Bed Based Care – Care Homes   

Where are we now

Care homes in Sutton are an essential part of the Health and Social Care landscape providing care to some of our most vulnerable residents, who often enter a care home with very high levels of need such as severe physical frailty, advanced dementia and complex co-mordibities, which require support and interventions from other parts of the health and social care system. 

Sutton currently has 74 Care Quality Commission (CQC) registered care homes supporting older adults (65+) with physical and mental health age related illnesses (including severe physical frailty and organic mental health illness such as dementia) and adults (18-64) with profound or severe learning disability, physical disability, autism, functional mental health illness and sensory impairment. 

There are some care homes in Sutton that do not fit neatly into the adult (18-64) or older adult (65+) distinction. There are a small number of care homes that provide services for people aged 65+ in what would be categorised as a younger adult care home. For example, a number of older adults have lived in care homes for many years moving in when they were younger adults (some were former residents of the old long stay institution at Orchard Hill which closed in 2009).

Diagram 1 – Percentage of Sutton’s Care Home Placements that are in Borough compared to the Greater London Average

   Data Source: London Information Exchange Group (LEIG) Bed Based Care Services  Review 2021/22

 

Despite a broad range of Sutton based provision, some Sutton residents are placed out of the area due to the current market being unable to meet the needs of our more complex residents. 

Sutton’s preference is always to place residents who require long term care and support in a care home within the Borough, wherever possible. Over half (55%) of the placements made by Sutton into care homes for all adults (aged 18-64 and 65+) are within the Borough. This percentage is higher than the Greater London average of 52.5%.

  

  Diagram 2 : Total Number of Beds Available for Adults Aged 18+ in Sutton

  Data Source: Adult Social Care Sutton.

There is a total capacity of 1276 care home beds (residential and nursing) for adults aged 18+ in Sutton. Of this total, 73.3% (935) are for older adults aged 65+. For adults aged 18-64 with a learning disability, there are 274 (21.5%) residential beds and 5.3% (67) are residential and nursing beds for adults aged 18-64 with a mental health condition.

Although with fewer care homes, the older adult (65+) care home market is almost three times the size of the adult aged 18-64 market and often with much larger care homes (typically over 20 beds). As home size is such an important factor for understanding the costs of care home provision, adult (18-64) and older adult (65+) care homes are often incommensurable. 

Diagram 3 : Size of Companies that own care homes in Sutton

  Data Source: Adult Social Care Sutton

Of the 74 registered care homes, a substantial proportion (28 homes or 37.8%) are smaller, ‘locally’ owned care homes with the provider being Sutton based and predominantly owning just one care home. National care home providers make up 48.6% of the care home market in Sutton, with the smallest proportion being regional based companies (London and the home counties) owning the remaining 13.5% (10 homes).

Sutton also has a high proportion (61%) of small care homes with under 10 beds. On the whole, these small care homes support adults aged 18-64, mainly with profound or severe learning disabilities and/or mental health conditions, and often providing services in converted domestic houses. The larger care homes (over 30 beds) are for older adults only, mostly provided in large converted domestic houses with the exception of a small number of purpose built nursing homes. 

The quality of care home provision for our residents remains a key focus for Sutton.

  Diagram 4 : CQC Ratings by Domain for Sutton’s Care Homes 2021/2022

Data Source: London Information Exchange Group (LEIG) Bed Based Care Services  Review 2021/22

Each care home is rated across 5 domains (safe, effective, caring, responsive and well-led) by the Care Quality Commission (CQC) with a rating of either outstanding, good, requires improvement or inadequate. For the period 2021 to 2022, across the whole care home market provision, the majority of CQC domain ratings were good (78%) with 17% of domain ratings as ‘requires improvement’. There were 16 domains rated as ‘outstanding’ which has increased from previous years. 

  Diagram 5 : Greater London Councils’ Total Beds by the Average Weekly Cost of a Placement

Data Source: London Information Exchange Group (LEIG) Bed Based Care Services  Review 2021/22

The average weekly cost of a placement (including residential and nursing care) in Sutton is £1035 (based on 420 placements). This is slightly lower than the expected average for our size compared to other London Boroughs. Sutton has relatively fewer placements when compared to other London Boroughs, but is also below the trend line on the average cost of a placement. Sutton pays less on average than Kingston Upon Thames and Merton despite having similar numbers of care home placements.

Our Care Home Market – Adults Aged 65+

There are 26 registered care homes within Sutton supporting older adults aged 65+, providing a total of 935 beds.

Diagram 6 : Number of Beds for Adults 65+ by Service Type

Data Source: Adult Social Care Sutton

 

Diagram 7 : Number of Beds for Adults 65+ by Market Sector Type

Data Source: Adult Social Care Sutton

Approximately three quarters (684 or 73.2%) of these are nursing beds with the remainder (251 or 26.8%) being residential care beds. The prevalence of nursing beds for older adults (65+) would suggest that there is more of a need for placements that support people with significant nursing care needs (e.g. severe physical frailty, advanced dementia, end of life care) as opposed to residential care. It should be noted however that currently there are no designated nursing homes in Sutton for adults aged 65+ with a learning disability.

Of this total of residential and nursing beds, 810 (86.6%) are provided by private sector commercial organisations, with the remaining 125 beds (13.4%) provided by voluntary sector / not for profit organisations. 

Diagram 8 : Location of Suppliers by Adults Aged 65+ by Service Type

Data Source: Adult Social Care Sutton

Of the total number of care home suppliers for adults aged 65+, 18% are residential care home providers located within Sutton itself, compared to 22% of residential care home providers who are located outside of the Borough. For the nursing home market, 27% are located within Sutton, with 34% being located outside of the Borough.

Diagram 9 : Overall CQC Ratings for Residential Homes for Adults 65+

Data Source: Adult Social Care Sutton/CQC

Of the residential care homes for adults aged 65+, 80% are rated ‘good’ and 20% are rated as ‘requires improvement’. There are currently no residential care homes for adults 65+ that are rated as ‘outstanding’ in Sutton.

Diagram 10 : Overall CQC Ratings for Nursing Homes for Adults 65+

Data Source: Adult Social Care Sutton/CQC

Of the 16 nursing care homes for adults aged 65+, 87.5% (14) are rated ‘good’ and 2 (12.5%) are rated as ‘requires improvement’. Similarly to residential care homes there is currently no nursing care provision for adults 65+ that is rated as ‘outstanding’ in Sutton.

To incentivise the care home market to continually seek improvement and to strive for ‘outstanding’, Sutton has initiated a scheme that will reward care homes that receive outstanding ratings from CQC with a cash payment of £1,000 per rating (for safe, effective, caring, responsive and well-led), including an additional £1,000 bonus if a care home receives 5 outstanding ratings overall. Successful care homes will be expected to spend the money on their staff team through the provision of gift tokens and/or a celebratory event. The scheme is effective up to 31/03/2023. Only outstanding ratings achieved during this period will qualify for the reward. The scheme will also apply to care homes who retain an existing outstanding rating during this period.

As part of the adult social care assessment process, individuals who are identified as having an eligible need for ongoing care and support, have their ‘Primary Support Reason’ identified and recorded. Individuals may have a number of identified needs, however a primary reason for support will always be identified.

Diagram 11 : Primary Support Reason for Adults 65+ in Care Homes

Data Source: Adult Social Care Sutton

Of the total number of adults aged 65+ being placed in either a residential or nursing care setting, the graph above identifies that for just under half (45.5%) the primary reason they have been placed within this type of care setting is due to the requirement for physical support, likely to be linked to the frailty of older age. Just over a quarter of adults aged 65+ (26.5%) have been identified as requiring long term cognitive support, most likely for dementia. For the remaining quarter combined, the primary need for support has been identified as a learning disability (16.7%), a mental health condition (9.8%) or for sensory support (1.5%)

Diagram 12 : Percentage Breakdown of over 65s in Sutton in receipt of support from Adult Social Care

Data Source: Adult Social Care Sutton

The pie chart above provides an overview of the percentage breakdown of adults 65+ in receipt of support from Adult Social Care in Sutton. The 80+ age group is less than 20% of the older population in Sutton but represents 70% of those in receipt of support, with those aged 85-89 making up 25.9% and the 90+ age group 26.7% respectively.

This would indicate that the majority of care home residents are of an age which brings further complexities and frailties.

Diagram 13 : Location of Residential Placements for Adults Aged 65+ in Care Homes


Data Source: Adult Social Care Sutton

Sutton makes 75% of its residential care home placements for adults aged 65+ within the Borough, with the remaining quarter requiring placement out of Borough. This may be for reasons of complexity of need but also to be placed nearer to family members.   

Our Care Home Market  – Adults Aged 18-64

There are 48 registered care homes within Sutton supporting adults aged 18-64, providing a total of 341 beds.

Diagram 14 : Number of Beds for Adults Aged 18-64 Service Sector

Data Source: Adult Social Care Sutton

Of the 274 residential care beds for adults aged 18-64 with a learning disability, the majority of 237 beds (86.5%) are provided by private sector commercial organisations, with the remaining 37 beds (13.5%) provided by voluntary sector / not for profit organisations. This percentage split almost identically mirrors that of the care market for adults aged 65+. Currently there are no designated nursing homes in Sutton for adults aged 18-64 with a learning disability.

Diagram 15 : Number of Beds for Adults Aged 18-64 with a Mental Health Condition by Service Type

Data Source: Adult Social Care Sutton

 

Diagram 16 : Number of Beds for Adults Aged 18-64 with a Mental Health Condition by Sector

Data Source: Adult Social Care Sutton

Of the 77 care beds for adults aged 18-64 with a mental health condition, residential care beds make up 62.7% of the total (42), with 37.3% being nursing home beds (25). Of this total market, the majority of 53 beds (79.1%) are provided by private sector commercial organisations, with the remaining 14 beds (20.1%) provided by voluntary sector / not for profit organisations (a higher percentage than that of other care home market areas).

As with care home provision for older adults, the quality of care home provision for our resident adults aged 18-64 remains a priority focus for Sutton.

Diagram 17 : Overall CQC Ratings for Residential Homes for Adults 18-64 with a Learning Disability

Data Source: Adult Social Care Sutton

Of the 41 residential care homes for adults with a learning disability aged 18-64, the majority of 34 homes (82.9%) are rated ‘good’ and 2 (4.9%) are rated as ‘requires improvement’. There are 3 residential care homes (7.3%) that are rated ‘outstanding’ but also 2 residential care homes (4.9%) that are rated as ‘inadequate’ in Sutton.

Diagram 18 : Overall CQC Ratings for Residential Homes for Adults 18-64 with a Mental Health Condition

Data Source: Adult Social Care Sutton/CQC

Diagram 19 : Overall CQC Ratings for Nursing Homes for Adults 18-64 with a Mental Health Condition

Data Source: Adult Social Care Sutton/CQC

Of the residential and nursing care home provision for adults with a mental health condition aged 18-64 (7 homes in total), 6 homes are rated ‘good’ (85.7%) and 1 home (14.3%) is rated as ‘requires improvement’. 

Diagram 20 : Primary Support Reason For Adults aged 18-64 in Care Homes

Data Source: Adult Social Care Sutton

Of the total number of adults aged 18-64 being placed in either a residential or nursing care setting, the graph above identifies that for the significant majority (75.2%), the primary reason they have been placed within this type of care setting is due to their requirement for support for a learning disability. For the remaining quarter of adults aged 18-64, the primary support reasons for requiring long term care and support have been identified as physical support (9.7%), mental health support (9%), social support (4.1%) and cognitive support (2.1%) respectively.

Diagram 21 : Location of Care Home Placements for Adults Aged 18-64

Data Source: Adult Social Care Sutton

Diagram 22 : Location of Suppliers for Care Home Placements for Adults Aged 18-64

Data Source: Adult Social Care Sutton

Sutton makes 63.4% of its care home placements for resident adults aged 18-64 out of the area, with the remaining 36.6% being placed in Borough. This is in direct contrast to the placements of adults aged 65+ where the majority are placed within the Borough. The primary reason for this is that the current market within Sutton is unable to meet the more complex needs of some of our adult residents aged 18-64. This situation may be heightened by the limited care home provision for adults aged 18-64 with a mental health condition and the lack of nursing care home provision for adults aged 18-64 with a learning disability.

Where we want to be – Our Vision

Over the next 5 years (2022-2027) our joint vision with the SWL ICS is to develop an innovative and sustainable market that is responsive to the needs of our residents, remains safe, supports excellence and provides value for money. Our joint approach to commissioning a sustainable range of high quality care home services will include:

  • Managing the local care home market as part of the integrated care system
  • Supporting quality in care homes through joint monitoring, quality assurance and data collection
  • Developing opportunities for joint commissioning of new in-Borough models of care over the 5 year period
  • Informing the planning of care home provision beyond 2027

We want to improve outcomes for people living in care homes by enabling choice, delivering person centred care, managing risk and promoting wellbeing.

We will know we have achieved our vision when we see:

  • Care home fees that are considered fair and reasonable by providers
  • Integrated commissioning is developed and implemented
  • More use of digital and care technology to keep residents safe
  • More care homes achieving outstanding ratings from CQC
  • People are supported to live in their own homes as long as possible
  • An up to date list of quality assured Approved Providers
  • A contract supported by a joint service specification
  • New service models that deliver better Sutton based provision

To support our vision, our joint long term commissioning intentions are:

  • We have a joint strategic direction for care home commissioning in Sutton
  • Our care home commissioning methodology is aligned across health and social care
  • We have evidence of improved outcomes for people living in care homes
  • We will deliver enhanced health care services to care homes
  • We have alternatives to care homes for residents in Sutton

Challenges and Market Influencers

From a local care system perspective, there is currently an over-supply of residential and nursing places in capacity terms of the proportion of beds purchased by Sutton. There is currently no additional NHS or social care funding for unplanned increases of capacity in the care homes market.

The placement fees that Sutton can afford to pay are seen as inadequate by many residential and nursing homes providers. This has led to an overall reliance on the self-funding residents in our older adults (65+) care home market who make up 57% of the older adults 65+ market. There are three care homes predominantly for self-funders who provide 218 beds (22% of the market). Self-funders’ contributions cannot be matched by Health and Adult Social Care. Self-funders often pay significantly more than people who are fully or partially funded by Sutton. Through section 18.3 of the Care Act 2014, the Government will in the future enable self-funders to ask Sutton to arrange their care at the rate the Sutton pays. Through the national cost of care exercise for the older people care home market, we will gain a clearer picture on the cost of running local, regional and national care homes to assist us to establish a fair cost for residential and nursing care placements and to support sustainability in the market. 

There are tensions within the health and care system itself within Sutton, as the placement fees paid by Health as part of the Any Qualified Provider (AQP) contract are higher than those paid by Sutton. Preference of placements therefore is often given to Health funded individuals on purely a financial basis.

Need and Demand

As at September 2021, there has been a minimal increase in long term residential and nursing placements. For the 10 month period from September 2021 to June 2022, the increase was 1.1% indicating that older adults are being supported to remain safely independent in the community with the majority being admitted to a residential or care home at the age of 75+.

Diagram 23 : Percentage Breakdown of over 65s in Sutton in receipt of support from Adult Social Care

Data Source: Adult Social Care Sutton

Diagram 24 : Percentage Breakdown of over 65s in Sutton

Data Source: Adult Social Care Sutton

Sutton, like many other places, has an increasing older population. The pie charts above compare the percentage breakdown by age group of the older population in Sutton with the percentage breakdown by age group of the older population in Sutton receiving support from Adult Social Care. The 80+ age group is less than 20% of the older population but represents 70% of those in receipt of support. Although Sutton’s older population is increasing, it is currently made up mostly of the least dependent age groups, however as this older population ages further, it is likely that an increase in care and support will be required for a cohort of our residents with age related frailties, health and cognitive conditions.

The impact of dementia on our aging population requires further analysis and understanding to fully appreciate future need and demand both from a population and Adult Social Care perspective.

Diagram 25 : Comparison Between Sutton, London and National Rates of Dementia Per 100,000 (PHE Diagnosis)

Data Source: Public Health England Fingertips (Dementia Profile)

The rate of diagnosis of dementia in Sutton for adults 65+ is 727 per 100,000 people. This is higher than the London average of 519, but lower than the England average of 755.

Diagram 26 : Dementia Prevalence Projections in Sutton and Neighbouring London Boroughs (POPPI Estimate)

Data Source: Projecting Older People Population information (POPPI)

Sutton’s estimated 60+ population with dementia is estimated to increase by 40% from 2300 to 3300 between 2020 and 2040. This is comparable to our London neighbours. It should be noted this rate is an estimate of all those who may have dementia, regardless of their need or the impact of dementia on their lives, and as such this rate is higher than the diagnosis rates reported by Public Health England (PHE).

According to PHE data in 2020 there were 1491 people, or 4.66% of the 65+ population, living within Sutton who have been diagnosed with dementia. This is higher than the London average rate of 4.17%, and the England total rate of 3.97%, but is similar to geographical neighbours like Croydon (4.51%).

We can use data projected by POPPI (Projecting Older Peoples Population Information) around the total prevalence rates of dementia (both diagnosed and undiagnosed) to predict the true number of people with dementia in a population. The average prevalence rate for dementia at 65 is 1.5% for men and 1.8% for women. This number rises slowly to around 1 in 10 at 80-85 across both genders before quickly rising to 30% for men at 95+ and almost 50% for women at 95+. Using these rates we can estimate that the Sutton population has a total of 2339 adults aged 65+ with dementia (or a 7.3% rate of dementia across adults  65+) with around 850 people being undiagnosed. The graph below outlines how this may develop in the coming decades in comparison to our geographical neighbours. While the growth of dementia seems to be slow until 2025 (2339 to 2481) it then rapidly increases across the population to around 3000 in 2035.

How we need the market to develop for the future

Over a number of years we have identified options for service redesign or improved placements that will assist us to meet need and keep people within Sutton including:

  • Improved access to short breaks provision such as respite care and short term placements
  • Residential provision for young people (25+) leaving residential college for example
  • Placements for people with a learning disability who have forensic backgrounds
  • Appropriate residential or nursing provision for people with Down’s Syndrome and Dementia
  • More residential provision for people requiring ground floor accommodation due to serious mobility issues
  • Residential provision for young people (35+) with ASD and exhibit behaviours that challenge
  • More residential provision for younger adults with severe physical disabilities
  • Nursing care provision for adults with a learning disability.