‘It’s like being at home,” was the verdict that one resident at West Hall, a care home in West Byfleet, relayed to inspectors. When you walk through the doors, you can see why. The first thing that strikes a visitor is its immaculate grounds and impressive architecture, which blends a beautifully converted old manor house with three eco-build residential lodges.
But the impressive surroundings fade into the background when you start talking to the people who live and work in West Hall. The warmth and affection that characterise the relationships between staff and residents light up its smart interior, creating a comfortable, homely atmosphere. Arriving on a Thursday lunchtime, I’m introduced to several relatives visiting their parents: Nigel Allen, the home’s manager, stresses they are welcomed with open arms. There’s a huge range of activities to take part in: the day I was there, they included a sing-along, a lunch outing to the local pub and a Scrabble group.
West Hall, run by the not-for-profit Anchor Trust, is not a typical care service. It is one of the few homes to have received an outstanding rating from the regulator. Data provided to the Observer by the Care Quality Commission shows that there are just 91 outstanding care homes in England for the over-65s – less than 1% of those the CQC has inspected under its new regime. Almost one in three have been rated as requiring improvement or as inadequate. The quality of care provided to older people in their own homes is similarly variable.
Another thing that sets West Hall apart is that it doesn’t seem particularly short of resources. Set in a leafy corner of Surrey, where very few older people qualify for state support with the costs of their care, all of its residents are privately funded. Its fees put it at the high end of the market. Walking through its excellent facilities, there’s a sense that money is no object, and there’s one carer for every four residents.
Care homes and homecare agencies that rely at least in part on public funds face a far more straitened set of circumstances. Council funding for adult social care has fallen by 11% on average since 2010, and in some areas by as much as 30%. Cuts to local government funding, together with increasing demand as the population ages, and rising costs as a result of higher regulatory standards and the introduction of the “national living wage”, have created a perfect storm for councils.
The government points to the introduction of the social care precept, a new measure allowing councils to charge an extra 2% on top of their council tax rates to pay for care services from this year. But new analysis by the King’s Fund exclusively for the Observer shows the precept will raise just 3% of what councils are already spending on social care this year. The 10 most affluent areas will raise more than twice as much as the 10 most deprived areas, further widening inequalities in older people’s access to care. Another source of extra funding, the Better Care Fund, will not kick in substantially for another few years.
“Services supporting our loved ones are close to breaking point”, says Izzi Seccombe, chair of the Local Government Association’s community wellbeing board. “The system with which we provide state-funded care to the elderly really is on the brink of financial failure.”
As a result of funding cuts, councils have reduced the rates they pay care-home providers and homecare services for residents who get financial support. Some local authorities are now paying just £330 a week for a care-home place, which works out at less than £2 an hour. It’s becoming increasingly common for providers to cross-subsidise the fees of those who are council-funded using the fees of private funders: industry research suggests privately funded residents are paying up to 40% more for a like-for-like service.
Councils have serious concerns about the sustainability of the care market. According to the Local Government Association, 48 councils have seen at least one home care provider cease trading in the past six months, and a further 77 councils have lost at least one residential or nursing care provider.
The number of people getting state support to help with the cost of their care has also fallen by more than 25% in the past five years. Age UK estimates that there are now more than a million older people who struggle without the help they need to carry out everyday tasks, such as getting out of bed, going to the toilet and getting dressed.
“Growing numbers of older people are going without enough care or, in some deeply worrying cases, no care at all,” says Caroline Abrahams, charity director of Age UK. “Ultimately this means many older people are living sadder and lonelier later lives, a tragedy for them and for our society.” Gary FitzGerald, chief executive of the charity Action on Elder Abuse, says a lack of support is having a knock-on impact on safeguarding referrals for neglect, which have increased by 24% in the past four years. “Someone is having to support them. Often it’s family and friends trying to do their best without the skills, knowledge and equipment to care for them securely and safely.”
He remembers a case that emerged a couple of years ago of an elderly woman who tied her husband, a dementia sufferer, to a chair in order to go out shopping. “All the weight of criticism came down on her. But she couldn’t get any help with her husband’s care, so she couldn’t get out to shop. She was damned if she did, damned if she didn’t. That’s the sort of choice we’re forcing people to make.”
Beyond the tragic human cost, the care funding crisis is having a severe impact on the NHS. A lack of state-funded care means thousands of older people are left languishing on hospital wards when they are well enough to be discharged, costing the NHS £800m a year. It also drives more older people to hospital: it is vastly more expensive to treat a broken hip than to prevent it by helping with washing and dressing.
The funding crisis has been a long time in the making. “The need for action was recognised as long ago as 1997, when Tony Blair established a royal commission on the funding of long-term care,” says Richard Humphries, assistant director of policy at the King’s Fund. “There have been three significant reviews and commissions since then. The problem is not a lack of evidence or solutions.” Rather, the issue seems to be the lack of political willpower. “When the NHS is in trouble, we see the visual evidence,” Humphries adds. “Images of overflowing hospitals and queuing ambulances. The consequences of stretched care services are far less visible. Care does not resonate as a significant issue in MPs’ postbags and surgeries in the same way.”
Many believe the solutions required are so long-term that they will only be delivered through a degree of cross-party consensus. Cross-party talks were started a few years ago, but broke down acrimoniously just before the general election in 2010.
Andrea Sutcliffe, the chief inspector of adult social care, has warned that the funding predicament risks jeopardising quality of care. “The reduction in resources and the level of unmet need means adult social care is reaching a tipping point,” she told the Observer. “There is a fragility and a lack of resilience in the sector which I am very concerned about … It’s leading us into situations where we don’t have enough trained staff to deliver good care.”
Many councils struggle to find good-quality care for their residents. “I’m worried about the quality of care homes available locally,” says Rebecca Lury, a Southwark councillor who chairs the authority’s health scrutiny committee. “Earlier this year the council was in a position where one care home announced its closure following an inadequate rating from the regulator. It had to move residents to another care home; it had also put in special measures.”
Some councils are still commissioning 15-minute care visits, despite strong government guidance that such cursory visits are seen as wholly inadequate.
John Kennedy, former director of care services at the Joseph Rowntree Foundation, believes funding isn’t the only problem. He published a personal inquiry into the quality of care homes in 2014, and since then has spent time visiting outstanding care homes to find out what makes them different.
Too many carers face poor pay and working conditions. But John Kennedy also believes the care system fails to support care-home managers adequately – a job often invisible to society at large. “This is a job with an immense level of responsibility,” he says. “In a home with over 50 residents, you might have a staff team of the same number, with turnover around the £2m mark. All care homes are 24/7 operations. The show must relentlessly go on.”
Yet average pay for a care-home manager is just £27,700 a year. “I doubt you could find any other job in any other sector that requires this level of responsibility for that level of pay.”
He believes government has placed too much emphasis on red tape and regulation as a way to improve care services. “We’ve created a system that makes it too difficult for any but the most skilled managers to deliver consistently good care,” he says. “Instead of valuing relationships, people and life, we concentrate on value, systems and processes. The system puts avoiding blame above ensuring people are having a good life. This attitude permeates and damages the culture of care.”
Kennedy is worried that, given the relentless nature of their role, care-home managers are at risk of burning out: on average, one in four care managers leave every year. He argues that this makes quality in care homes fundamentally fragile, citing the example of one care home he visited that was rated outstanding by the regulator, but whose standards plummeted to inadequate after it lost its manager.
If it’s great management that makes a great care home, it’s poor management that paves the way for the kind of abuse that has been periodically uncovered by the media, according to FitzGerald. “Where you see abuse situations in a care home, you’ll see bad leadership with 40 or 50 ordinary people working in an environment that’s abusive and neglectful, and not seeing anything wrong with it,” he says.
FitzGerald doesn’t believe incidents of abuse are isolated or rare incidents that can be dismissed. He points to the fact that there has been no reduction in the use of antipsychotic drugs in care homes, despite a 2009 government review that concluded they were overused to the detriment of patients. His charity has raised concerns with the CQC that relatives who have complained about the quality of care have been banned from homes, or told they will have to move out their elderly relatives within 28 days.
He doesn’t mince his words. “We’ve created an institutionally abusive environment in social care. It’s ageism in action.”
Sara McKee, the founder of Evermore, agrees we have a problem with ageism. “Why is it considered acceptable to institutionalise older people when other forms of institutionalisation have been eradicated?” she asks. “Our fundamental model of care has not changed for over 40 years. Modern nursing homes look like they did decades ago, just with newer carpets.” McKee is setting up a new model of supported housing designed to be somewhere people can live their life out, regardless of how high their level of need escalates. “Many health and care providers see ageing as a condition that needs to be managed. We want to provide positive choices where growing older means doing what you love and feeling good, rather than managing declining health.”
The Evermore concept is based on the Green House ageing project in the US, developed by geriatrician Bill Thomas, with whom she now works. She describes the Green House as an “anti-institutional” environment. “He has stripped away all the hospital-like paraphernalia you would find in many traditional care homes, such as nursing stations, uniforms and rigid schedules. In its place is a building designed like a family home, with self-contained residences for six to 12 people.”
Unlike in traditional supported housing, the emphasis is on communal living, with meals prepared in an open kitchen and shared at a communal dining table. McKee says the staff are absolutely key to making it all work: she describes them as multiskilled and self-managed, with much more freedom to run the household according to the wishes of the residents, rather than top-down diktat from head office.
It has taken McKee a while to find an investor for her project, but she’s now working with a developer to build the UK’s first Evermore community in Wigan. But won’t it only be wealthier baby-boomers who can afford this type of living? McKee doesn’t think so. “Most local authorities want to stop paying for grim and expensive nursing home beds,” she says. She believes joining up NHS and council budgets could enable money to be spent on more innovative ways of delivering care like Evermore, not necessarily at higher cost.
Alex Fox is another person rethinking traditional models of care. He runs Shared Lives Plus, a network of local schemes in which paid carers share their home and family life with an adult who needs care or support. The goal is to share an ordinary family life, in which everyone contributes and benefits. This is a much more explicitly two-way relationship than in traditional professional care. It’s a model that was developed primarily for adults with disabilities, but there are now almost 2,000 older people with care needs using Shared Lives in England.
“The Shared Lives carer makes a positive choice to share their home and family life with the older person, so it’s a real relationship which can last a lifetime, not just a service,” says Fox. “People who use Shared Lives tell us they feel ‘one of the family’, and their relatives often say they feel like there are two families working together now, whereas before they often felt on their own and struggling.”
It might not be for everyone. But Fox believes that the rest of the care system can learn from it. “Shared Lives schemes spend time recruiting the right people, then giving them the space and freedom to be more human and flexible in their work. This isn’t just more cost-effective, it creates better care,” he says, pointing to the fact that, out of the 25 Shared Lives schemes rated by the CQC, 24 are good or outstanding.
Is there any work that is more fundamentally human than caring for others? Little wonder then that, whether it’s West Hall, the Green House or Shared Lives, the golden thread that runs through successful care organisations is the quality of their staff.
Perhaps this offers society a golden opportunity. From assembly-line manufacturing to book-keeping to driving a minicab, jobs that once required human endeavour are being replaced by technology. Jobs requiring uniquely human skills like empathy and care may take up a growing share of the labour market in the future. Older care falls into this category, especially given the needs of an ageing population.
Yet care is not exactly a career destination of choice for many young people. Charlotte Whittaker, 22, is halfway through a five-month work placement at care homes in Surrey. It’s a career she’d recommend, but she doesn’t think young people tend to see it as fulfilling or enriching. “Partly it’s a misconception about what care involves. There’s not much understanding of the relational aspects, and the potential to make a difference to a lot of lives over a career.” But she says it is also partly the misperception of care as a low-skill job. “I’ve been incredibly impressed by the skills and diplomacy of the carers I’ve been working with.”
Perhaps by investing more time, money and love in our care system, we can simultaneously improve the lot of both the older and younger generations. That’s an attractive proposition at a time when so much political debate seems to set the young against the old. But it’s not a job that can solely be left to the politicians. Nothing will change unless we face up to the reality that the way we as a society care for older people is just a mirror that reflects back our cultural attitudes towards ageing.
THE MANAGER
Karen Cooper runs Mount Ephraim House, a Greensleeves care home in Tunbridge Wells. “My job is demanding, incredibly demanding, but I adore what I do,” she says. “You get so much back from it. You wouldn’t do this job for the money, but because you care about making a difference at the end of the day.”
It takes a high level of skill to care properly for someone with dementia, she says. “They might constantly ask you the same question day in day out, looking for a family member long passed on. You have to be careful how you respond, otherwise a person can go through the grieving process eight times a day.”
It’s not a nine-to-five job. “You can’t really switch off. You’re on call 24 hours a day unless you’re on holiday.” She used to work for a standalone home, which she found more difficult than working for a care home group. “You’re on your own – you don’t have any backup.”
While she loves her work, Cooper feels it’s sad the care sector has to fight its own corner because of the negative publicity generated by stories of abuse. “Sadly, the general public think all care homes are the same, when there are an incredible number of excellent care homes.”
THE CARE WORKER
Charlotte Whittaker, 22, is halfway through a five-month work placement as part of an activities team in two care homes in Surrey. She’s doing the work as part of Year Here, a postgraduate qualification in social innovation.
Having seen both her grandmothers need care, she has a close personal interest in the subject. “Elder care is a big societal issue that isn’t necessarily very glamorous but needs a lot of thought and innovation”, she says. “The best thing about my work is the residents: getting to know them as individuals, finding out about their lives and what they like doing now. There are a lot of laughter moments, singing or doing arts and crafts.” But there are harder moments too. “Sometimes you have residents who are very upset, and it’s difficult to comfort them, because the person they’re missing isn’t around any more, or they want to go home but no longer have a house.”
She has been overwhelmed by the emotional investment made by her colleagues in the people they care for: “They do it because they love doing it.”
THE DAUGHTER
Michele Simmons thought the small privately owned care home in London she carefully chose for her 77-year-old mother, Gilda, (pictured below) who has dementia, was a warm and welcoming place. However, neglect soon became evident in a number of ways. “My mother was someone who took great pride in her appearance and I took time labelling all her clothes,” says Michele. “But she was increasingly put in other people’s clothes, things that didn’t fit.”
She recalls finding her mother in plastic shoes two sizes too small, her toes bent over. “Mum couldn’t speak, but her face conveyed the pain,” says Michele.
One freezing winter morning, Gilda was sent to hospital in an ambulance. “She was in a thin nightie with no slippers, no blanket, no notes and no one went with her,” says Michele. “The manager said it was because there was a changeover of staff and no one was available. I eventually found her hours later, terrified, on a trolley in a hospital corridor.”
Michele, who paid £3,500 a month for her mother’s care, talked to the manager many times but her complaints were brushed aside. “I became worried about making too much fuss in case they [the care home] took it out on mum. All I wanted was the best for my mum and for her to be treated with dignity and kindness – it was just a shame the home didn’t feel the same.”
THE WHISTLEBLOWER
“Witnessing the abuse and not being able to do anything about it was the worst thing I had to endure,” says Alex Matthews, a former care home worker who was shocked by what he saw during a year at an “expensive and luxury” home. “Rough handling by carers was evident on a daily basis,” he says. “Feeding was done in a hurry and people were often left dribbling porridge and other food over their clothes. Personal hygiene was terrible. ”
But most of those he worked with were good people, he adds. “The neglect was to do with the heavy workloads and having too many people to deal with in a short space of time.” As bad as the physical neglect, he says, was the lack of care over patients’ emotional wellbeing. “We were always asked to move from one to the next as quickly as possible. This leaves you with a lot of guilt.”
Alex Matthews (his pen name) has written a book about his care home experience; She’ll be Alright, Pavilion Publishing, £19.95.
Underfunded and overstretched – the crisis in care for the elderly
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