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Crisis in the care home sector

Given the right conditions, care homes offer rewarding roles for nurses and create innovative partnerships with NHS teams. But in the current perfect storm of inadequate funding, staff shortages and critical CQC reports many are struggling to survive.
Care home crisis

Given the right conditions, care homes offer rewarding roles for nurses and can create innovative partnerships with NHS teams. But in the current perfect storm of inadequate funding, staff shortages and critical CQC reports many are struggling to survive

There are more beds in nursing and care homes than in NHS hospitals, yet it is only when things go wrong that the importance of the care sector is brought home to us because the implications are felt across both sectors.

At present many homes are struggling to survive, with the money accrued in fees unable to cover increasing costs, general difficulties in recruitment and a number closing after poor Care Quality Commission (CQC) inspections. Just as much as the NHS, the care home sector is experiencing a perfect storm, with the recent

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Given the right conditions, care homes offer rewarding roles for nurses and can create innovative partnerships with NHS teams. But in the current perfect storm of inadequate funding, staff shortages and critical CQC reports many are struggling to survive


Worrying times...recruitment difficulties can force care homes to close.
Picture: iStock

There are more beds in nursing and care homes than in NHS hospitals, yet it is only when things go wrong that the importance of the care sector is brought home to us – because the implications are felt across both sectors.

At present many homes are struggling to survive, with the money accrued in fees unable to cover increasing costs, general difficulties in recruitment and a number closing after poor Care Quality Commission (CQC) inspections. Just as much as the NHS, the care home sector is experiencing a ‘perfect storm’, with the recent CQC State of Care report warning, ‘the sustainability of adult social care is approaching a tipping point’.

Recruitment issues

Staff shortages, especially of registered nurses,  are a key factor. Recruiting nurses in the current environment is at least as difficult for care homes as it is in hospitals, and often they are chasing the same agency staff to fill gaps in rotas. The care home sector may offer comparable wages on many occasions, but often pensions and other terms and conditions will not match those in the NHS.

And these are challenging roles to fill, points out independent nurse consultant Deborah Sturdy, who is an expert in the sector: a nurse may be the only registered professional on duty, so will need to have good judgement and risk assessment skills. 

Ms Sturdy says difficulties in recruiting nurses are likely to be factors in home closures in some areas. Not being able to find permanent nursing staff or having to pay high agency rates can make homes unsustainable.

Closures

According to CQC figures for 2015-2016, the number of nursing homes in England dropped from 4,697 to 4,633, and the number of beds fell from 224,674 to 224,026, reversing the increase seen over the previous 5 years. In May, the BBC reported that a quarter of care homes are in danger of going out of business within 3 years.

This isn’t just a problem for the care home sector, as Ms Sturdy points out. ‘One of the things I am concerned about is there does not seem to be an understanding about the chaos that home closures will cause the NHS. It is a workforce issue that nobody has quite got.’

The Brexit effect

Much of the nursing home workforce come from overseas, often the EU (the CQC estimates that 90,000 workers in the care sector come from other EU countries). The looming reality of Brexit and the falling value of the pound – which means UK wages look less attractive to those coming from overseas – may make this more challenging in future.

‘One of the biggest providers said as soon as the Brexit vote happened, people started to withdraw from interviews,’ says Ms Sturdy. ‘I think the xenophobia that is being displayed at the moment is worrying. People will start to go home.'

Head of nursing at Four Seasons Health Care Joanne Strain says her company employs about 3,000 nurses but has 800 vacancies. It has recruited hundreds of nurses from the EU and is now beginning to look further afield to India and the Philippines.

Increased dependence

This shortage of nurses is being felt even more acutely because of the increased dependence of many residents in homes. ‘Twenty years ago, if someone wanted to come and live in the care sector they just presented at the door with a pension book. Now, few people walk in the door, they are on a stretcher,’ says Ms Strain.

To add to the sector’s problems, often care homes are not making a profit. Councils, which pay fees for many residents, have kept these at a level many providers say does not cover their costs and allow them to make a profit. Some care homes have been effectively subsidising council-supported residents by charging private residents more.

Many homes are paid a set amount by the NHS to cover the nursing element of care for individual residents. Although this was recently increased significantly as an interim measure, the future level has still to be confirmed and there are suggestions it could be set to reflect regional costs. 

Homes have also been affected by the increase in the minimum wage – now £7.20 for those aged 25 and over. Nurses will be paid more, of course, but many care assistants will be paid at this rate. ‘The big risk is that there will be an increase in the national living wage again next year,’ warns Ms Strain. ‘There is the potential for the loss of thousands of beds.’

The CQC’s State of Care report highlighted how contracts were being handed back to local authorities: 32 residential or nursing home contracts were returned in the 6 months to May 2016. Some providers had considered moving from providing nursing care to residential care only and there has also been a number of closures, especially among small homes.

Nursing in a cash-strapped environment is inevitably tough and may result in staff-to-patient ratios that would be considered unacceptable in the NHS: one nurse covering as many as 56 people overnight has been known.

‘Heroic’ staff

Consultant nurse for older people Nicky Hayes works to support nursing homes in three London boroughs and has seen homes close, some of them because of poor standards. ‘They may have struggled with quality, they may have lacked investment,’ she says. Staff morale can be affected as homes decline and they are inevitably worried about the future for residents. ‘There has been some really heroic work by staff,’ she says. 

But despite all the challenges, Ms Sturdy thinks there are opportunities. The sector is providing integrated personalised nurse-led care, she says, and could have a big part to play in the future, if it can get through the current difficulties.

Four Seasons already provides some intermediate care working closely with NHS organisations. For example, in Northern Ireland, NHS staff up to consultant level visit homes to give expert advice and work alongside care home staff to aid recovery. ‘NHS hospitals will require nursing homes to upscale in the future as they won’t have the beds,’ says Ms Strain.

The future for the sector could be bright, with great roles for nurses and better partnership working with NHS multidisciplinary teams. The issue, as always, is whether there will be the money to pay for a brighter future.

 

What will nursing home closures mean for the NHS?

A reduction in beds in the care sector could make it more difficult for patients to be discharged from acute care if they are not well enough to return to their own home. With delayed transfers of care already at record levels, this could add significantly to bed pressures in hospitals. It may also affect ‘admission avoidance’ – a nursing home bed might be an option for someone who needs more support but does not need the care offered by acute hospitals.

Some areas of the NHS are also looking at reducing the number of inpatient beds in community hospitals. In the past, some of these beds have been ‘re-provisioned’ in nursing homes, often offering an alternative where patients are closer to home. If more homes close this may become harder.

However, some NHS organisations have already seen the need for more nursing home beds. Dartford and Gravesham NHS Trust runs a nurse-led unit in the grounds of a nursing home. NHS staff provide care and rehabilitation to patients, with input from specialists at the hospital.

East Kent Hospitals University NHS Foundation Trust is examining whether it could set up its own nursing home next to an acute site, which will enable it to deliver care to patients waiting for discharge or in need of rehabilitation. It could potentially also take in residents who were not patients who would either self-fund or be funded by local authorities, generating income for the trust.

 

Making care sector nursing more satisfying

For Deborah Sturdy, nursing homes offer the epitome of nurse-led services, with nurses often taking on great responsibility and autonomy, including making complex clinical decisions about the best care for unwell residents. The challenge is convincing people of this.

Foundation of Nursing Studies (FoNS) chief executive Theresa Shaw says there is often a perception that nurses in care homes are in some way ‘second rate’, which makes recruitment more difficult. She praises the care home managers she works with for their ‘can-do’ attitude and suggests different approaches, such as staff exchanges, could help those outside the sector have a better understanding of the role.

FoNS has developed a Teaching Care Home project aimed at demonstrating excellence in caring. Robin Willmott, general manager of Millbrook Lodge in Gloucestershire, one of the homes involved, says it has enabled the work they do to be showcased and has helped to attract more nurses to the sector. The home, which is run by a charity, also takes students on placement and works closely with local NHS staff. Mr Willmott says care home work can allow nurses to tap into the compassionate side of the profession and allows nurses to forge caring relationships with patients and families.

Offering nurses the opportunity to develop skills and move on in their career is important, and may be hard for smaller settings. However, there have been some improvements, such as a small-scale initiative supported by Health Education England, which has enabled some care home nurses to work towards Master’s level qualifications. The RCN Foundation is also offering funding for projects supporting nursing in care homes.

Supporting younger, less experienced nurses is also important: Four Seasons has a preceptorship scheme and has also developed an assistant practitioner role that allows nurses to concentrate their input where it is needed most. It is also looking at IT assistance to ensure patients receive quality care using a series of prompts, for instance about medications. 

Some of the areas piloting new models of care have also worked with care home staff, aiming to improve their skills and relieve the pressure on the NHS.

 


Alison Moore is a freelance journalist 

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