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Supporting health and social care providers in Devon

MPS: Care homes

MPS: Care homes

Trends

1. The Devon County Council area has more residential beds, fewer nursing beds, and fewer beds overall relative to population than both comparator and national averages. It also experienced a decline of -2% in residential beds and -1.6% in nursing beds.

Service provision - adult social care service provision: Number of residential and nursing care home beds for the population of Devon local authority as at 18/07/19. As a comparison to England Devon has 5275 and England has 4599 average. Nursing care beds for Devon 2863 and England average 4336. The Devon County Council area has more residential beds, fewer nursing beds, and fewer beds overall relative to population than both comparator and national averages. It also experienced a decline of -2% in residential beds and -1.6% in nursing beds.
Service provision – adult social care service provision: Number of residential and nursing care home beds for the population of Devon local authority as at 18/07/19. As a comparison to England Devon has 5275 and England has 4599 average. Nursing care beds for Devon 2863 and England average 4336. The Devon County Council area has more residential beds, fewer nursing beds, and fewer beds overall relative to population than both comparator and national averages. It also experienced a decline of -2% in residential beds and -1.6% in nursing beds.

2. Commissioners continue to place fewer older people in residential/nursing care relative to population than the comparator and national averages. Short-term services are effective at keeping people out of hospital and not dependent on long-term care but don’t reach enough people, partly because capacity is diverted as contingency for personal care insufficiency.

Service provision - short-tern treatment outcomes and long-term care home admissions. This chart and tables shows the rate of council supported older people (aged 65+) whose long term support needs were met by a change of setting to residential or nursing care during the year per 100,000 population.
Service provision – short-tern treatment outcomes and long-term care home admissions. This chart and tables shows the rate of council supported older people (aged 65+) whose long term support needs were met by a change of setting to residential or nursing care during the year per 100,000 population. Commissioners continue to place fewer older people in residential/nursing care relative to population than the comparator and national averages. Short-term services are effective at keeping people out of hospital and not dependent on long-term care but don’t reach enough people, partly because capacity is diverted as contingency for personal care insufficiency.

Demand

The future demand for care home provision needs to be understood in the context of the overall demand for lifetime homes and housing with care services because people at the same or comparable level of need can be and are supported in any of these options.

Demand for services is anticipated to grow significantly because of an increasing ageing population and because more children with disabilities are living into adulthood and older age. It is also the case that with advanced age comes increased intensity and complexity of need arising from multiple long-term conditions[1],[2] .

However, predicting future demand for specific care service types such as care homes is difficult. Changes to the legislative, financial, political and policy framework, people’s changing expectation about how and where care is delivered and developing best practice all impact on actual demand. For example, the numbers of older people funded by DCC or the NHS in care homes has declined in recent years despite demographic growth. Also, there is local and national evidence that people at comparable levels of need find themselves living in care homes and housing with care service such as Extra Care Housing or Supported Living. This makes defining the need for specific service types difficult.

The needs assessment, published with this MPS, offers a preliminary view and this is being revised. This revised needs assessment will be published in the tender pack which will be issued as part of establishing a new care homes framework from April 2020 and updated as further information becomes available.

Key Messages from the MPS needs assessment:

  • DCC fund 2769 people within 304 care homes in Devon. This represents 35.29% of the beds available in these homes
  • The largest cohort of clients are 90+ with 786 placements and 85-89 with 576 placements. This means that 49.2% of all care home placements are for people over the age of 85.
  • However, 50% of people are under 85 years of age who may have been placed within housing with care had an appropriate service been available at the time of their placement

The trend of placements is shown in the graph below which illustrates a notable net increase in the numbers of placements made over the last year. The updated needs assessment will consider the factors that have led to this increase:

The trend of placements is shown in the graph below, which illustrates a net increase in the numbers of placements made over the last year:

Devon County Council funded residential clients 12 month trend (increases in September from 2060 peaking at 2820 (approx) in May 2019 then falling a little in July to 2750 approx.
Devon County Council funded residential clients 12 month trend (increases in September from 2060 peaking at 2820 (approx) in May 2019 then falling a little in July to 2750 approx.

Devon County Council records the primary support need of people being placed into care homes which shows;

  • Physical support 43.2%
  • Memory and cognition 15.5%
  • Mental health support 12.75%
  • Learning Disability Support 12.4%
  • Sensory support 9.3%
  • Unknown 6.8%

An analysis of admissions over the last 12 months has shown an increase of 28.7% in people with a primary support need related to memory and cognition. Around 17,725 people in Devon are estimated to have dementia, nearly 2 per cent of the population. This figure is expected to rise to around 25,000 in the next ten years, affecting nearly 3 per cent of the population, around 6.5% of the over 65s.

We will be working with housing authorities and other stakeholders to describe the demand for accessible housing and housing with care and the demand for care homes at a district council level area.

We will work with housing with care providers to increase supply where there are shortages. This will include discussions with those care home providers who are considering with CQC the deregistration of care homes to supported living accommodation.

Many people are discharged into care homes directly from hospital when their needs are at their most acute and intensive[3]. Laing Buisson national surveys indicate that 53% of admissions to care homes with nursing and 31% of care homes without nursing are from hospital[4], sometimes following a significant length of stay in hospital where a deterioration in health and functioning makes it more likely that people will be discharged to a care home or with an intensive package of care[5]. We will examine the position in Devon as part of our updated needs assessment.

In circumstances where people are discharged from hospital our approach will be to place people in care homes with an expectation of a discharge to a less dependent setting.

We will be adopting a similar approach when admitting a person of working age, in particular when that person is a younger adult who has a reasonable expectation of a moving to more independent living in the future

We want to work with care homes to deliver time – limited and outcome – focussed services that promote independence and, where appropriate, facilitate a move to a less dependent community setting.

Good quality care homes also make a significant contribution to supporting family carers both in terms of the provision of respite/replacement care services but also in terms of supporting carers as valued partners in the delivery of care and support.

We will bring forward an opportunity for care home providers to become part of an accredited list of replacement care providers by October 2019. 

 

Supply

Lack of appropriate supply can result in younger people with disabilities being accommodated within care homes designed primarily around the needs of older people, or people with sensory or physical disabilities being accommodated in care homes for people with a learning disability or adults of any age displaying behaviours that are challenging being placed in care homes or hospital settings out of county.

Furthermore, people who have complex needs, but do not require 24/7 nursing oversight may be placed into care homes with nursing because there are insufficient care homes without nursing able to manage that persons needs in their locality.

Despite the apparent availability of placements for people who require a care home with nursing, the actual number of placements suitable for people with complex needs can in practice be limited due to the characteristics of the care home building, or the level of staff experience and skills profile. For example, in an audit of 48 cases that had been through the brokerage system more than three times( April 2018- April 2019) including eight discharges from Franklin Hospital Exeter only a third of care homes offering services for people with dementia were willing to accept referrals of patients from the older persons mental health hospital. Placements were declined because of the complexity of need of the individuals or lack of appropriate facilities .Social care and health practitioners are alerting us to localities where care home sufficiency is challenging, and we continue to collect data to understand where those areas of limited sufficiency exist and for what reasons. Further detail will be provided in early 2020.

To understand sufficiency we are combining this analysis with information about market premiums and information from operational teams. For a care home with nursing there may be less of an expectation of being able to source a placement in your own Market Town.  In terms of the numbers of beds per head of population with a life-limiting illness Mid Devon and Torridge would seem to have proportionally fewer beds available. However, if we combine the above data with areas shown to have the highest rates of Market Premium and operational feedback; that would suggest greater pressure on Nursing Home places in Teignbridge, East Devon, Exeter and North Devon with Barnstaple, Newton Abbot and Exeter as specific locations where additional, modern nursing home capacity is needed.

Nursing home profile (commissioned placements only)

  • There are 66 nursing homes with 2783 registered beds. Devon County Council and Devon CCG purchase 1033 of those beds (37%) (June 2019)
  • 27% of beds purchased by the commissioners in Nursing homes are purchased as residential placements
  • 4% of Care Home with nursing placements are funded under section 117 Mental Health Act aftercare
  • At 27/6/19 care homes self-reported 97 vacancies
  • 5% of all placements are made in care homes out of county

A review in 2018 of sufficiency within the Care Home with nursing sector revealed a complex picture. It became apparent that:

  • There was significant underutilisation of existing nursing capacity. With 97 vacancies and 279 beds purchased by commissioners as residential beds, then there are arguably at least 376 beds (this doesn’t include private purchase of residential beds in Nursing Homes) which with some reconfiguration could be made available for nursing capacity within existing stock (the level of vacancies and residential placements vary significantly by care home).
  • challenges around recruitment of qualified nurses were resulting in reductions in available nursing beds
  • A lack of placements for people with very complex needs was arising from limitations of building design or lack of skill base within the workforce. This can result in placements out of county, or placements with high levels of 1:1 support commissioned.

Devon County Council would wish to explore with Nursing Home providers opportunities for investment to address the challenges around maximising existing nursing home capacity, remodelling existing capacity and introducing new modernised care homes for example in North Devon, Newton Abbot and Exeter (and potentially Okehampton) and upskilling the workforce. We are also keen to explore new workforce models in relation to nurses and nurse associate roles and develop provision and support that reduces the need for high levels of 1:1 staffing for individuals with complex needs.

During 2019/20 we will work alongside NHS England, NHS Devon CCG, Primary Care Networks and NHS local providers as well as care home providers to specifically address our requirements for care homes with nursing and the best way to ensure appropriate care home environments and service models to meet demand now and into the future.

We will continue to refine our bed vacancy tool to ensure that we understand both the available supply of care home placements in any locality but also the features of that supply so that we better understand sufficiency at a local level and match care homes placements to the specific needs of individuals requiring a placement.

We launched a survey of care homes in the summer of 2019 to better understand the opportunities and challenges that are present in existing care home buildings. The outcome of the survey will be made available in late Autumn 2019. We are also considering introducing a requirement on providers to update critical information about care home buildings as part of the introduction of the new care homes framework. We will be seeking the engagement of care homes in the development of both these initiatives.

 

The increasing availability of housing with care services and a continued drive to support people at home as part of our promoting independence strategy is likely, in the longer term, to reduce the numbers of people overall who are supported in care homes without nursing. However, the increasing complexity and intensity of the needs of people being admitted into care homes is likely to mean that the demand for care homes capable of managing increased levels of need is likely to remain buoyant; for example, for people with multiple disabilities and behavioural difficulties associated with mental health, dementia or cognitive difficulties. This will require a different balance of care home provision with or without nursing and will have a consequential impact on buildings, facilities and workforce.

There are also challenges associated with outdated care home environments. The profile of care homes in Devon indicates a significant proportion of smaller and older care homes that may not be fully care and technology ready and where the challenges will be greater. We are already working with care homes for people with disabilities or mental health who are considering deregistration into housing with care services where appropriate.

We require modernised care and technology – ready care home environments that provide safe, appropriate and affordable services in which to deliver regulated care for people who have very intensive and/or complex needs.[6]

To improve the availability of appropriately built care home environments, we will:

  • Support provider development plans, where appropriate, through Business Relations support, support with planning applications, needs analysis to support business case developments and building design. The aim will be to develop existing care homes, wherever possible, so that they are suitable for the increasing intensity and complexity of demand and to attract new build care homes, potentially replacing older buildings over time.
  • Continue to work with care homes who wish to deregister in response to falling referrals for residential care and increasing demand for Housing with Care services such as Supported Living in their locality, where it is strategically appropriate to do so (see Supported Living section).
  • Work with care homes to explore how assistive technologies can improve and modernise service delivery and improve personal outcomes.

 

Service model and fee model

The care home providers we are most likely to commission services from in the future will be those who:

  • are consistently rated by CQC as ‘Good’ or ‘Outstanding’ and that offer services personalised to the needs and wishes of individuals and deliver outcome-focussed care and support based upon what is important to that individual.
  • demonstrate an understanding of the requirements of people with complex and intensive health and social support needs and the most appropriate way to meet those needs.
  • promote people’s independence and encourage the maintenance or gaining of self-care skills and where appropriate facilitate a move to a less dependent setting [7],[8].
  • work with community-based and acute health services to promote people’s health and wellbeing [9],[10] and to significantly reduce the risk of residents being unnecessarily admitted to hospital or transferred to a more dependent setting such as a care home with nursing.
  • improve people’s outcomes through training and support around key areas such as dementia, falls, nutrition and hydration and complex mental health needs.
  • provide a range of support to family carers including respite or replacement care and ensure that carers are involved as valued partners in the provision of care.
  • provide or support and encourage stimulating physical and mental activity and greatly increase opportunities for social interaction with other residents, staff and the wider community.

By summer 2020, we will introduce a new Devon specification for care homes that will embed the standards and levels of quality described above and will introduce clearer quality assurance and performance management arrangements.

The performance of care home providers in terms of successfully supporting people with complex and intensive care needs and of promoting independence and transition to less dependent settings where that’s appropriate will be actively monitored to understand which care homes best deliver those outcomes to facilitate choice of care setting.

This service model will require workforce changes in terms of the skills and competence of care workers and the leadership of registered managers. We recognise that there are significant workforce challenges now in terms of access to training opportunities for care workers and managers and recruitment and retention of care staff and registered nurses. We will continue to work with care home providers to increase the numbers of apprenticeships and to test the Nursing Associate role.

We will work with care homes through Devon’s Proud to Care initiative to explore with providers how we (Devon County Council), the NHS Devon Clinical Commissioning Group (CCG) and Devon Partnership NHS Trust (DPT) can support recruitment, retention and staff training including apprenticeships

 

Procurement, fee model and pricing

Devon County Council introduced a personalised fee model for all new placements in care homes for older people, from 2018, which established a set fee for accommodation, related costs and a set rate per hour of care depending upon the needs of the person being accommodated. This is based on a spot contracting arrangement where individual placements are ‘called off’ primarily based on personal choice of care home, subject to Devon County Council fee.

From April 2020, we intend to introduce an open framework contract, supported by a revised and modernised specification, which will continue the personal choice – based call off arrangements and personalised fee model for Devon County Council funded placements.

We are working with other local authorities to explore the feasibility of a regional framework for learning disability that focusses on the needs of the most complex individuals, for example those with multiple disabilities and who require significant behavioural management support.

The commissioners will work with care homes during 2019/20 to explore how the two framework agreements (Devon County Council framework and regional framework), might interface with one another and operate in practice.

Market opportunity - care homes
  • Devon County Council and NHS open framework contract for all care homes for all adults will be put in place 2020/21.
  • Regional framework for people with complex and intensive needs associated with a learning disability by April 2020.
  • Accredited list of replacement care providers including care homes by October 2019 (see section on replacement care).
  • Increased opportunities for care home providers capable of delivering time – limited placements to promote independence particularly for people of working age and even more particularly for people 18 – 35.
  • Opportunities, where appropriate, to de-register or diversify into the provision of housing with care services.

 

[1] Public Health England –commissioning for  improved health through the home accessed via; https://www.gov.uk/government/collections/housing-for-health

[2] Is late-life dependency increasing or not? A comparison of the Cognitive Function and Ageing Studies (CFAS) by Kingstone et al 2017 – Lancet

[3] Bolton, J. and Provenzano, P., (2017) Six Steps to Managing Demand in Adult Social Care – A Performance Management Approach.

[4] laingBuisson Care of Older People – UK market report 27th ed 2015

[5] Covinsky KE, Palmer RM, Fortinsky RH, Counsell SR, Stewart AL, Kresevic D, et al: Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: Increased vulnerability with age. J Am Geriatr Soc. 2003

[6] laingBuisson Care of Older People – UK market report 27th ed 2015.

[7] Covinsky KE, Palmer RM, Fortinsky RH, Counsell SR, Stewart AL, Kresevic D, et al: Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: Increased vulnerability with age. J Am Geriatr Soc. 2003

[8] Emerging practice in outcome-based commissioning for social care. IPC John Bolton 2015

[9] Enhanced Heath in care Homes NHSE accessed via https://www.england.nhs.uk/wp-content/uploads/2016/09/ehch-framework-v2.pdf

[10] Your Future Care NEW Devon CCG 2016.

 

 

(Return to the Market Position Statement)

Last updated: 29/01/2020


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