Last reviewed 11 January 2012

Jef Smith looks at extra care housing, still largely unexplored as a care option.

Within the social care market, it is not always acknowledged, the providers of residential and domiciliary care are often effectively rivals for business. They depend on, and compete for, pretty much the same customers, but they set out very different theories of what those service users want, or would want if given all of the relevant information and the freedom to choose.

Advocates of support at home lay stress on its contribution to retaining their clients’ much-valued independence, while residential care managers and workers, particularly those in nursing, quote their capacity to provide security and comfort for vulnerable people.

Both are, in a way, right. Clients seeking care come with a variety of needs and there must be scope for a diversity of provision. Some organisations are able to supply both sorts of support, and the short-term, respite and intermediate care offered by some forward-looking homes goes some way to bridging the divide.

But there is a third category of caring regime which could be seen as incorporating the best elements of both residential and domiciliary care. Extra care housing, otherwise known as very sheltered housing or accommodation with care, which has progressively established itself over the last quarter of a century, offers such flexible possibilities that it is in some ways surprising that it does not have a larger market share: many social care customers seem still unaware of its existence.

A home of one’s own

The tenants or leaseholders of extra care flats — the model can be adapted to either sort of occupancy — retain a home of their own, with their own front door, independently controlled space several times the size of that of the average resident’s room in a home, and often an additional bedroom for a spouse, friend or guest. By taking housing rather than care as a starting point, extra care more or less bypasses the threats to dignity and autonomy claimed by residential care's detractors.

The accommodation element of an extra care complex consists characteristically of a number of flats grouped over one or more floors, linked by spacious lifts, with generous circulation space allowing for casual but not enforced social interactions. The range of additional facilities provided on site is as wide as in any care home, and has usually been purpose-built to a high design standard. There is generally a communal entrance providing security for the whole complex, a dining room where at least one daily meal can be taken, a comfortable sitting area, perhaps space for other activities, a mini-shop for residents to buy their own supplies and luxuries, and a well-maintained garden providing easy access for people with disabilities.

Like a residential home too, the personnel on site include catering and domestic workers for the hours they are needed, a manager usually on duty only during the day time, and handymen and gardeners as required.

Differences and similarities

The major difference from a home, as far as staff are concerned, is that personal care and support for people in extra care housing is provided not by the establishment’s own care assistants but by a domiciliary care agency, which generally has a base in the building. Theoretically, users can choose whichever local agency they like for their support, but in practice few if any look beyond the in-house service, which of course is conveniently placed for all concerned.

As in a home the team of workers get to know all of the residents, so they can quite easily cover for each other. Supervision is relatively straightforward and more effective than that provided in domiciliary care where care assistants are operating remotely across a wider geographical area. The care plan for each resident specifies the quantity and nature of the personal care they are to receive. This is programmed for delivery at specified times, is charged for accordingly, and can be varied whenever the plan is reviewed, in contrast to the residential care model under which care is provided more or less on demand.

There are many similarities with the way a care home operates. Residents get to know each other and become familiar with each other’s needs, are rarely without company and peer support if they want it, but always have the possibility of retreating into their own privacy when that suits them.

Whether or not the lifestyles of residents incorporate as much stimulation as they would wish or is beneficial depends, as it does in a care home, on the quality and imagination of management. The better resourced extra care schemes, like the best homes, have lively social programmes, with plenty of visitors, organised entertainment, good service user participation in planning communal events, well-trained activity organisers and outward-looking attitudes to the local community.

Scarcity of research

Despite the appearance of a form of provision which has everyone as winners and a good deal of anecdotal evidence of service user satisfaction, there has been a surprising scarcity of hard research on extra care’s effectiveness. This gap was recently helpfully addressed by a project of the International Longevity Centre, whose report Establishing the Extra in Extra Care was published in September 2011. This document summarises such research as already exists, and considers fresh evidence from three providers, using in-depth data about extra care service users and others, assembled over 15 years.

Contrasting extra care residents with a matched population of older people receiving conventionally delivered home care, the researchers found a significantly lower rate of admission to what they call “institutional accommodation” among the former. This must be seen as a positive outcome for people who had been able to maintain their independence for longer and it certainly represents substantial savings to social care budgets.

Analysing the numbers of people who eventually moved into a residential home as against those who died in extra care, the “a home for life” idea for the majority of extra care residents seems justified. One of the explanations could be that living in extra care housing improves residents’ health, and the researchers claim that there is “plenty of evidence to support this assertion”.

When changes in care packages were used as a proxy for health status, presumably because more specific health data was not so readily available, it emerged that 24% of residents experienced an improvement, that is a lowering of their care needs, over five years. One specific example, drawn from a small sample in one of the participating schemes, suggested that only 31% of extra care residents had a fall as against 49% in a matched sample of people receiving home care while living in the wider community. This certainly rings true, since extra care flats are designed with disabilities in mind, safety hazards are likely to be spotted and dealt with, and help is on hand for risky tasks like changing light bulbs.

Given the potential of falls to lead to expensive hospital treatment, extended pain and dependence, and even death, it is useful for have statistics to support everyday experience. Similarly, though rather more tentatively from the available evidence, it appears that the rate of overnight hospital stays is lower for extra care residents. Again, cutting costs and promoting wellbeing run happily hand in hand.

Care of the vulnerable

The report’s authors claim that “extra care housing, on the whole, supports some of the oldest and frailest members of society”. They back this with the fact that the average age on entry “tends towards the high 70s” and that “the average age of residents living in these properties can reach as high as 85”.

Managers of care homes will immediately spot that such older people are relatively youthful compared with their own residents and will note too that a significant proportion of people living in extra care eventually graduate to full residential care. This appears to re-establish the hierarchy of care provision which extra care’s “home for life” claims seem to dispute. Extra care may be a better place in which to receive domiciliary care than the draughty dangerous isolation of living in the wider community, but the residual role of residential care in looking after very vulnerable people in their last years can be reasserted.

Such complacency may be dangerously misplaced, since the full potential of extra care housing has clearly not yet been realised. It has often been noted, for example, that the development of dementia in an older person presents problems which are not easily managed within an extra care scheme, especially if the service user’s behaviour becomes disruptive or seriously antisocial towards others. Residential care has considerable experience of this problem and practitioners have learned that early intervention by readily available staff can diffuse confrontations, in extreme situations by restraint but more positively through good communication, sympathetic distraction and fulfilling activities.

There is, however, no reason why the pattern of care in extra care units cannot make use of and build on this expertise. Applying it within a less institutionally structured regime may, it is true, require a somewhat different approach both to the fundamental contract of support when it is drawn up and to the detailed care plans formulated for potentially disturbed and disturbing residents. This may call for some changes in the way in which extra care housing is perceived by both residents and providers, a calculated shift towards the way homes operate.

Suppose, for example, that schemes accommodating people with dementia had additional staff and resources so that they could offer something akin to day-care on the premises. It might be required in the care plans of selected service users that, as an alternative to withdrawing into isolation or terrorising their neighbours, they should sign up to attend sessions at which they would be provided with a safe environment, staffed care and appropriate activities.

Such initiatives are exactly in the spirit of the first of the report’s nine recommendations, that “policy makers need a co-ordinated response to providing housing, healthcare and social care for our ageing population”. The last of the recommendations is that more research on these issues is needed. Some of that additional thinking will doubtless be going into devising further forms of hybrid care.

There is no room in this fast-developing market for social care providers who think that their potential clientele will always be content with services as traditionally delivered. Extra care provides many pointers to the shape of things to come.