Section 1: Revised assessment of the Current Sustainability of Local Care Markets
The London Borough of Hounslow is located in west London. It is ethnically diverse, with residents speaking approximately 188 languages and has seen a demonstrable increase in demand for care and support that reflects the different cultural needs and an ageing population in recent years.
The 2021 Census shows a total population of 288,200. This is an increase of 13.5% from 2011. The population of older adults (defined as adults 65 years +) living in Hounslow has increased by 26.6% in the same period. The older population is projected to grow further.
a) Assessment of Current Sustainability of the 65+ Care Home Market
Diversity, Demand and Sufficiency of Supply
There are thirty registered care homes in Hounslow. There are nine nursing homes for older people in Hounslow and in scope for the Cost of Care exercise. The majority of these nine care homes have a registered capacity of between 50 and 60 beds. The care home ownership is a mixture of national, regional, and local providers.
There are 651 registered beds in Hounslow Older People’s care home market. 105 residential beds are provided by two ‘in-house’ care homes operated by the Council and fall outside of the scope of the Cost of Care exercise. One nursing home is currently operating at a 65-bed capacity despite being registered for 92 beds and so the number of beds in scope for the Cost of Care exercise is 519 nursing home beds. For the care home operating below occupancy, the care provider is increasing occupancy in a managed way when staff recruitment allows and this is supported through commissioning, including NHS ICB commissioned winter step down beds.
The Cost of Care exercise (July and August 2022) and contemporaneous data submitted by the nine care homes on Capacity Tracker (August 2022) demonstrated that the older people’s care homes were operating close to full capacity.
The exercise demonstrated an average occupancy of:
- 92% from active beds
- 94% occupancy from the total number of CQC registered beds
- 93% median occupancy from active beds
- 84% median occupancy from total no. of CQC registered beds
When looking at occupancy from the total number of CQC registered beds, the occupancy is at a lower rate than would be expected from national benchmarks. For reference, the Council’s two in-house residential care homes, have an average current occupancy rate of 96.62%.
There is a lower supply of nursing care than is required in Hounslow and some placements are made in neighbouring boroughs. Nursing home beds in-borough are commissioned by Hounslow Council, the North-West London Integrated Care Board (NWL ICB), other local authorities, or ICBs and self-funders. Hounslow’s in-house residential provision is unable to meet all the residential care demand. Where it is not possible to meet demand for residential care provision, Hounslow Council place residents outside of the borough.
Hounslow has established, experienced care home providers who take a partnership approach to service delivery. The Council has clients placed in all the nine nursing homes in-borough. The care home providers and Council also have a strong working relationship with the NWL ICB.
Hounslow currently has 201 Extra Care beds available across four schemes. Extra Care provision has historically demonstrated a reduction in demand on residential care.
Hounslow Council currently faces difficulty in commissioning care home beds for:
- older people with residential care needs; and,
- older people with dementia and/or behaviours that challenge.
The Council is projecting a significant increase in demand for residential care, with a growth in demand of 46 beds between now and 2025. We are projecting a slower growth in demand for nursing home beds over the next three years of 10 beds.
Prior to the Covid pandemic the Hounslow Older People’s care home care market was divided into care homes that marketed services for the self-funder market or care homes that largely marketed beds to the public sector. At the start of the Covid pandemic, care home occupancy fell in all Hounslow care homes. During the pandemic, the Council placed clients in all nine nursing homes in the borough and in care homes out of the borough. Since 2021, care home occupancy has recovered, and the care market is returning to pre-pandemic trends. The Council expects to place most clients into care homes in the borough offering competitive market rates. Placing residents outside of the borough presents a challenge as we know from residents that they or their next of kin largely wish to remain in the borough of Hounslow.
During the Covid pandemic, Hounslow Council (as part of the sub-regional health and social care system) has operated Discharge to Assess, which led to an increased demand for care home placements, particularly in residential care. During this period, our impression is that a greater number of beds than usual in the Hounslow care home market have been purchased by other public sector commissioners. These are other local authorities and London based Integrated Care Boards.
One nursing home in Hounslow, specialises in care for older people with dementia and/ or behaviours that challenge. It operates at capacity and provides care for publicly commissioned placements from across north-west London. These developments in cross borough care home markets are likely to continue, particularly for scarce residential care beds and for specialist beds.
The Council has entered into dialogue with the care market regarding current and future market intentions. We are aware of one new care home being built and growth in Supported Living schemes. We are in dialogue with the market over the type of Supported Living scheme required (which is higher level need for learning disability or mental health clients). The Council is in the process of drafting an outline business case to support the extension of one of its in borough care homes.
Quality of Provision
Eight of the nine nursing homes in scope have a current Care Quality Commission (CQC) rating of ‘Good’. One is rated ‘Requires Improvement’.
The Council audits nursing homes and has concerns about the quality in the home rated ‘Requires Improvement’. During January 2022, the Council was sufficiently concerned to decant all Council commissioned residents from another nursing home which has since improved, been re-inspected and rated ‘Good’ by the CQC. The Council has since identified concerns at a separate care home, which is rated ‘Requires Improvement’. Overall, we have learned that the combination of rising levels of acuity for care home residents, quality issues relating to management oversight and training are challenges to the sustainable operation of the Hounslow care home market.
Hounslow has committed up to £60k from the Market Sustainability and Improvement Fund in 2023/24 to recruit one additional quality officer to support care homes and home care. This builds on existing measures and reflects our concern over quality and commitment to supporting providers maintain their CQC rating. Hounslow already employs one quality officer and manages the contract for the Hounslow Care Home Support Team. The Care Home Support Team is comprised of three full time care home practitioners (which can be nurses or therapists) and was introduced by the local health and social care system in 2021. The Care Home Support Team is delivered by the Hounslow and Richmond Community Services NHS Trust. The team cover all 30 care homes in Hounslow (21 are out of scope of the Cost of Care Exercise) and the four Hounslow Extra Care schemes. The Care Home Support Team visit care providers, supporting staff with assessing resident's needs, skills training, ordering equipment and accessing wider NHS community support services.
Hounslow regularly engages with care homes at the monthly Care Home Forum. This is a co-produced meeting, with care homes and extra care schemes invited to propose agenda items. Care Homes will also attend a contract meeting with the Council, with a Social Work Team Manager attending to discuss clients and a quality officer in attendance to discuss quality.
The Quality Officer visits care homes and assesses quality using the PAMMS Tool. The results of audits are discussed with the care home during the audit and afterwards.
Hounslow Council also operates a monthly forum for all care providers, called the Provider Forum. The meeting is co-produced with care providers and will include agenda items requested by care providers. Standard agenda items include updates from the care home support team, the primary care team at the NWL ICB and feedback on topics requested by care homes. Care homes have recently initiated dialogue on mental health referrals, transport and discharge.
Workforce and Recruitment
Providers were able to contribute to the market sustainability plan as part of forums and through 1-2-1 calls during the engagement process. Further feedback was received at the North- West London wide provider engagement event on the Cost of Care exercise in August 2022, where care providers gave feedback on strategic challenges, which focussed on the two main issues of workforce retention and recruitment.
The care home provider’s attending the NWL cost of care forum, identified that they face challenges recruiting to senior and middle management positions in care homes.
In 2022, most of the nine nursing homes in borough recruited new registered managers. However, while providers reported to People Too (the consultancy firm engaged to support the Cost of Care exercise) that they faced challenges with recruitment to management positions and higher use of agency staff, all the homes have successfully recruited to vacant senior management posts. In addition, the August 2022 Capacity Tracker data for care homes in Hounslow does not show a high use of agency staff. It appears to be more difficult for care homes is to recruit to senior nurse positions.
Current Fee Rates and Inflationary Impacts
Hounslow Council spot purchases care home beds. The NWL ICB block purchase 29 nursing home beds within the borough and pay the Pan-London NHS Any Qualified Provider (NHS AQP) nursing home rate. A further 15 step-down beds have been purchased by the NWL ICB during the winter of 2022/23 at a spot rate. Other local authorities, and NHS ICBs, purchase beds within the borough and use spot contracts.
The Council operates an annual process of contacting care homes in the borough to review fees paid. This involves a spreadsheet being sent to each care home provider requesting evidence costs. Subsequent dialogue is informed by the evidence supplied by the provider, inflation guidance from the Council’s strategic finance team, benchmarking data where available and by a cost analysis undertaken by consultants commissioned by London Council/ the London Association of Directors of Adult Social Care. The outcome leads to small differences between providers based on their costs and larger differences based on the needs of the resident. There is no ‘rate’ set by the Council but there is local dialogue.
During January and February 2023, the Hounslow Executive Director of Children’s and Adults’ Services and the Director of Commissioning met each of the nine nursing homes covered by the cost of care exercise. The purpose was to discuss the Council’s approach to inflation for 2023/24 and to ensure that fees are set before the start of the new financial year. The impact upon rates will be informed by the meeting, evidence submitted by the provider, the adult social care Use of Resources report (developed by the Care and Health Improvement Programme at the Local Government Association), benchmarking and the cost of care data.
For care homes in other boroughs the Council will pay the rate paid by the host borough. For neighbouring boroughs in north-west London, the Council applies rate changes to care providers based on information provided by those boroughs. For clients placed in care homes further afield, the Council will apply fee changes if requested by the care provider and when requested to do so by a care provider.
Based on the cost of care returns submitted, during 2022/23 Hounslow concluded that current fee rates for Care Homes were sufficient to sustain the existing market. This is demonstrated through the current relatively high occupancy, the rates paid and the marginal gap between the market rates being paid in September 2022 and those produced by the cost of care exercise.
(b) Assessment of Current Sustainability of the 18+ Domiciliary Care Market
Diversity, Supply and Demand
There are currently 57 home care providers registered in Hounslow. This is a very diverse market. Many providers are SME and / or BME providers. There is a mix of local, regional providers and national providers.
Hounslow has in place a seven-year (4 + 3 year) homecare contract with 17 providers. The two-tier contract has seven main providers, supplemented by a further 10 select list providers. The contract requires providers to work across the entire borough. This, and the number of providers contracted with, was intended to remove reliance on a small number of providers and give sufficient volumes to providers to ensure a sustainable and profitable business for each of them.
Contracted providers are mostly registered in Hounslow, with a few registered in the neighbouring boroughs of Ealing and Richmond. They meet 88% of the current level of demand in homecare as commissioned by the Council. Where the contracted providers are unable to meet demand, work is commissioned through spot providers. The vast majority of packages of care, both in the height of covid and since have been placed with contracted providers.
Demand is complex and multifaceted and can prove challenging to meet at all times as a result of numerous language, cultural and gender-based requirements that reflect the multicultural and diverse community in Hounslow. There are areas where supply can struggle to meet demand and this occurs mostly where there are specific requests made such as language, religion, gender or the packages of care are located in a challenging part of the borough e.g., lack of public transport or lack of parking.
Due to the geography, relative affluence, and difficulty in accessing transport/parking, often supply is challenging at the fringes of the borough, namely the Chiswick and Feltham areas. Despite a main contracted provider being based in the Chiswick area and another in Feltham, it remains a challenge to place packages in these very different areas at opposite ends/edges of the borough.
Demand has increased and is predicted to continue with an increasing ageing population. People are being discharged from hospital with higher levels of need resulting in larger and more challenging packages of care. This was most notable at the height of the pandemic with double-handed, four calls a day packages of care being requested at a previously unseen levels. Complexity and challenging behaviour is increasing. The requirement for providers to administer or prompt medication is also increasing. Providers often struggle to accept more challenging packages of care.
Utilising winter pressures funding, we are seeking to roll out a program of training to our providers to upskill them in utilising equipment that will ensure packages of care can be safely delivered by a single care worker, where currently, due to lack of training/skills, these are delivered by two care workers. This will increase available capacity in addition to supporting care workers in areas they find challenging.
While recruitment and retention remain one of the largest challenges in this sector, we work closely with providers to understand where support is required. Examples of recent support in this area are funding visa applications for overseas care workers, providing free on line training through Virtual College to all in borough providers and care workers, payment of the LLW and where possible supporting staff through retention bonuses, golden hellos and enhanced pay at challenging times.
Quality of Provision
Hounslow is very focused on providers achieving and maintaining a good level of quality (as measured by the CQC). A requirement for a provider to bid for the current homecare contract was that the provider held a current rating of ‘Good’ with the CQC. Providers have found retaining this level difficult in the face of recent market issues, in particular Covid and a very challenging recruitment landscape.
Hounslow recognises that the quality of care is varied across their home care market.
- 54% of providers have an overall CQC quality rating of Good
- 40% of providers have an overall CQC quality rating of Requires Improvement or Inadequate
- 7% of providers represented are yet to be rated at the time of this report
Within the brokerage team Hounslow has a Team Manager role. The remit of this role extends to include a significant focus on monitoring and supporting providers across both home care and care homes in achieving and maintaining a ‘Good’ rating. To assist in this process the PAMMs tool is used to complete quality assurance audits with the input of the provider. It is a two-way, collaborative process that looks for similar assurances demonstrated with a CQC audit, and the results are shared with neighbouring boroughs using the same tool. This, and the council mandated electronic call monitoring (ECM) data, have been used in conjunction to spot early warning signs of a decline in quality and to support providers in forthcoming audits.
Monthly contract meetings are held with all HHC list providers to review KPI data, quality alerts, the over and under delivery of care packages, safeguarding, bill payments and other ad-hoc issues arising. These meetings are attended by the brokerage team manager, a nominated social worker, data and performance analyst and where required, the commissioner.
The ECM data collected monthly is analysed to identify trends that may indicate a potential drop in quality. For example, late calls, missed calls, poor scheduling of call times suggesting that the provider is struggling to meet demand or has issues with scheduling that will ultimately impact on the quality of care delivered.
The contractual KPIs were developed with quality of care at the heart. Each month call lengths are reviewed, the number of care workers visiting one person and punctuality of calls to highlight a few.
The combination of ECM data, regular and quality targeted KPI reviews and the PAMMs tool have prevented the potential failure of two of the borough’s main providers.
This process has been embraced by all the providers and acknowledged as a useful and valuable tool. Hounslow continues to work closely with its contracted providers to support them in improving the quality of services provided to our most vulnerable residents.
Maintaining continuity of care can be challenging to maintain where a person is discharged from a hospital setting. Pressures of capacity often mean original providers are unable to restart a package of care when their client is discharged.
High levels of sickness due to Covid, flu, seasonal illnesses, and a rapidly changing employment market mean that maintaining continuity of care, with regard to the carers a person sees, continues to be a challenge. Hounslow believe this to be a key indicator of good quality care and it is measured monthly.
Hounslow are working with and will continue to work with providers who are rated Requires Improvement or Inadequate to ensure safe care for people and continue to respond to provider requirements and feedback. An example being the upcoming homecare provider Hospital Discharge forum, a response to providers raising ongoing issues with the smooth and safe discharges from a hospital setting.
Current Fee Rates and Inflationary Impacts
The contracted fee rates for Home Care are competitive and above average when compared to rates of neighbouring boroughs. The rate is higher than some neighbouring boroughs due to the contractual requirement for providers to pay a minimum of the LLW.
Main contracted providers are paid a minimum of 30 minutes per call and are capped monthly to the total of their commissioned care. Providers are obligated to pass this on to their carers.
This allows the providers to flex care needs for individuals whilst removing the need for the social workers to have to adjust the package of care for one off circumstances. This approach was taken to support carers by giving a better degree of certainty over earnings, in addition to the minimum payment of LLW. Over and under delivery of care is closely monitored monthly. Hounslow works with providers to ensure carers spend a minimum of 30 minutes with residents where possible. This approach reflects on actions taken as a result of feedback from carers and providers and was also intended to improve recruitment and retention levels.
Annual fee rates are set with the input of contracted providers and with regard to benchmarking, the cost of care exercise and LLW increases.
Whilst there is a gap between the median cost of care for home care and the rates currently paid, Hounslow is confident that the current rate is sustainable and allows for the payment of LLW. Providers are audited monthly to check compliance with the LLW and since the start of this contract there have been no provider failures. Please refer to Annex B regarding the reliance and weight placed on the outcome of the exercise with regard to median rates.
The London Borough of Hounslow is a London Living Wage payer and whilst the increase to the National Living Wage in April 2023 from £8.91 to £9.50, 6.6%, places additional budgetary pressures onto the Council and providers, it is the increase of 8.14% to LLW that is more relevant to the market and Local Authority.
The grant funding for the Cost of Care exercise was partially used in 2022/23 to bring forward the early uplift to the new LLW of £11.95 from January 2023. The hourly rate for contracted providers was uplifted for those elements related to this increase in carers rate.
Providers are facing additional pressures from inflation on non-staff related costs, potential increases in PPE costs once the free supply is exhausted and other costs such as ULEZ fees. The council continues to work with providers to understand how these and other pressures affect them and work together on affordable and sustainable solutions.
Workforce and Recruitment
The homecare workforce is largely resident in the borough and is reflective of the cultural diversity present in Hounslow. Carers predominately work part time and use the flexibility of the role to manage childcare and other commitments. There is often a shortage in male care workers. Whilst the data below is reflected in Hounslow there is an increasing number of non-EU care staff after Brexit (not demonstrated fully in the data below).
Hounslow is currently able to meet demand for home care, but it is a finely balanced position and the brokerage team work closely with providers daily to ensure packages are placed without delay. However, workforce challenges have meant that contracted providers aren’t always able to accept packages of care and so packages are placed with spot providers. We are not currently projecting a demand for more home care providers, the challenge and demand remains attracting and retain care workers to the already existing home care providers
Hounslow faces numerous challenges to workforce capacity:
- The demographic usually applying for care roles are being hardest hit by the cost-of-living crisis and are leaving the industry for better paid roles or not joining for the same reason.
- Retail and hospitality sectors are strong in Hounslow and provide similar or greater rates of pay, more attractive working conditions, certainty of earnings and minimal/no travel.
- Heathrow airport, although not in the borough, is easily accessible by public transport and a dominant recruiter in Hounslow.
- Care is not viewed as a career or an attractive alternative to those joining the workforce.
- Other care sectors (care homes, the NHS, extra care) offer more attractive conditions and have been attracting workers out of home care.
- Demand for male care workers is challenging to meet as males are less likely to apply for jobs in care.
- Providers report higher levels of turnover relative to pre covid and struggle to maintain current workloads. They wish to grow but are unable to due to lack of good applicants that remain beyond induction.
- The extension of the ULEZ zone into one of most challenging areas of the borough to deliver home care. The impact has been that carers struggle to service the area which was already challenging on public transport and now limiting to certain vehicles or at a significant additional cost.
Good quality registered managers are challenging to replace and although there are no vacancies at this level currently, they have taken a significant time to fill in the past.
Development and investment in the workforce are hard for providers to achieve due to the continuing and ongoing pressures of the volume of work and shortage of staff. They are not able to invest further time training beyond statutory requirements. This leads to staff feeling under-valued or unsupported in areas where they struggle (i.e. complex behaviours).
Providers continue to use known recruitment channels (job centres, job boards, word of mouth, refer a friend, faith groups etc) but feel that these are low yielding sources. Some providers have used previous grant funding to utilise overseas recruitment options through visa schemes. They have found this to be very time intensive and to also yield low numbers, however the quality of carers and the capacity they are able to provide is proving to make this a viable, although costly, option. The local authority, where funding is available, is supporting providers choosing this recruitment channel.