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Market Position Statement: Residential and Nursing Care

Foreword

Welcome to Staffordshire’s Market Position Statement for residential and nursing care. Our hope is that all care home providers will find this a valuable resource, whether you currently work with us or not.

We are only able to support people with adult social care and health needs thanks to the huge range of providers who work across Staffordshire. Care home providers have been at the heart of our response to COVID-19, and we continue to thank you for the care and support you provide to people with health and social care needs.

As we look ahead in this Market Position Statement, we hope that we will not have to experience anything like the turbulence and challenge presented by the pandemic, but we can expect that we will all have to adapt to other challenges – including some changes that we can already identify, and others that may be less immediately evident. The challenges of the social care reform, workforce, a changed landscape for integration and improving personalised and strength-based approaches will undoubtedly form part of our journey over the coming years. And, as we have learned over the last two years, the pace of change in areas such as digital and other technologies might also give us opportunities and challenges in ways that we are not even aware of yet.

We would like to understand your challenges as well as your ideas about what we could improve together, and we want to hear from your teams and the people whom you support as well.

We are clearly entering into a difficult economic period in the country, and we know that the challenge will be to continue to commission services in a tough financial context, even though we have prioritised investment into these services. Some of the solutions will come from technology, but most will come from people – all of us, working together, building on best practice and testing new and innovative solutions. I hope that you find this Market Position Statement a helpful element of how we achieve that.

Dr Richard Harling
Staffordshire County Council Director of Health and Care

Chris Bird
Chief Transformation Officer
Staffordshire and Stoke-on-Trent Integrated Care Board

Answer:

In adult social care, we support the County Council’s vision of being an ambitious, innovative and sustainable county, where everyone has the opportunity to prosper, be healthy and happy – including people with adult social care needs. In particular, we support the Council’s priority outcome that everyone in Staffordshire will be healthier and independent for longer, with a priority to encourage good health and wellbeing, resilience and independence. These outcomes and priorities increasingly shape our approach to strength-based working, integration, prevention and community services.

For the residential and nursing care sector, the more successful we are in achieving these outcomes and priorities, the fewer people (as a percentage of the whole population) will enter long term care. However, for those that do, the quality and outcomes in the care home will remain hugely important. The average complexity and extent of care needs of people in care homes will continue to increase over time, and this will continue to have implications for the physical environment, skills within the staff teams, and links with primary, community care and other services. These will all continue to grow in importance over the coming years.

Our strategic objectives for the whole of the Council’s Health and Care Directorate are to:

  • Promote good health and independence, and encourage and enable people to take personal responsibility for maintaining their well-being
  • Ensure effective and efficient assessment of needs that offers fair access to services
  • Maintain a market for care and support that offers services at an affordable price
  • Ensure best use of resources, people, data and technology

Specifically for commissioning residential and nursing care, our strategic objectives are:

  • Improving the quality-of-care homes in Staffordshire, primarily measured by the proportion of care homes rated by the Care Quality Commission (CQC) as ‘outstanding’ or ‘good’
  • Ensuring timely access to care home placements when required, with difference timescales depending on the pathway – ranging from same or next day for Discharge to Assess services commissioned by the NHS, and emergency respite requested by the Council, but with a longer period of time for non-urgent assessments
  • Ensuring affordability of care home placements, with the Council aiming to pay a fair price, achieving value for money for the Council taxpayers, and remining within budget

The NHS Long Term Plan sets a commitment to guarantee NHS support to people living in care homes through the delivery of the Enhancing Health in Care Homes (EHCH) model which will ensure stronger links between primary care networks (PCNs) and their local care homes, with all care homes supported by a consistent team of healthcare professionals, including general practice support. In 2020, Staffordshire and Stoke-on-Trent committed to roll out the EHCH model and this work will continue in 2024. This model moves away from traditional reactive model to one centered on the needs of individual residents, their families and care home staff.

We will ensure that all individuals living in a care home have good oral health, stay well hydrated and well-nourished and that they are supported by therapists and other professions in rehabilitating when they have been unwell. Care home residents will get regular clinical pharmacist-led medicine reviews when need. Care home staff will have access to NHSmail, enabling them to communicate effectively and securely with NHS teams involved in the care of their residents.

The NHS ambition is to strengthen support for people who live and work in and around care homes. People living in care homes should expect the same level of support as if they were living in their own homes. This is achieved through collaborative working between health, social care, voluntary, community, social enterprise sector and care home partners.

Answer:

Older people in Staffordshire The table below shows the projected needs of older people living in Staffordshire.

Table 1: Projected needs of older people in Staffordshire 2021-2040

 
 20212025203020352040% change 2021-2040
Population aged 65 and over 197,600 209,800 229,600 247,500 257,000 30%
Limiting long-term illness 100,600 108,800 119,100 128,300 135,100 34%
Unable to manage at least one self-care activity on their own 56,000 60,700 67,000 72,100 75,900 36%
Unable to manage at least one domestic task on their own 56,500 61,500 67,800 72,800 77,100 36%
Number of falls in last year 52,200 56,000 62,200 67,400 70,500 35%
Number of hospital admissions due to falls 6,200 7,000 8,000 8,500 9,100 46%
Dementia 13,600 15,00 17,000 18,800 20,400 50%

1 Numbers and percentages may not add up due to rounding. Source: Projecting Older People Population Information (POPPI); Dementia UK: update, © Alzheimer’s Society 2014; 2018-based population projections, Office for National Statistics, Crown copyright

  • The number of people aged 18 and over with a moderate or severe learning disability (who are therefore likely to require care) is estimated to increase from 3,400 to 3,600
  • The number of people aged 18-64 with a mental health condition is estimated to increase slightly from 97,800 people in 2021 to 98,500 in 2040
  • The number of people aged 18-64 estimated to have a moderate or severe personal care disability is estimated to fall from 26,400 people in 2021 to 25,600 in 2040

Adults aged 18-64 in Staffordshire

Based on 2018-based population projections, the number of Staffordshire residents aged 18 to 64 is predicted to remain static between 2021 and 2040.

Table 2: Population projections for those aged 18-64 in Staffordshire 2021-2040

 20212025203020352040% change 2021-2040
Population aged 18-64 518,100 520,300 519,300 518,000 521,300 0.6%
Learning disability (18 and over) 7,000 7,200 7,400 7,600 7,700 10%
Mental health conditions 97,800 98,200 98,100 97,900 98,500 1%
Autism spectrum conditions 7,000 7,200 7,400 7,600 7,700 10%
Moderate personal care disability 21,700 22,000 21,600 20,900 21,000 -3%
Severe personal care disability 4,700 4,800 4,700 4,600 4,600 -2%
Impaired mobility 30,200 31,100 30,600 29,200 29,100 -4%

Source: Projecting Adult Needs and Service Information (PANSI), Adult Psychiatric Morbidity Survey 2014 (APMS 2014), NHS Digital, Copyright © 2016, Health and Social Care Information Centre. NHS Digital is the trading name of the Health and Social Care Information Centre, 2011 Census, Office for National Statistics, Crown copyright and 2018-based population projections, Office for National Statistics, Crown copyright.

  • Around 51% of people aged 65 and over in Staffordshire are estimated to have a limiting long-term illness. Between 2021 and 2040, this is projected to increase to 53%, which would equate to 34,500 additional people
  • Around 28% of older people are unable to manage at least one self-care activity on their own. This is projected to increase to 30% or 19,900 additional people by 2040. In addition, around 29% of older people are unable to manage at least one domestic task independently
  • National research indicates that around seven in ten people aged 65 and over who are admitted to hospital due to a hip fracture require post support and care. In Staffordshire around 52,200 people aged 65 and over are estimated to have fallen at least once in the last 12 months which is predicted to increase by 35% to 70,500 people by 2040
  • Assuming that the prevalence of dementia remains the same, the ageing population means that the total number of people aged 65 and over with dementia in Staffordshire is projected to rise from around 13,600 in 2021 to 17,000 in 2030; an increase of 25% and to 20,400 by 2040; an increase of 50%
Answer:

The net Health & Care budget for adult social care in 2022/23 is £243.3m

  • The Council spent £210m (net) on adult social care in 2020/21 compared to a net expenditure of £208m 2018/19 and £200m in 2017/18, indicating increasing pressures on budgets. The spend on adult social care is over 41% of the overall Council spend
  • In 2021/22 we issued around £29.8m in support grants to our care providers, £15.8m of which to care homes.
  • In addition to savings previously agreed, the Council needs to make ongoing further savings of £19.7 million by 2026-27. We want to work with providers in addressing this challenge.
  • The Staffordshire and Stoke-on-Trent Integrated Care Board (ICB) 2022/23 budget for NHS Continuing Healthcare (including Funded Nursing Care) is £85,531,959 with a £91,315,568 spend resulting in a cost pressure of £8,783,609 at month 6 (September 22). The forecast outturn cost pressure at month 6 is circa £20m.
Answer:

Overall care home market in Staffordshire

  • There are 254 care homes with 8,101 beds in Staffordshire (as of May 2022). The numbers of homes and beds has increased in recent years. Since May 2019, there has been a net increase to the care home market of 7 care homes and 462 care home beds.
  • Currently (October 2022) occupancy levels for residential homes are 81% and for nursing homes at 84%.
  • Care Homes when registering with CQC can detail their specialism of the type of client they support. Table 3 shows how many homes in Staffordshire have a client type specialism within their CQC registration. It is important to note that a care home can be registered for more than one specialism.

Table 3: Staffordshire care homes by client type

CQC SpecialismNumber of homes
Residential older people 111
Nursing older people 173
Residential dementia 83
Nursing dementia 61
Residential: Learning Disability / Autism 93
Nursing: Learning Disability / Autism 4
Residential: Mental Health 56
Nursing: Mental Health 32


Quality

There are 175 residential homes in Staffordshire with the following CQC ratings (April 2022):

  • Outstanding: 7
  • Good: 113
  • Requires improvement: 24
  • Inadequate: 2
  • The remainder have not yet been inspected.

There are 79 nursing homes in Staffordshire with the following CQC ratings (April 2022):

  • Outstanding: 1
  • Good: 48
  • Requires improvement: 22
  • Inadequate: 1
  • The remainder have not yet been inspected.

Current admissions and placements funded by social care in Staffordshire

Residential and Nursing care homes

  • The Council funds just under 3,000 care home placements at any point of time; just over 1,700 in residential homes and under 1,100 in nursing homes, and around 80% within Staffordshire. The remaining beds in county are commissioned by the NHS, other local authorities, or occupied by self-funders. A breakdown of Council funded placements by client group and location is shown in Table 4.

Table 4: Council funded care home placements (March 2022)

LocationIn countyOut of countyTotal
Older people 1,855 360 2,215
Physical disability 69 37 106
Learning disability 235 159 394
Mental health 59 30 89
Total 2,218 586 2,804

The Countys care home population over the past 12 months for all adults is 612 per 100,000. When looking at those aged 65+ only, Staffordshire’s care home population increases to 1923 per 100,000 people. In comparison, for the West Midlands this figure for their 65+ population is 2097 per 100,000 and for England the rate is 2005 per 100,000.

Residential and nursing care for older people

This section relates to care homes providing the following categories of care: Residential Older People, Residential Older People (with Dementia Care), Nursing Older People or Nursing Older People (with Dementia Care).

  • New Council care home placements for older people now seem to be returning to pre-pandemic levels, that were just over 100 placements per month, with just under 100 per month currently.
  • It is anticipated that the number of Council placements for older people will rise over the next ten years to 3,900 by 2031
  • Supply of care home placements is also rising, with a 5% increase in capacity since September 2020

Accessibility and sufficiency

In nursing and specialist nursing with dementia there is a shortage of staff to meet demand. We expect to see an increasing demand for higher level, complex care (often linked to dementia) in both residential and nursing care homes. The average age of people entering into care homes is 83 – on average, people are increasingly older and frailer when they access care home services.

Whilst there is capacity in the market for nursing home placements, these placements can be difficult to source (across key criteria such as quality, cost effectiveness and timeliness of access) especially in certain areas of the county such as South Staffordshire, Cannock, Lichfield and Tamworth.

Care homes in the county are currently (April 2022) averaging around a 20% vacancy rate.

Residential and nursing care for people with learning disabilities, autism, mental health, physical or sensory impairments

This section relates to care homes providing the following categories of care: Residential care for physical disability/ sensory impairment; residential care for learning disability or autism; residential care for mental health; nursing care for physical disability/sensory impairment, nursing care for learning disability or autism; nursing care for mental health.

Accessibility and sufficiency

Learning disability and autism

It is anticipated that the overall number of people with a disability in Staffordshire will increase by around 1.3% in the next 3 years. The greatest increases are projected to be in those over the age of 55, as people with learning disabilities and/or autism continue to live longer, and also the age groups 0–18 and 25-34. Data suggests that the number of people with a learning disability in receipt of long-term services funded by the Council will remain relatively consistent over the next 10 - 15 years. However, as per national trends, the complexity of need is likely to increase as people live longer with associated health conditions. In response to this, we are currently exploring how to best meet the combined needs of individuals (including for example, those with both dementia and a Learning Disability).

Nursing provision is currently focused around Lichfield, Staffordshire Moorlands and South Staffordshire. Conversely, South Staffordshire, Lichfield and Tamworth have the lowest numbers of residential care homes currently for these groups and East Staffordshire, the greatest concentration.

There are people currently under the age of 18 (mainly in educational residential establishments) who are likely in future to need accommodation and care and support solutions in either residential or community support settings. The number of young people supported to prepare for adulthood is shown to have increased over the last few years as shown in Table 5, this is due to the advent of the ‘preparing for adulthood pathway’ however not all these young people will go on to receive adult social care services. The County Council is currently reviewing its Preparing for Adulthood pathway, further work is needed to understand the proportion of young adults within the preparing for adulthood pathway likely to require long term services.

Table 5: Number of young people ‘preparing for adulthood’

Report MonthAge (Years)Staffordshire NorthStaffordshire SouthYoung Adults TeamTotal
July 2018

14-17

18

30

22

37

23

N/A

N/A

67

45

July 2019

14-17

18

26

24

35

226

N/A

N/A

61

50

July 2020

14-17

18

N/A

N/A

N/A

N/A

123

67

123

67

May 2021

14-17

18

N/A

N/A

N/A

N/A

146

60

146

60

May 2022

14-17

18

N/A

N/A

N/A

N/A

136

62

136

62

 

Mental health

There is currently a relatively high usage of residential and nursing care for people with mental health needs – these placements currently make up 78% of the overall mental health placement spend. The availability of step-down supported living care for individuals with a Learning Disability, Autism and/ or mental health condition with challenging behaviour and/or complex needs, including forensic needs is increasing pressure on care home beds currently. This is a gap we arelooking to address through the recommissioning of supported living services. It is our aim to work with our key partners and the independent and voluntary sector to rebalance the current service support far more towards recovery focused, short term interventions and an increase in support within people’s local communities. This is likely to reduce the number of residential and nursing care required in the longer term.

There are occasions where the complexity of need of the person requiring a placement means that the number of care homes which could meet the need are relatively few, and the requirement is often time sensitive. A lack of placement offers within the necessary timescale can lead to placements being sourced in an emergency in care homes unnecessarily far from family and friends, which can then lead to a requirement for a second move, or unnecessary and overly restrictive use of one-to-one staffing.

Physical Disability

Just over 42,000 people aged 18-64 in Staffordshire are estimated to have a moderate physical disability and 12,700 a serious physical disability (All Age Disability report, October 2017). Prevalence increases with age for both moderate and serious physical disabilities

It is our aim to support working age individuals with a physical disability to remain living independently for as long as possible whilst maximising the use of technology to support them. The Council aims to explore all other options for a working age individual to remain living independently, before considering a long-term care home placement to manage social care needs. The average Council placement length for a working age physical disability placement is 83 weeks (April 2022).

Answer:

The key challenges for residential and nursing care in Staffordshire include the following.

Quality and person-centred care

We primarily judge the quality of care within care homes by their CQC ratings, although we recognise that in some cases there can be a considerable period of time between CQC inspections. Every care home should aim to be assessed by CQC as ‘Good’ or ‘Outstanding’, and every care home that is below this level should be enacting a clear plan to improve.

Some care homes have been unable to demonstrate capacity or capability to achieve a ‘Good’ or better rating from CQC, even where considerable support has been offered. There is a risk to the longer term future of those care homes.

As a County Council, working with the market, our processes for commissioning care home placements (e.g. our pen portraits) are not always as effective as we would like in supporting strength-based and outcomes-based commissioning, and so there is a need for a stronger focus on achieving personalised outcomes that maximise independence when delivering care and support for all individuals, particularly important in a group setting such as a care home.

Choice and accessibility

There is not always sufficient availability of good quality nursing care to meet complex needs. This includes dementia, complex communications needs, complex and challenging behavior, forensic mental health needs and complex physical and health needs.

In some areas of the county, there is a more limited choice of care homes that are available to people, and sometimes commissioners experience lengthy delays in being able to confirm placements in care homes, (which can be affected by the availability of decision makers within the care home setting): this can also affect the choice of placements available in practice.

Working in partnership with the NHS, there is an ever increasing expectation of being able to support hospital discharges 7 days a week. Swift decision making and support to discharges is particularly important for care homes specifically commissioned to provide Discharge to Assess or other services which support step down from acute hospital settings. It is also important for a reasonable pace to be achieved in sourcing care for people at the end of a Discharge to Assess episode, or for people living in their own homes who require an urgent placement due to a sudden escalation in needs or reduction in unpaid support.

Cost effectiveness

There is a wide variation in rates paid by the County Council for categories of care home in some areas of the county – a wider variation than would appear to be explicable by the nature of the care provided alone, and therefore appears to be unwarranted.

For all care homes, there are increasing cost pressure due to increases in national and living wage, national insurance, supplies, services and the impact of COVID-19.

The Council has recently completed and submitted to the Department of Health and Social Care (DHSC) the Fair Cost of Care exercise. The exercise was a condition of the Market Sustainability and Fair Cost of Care Fund.

The exercise was designed to identify median rates for older people care home services. At the present time there has been no confirmation of additional funding made available from central government to cover any cost changes from this exercise.

Workforce

The care home sector continues to be challenged in retaining and recruiting a sufficient and appropriately skilled workforce especially in leadership roles and clinical roles such as nursing, but also including other care workers. While there was a reduced turnover of staff during 2020/21, the overall trend in vacancy rates has been an increase over the past five years across the region. For many roles, the ability to retain and recruit can be significantly affected by the wider economy – i.e. the pay and conditions of roles in other sectors outside health and care. Many care homes are increasingly reliant on agency staff, which increases costs, and can adversely affect care if it adversely affects the continuity of relationships within the care home.

In January 2021 the Council commissioned Skills for Care to complete a district analysis on the County’s workforce, in order to understand the opportunities available in Staffordshire from the social care sector. The analysis concluded there are 10,900 jobs in care homes and of these 6,300 within a nursing home and 4,600 within a residential home. Of the 10,900 jobs, 7,300 of those roles are delivering direct care. The analysis highlighted the need to attract future generations into social care careers. In Staffordshire care staff aged 50 and over made up 39% of the workforce whereas only 2% of the workforce is aged under 20.

COVID-19

The pandemic has had a profound impact on care homes, and we recognise and appreciate the incredible role care staff have played in protecting those most vulnerable in our communities during this challenging time. We are grateful to local providers who have risen to the challenge, responded quickly and been prepared to deliver services differently, and we believethat providers who have been best able to do this are most likely to have the skills and capability to adapt to future challenges in social care.

During the pandemic there has been substantial short-term investment in the sector, often through specific government grants. This may, however, mean that for some care homes there are longer-term challenges to sustainability that may become evident during 2022 and beyond. We will continue to work collaboratively with the sector and share intelligence about the changing care market to inform commissioning activity and enable care providers to make informed decisions about their services.

Digital and technology enabled care

Digital and technology is advancing at pace in our sector and presenting opportunities to improve the delivery and quality of care. Care homes need the ability to increase the use of assisted and digital technology enabled care. The Council in partnership with care homes need to consider the use of technology to prioritise the time of the available workforce and support them to deliver quality care. In addition, technology has become key in proactively monitoring and managing health conditions. Care homes need to ensure their practices are technology enabled.

Estates and property

Some care homes have challenges in providing the best possible quality of care due to the nature of their physical estate, and this has sometimes made it particularly difficult to implement all the guidance relating to COVID-19 - for example, care homes without ensuite facilities in every room, a large number of shared rooms, or buildings that make it more difficult to cohort residents.

When considering a care home placement, the Council requires a supply of appropriate specialist and adapted accommodation to allow people with physical disabilities and/or support needs to remain independent. In addition, the ability to safely accommodate and meet the needs of bariatric residents.

There are a number of new builds in the county recently opened or still at the planning or build stage. As a Council we want to work with those property developers to ensure the build offers a service that meets the needs and expectations of our communities. The Council wants new builds to be designed for the people in our communities who can no longer manage to live independently with varying level of complexities of care needs and to provide cost models that are affordable to all.

Adult social care reform

The Governments white paper, People at the Heart of Care, sets out an ambitious 10-year vision for how the government intends to transform support and care. The intentions from the white paper will support to shape the Staffordshire care home market and as a Council we will ensure all practices and approaches embedded deliver the three key objectives of the reform for the people we support;

  1. How we will support people to have choice, control and independence
  2. How we will provide an outstanding quality of care
  3. How we will ensure that care is provided in a way that is fair and accessible to everyone who needs it.

To prepare for the social care reform like all other local authorities Staffordshire is undertaking the fair cost of care exercise with the aim for all Staffordshire care home residents to pay a fair and sustainable cost nondependent on how the placement is funded. To achieve this the Council believes a reduced variation in all care home weekly charges will be required.

The scope of the national cost of care exercise is for care home placements for those aged 65+. The spread of varying fees remains a challenge to the Council, and in order to achieve a fair and sustainable market for all client types we intend to look at a localised exercise for placement costings for those aged under 65.

Answer:

When looking at current people supported to live a care home of those who responded to the annual return 70% of people were satisfied with the service received with a further 21% quite satisfied. The Council wants to work with people using the service to understand where improvements are required to ensure the marketplace meets their expectations and desired outcomes. The importance of these improvements and the need for service design to be customer led is highlighted where 26% of responses to deeming their quality of life in a care home as requiring improvement.

The Council in the upcoming care home recommissioning aim to redesign based on the feedback of current and future residents to co-design a service that meet their expectations.

For many residents continuing family connection when moving into a care home is their priority.

Answer:

Block booked beds

Contracts for block booked provision (including respite) can be procured through the dynamic purchasing system agreement. The Council then makes individual placements under the call off contracts with the successful contracted providers.

The Council currently has 353 (October 22) block booked beds active across Staffordshire with care homes.

Although care homes that have a Care Quality Commission rating of “inadequate” may apply and join the DPS they are contractually suspended from accepting new placements until such time that they improve this rating. We will work with care homes to improve provision and quality of care through support from the Care Market Development and Quality Assurance teams. Contractual suspensions are reviewed on a case by case basis accounting for improvements.

Dynamic Purchasing System

Since December 2017, Staffordshire County Council has used a Dynamic Purchasing System (DPS) for the supply of residential and nursing care services. The DPS is an electronic sourcing process through which a wide range of providers can respond to requests for placements.

Services under the arrangement are split into lots. The lots are divided by either residential care or nursing care, each of which is sub-divided into the five care categories. Call off contracts for individual placements are awarded through the DPS as a result of specific invitations to tender being issued and call off process undertaken in line with the terms and conditions of the arrangement.

NHS CHC DPS (ADAM)

The ICB utilizes a dynamic purchasing system for all NHS Continuing Healthcare (CHC) placements for individuals placed in a care home with nursing. The ADAM system was implemented as a brokerage tool in February 2016 for the previously 6 Staffordshire and Stoke-on-Trent CCGs.

The aims and objectives of a DPS enable the following:

  • Improved measurement of quality
  • Improve personalisation of care and delivery
  • Improve speed of placement and discharge times
  • Increase supply capacity and competition
  • Robust contractual management of the supply chain
  • Open framework approach leading to a fair marketplace

CHC Placement Tiered Pricing for Care Homes with nursing

The tiered pricing structure for CHC eligible individual within a Care Home with nursing was implemented on 1st April 2021. The pricing structure is based on three tiers and is supported by a clinical criterion based on the domains within the Decision Support Tool (DST), with a lower and upper limit to enable providers to offer care and maintain competition in the market. Tier allocated is based on an individual’s highest level of need, assessed, and determined by CHC. Placements continue to be brokered via the DPS on an individual basis.

Net to Gross Payments

The Council has implemented a change to all placements to pay providers gross rather than net of client contributions. This change became effective during August 2022 and resulted in providers having greater certainty of income and reduced bureaucracy associated with invoicing residents.

Quality

The County Council’s quality assurance and quality improvement approaches include:

• Support from The Quality Assurance Team, which monitors and supports contracted adult social care services

• Support from the Provider Improvement and Response Team (PIRT), which is a jointly funded team with the County Council and the Clinical Commissioning Groups in Staffordshire. This nurses and officers who work with care homes who require more intensive support to help them to improve

• The Care Market Development Team, which assists adult social care services in Staffordshire with issues such as staff recruitment, training and retention, as well as sharing good practice and examples of innovation, and supports the sector in developing its workforce

The NHS has also provided additional support, including the PIRT team, and also a Care Homes Intensive Support Team (CHIST) provided by Midlands Partnership Foundation Support. The Quality Assurance Team, PIRT and CHIST are all above to facilitate access to other advice and support from within the NHS, such as Infection Prevention and Control, SALT, and other specialisms. Primary and community care services are also linked to every care home in the county.

Although there has been a significant improvement in the quality of care homes in Staffordshire over the last five years, quality remains below the England average, with nursing care homes being the category of care with the greatest percentage of care homes requiring improvement.

Market price

The County Council funds nearly 3,000 care home placements, just over 1,800 in residential homes and over 1,100 in nursing homes. The proportion of beds purchased by the Council does vary by locality and type of care home.

The Office of National Statistics (2021) estimates that in Staffordshire 35% of care home residents are self-funders. The Council commissions around 28% and around 20% of the capacity is vacant. The remaining 17% of placements being placed by Health colleagues or by other Local Authorities.

The price that the Council pays for care home places is set through the purchase of block booked beds and the DPS. Reference rates provide an indication of the price the Council expects to pay. However, there is substantial variation in prices in all lots across the county. The spread of varying fees remains a challenge to the Council with its aim to deliver Staffordshire with a fair and sustainable market.

Since April 2020 there was an increase in the average bed price for older people by 9.3% for Residential and 8.2% for nursing more than the annual inflation award made by the Council. During 2020/21 this increase reduced to 3.7% for residential and 3.9% for nursing.

The average cost of new commissioned placements for older people did drop during 2020/21 for Nursing but in Residential this increase has been gradual since before the pandemic.

Setting the Contracted price

The Council forms the contract price based on the cost submitted by a provider that has been calculated based on the care needs of the resident which is stated in a document known as a Pen Portrait and the residents full social care assessment. A provider should develop this weekly cost based on the support and staffing required to safely meet the individuals care needs. The delivery of the care should be based on the individual care needs and should be staffed as required to safely meet those needs. The delivery of any assessed 1:1 care for ongoing care needs should be considered and costed into the contracted care price and not requested outside of the agreement. The expectation is that most daily tasks on a 1:1 ratio would be managed through core staffing with an expectation additional 1:1 may be required to manage a crisis or a short-term period. Once the contract is agreed, there should be no additional agreement costs outside of the contracted price set for a placement for needs that were stated in the initial assessment and Pen Portrait.

Answer:

Overview

Working jointly with our partners in the NHS and the provider market, we intend to deliver our strategic objectives for care homes (Improving the quality of care homes in Staffordshire, ensuring timely access to care home placements when required, and ensuring affordability of care home placements). In addition, we also aim to strengthen our collaborative approaches to the care workforce, clinical support to care homes, digital and technology, and strength based and outcomes based commissioning.

Quality

We will measure this primarily by the proportion of care homes rated as ‘Good’ or ‘Outstanding’ by CQC with a target to reach the England average within the next 3-5 years.

Whilst progress has been made in shaping and supporting the quality of marketplace, there are areas still for further improvement.

  • The Council will maintain an ongoing and enhanced focus on quality assurance and quality improvement. The Council is developing a Quality Assurance Framework and the new care home contract will align with this enabling the Council to effectively manage the risks and quality improvement work with the market
  • The Council and its partners will continue to build on their experience during the pandemic to continually refine their support to care homes for quality improvement.
  • Where care homes are repeatedly identified by CQC as requiring improvement, and unable to demonstrate a capacity for sustained improvement despite advice and assistance, the Council will consider whether it can continue to make new placements and also consider supporting a move of residents, where this is in their interests on a balance of risks.

Accessibility and sufficiency

We aim to ensure timely access to care home placements that meet people’s needs. This will be measured by the proportion of placements sourced to target timescale (Priority, Urgent or Standard) with a target of 85% achieved to time.

  • It will remain important for the Council to continue to track occupancy and staffing levels at a home-by-home level, and to remain engaged with care homes to understand their individual positions. We will gain this information through any national tools that are provided, rather than duplicate information requests from care homes. If no national system is put in place, then we will seek to collect this information locally and share it across the Council, the NHS and other commissioners
  • The Council is intending to increase the percentage of block booked beds that it commissions from the market, while continually reviewing the level of block booked beds to ensure that unoccupied beds are kept at a low level. Timescales for assessments and acceptances by homes with block booked beds will be robustly managed
  • To further improve the timeliness of assessments we will review our approach to trusted assessments, and the Council is therefore interested in discussions with providers who wish to help us shape this.
  • The nursing care market is the market with the greatest percentage of care homes that have not reached a ‘Good’ CQC rating. The Council is keen to improve access to good quality, affordable nursing home provision and is interested in discussions with innovative providers who want to diversify or any residential homes who wish to develop nursing with dementia care.
  • The Council may also develop additional nursing capacity with trusted partners in areas of the county where there is a long-term insufficiency in nursing care of a suitable quality and price, subject to business case for any such developments.
  • The Council are interested in working with partners to develop services to support young adults transitioning from children’s services, including those from the age of 16.

Price

As a commissioner of care, the Council seeks to pay a fair price, with cost effective placements, and overall expenditure within budget. This is measured by the tracking the average price of placements against the modelled average price, and by seeking to reduce unwarranted variation in price within lots.

As part of the national implementation of social care reforms, the Council has carried out a cost of care exercise.

Person centered care and support

The Council aims to improve current practice by working with care home providers to ensure the delivery of care is driven by what is important to the individual’s being supported.

For every person supported in a care home the following statements from the Think Local, Act Personal Making it Real campaign need to underpin the delivery of care;

  • I am treated with respect and dignity.
  • I feel safe and am supported to understand and manage any risks.
  • I am supported to manage my health in a way that makes sense to me.
  • I have people in my life who care about me – family, friends, and people in my community.
  • I have a place I can call home, not just a ‘bed’ or somewhere that provides me with care.
  • I can get information and advice that helps me think about and plan my life.
  • I can get information and advice about my health and how I can be as well as possible – physically, mentally, and emotionally.
  • I can get information and advice that is accurate, up to date and provided in a way that I can understand.
  • I can keep in touch and meet up with people who are important to me, including family, friends and people who share my interests, identity, and culture
  • I have a co-produced personal plan that sets out how I can be as active and involved in my community as possible.
  • If my medication has to change, I know why and am involved in the decision.
  • I am supported by people who see me as a unique person with strengths, abilities, and aspirations.
  • I am supported by people who listen carefully, so they know what matters to me and how to support me to live the life I want.
  • I am supported to make decisions by people who see things from my point of view, with concern for what matters to me, my wellbeing and health.
  • I have considerate support delivered by competent people.

Capacity

In all circumstances where possible the Council supports people in our community to live independently in their own homes. In the cases when a person can no longer live independently care home placements are considered. Due to advances in technology and support to manage people safely at home the Council has a greater need for new capacity to deliver nursing care rather than residential only provision.

Staffordshire has relatively fewer total care home beds (residential and nursing) compared to similar local authorities and the England average, but a relatively higher number of nursing beds, as shown below. However, the availability of affordable nursing care to meet the needs of people placed by the Council is reducing.

Residential and nursing capacity per 100,000 population over 65

Residential care beds per LA population (age 65+)

 Local AuthorityComparatorsEngland
Weighted number of beds 3336 4761 4308

Nursing care beds per LA population (age 65+)

 Local AuthorityComparatorsEngland
Weighted number of beds 4430 3755 4106

Over the last few years there has been a reduction in nursing home capacity in Staffordshire.

Planning consent for new build care homes is managed through the district and borough councils. The planning regulations do not require that an application identifies whether the care home will be for nursing or residential care. Planning consent is awarded for three years; if a development has not started in that time the applicant has to reapply. Staffordshire County Council and the Staffordshire Integrated Care Board would welcome discussions with Providers considering developments for affordable nursing care provision.

Workforce

The Council will continue to support the care home workforce through:

• Providing information and support for providers regarding recruitment and retention, training and events and signposting to local and national resources.

• Working with the NHS to develop apprenticeship and Care Reserve models

• Advocating for the sector, for example through our Dignity in Care Awards

• Supporting opportunities for innovation and technology within the sector and associated skills

• Working with the NHS to develop more resilient support and advice for nursing staff

• Developing and implementing a sector wide Workforce Strategy with partners

Digital and technology enabled care

The Council is committed to addressing digital exclusion and has a digital strategy, acting as a catalyst to enable more supported and connected communities. The Council intends for digital to underpin a transformed health and social care system that focuses on self- care, early intervention and prevention and has improved healthy life expectancy.

We have a number of current schemes and initiatives in place relevant to care home sector, including the deployment of Reminiscence Interactive Therapy Activities (RITA) in up to 51dementia care homes. We also support care homes in accessing secure information exchange with the NHS and other partners, including through support available to the marketplace through the Staffordshire Association of Registered Care Providers (SARCP). The completion of the digital toolkit to support access to secure information exchange will be an expectation in future contracts.

By 2024 we expect that there will be increased digital information sharing as appropriate of care records, and we will support the sector in developing the skills and capabilities to do this.

Strength based/outcomes based

The Council will review our processes for sourcing care home placements to emphasise the personal outcomes and strengths of people placed in care homes by the Council, alongside the needs and risks that care homes must be able to safely manage. Our Quality Assurance Team will place a stronger emphasis on gaining evidence of how care homes implement person-centred, responsive care for residents, and incorporate the voice of residents in their own continual improvement plans.

Clinical support

The Council and our NHS partners will work together to provide advice and support to care homes where necessary. This includes the Enhanced Health in Care Homes support provided by the NHS to support access to primary and community care for residents. We will also build on the role of the Provider Improvement Response Team and the Care Homes Intensive Support Team to enable good quality clinical advice to the sector, and access to specialist services such as Infection Prevention and Control (IPC), Speech and Language Therapy (SALT) and Tissue Viability Nurse (TVNs). As part of their own quality improvement, we do expect care homes to make best use of this advice and support.

Where appropriate, we will incorporate the expectation of close and consistent working with the NHS into our future contracts – for example, utilising the Deteriorating Patients Network tool to identify and intervene proactively where residents’ needs are escalating.

Answer:

Engagement and consultation

Our Market Position Statement is intended to promote a dialogue between the Council and providers. We have undertaken consultation activities with providers to gather views on our Market Position Statement. Feedback on the draft version was shared by Providers through a survey and focus group. The two main areas of feedback were financial planning shared with providers to support their future service delivery sustainability and the need for partnership working between health, social care and the marketplace providers to deliver the aspirations and meet the challenges of this market position statement.

Partnership working

We are encouraging organisations to contact us to discuss how the Council can work with you, especially if the following apply:

  • Partners who are interested in developing or re-developing nursing care homes (especially dementia nursing care homes). Please note, all procurement opportunities will be placed through Proactis (the Council’s procurement system) and advertised through Find a Tender Service and Contracts Finder.
  • Nursing care home partners who would be looking to increase local capacity especially where supply is more limited.
  • Nursing care home partners who would be interested in working collaboratively to improve career pathways and opportunities for nursing staff (for example, creating a pool of nursing staff to operate more cost effectively across a number of organisations).
  • Care home partners who are able to support people with complex needs and joint funded placements with the NHS that may require specialist knowledge or equipment (e.g. bariatrics).
  • Care homes who want to work with the Council and its partners to support people with complex needs and reduce the ongoing need for one-to-one support and intensive supervision and support.
  • Care homes interested in developing services to support young adults transitioning from children’s services, including those from the age of 16.
  • Care home partners or agencies wishing to upskill their workforce to support better quality or more specialist care provision.
  • Care homes keen to innovate (e.g., utilise more assistive technology and technology-enabled care, diversify their provision, diversify delivery of the traditional nursing home delivery model
  • Care homes keen to seek further support on improving how they run their business and or how they meet expected quality standards and use this support to make sustainable improvements.
  • Care providers who are keen to ensure there is a clear focus on the mental health recovery model, focussing on working with the individual person to identify their strengths and build resilience.
  • Care providers who want to explore opportunities of reducing the cost of care and support through cost improvement programmes (CIP) to reflect the pressures of CIP on statutory service delivery

Downloadable PDF version (2.01 MB)

Further Contact

Should you wish to make contact following review of this document please email oppdcommissioning@staffordshire.gov.uk.

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