Last reviewed 2 April 2015

Jef Smith assesses whether the current nursing home system reflects the necessary provisions for delivering quality care.

It is a truism of social care that the average level of frailty of residents in homes has risen, is still rising, and will continue to rise for the foreseeable future. Increased life expectancy and the accompanying morbidity — many of those increasingly elderly people having to deal with long-term health conditions and disabilities — means that a significant and growing proportion of the population need to be looked after. Informal carers, many of them quite old themselves, will not be able to cope with this pressure, and even professionally provided domiciliary care cannot realistically fill the gap for the most dependent.

Care in a residential setting appears to be the obvious answer, but not just any care. The needs of people going into homes are increasingly complex. The majority have or will develop dementia; most have some sort of mobility or sensory disorder, usually severe — not just poor gait but difficulty in making a range of movements, not just slight hearing loss but near-total deafness. Multiple conditions are common, so most residents are taking diverse medicines.

Disability breeds problems and such vulnerable people are constantly at risk of falls, pressure sores and a range of other health problems. Whatever else may be said about them as varied individuals and about the need for a lifestyle which responds holistically to their needs and wishes, it is undeniable that most residents in homes face serious, sometimes almost overwhelming, health issues. It is difficult to imagine that their lives can be made in any sense fulfilling unless tackling ill health is central to the prescription.

The nursing profession surely came into existence precisely to attend to the needs of sick and disabled people, which is just the group that is now heavily concentrated in homes for older people. Hence, a care home which also provides expert nursing seems the natural answer. This point is so obvious that, in the public mind, any sort of care home tends to be thought of as a nursing home and even manifestly unqualified staff are often described as nurses. In reality, however, only about a quarter of registered homes have in-house nursing and even those employ nurses in senior roles only.

CQC report

It was therefore startling to read in the latest annual report from the Care Quality Commission (CQC) — The State of Health Care and Adult Social Care in England 2013/14 (published in October 2014) — that “people living in nursing homes experienced poorer care than those living in residential care homes with no nursing provision”. Though shocking, this is not surprising to anyone who has followed recent care statistics, since this situation accords with a pattern apparent over at least the last three years.

The report found that the percentage of nursing homes which failed to comply with essential standards were:

  • 14%: respect and dignity

  • 16%: care and welfare

  • 17%: monitoring quality

  • 19%: suitability of staffing

  • 22%: safeguarding and safety.

In all cases, these figures are significantly higher than those for residential care homes and, for all except care and welfare, the position is actually getting worse. The CQC describes these findings as prompting “continuing concern” — hardly an over-statement.

Sharon Blackburn, qualified in both general and mental nursing, is Policy and Communications Director for the National Care Forum (NCF). In December 2014, she wrote in an NCF blog entitled Valuing the Contribution of Nurses in Social Care that the fact that “the topic of nursing in adult social care has suddenly made its way up the political agenda” is “good news”. She then added that “nurses working in this sector have made an excellent contribution to ensuring that relationship-centred care is delivered in a person-centred way”.

Her optimism would be more persuasive had her words not precisely coincided with the CQC’s initiating of urgent action to close a nursing home in Surrey — a step it took with some reluctance since the lives of the extremely vulnerable residents were severely disrupted as they were moved to fresh locations. Nevertheless, inspectors were forced to act having found “an overpowering smell of urine”, “poor manual handling”, a broken lift which left some residents unable to get downstairs for several weeks, and people with dementia “being washed in cold water” and exposed to “a high risk of developing pressure sores”.

The satirical magazine Private Eye has a long-running cartoon called “Fallen Angels” mocking the uncaring attitudes of nurses, but what happened at this home went well beyond a joke. In a final twist to the story, the local Clinical Commissioning Group failed to make the necessary transport available on time, so some residents were obliged to wait until late in the day before being taken to their new homes.

This closure is just the sort of bad publicity which Frank Ursell, Chief Executive of the Registered Nursing Homes Association, worries about as he believes it reinforces the wider prejudice against the homes his members manage. The association, which regularly attacks the CQC and others for what it sees as their negative and unfair criticisms, says that the comments in the CQC’s report were “unjustified and sensational”.

Last year, it criticised the CQC’s chairman who had announced plans to increase the use of court action against providers showing poor practice, and a few days later Care Minister Norman Lamb was “rapped for besmirching (the) reputation of care homes through over-generalised comments”. When we spoke with Mr Ursell, almost his first remark was to deplore national newspapers’ often unsympathetic coverage of care home issues. He certainly has a point, but in the wider world this attitude can look overly defensive, and the issue of nursing home standards requires deeper analysis.

Nursing home fees

The level of fees is one obvious area of concern. Mr Ursell points out that an overnight stay in a chain hotel in Worcestershire, the county where he himself runs a home, costs less than he is paid for the 24-hour care of an older person with multiple needs. Financially speaking, nursing homes face particular problems within current pricing arrangements as most local authorities offer a one fee band level only; by contrast, residential care homes benefit from up to five bands, adjusted to varying degrees of service user dependency.

Nursing homes also have to offer higher care staff ratios — characteristically one staff member for every five residents, which is double that of some non-nursing homes — and of course they are obliged to have qualified nurses on duty at all hours. Ms Blackburn adds that the Registered Nursing Care Contribution and Continuing Health Care monies, which should somewhat mitigate this situation, are both paid as flat rate sums which do not adequately reflect an individual’s assessed needs.

Costs — staffing, pensions, fuel and other commodities — have all escalated over the last four years, while fees have certainly not kept pace. In addition Mr Ursell feels that local authorities, as lead commissioners, have a poor appreciation of health needs, not being an area included in their traditional responsibilities. Could this change, however, as the relatively new health and wellbeing boards begin to make an impact?

The system through which nursing home places have to be commissioned by cash-strapped councils results in the absurd anomaly of a place in Mr Ursell’s home attracting a fee of just £538 per week, while a long-term bed in the nearby Heartlands Hospital in Birmingham costs the exchequer nearly four times that amount.

Training of nurses

The health service has certainly not treated nursing homes well. The universities which educate nurses routinely use placements in hospitals but only a minority of nurses in training are offered the chance to work in a home. The newly qualified therefore feel little incentive to work outside the NHS, and those who do opt to work in homes find that salaries, conditions of employment and career prospects are generally poorer.

Nursing homes exercise no control over nurse training and employment policies, and Mr Ursell is highly critical of Health Education England’s lack of a long-term strategy or even short-term plans which would reflect nursing homes’ staffing needs. Certainly, the present staffing situation in homes is serious, with a nurse vacancy rate of 8% and nurse turnover at 32% — easily the highest for any social care job role.

The government’s Migration Advisory Committee has been exploring whether nurses should be added to the Shortage Occupation list, but poaching staff from overseas (political, language and ethical objections aside) is surely not a sensible long-term solution to recurring domestic shortages. Indeed, Dr Peter Carter, Chief Executive of the Royal College of Nursing, has criticised “a system that has such lamentable workforce planning that…you have got people recruiting from all points of the compass”.

The nursing home market

Two other factors may play a part in nursing homes’ current malaise: the size of homes and their ownership. Frank Ursell reports that the larger corporate organisations — those operating several homes within an overarching brand — control over 50% of the nursing home market. The CQC’s analysis of its data on compliance with standards reveals that corporate providers have more problems with staffing levels than smaller-scale operators, despite their generally superior processes for recruitment and training.

This may, in turn, relate to the size of homes. Corporate provision is generally supplied in larger premises, but small homes on average easily outperform the competition on all five key standards. It seems likely that the CQC will soon be exploring these complex inter-relationships in greater depth.


“Nursing older people”, says Ms Blackburn, “requires a high level of skill and competence combined with compassion and excellent relational skill” — a sentiment probably echoed by every manager in the nursing home sector. However, due to a complicated set of financial, commercial, political and professional reasons, the system is currently nowhere near delivering dependably high-quality care.