The Care Market in the County is large and includes 289 Care Homes – of which 168 are for older people, 30 supported living providers contracts and 48 contracted domiciliary care providers.
The Care Homes themselves are often small averaging around 40 beds and in single ownership with a number carrying high levels of voids which itself causes commercial issues and risk. In short it was already a market that was under pressure and fragile. There have been 5 care homes close In Nottinghamshire in the last year (during the pandemic) with the theme for most of the closures being viability and/or quality issues. Whilst there has been a reduction in the number of care homes there will be a further increase with an expected 3 new care homes with 40 plus beds opening in the next year (offering personal care only).
During the pandemic there have been high infection rates across the County and by November/December 2020 there were around 130 outbreaks in the care sector, with the majority of those in older person care homes.
The population across the large geography of Nottinghamshire is aging and presenting with a complexity of challenging issues as well as frailty which meant as a consequence the population in care homes was at high risk if there were any outbreaks. The Health and Social Care system may appear simple to the professionals already working within it but as somebody “coming in” it felt complex and wired into professional silo’s that did not give much scope for joined up thinking. Early Government advice around the pandemic and it impact on Care Homes tended to be reactive and patchy- which meant practitioners across the system struggled to deliver a joined-up approach.
Signs of Market Stress – what have been the indicators?
- Care Homes have indicated that they are subject to financial pressures and a number of homes have closed due to commercial considerations. This is pertinent in Nottinghamshire as the market is dominated by homes with less than 40 beds in single ownership (high void levels- 30%)
- A number of Care Homes have been identified as requiring improvements in their delivery and quality of care and a number have subsequently closed. This issue is exasperated by the inability of Care Homes that have inadequate ratings to access insurance and when they do so it is very expensive.
- Increased numbers of safeguarding referrals in the Care Home market – for quality concerns and issues related to safe Covid practices
- One large national provider has decided to put its Care Homes on the market as they do not fit its delivery model – large 80 bed units.
- There is an increasing reliance on agency staffing across the sector and an inability to recruit Nurses in the Nursing Home sector
- A number of small services supporting the direct payment market have closed
- It was difficult to manage and monitor the diversity of the Direct Payment market more specifically PA’s.
What have been the limitations around data?
- Initially the Council did not have the data that was required (Covid specific) and very quickly set up a Covid dashboard that providers updated. This was superseded by the NHS Tracker which was then used for care homes data collection (One Version of the Truth)
- Although the Care Homes adopted the NHS Tracker (was helped by aligned to the payment of Covid Grant monies) the Dom Care providers were slow to adopt the Tracker and the data-set was limited
- Data inputting for single providers was time-consuming and a further task at a time when they were under the greatest pressure- data inputting fatigue
- National Trackers did not extend to Extra Care and Supported Living
- The vaccination programme was not initially capture by the Trackers
Has there been high staff vacancy rates – causes?
- Staff vacancy levels have been minimal across the Care Home sector- indeed some Homes have furloughed staff due to the high levels of vacancy (staff shortages have been the result of specific Covid outbreaks)
- The issues around vacancy impact in care homes relate to accessing Registered Managers and Nurses- and that follows the national trend.
- Vacancy levels in the Homecare market remain high especially in some rural and affluent (over employment) areas.
- Vacancy levels in the Extra Care sector remain low as staff are attracted to the static provision and flexible care hrs.
Has there been high staff turnover rates – causes?
- The turnover of staff in Care Homes has remained low, however there is anecdotal evidence that some staff that have managed through the pandemic are choosing to leave due to exhaustion and other allied issues (burn-out).
- The turnover rates for those staff delivering Homecare remains high and although it reduced at the beginning of the pandemic it is rising again as some carers return to past alternative occupations.
- Care homes have experienced a reduction in occupancy levels which saw a reduction in workforce or staff furloughed
How are we managing the care market to support people with more complex care needs?
- A multi-agency taskforce which includes staff from the LA, CCG, CQC, PH have worked to support the entire market
- Regular communication through newsletters, webinars have been in place to provide expert advice to the Care Market
- Training has available to up-skill staff to work in area’s supporting people with complex needs
- Care providers have worked together to deliver mixed packages of care to support people in the community
- Changes in packages to support people intensively – as a consequence of day services working differently
- More people going home from Hospital with complex care packages/mixed packages of care
• The sector needs to be valued, respected and connected - an equal partner in the system
How are we developing the system to support an ageing population?
- Development of a prevention strategy including approach to community assets, target early intervention Technology Enabled care and Equipment, carer support
- We are having further conversations with providers in relation to an ageing population even in younger adult settings. Throughout the COVID outbreak this has highlighted some vast inequalities in settings. Where people are not treated effectively when unwell and there is an expectation that the provider can manage situations. This has not been the case as there is little oversight from staff and managers about how to manage health needs in house.
- Housing with care HWC) is an ideal solution for people who have health and social care needs that will increase as they age. People need to be encouraged to move earlier so it is a housing choice rather than a care need.
- We have refreshed the Market position statement as a consequence of the impact of Covid pandemic to support the ageing population going forward
- Carer Strategy – Development of a strategic approach across Bas, County and City Council
- Reviewing Discharge to Assess Reablement Services to make them fit for purpose and supporting lessons learnt out of Covid
How is the whole system working to support the Market ?
- Governance has been put in place to deliver a strategic approach to supporting the market
- This has operationally delivered by the multiagency Taskforce delivery approach
- Actions have been informed across the system through the one-version of the truth
- Communication has been consistent across the system and readily available – the market has told us it has not been isolated
- Co-production with providers in Webinars has allowed the system to flex and deliver specific outcomes when the market has been at stress points
- Lessons learnt have been a regular feature of the system decision management and informed operational practice
- Systems have concentrated on outcomes rather than individual financial silo’s
- Working with Health partners to create a solution-based agenda – bringing partners together
- Focus on beds – rather than home based solutions – from a Hospital perspective
- Designated Settings have been driven as a solution
- Monitoring & Understanding of Skill-Mix & Workforce (Clinical, Non-Clinical, Support Staff)
- Increasing the care support worker offer through bank and active recruitment e.g. Nottinghamshire County Council recruited additional supply staff with the aim of being able to offer short term emergency support to care home providers in severe crisis
- Care Home Response Hub
- WhatsApp Peer to Peer group was set up including all partners from Health and Social Care
- Webinars (planned & unplanned)
- Provider forum/newsletter and daily contact
- Toolkit - supporting providers to interpret national guidance
- Extended Roles - Support to secondary care for discharge, application of Restore and Respect with signpost to pathways
- Nottingham University Hospital with NHS Professionals and Sherwood Forest working across boundaries with the care sector to enable rapid discharge
- Government funding has supported the work with the market
- The policy perspective has been complex and timings have not been helpful
- We may need to stop services as the funding ceases – short-term
- Need to deliver a sustainable funding model for long- term impact
- Not a lot of understanding of Social Care and Market Commercials (short-term funding does not work in supporting longer term business models for social care providers)
- Little consideration of LA responsibilities around charging and self-funders
- Admin burden placed on the market – with high levels of data requests for a long period – challenging data/tracker – the ask was constant
- The complexity of the separate grants impact on the LA as well as the providers
- Health partners struggles to understand the diversity of the Social Care Market with specific reference to Extra Care
- Financial support in respect of Insurance (care home) has not delivered a solution
- CQC changes and priorities – impact on LA Quality approach
To conclude after a difficult year there has been some positives outcomes which are being built on to support the system wide approach in supporting the social care market. The trust, confidence and experience that has been developed and built on will be used to ensure that all the partners are joined up in their work to reduce unnecessary impacts on the market.
The pandemic has enabled better sharing of information between organisations and has led to reduced duplication and added assurance. Data has been enriched and used for support. Integration of approach at all levels has been implement with the leadership, tactical and operational roles/processes.
There has been greater communication at every level across the system which has supported and enabled greater understanding of the roles and responsibilities of all the partners. Early conversations about future joint appointments across health and social care, as well more regular discussions with care managers and the market has and will have a positive impact on working with the social care market going forward.
The sector has been integral to shaping the agenda and articulate their needs and own messages and the conversation/co-production will be essential in ensuring that there is a fit for purpose market in Nottinghamshire. Shaping the market is key in ensuring that the right services are there to meet the needs of the people requiring them now and in the future. This journey of change will need to be taken forward by all system partners ensuring that the providers are included rather than any changes being ‘done to’ them.
Conversation and work have commenced on the care sector workforce blueprint with the development of a social care and health network which will work in partnership with a pioneering Social Care Faculty.