform plan is delivered although new care developments will continue on the basis that investment in other industries such as hospitality and retail is even more risky.

Investment in existing care homes, that are fit for purpose in the mid to long term, will increase as investors see bargains ahead. This will either be from existing providers to add to their portfolios, or external investors who will want locations with a track records and an existing occupancy, however low, which will increase the market for the companies who manage for investors.

The full magazine can be viewed on line here

Ok, I am going to get personal for a while. My mother has been very comfortable in her care home for a couple of years now. My wife and I, mum's grandchildren, and great grandchildren would visit her regularly making her happy. My wife and I last saw her in April, on a bright sunny day in the home’s lovely large garden. We were the only ones in the garden, nicely socially distanced.

She has had no visits since then and now in October, I delivered some latest photos and a plant, leaving it at the care home door and thinking sadly, “I am only a few yards away from my mother, but cannot get to see her, or for her to see me.”

Now I am not going to cover this heart breaking subject in this investigation but feel astounded that untested CQC care inspectors can gain entry to that same home, to any home.

One month ago my first editorial on this subject included a statement from the CQC that "requesting a negative COVID-19 test before an inspection… could “restrict how our (CQC) inspectors do their job and could cause risk to people using the service” and “Attempts to prevent or limit our ability to fulfil our statutory responsibilities are unacceptable.”

In Shutting the Care Home Door 1, I reported that there were around 60 CQC inspections undertaken between the ends of June and July and published in August. That is 60 care homes for older people and up to 2,300 residents and the same number of care staff being put at risk, purely for the CQC to fulfil their “statutory responsibilities” even though the rest of us are living, working and behaving under strict guidelines or even laws.

And that is evidently, worryingly, unbelievably, still the case.

And to make it worse without the guarantee of inspectors being tested, there were twice as many inspections that took place in July and August, published in September!

Pre-COVID-19 there were on average around 350 inspections every month, and so this means the CQC were undertaking over one third of its normal capacity.

The latest figures show 122 care homes, with up to 6,000 residents, had an inspection between the ends of July and August and published in September.

Were these to protect our loved ones by inspecting homes that were Inadequate?

No, only a quarter of these were to Inadequate homes, and nearly half of them improved their ratings to Requires Improvement, one even became Good. Not bad considering that in addition to trying to meet the CQC’s self-defined standards, these homes were also battling things such as COVID-19 testing, PPE, families protesting their inability to visit their loved ones and much more.

I say well done to them.

So this means that around 75% of homes that were inspected during this period were either Good or Requires Improvement, and this grew to 78% with the new ratings. Again well done to them.

We are all hoping that the restrictions under which we are living, some in greater levels of lockdown than others, will disappear as the real risk of COVID-19 does likewise, and that the period between then and now is as short as it can be. I like hundreds of thousands of people want to see their loved ones.

CQC, if you insist on undertaking further inspections, and I imagine you will have done many more in September that we have still to see, get your inspectors tested first. Play the same game as we are being asked to, you are not a special case.

8th October 2020