CSI Market Intelligence

Care Sector Investigations

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

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Where is Outstanding? 2021 Update
Keeping a close eye on the care home transfer market
CSI investigates the CQC COVID-19 Insight into care home deaths
Keeping a close eye on the care home transfer market
Covid impact on the care home market
Where is Outstanding?
Covid impact on the care home market
Shutting The Door After CQC has Bolted October Update
Shutting The Door After CQC has Bolted
What is the Future of Social Care
Staying Alive

Care homes – an upward trend despite everything that COVID has thrown at the sector

CSI Market Intelligence has published Say Hello Wave Goodbye – Care Home Openings and Closures 2021, its 7th annual report and has surprisingly shown that, despite years of being in decline, the trend in care home beds is an increasing one despite everything that the last few years of turmoil.

Care home openings increased by 8% between 2019 and 2020, and by 12.5% between 2020 and 2021, whilst closures were lower in 2021 than in 2019. This means that a net loss of around 1,500 beds in 2019 has become a 440 bed growth in 2021.

Author Mike Short, who is director at CSI MI say “every year when we sit down to compile the data I peak at the numbers through a hand in front of my eyes, as I have been so used to report what is bad news when we see a reduction in care home beds as the 75 plus age sector grows so fast. This was especially the case this year, looking back on what must have been an arduous twelve months for all involved in the sector”

Care home closures still outnumber openings and continue to affect thousands of vulnerable people who lose their homes and have to be found new accommodation, and possibly lose the friends with who they have become so close.

“When one reads the reported precarious financial situation that so many care homes find themselves in,” continues Mike “closures are going to continue, and if anything increase unless anything changes drastically for the better, but at least investment in new larger locations means that that is still a supply of beds for those who need them”

On average a new home in 2021 was registered for 54 beds against 32 for those that closed, and there is an ongoing shift towards nursing dementia homes. Around one fifth of closures did so with an inadequate CQC rating (against one in fifty of all care homes) therefore implying care quality as the rationale for closure, whereas nearly half of closures were either rated good or outstanding (against around two thirds of all homes) which suggest commercial reasons for closure.

The report goes on to show that supply levels still vary greatly by local authority with areas of over supply and low occupancy levels, and areas low supply and a lack of choice for the public.

Mike says, “this has been the pattern throughout my time in this sector, and does not appear to be improving, in fact eight of the ten local authorities that have lost the highest percentage of beds since my reports began also show a higher than average forecast growth over the next five years, so the situation will become even more drastic than now, and are crying out for new developments to rectify this.”

The report can be accessed for free here

How to go from Outstanding to Inadequate? Change providers

In June last year CSI produced a report that looked at where the 420 care homes in England that had a CQC Outstanding rating were located and discovered 8% of all local authorities made up 25% of the Outstanding homes, whilst more than a quarter of them did not have a single home that could boast this top rating.

A year on I have analysed the current situation and can report that:

No care home caring for older people has since been promoted to an Outstanding rating since then
3 care homes were re-inspected and retained their Outstanding ratings – well done to them
12 Outstanding care homes have changed provider and as yet have not been inspected under the new ownership
1 Outstanding care home has changed provider – and has now been given an Inadequate rating
1 Outstanding care home has closed (as identified in my report Say Hello Wave Goodbye 2020)
3 homes have since had their Outstanding ratings relegated to Good (one home) and Requires Improvement (two homes)

With regard to no new homes being awarded an Outstanding rating, during these COVID laden months the number of CQC inspections had been reduced to the number of visits to homes, and when undertaken these were more about inspecting homes where the CQC had concerns over care quality and resident safety.

And with regard to the home going from Outstanding to Inadequate? CSI will not give more details, other than to say that just by buying an already Outstanding care home doesn't guarantee a continuation of that accolade - far from it in this case.

We will wait to see what will happen to the other 12 Outstanding care homes that have changed ownership and have still to experience an inspection. We wish them well.

The original report still holds true and makes very interesting reading and can be seen here.

If you would like to read this report as a pdf click here

I will preface this investigation by saying that whilst I normally enjoy cutting through data and creating my reports and insights, and fulfilling my clients' needs, this particular subject is one that is hard to cover. As the CQC themselves say “every number represents a life lost”, but it is one that needs to be published to hopefully help us all understand what has happened over the pandemic period across all care homes in England.

On 21st July the CQC published the number of deaths attributed to COVID by individual care home – something they initially said they would not do.

Whilst the analysis lists the individual care home numbers (they do publish a Microsoft Power BI dashboard) this is only a glimpse into what really went on. It presents deaths attributed to COVID-19 in isolation, without also showing the total number of deaths, through natural causes, or other reasons such as influenza.

In October 2020 the ONS estimated there were 15,356 deaths in care homes attributable to COVID-19 between April and September 2020, but these accounted for 17% of the nearly 95,000 care home deaths during that same period. The latest CQC figure is 23% higher, but still accounts for just one in four of all care home deaths during that period.

Surely including deaths due to other causes may have give more relevance to the CQC analysis?

Less than 7,000 care homes are listed with attributable deaths, out of the 15,500 homes that were operation across that period. And 50% of the recorded COVID-19 deaths were in just over 1,400 care homes, that’s just 9% of all care homes.

The CQC figures cover four quarters that include two separate peaks in the number of deaths – firstly those early on in the pre-testing, pre-suitable PPE days of April and May 2020, and those in the second “winter” peak – representing two most different periods.

Basing these two peak periods on; April to September 2020 as the first and; October 2020 to March 2021 as the second, out of over 39,250 attributed deaths 48% were in the first peak and 52% the second.

In the following charts I have analysed the number of deaths by indexing them against the total number of beds nationally. So if a sector accounts for 50% of all mortalities, and 50% of all beds, this would be in line with the national average, and indexed at 100. Anything above an index of 100 would mean a relatively higher number of attributable mortalities, below 100 would mean a relatively lower number, the higher or lower the index the greater the variation on the national average.

We have not highlighted individual homes and focused on higher measurement levels.

But before we look at these measurements it is interesting to note that 56% of all care homes in England did not have a single death attributed to COVID-19, whilst a further 20% had single figure percentages based on their number of beds. Of care homes caring for older people these figures were 40% and 27% respectively.

So it is concerning that whilst over a half of all care homes managed it through these terrible times without a single death, ALL care homes are being asked to get rid of non-vaccinated care workers, those same people who spent all those months keeping infections and deaths away without proper protection, and definitely without the availability of said vaccinations.

Size of home

We were hearing that the larger the home, the higher the chance of mortalities and whilst this is substantiated by our research into the CQC data for the first peak, this is not so true for the second.

Chart 2 shows that in the first peak care homes of 61 beds or more were about one third higher than the average, but in the second peak they were below the national average.

Throughout both peaks mid-sized care homes of between 41 and 60 beds were around 13% above the national average, the 26-40 sector was around 73% in the first peak and just above the national average in the second.

Relative safety could be found in the smallest sized sector, albeit not so much in the second peak.

Please note that the CQC did not publish quarterly figures for homes of 10 beds or less “as data considered personally identifiable at quarterly level and has therefore only the total figure presented for data protection purposes.”

The impact of dementia

Where a care home is caring for people living with dementia, it is understood that getting residents to comply with social distancing is harder. Whilst this cannot be seen as the all-embracing rationale for higher mortality levels, this is in fact the case as is shown in Chart 3, albeit dementia homes are in total only around 6% above the average.

Residential or Nursing?

Chart 4 shows that attributable mortalities were far more prevalent in care homes with nursing in the first peak, but things relatively levelled out in the second.

One may say that "Nursing Homes are by definition larger than dementia homes", but these figures are based on percentage of deaths attributted to COVID-19, not the total number.

Care Quality

When publishing this data the CQC states “Death notifications alone are not a reliable indicator of quality or safety” – but we must assume that their CQC ratings are exactly that; an indicator of quality and safety.

So how did the care homes fare when aligned to their CQC rating.

Chart 5 shows that homes with a Good, Outstanding or Requires improvement ratings were very much in line with the national average.

Homes with Inadequate ratings actually performed the best (probably the wrong phrase to use, sorry) but a caveat here is that the measurements are based on total beds, and one can assume that homes with such a rating would have lower occupancy levels which would mean that a) whilst it cannot be measured, attributable mortalities against number of actual residents will be relatively higher than total registrations and b) a half empty home would allow more space between carer workers and residents. They also only account for around 1.5% of all homes.

So in summary we can agree with the CQC that “Death notifications alone are not a reliable indicator of quality or safety.”

Company Sector

Broken down by the provider company sector we see in Chart 6 that the not for profit and public sectors fared better than the private sector, the latter having a slightly higher number of attributable mortalities against their total number of beds.

Another interesting fact is that whilst 40% of all care homes that cared for Older People did not register a single death attributable to COVID-19, when broken down by Company Sector this grows to 45% for the for not for profit sector, against 39% for private ownership and 47% for the public sector.

When one includes all care homes the percentage of homes without a single death in the not for profit sector was around 65%, with around 53% in the private sector and 59% in the public sector.

Whilst this will include care homes with less than 10 beds who will have stood a better chance of escaping casualties, these same homes are included within the blanket requirement for all care workers to be vaccinated, and so these figures are valid.

Regional variations

Chart 7 shows the relative performances of the nine regions. Northern regions appear to have come off worse during the first peak, with North East indexed at 146, North West at 118 and Yorkshire and Humberside at 116. London was also above within this phase at 116.

The North East was also above the national average in the second peak, as were East of England and South East.

The region with the lowest attributable mortalities is the South West which also has the lowest number of people per square km.

Local Authorities least and most affected

Indexing the number of attributable mortalities to the number of beds in each local authority I have shown the 10 least affected (Table 8) and most affected (Table 9) Of the ten least affected authorities, five are in the South West, four in London and one in Berkshire.

Seven of the most affected are Northern authorities, two (again) in London, and (again) one in Berkshire.

The map shows the affects for each Local Authority. The reds are equal to or above the 100 index the darker the higher the index. The greens are below the 100 index the lighter the lower the index.

Summary

In summary the CQC insight is a sad reminder of all the personal losses that the COVID-19 pandemic has brought but is in itself not a full picture of mortalities within care homes over that period, when mortality rates are by definition high due to the age groups and vulnerability of those people living in such an environment.

Larger homes had a greater share of deaths attributable to COVID-19 in the first peak, but this was not the case in the second, whilst there was a higher prevalence in homes specialising in dementia, and in nursing homes. A care homes CQC rating did not seem to have a bearing on the numbers issued by the CQC.

On a geographical basis prevalence was higher in the northern regions.

What the figures do show, however that a majority of care homes managed their way through these traumatic times without a single death, even though half of the mortalities were during the times when the homes were blatantly unprotected from the infection.

Such a superb performance does not warrant a blanket Government ban on non-vaccinated employees after November this year, and we should instead rely on the continuation of the testing programme.

CSI compares the Football transfer market to that in the care home sector

So with the European Championship out of the way we (i.e. the long term footie fans rather than those nouveau fans entranced by Mr Grealish and co.) look forward to the next season that will begin in August, paying particular attention to the transfer market – and “will they, won’t they move, and if so to where?”

Will those loyal stalwarts Harry Kane and the aforementioned Jack Grealish finally leave their beloved Tottenham and Aston Villa? And if so, for how much?

And whether they do or not (and they probably will) they will not be the only ones to move.

One thing than I can say for certain. A footballer with probably a ten year life span (as a player not on this earth) will sell for exponentially more than a care home that will have a much longer lease or even a lifelong freehold.

For a long time now, and as a service to my clients, I have been monitoring the care home transfer market, and registering who is sold to whom, and who is still sitting in the wings – or on the subs bench - waiting to be sold. (Some have been on that bench for over 5 years, so I imagine their backsides are getting a bit numb, and their agents a bit nervous.)

In summary around 5% of all care homes have changed teams over the last two and a half years, but it is definitely not a case of the big clubs (and especially those with foreign ownership) buying them all up, and if anything one big club (massively relegated from the premiership I am afraid) is selling more than any other, with another, still in the top tier, openly stating that they wish to sell a sizeable share of their squad to smaller local teams.

In fact on average there have been just 1.3 purchases per buyer, and for around two thirds the purchase is their only care home.

There is however recently one piece of hot transfer news where one provider with two brand names has sold out to two other providers, that being Sunrise Senior Living and Gracewell Healthcare selling a mix of their portfolios to Care UK and Senior Lifestyle – 46 locations involved.

As we hopefully close in on some form of social care reform, we still hear from the uneducated that extra Government investment would only line the pockets of the “vultures” (just seen that term on Twitter) and their off shore businesses with numerous yachts per shareholder.

This is certainly not the case with recent transfers and nor is it the case with the total market in which the Top 6, the care home equivalent of the two Manchester clubs, Liverpool, Chelsea, Tottenham, and Arsenal account for less than 10% of all care homes, the rest being owned by small providers with only 2 homes each on average.

So whilst we all watch the TV news and scroll through the football websites for the latest transfer news, I will continue to check out what is going on in the care home transfer market. Let me know if you want some more information or want to get involved in the market.

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 extends 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%.

July 2021 Update - to find out what has happened since read my update here

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

Shutting The Care Home Door After The CQC Has Bolted - October Update

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

Shutting The Care Home Door After The CQC Has Bolted

There is currently a lot of lobbying currently being undertaken by the likes of care associations such as the National Care Forum who at the end of August wrote an open letter to Matt Hancock, Secretary of State for Health and Social Care, and Helen Whately, Minister for Care, calling for a reversal of the decision to allow CQC inspectors into care homes without testing.

In a CQC September COVID-19 Update Kate Terroni, Chief lnspector of Adult Social Care says that provider requests such as:

requesting all inspections to be announced
limiting the number of inspectors on site
restricting the use of toilet and hand washing facilities
requesting a negative COVID-19 test before an inspection

… could “restrict how our inspectors do their job and could cause risk to people using the service” and “Attempts to prevent or limit our ability to fulfil our (CQC’s) statutory responsibilities are unacceptable.”

How risking employees’ and residents’ life is less important than allowing CQC inspectors to do their job, or hinder the CQC's statutory responsibilities, escapes me. However, the CQC has already been into care homes carrying out inspections in recent months.

Their latest care register shows this. During the June to August period there are 104 published inspections listed. Now I know, much to the annoyance of care homes with an improved rating from their latest inspection, there is quite a sizeable time lapse between the actual inspection and its publication, so I have drilled down further to establish which inspections were undertaken during this period.

There were around 60 CQC inspections undertaken between the ends of June and July and published in August.

On average there are around 350 care home inspections every month, so this is only about one sixth of the norm, but why risk lives to undertake these inspections?

The Government promised regular testing in care homes from 6th July, but of the course in early August they put this back to September, and as of today it is still not properly in place. So that means during the July inspections it was not known if any care home employees, residents and CQC inspectors were COVID-19 positive.

Was it a unitary decision by a single CQC region to restart inspections? Not all 9 regions undertook inspections.

And from a Care Quality from a point of view, whilst most of a sample of reports I read said that the inspection took place “to check whether improvements had been made”, but two thirds of homes inspected did so with either a Good or Requires Improvement rating at the time of inspection.

Only a third were Inadequate – and therefore maybe of concern with regard to the “safety” of residents – but what sort of added risk to life did the inspections place on all these homes.

And from the subsequent inspections, the two thirds Good or Requires Improvement ratings became three quarters, so in general performance within these homes had improved, despite them all having to deal with the chaos and stress of life within a care home since April.

It will be interesting to see how many inspections took place in August. Watch this space.

It is imperative that the Government and CQC will concede that the regular testing of inspectors will take place before inspections take place, and also testing within homes will be sorted, and any homes identified with any positive COVID-19 tests are not inspected.

9th September 2020

The following is a reproduction from the Care Management Matters Magazine December 2019

Between January 2015 and the end of September 2019, 602 care homes have opened, but during that same period 1,221 have closed. The closures have accounted for nearly 38,000 beds lost – that is around 10% of the total number of beds currently available.

Assuming these homes had an average 75% occupancy level, this would mean that around 28,000 vulnerable older people will have had to find new accommodation over the last five years.

One very slight consolation is that over 600 homes have opened in this time and they are, on average, larger than those that have closed, meaning that 28,750 new beds have been generated. However, this still shows a net loss of around 8,900 beds, while the population of people aged over 75 in England has grown by half a million – or 11% – during that period.

The 1,221 homes that have closed since 2015 are actual closures and not what CQC would refer to as ‘De-Activations’, which total over 3,300 since the beginning of 2015. The 2,000 or so that bring us up to this figure entail change of ownership or legal entity.

It is interesting to see that not all closures were lost forever, and a few subsequently reopened under new ownership at a later date. Seven homes re-opened within a year, 13 reopened within one and two years, and two reopened three and four years after closure respectively. But 20 homes that opened since the start of 2015 have since closed.

The Office for National Statistics recently reported that the number of people aged 85 and over, who account for about half all care home beds, will double in 25 years’ time. This doubling in numbers has been forecast since I started reporting, so it is not exactly breaking news, but we still aren’t seeing much of an increase in the number of beds overall. Something needs to be done to turn this trend around and make sure supply matches demand in the coming years.

The where and why

Way back in 2002, the Personal Social Services Research Unit (PSSRU) published a report, Care Home Closures: The Provider Perspective and their headline reason for the 20 closures they studied was, ‘All but one of the homes (which was closed due to enforcement action) closed either to avoid further losses, or due to the business earning an inadequate return now or in the future.’

This will still undoubtedly be the case, although with the CQC rating system in place it is now more than one in three that has closed with an Inadequate rating, not the one in 20 homes that ‘closed due to enforcement action’.

Out of the 1,221 homes that have closed since 2015, 338 did so without being inspected under the CQC ratings system that was introduced in October 2014. Of these, only 42 were closed after March 2016 when the CQC had planned to have all services inspected (a target that it missed).

Of those who closed having had an inspection, around two thirds were ‘non-compliant’ – 37% were rated Inadequate and 29% Requires Improvement.

It is perhaps easy to understand why the Inadequate homes closed but there are currently nearly 2,000 homes trading with a Requires Improvement rating. Are some of these also likely to close as their occupancy and income suffers because prospective residents opt for their competitor homes with Good ratings?

If two thirds of closures since 2015 were non-compliant, this also means that one third of homes that closed were rated Good (two homes were in fact rated Outstanding), so we must assume commercial pressures as the reason for closure.

At CSI, we base estimated supply levels on the number of beds per thousand people aged 75 and over in the area. This age group, according to 2011 research by Bupa and PSSRU, accounts for 90% of all care home beds. Looking at this data, we can see that half of the Good homes that have closed since 2015 were located in local authorities with higher than average supply levels.

We can assume that those homes in areas with high levels of supply and increased competition would have probably suffered with lower than average occupancy levels. Another problem with too many care homes in one area is likely to be the ability to recruit and retain care management and staff.

Of the closures, half of those that were rated Good had 25 beds or less, and so the economies of scale may have played a part in the closure, where a change of use for the location was a better financial option for the provider.

Regional variations

It is certainly not a case of boom in the ‘affluent south’ and bust everywhere north. Across the 150 local authorities in England, only 40 have gained beds, and 15 broken even, since 2015. Most regions have lost beds overall. The biggest losers since 2015 have been London, the North East and the South West with net losses of up to 6% of beds. Yorkshire and The Humber fared slightly better with a net loss of around 3% of their beds, and the East Midlands, North West and South East had net losses of between 1% and 2%.

Only two regions, the East of England and the West Midlands, have added to their number of beds, but only nominally at less than half a percent.

When we look at the national average of a third of homes closing with a Good CQC rating, we can see that there have been higher levels of closures in this group in the East Midlands and the North East, both around 42%. However, with a potentially interesting East/West split, this figure stands at around 25% in the West Midlands and the North West.

It goes without saying that local authority contributions are lower than they should be across the board, but there was little difference in fee levels paid by the local authorities that gained beds compared to those that lost them.

According to the Improved Better Care Fund (iBCF): Provider fee reporting Quarter 2 2018-19, the eight local authorities that have grown their number of beds by 10% or more were paying, on average, £696 a week for a care home with nursing bed and £649 a care home bed.

At the other end of the scale, 36 local authorities have had a greater than 10% net loss in beds over the last five years, and the average weekly contributions from these local authorities were £665 and £625 respectively, so around 4% lower than the best performing authorities.

A shift in trends

Something perhaps unexpected is that it seems as though if your care home does not offer dementia care, you have greater chance of closure.

Whilst locations that are not providing dementia care (i.e. those homes that have not ticked Service user band – Dementia on their CQC registration) account for around 30% of all care homes, they accounted for 46% of all closures. Since 2015, there have been 660 closures of care homes not offering dementia care compared to only 200 openings, indicating a declining sector.

On the other side of this, with openings matching closures at around 220, the nursing dementia sector has in fact grown by around 3,750 beds, but the residential dementia sector has seen just 180 openings and as many as 438 closures, losing around 4,660 beds since 2015.

This increase in beds in nursing dementia care means that care homes with nursing overall have lost just a few hundred beds in the last five years, while the residential sector has lost heavily.

Looking at the size of a provider has also uncovered some interesting trends. Larger providers, with 10 or more care homes, make up around 30% of all homes, and 40% of all beds. They also account for 28% of openings and only 20% of closures but have still lost around 1,000 beds overall.

Out of the 950 different large providers that have closed at least one home in the last five years, 759 no longer appear on the CQC register at all.

Taking control

Survival of the fittest is a factor in all aspects of life and business, and there is no doubt that closures will include converted properties that were, or were becoming, unfit for purpose and are being replaced (but not in the same local area) with shiny new purpose-built units. And 8,272 beds were lost in care homes that were rated Good, which is almost as much as the 8,900 beds that were lost overall. This should not be happening.

Care home closures can shatter lives; the owners, their employees, residents and their families, and of course those people struggling to find a bed when local homes close down. Local authorities need to take control of what is going on in their domain, with social services working alongside planners to ensure that planning consent is not given where there is already an oversupply of beds, and that applications are fast-tracked where there is a proven need.