Accommodation Based Care – Extra Care Housing
Last Updated: 01 December 2023
Where are we now
There is no single model of Extra Care Housing. It can be more usefully thought of in terms of the key characteristics that make up a scheme:
- Self-contained accommodation, incorporating design features to facilitate independence and safety
- Personalised care and support that is accessible 24 hours a day, 7 days a week
- Access to meals, communal facilities and social activities on site and/or arranged in the community
- Access to digital and care technology (assistive technology) such as telecare and alarms and adaptations and specialist equipment to meet health and social care needs.
Schemes described as Extra Care Housing vary considerably in size, facilities, nature of accommodation, care provided, management arrangements, funding and staffing and how they relate to the wider community. Unlike residential care homes though, accommodation is self-contained and residents can be assured tenants or owners with security of tenure.
Extra Care Housing in Sutton plays an intrinsic part of the Health and Social Care provision landscape, providing flexible care and support to vulnerable residents. These residents often have mixed levels of need, including physical frailties, dementia and comorbidities but are seeking to live and remain as independent as possible as tenants in a community setting.
Sutton currently commissions 3 Extra Care Housing schemes each with an accommodation provider and a care provider. There are 2 schemes with different accommodation and care providers and 1 where the accommodation and care elements are provided by the same organisation. The care provision element is regulated by the Care Quality Commission (CQC).
The 3 Extra Care Housing schemes support predominantly adults aged 55+ with physical and mental health age related illnesses (including severe physical frailty and organic mental health illness such as dementia), learning disability and physical disability.
There is a total capacity of 156 flats within Extra Care Housing in Sutton.
Diagram 1 : Extra Care Housing Flats in Sutton by Client Group
Data Source: Adult Social Care Sutton
Of this total, 62.2% (97 flats) are generally identified for supporting older adults, learning disabilities and physical disabilities and 19.2% (30 flats) identified specifically for supporting older adults with dementia. There are also 10 flats (6.4%) identified specifically for adults with a learning disability. For those older adults in a position to self fund their later life and care, there are 10 flats (6.4%) designated for this purpose, together with a specific 9 units (5.8%) designated to support short term reablement following a hospital discharge.
From an accommodation provider perspective, 2 of the schemes (66.7%) are provided by the same national not for profit organisation and the remaining 1 (33.3%) provided by a local housing society.
Diagram 2 : Extra Care Housing Services by Size of Provider
Data Source: Adult Social Care Sutton
Diagram 3 : Number of Extra Care Housing Services in Sutton by Market Sector
Data Source: Adult Social Care Sutton
Diagram 4 : Number of Extra Care Housing Flats in Sutton by Market Sector
Data Source: Adult Social Care Sutton
From a care provision perspective, the graphs above show that 1 of the schemes (33.3%) receives care provision from the same national not for profit organisation, whilst the remaining 2 schemes (66.7%) receive their care provision from the same locally based private commercial organisation. This translates to 63 flats (40.4%) receiving their care element from a not for profit organisation, with the remaining 93 flats (59.6%) receiving the care element from a private commercial organisation.
The quality of care provision for our residents within Extra Care Housing schemes remains a key focus for Sutton.
Diagram 5 : CQC Ratings for Extra Care Housing Services in Sutton
Data Source: Adult Social Care Sutton /CQC
Each care provision element within an Extra Care Housing scheme 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. Currently the care provision within all 3 of the Extra Care Housing schemes in Sutton is rated ‘good’ by CQC.
There are currently 106 placements within the Extra Care Housing schemes in Sutton.
Diagram 6 : Breakdown of Placements by Age Group
Data Source: Adult Social Care Sutton
It is generally recognised that Extra Care Housing provision supports adults aged 55+ who have an identified care and support need. The graph above however, illustrates that of the 106 current placements, almost 15% of clients within Extra Care Housing are outside of the intended age range of the service. This suggests that Extra Care Housing may be being used as an overflow service for clients that are difficult to place.
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 7 : Primary Support Reason for all Adults in Extra Care Housing
Data Source: Adult Social Care Sutton
Of the total number of adults aged 18+ being placed in Extra Care Housing provision, the graph above identifies that for almost half (43.4%), the primary reason they have been placed within this type of care setting is due to their requirement for support for a physical disability. For the remaining adults aged 18+, the primary support reasons for requiring care and support have been identified as mental health support (19.8%), learning disability (15.1%), memory and cognition (14.2%), sensory disability (3.8%), substance misuse (2.8%) and other vulnerability (0.9%) respectively.
Over half of placements in Extra Care Housing are for reasons other than physical disability. Within this group there are overlapping and hidden needs that the data cannot show. Currently there is no dementia field within primary support reasons within the Adult Social Care Client Record and those with dementia may fall under any of mental health, memory and cognition, sensory disability or other vulnerable people. The primary support reason also only displays the cause of someone entering care and may hide further burdens on their wellbeing that have developed within care.
Diagram 8 : Average Weekly Cost of an Extra Care Housing Placement by Age Group
Data Source: Adult Social Care Sutton
The graph above shows that the average weekly cost of an Extra Care Housing placement (care element only) varies between £218 and £613 dependent on age group. The highest average weekly cost is for the older adult age group aged 96+, with an average cost of £613. The lowest weekly cost is for the 18-25 age group, at an average of £218.
There is a general trend highlighted within this graph that shows that as a client ages their placement gets more expensive. There are two major outliers to this trend in the age groups 26-35 and 36-45, whose weekly costs are more expensive than would be expected. This may be due to placements for this age group being inappropriate and thus needing higher funding to fill the gap.
Diagram 9 : Total Weekly Cost of an Extra Care Housing Placement in by Age Group
Data Source: Adult Social Care Sutton
The total weekly cost of an Extra Care Housing placement (care element only) averages at around £800 across all age groups. Over a third of Extra Care Housing placement costs (£15,111) fall within the costs for the 76-85 age group. Currently 85% (£35,000) of Extra Care Housing placement costs fall within the 56-95 age group. There is £6,500 per week being spent on clients between the ages of 18-55.
As would be expected, the majority of money spent within Extra Care Housing placements for the care element are for those adults aged over 55. Within this age group, the most expensive cohort is the 76-85 age group, as this group is smaller than the cohort for 86-95 year olds. About 10% of placement costs within Extra Care Housing is for those adults aged between 18-55.
Diagram 10 : Total Gross Cost of Extra Care Housing Placements
Data Source: Adult Social Care Sutton
The graph above shows the distribution of weekly gross costs of placements in Extra Care Housing (care element only). The range covers placements of a weekly gross cost from those costing up to £300 at the lowest end to those placements of a weekly gross cost in excess of £1050.
There is a large variation in the cost of an Extra Care Housing placements. The majority of spend (£17,675) financing placements costing between £300-£450. There are a significant number of placements (22) that cost less than £300 a week.
Our Extra Care Housing Market – Adults Aged 55+
There are currently 91 adults aged 55+ placed within Extra Care Housing schemes in Sutton.
Diagram 11 : Primary Support Reason for those aged 56-65 in Extra Care Housing
Data Source: Adult Social Care Sutton
Of the 13 adults aged 56 to 65 years old currently placed in an Extra Care Housing setting, for almost half (46.2%), the primary reason they have been placed within this type of care setting is due to their requirement for support for a physical disability. Almost a third of these adults (30.8%) require care and support in this type of setting due to a primary support reason of mental health. For the remaining adults, the primary support reasons for requiring care and support have been identified as a learning disability (15.4%) and substance misuse (7.7%).
Diagram 12 : Primary Support Reason for those aged 66-75 in Extra Care Housing
Data Source: Adult Social Care Sutton
For the age group 66-75 placed in an Extra Care Housing setting, there is a similar representation of almost three quarters (74%) having primary support reasons of either a physical disability (40.7%) or a mental health condition (33.3%). For the remaining quarter of adults within this age group, there is an equal balance of those requiring support for a sensory disability, a learning disability or for memory and cognition. The remaining 3.7% of adults require care and support for a primary support reason of substance misuse.
Diagram 13 : Primary Support Reason for those aged 76-85 in Extra Care Housing
Data Source: Adult Social Care Sutton
For the age group 76-85, there is an increase in those adults requiring care and support for a primary support reason of a physical disability (59.1%). For the remaining two fifths of adults within this age group, there is an equal balance of those requiring support for a sensory disability, a learning disability and for memory and cognition.
Diagram 14 : Primary Support Reason for those aged 86-95 in Extra Care Housing
Data Source: Adult Social Care Sutton
Within the age group of 86-95, the graph above shows an increase in those adults requiring care and support for memory and cognition (34.6%). There is a slight reduction in those adults with a primary support reason of a physical disability (53.8%) however they form the majority within this age group. The remaining 11.5% of adults in this age group within an Extra Care Housing setting have primary support reasons of either a learning or a sensory disability.
Diagram 15 : Primary Support Reason for those aged 96+ in Extra Care Housing
Data Source: Adult Social Care Sutton
For those adults aged 96+ who are receiving care and support in an Extra Care Housing setting in Sutton, two thirds (66.7%) have a primary support reason of a physical disability with the remaining third receiving care and support for memory and cognition.
The graphs above would suggest that from the age of 66+ (and as age increases) there is a requirement for care and support for age related health conditions and frailty for those adults within Extra Care Housing provision.
Our Extra Care Housing Market – Adults Aged 18-54
It is generally recognised that Extra Care Housing provision provides care and support (with an accommodation element) for adults aged 55+.
Within Sutton, 14.2% of adults currently in an Extra Care Housing placement are aged 18-54.
Diagram 16 : Primary Support Reason for those aged 18-25 in Extra Care Housing
Data Source: Adult Social Care Sutton
Diagram 17 : Primary Support Reason for those aged 26-35 in Extra Care Housing
Data Source: Adult Social Care Sutton
Of the adults aged 26-35 years old currently placed in an Extra Care Housing setting in Sutton, the primary reason they have been placed within this type of care setting is to provide care and support for a primary support reason of either a learning disability (50%) or a mental health condition (50%).
This group of younger aged clients, especially those with mental health issues, may be quite isolated by their placements in Extra Care Housing, given that they make up a very small percentage (5%) of the overall population within this type of care setting.
Diagram 18 : Primary Support Reason for those aged 36-45 in Extra Care Housing
Data Source: Adult Social Care Sutton
Of the adults aged 36-45, 100% are receiving care and support in this provision type for a primary support reason of a learning disability.
Diagram 19 : Primary Support Reason for those aged 46-55 in Extra Care Housing
Data Source: Adult Social Care Sutton
Within this age group of adults placed within an Extra Care Housing setting in Sutton, there is an equal balance of those requiring care and support for a primary support reason of either a learning disability (25%), a physical disability (25%), for substance misuse (25%) or another vulnerability (25%).
Where we want to be – Our Vision
Over the next 7 years (2023-2030) and taking into account the challenges faced in the health and care system, our vision is to develop in partnership, innovative and sustainable Extra Care Housing options and a market that is responsive to the needs of our residents, remains safe, supports excellence and provides value for money. Our partnership approach to commissioning a sustainable range of high quality Extra Care Housing provision will include:
- Manage the Extra Care Housing market as part of an integrated health, social care and housing system
- Support quality in Extra Care Housing through robust contract monitoring, performance management, quality assurance and data collection
- Develop opportunities for the commissioning of new models of care over a seven year period, including jointly commissioned provision such as reablement services
- Inform the planning of Extra Care Housing provision for future years beyond 2030
- A direct alternative to residential care for older people with increasing and/or complex needs who want to be as independent as possible
We want to improve outcomes for people living in Extra Care Housing by enabling choice, delivering person centred care, managing risk and promoting independence and wellbeing. We will achieve this by ensuring:
- The commissioning of Extra Care Housing providers that improve the wellbeing of tenants and consistently achieve positive feedback from tenants, friends and family and other external stakeholders
- Extra Care Housing provision is safe and effective and delivered in ways that improve the tenant experience
- Protecting the most vulnerable and ensuring tenants are supported to live the lives they want that may involve moving to more independent living options
- The market is responsive to national and local policies and trends
We will know we have achieved our vision when we see:
- Extra Care Housing in Sutton recognised as a market leader
- Integrated commissioning is developed and implemented
- More use of digital and care technology to keep tenants safe
- Partnerships deliver innovative, integrated care and support options
- People are supported to live in their own homes as long as possible
- High standards of quality of care evidenced by high satisfaction ratings from tenants
- More options in-house and in the community to improve the wellbeing of tenants
- New service models that continue to deliver better Sutton based Extra Care Housing provision
- Improved workforce recruitment and retention
To support our vision, our commissioning intentions are:
- The retendering of Extra Care Housing, which may require remodelling existing provision (service redesign) and/or commissioning new services to meet gaps in local provision or to improve access to existing provision
- Innovative Extra Care Housing options supported by outstanding quality of care and support
- Commissioning methodology that is aligned across health, social care and housing
- Evidence of improved outcomes for residents living in Extra Care Housing provision
- A workforce that is sustainable, career focused and is rewarded for excellence
- Co-production forums to influence planning and service development
Challenges and Market Influencers
Sutton continues to face significant financial challenges alongside pressures managing capacity and demand as well as having the resources to effectively quality assure the market. Similarly, the environment for Extra Care Housing is challenging, with concerns expressed by some providers about the viability of the way the market operates, as well as operational difficulties such as staff recruitment and retention and avoiding voids. Promoting partnership and collaborative working across the whole Sutton system will assist to identify and where possible address these and other system challenges.
The local health and social care system involves a variety of partners and care pathways. Extra Care Housing is a key element of the system, which also includes primary care, community services, adult social care, learning disability services, end of life care, acute care, mental health services and safeguarding adults. The system is complex and there are many challenges that require integrated commissioning solutions.
Due to the nature of the provision of Extra Care Housing, tenants have levels of need including physical frailty, dementia and comorbidities, which require support and interventions from other parts of the health and social care system to manage deteriorating health conditions and crises that could lead to the need for 24 hour nursing or residential care home provision.
There are barriers to the implementation of new digital and care technologies to improve tenants’ quality of life due to the availability of suitable infrastructure within Extra Care Housing provision and associated costs.
As with all provision, Extra Care Housing costs are escalating year on year due to:
- The erosion of care costs because prices are not increased to fund cost pressures such as inflation, minimum wage and pensions
- Low unemployment in Sutton, which affects recruitment and retention generally and specifically pushes up payroll costs
- Much higher dependency levels of people entering Extra Care Housing today, requiring higher levels of staff numbers and staffing expertise
- The perceived greater regulation of the industry by the local authority, creating more bureaucracy generally and specifically affecting staffing
There is a lack of awareness of Extra Care Housing provision amongst some health and social care professionals which can lead to inappropriate tenancies and confusion about what services can and cannot be offered as well as how Extra Care Housing supports independence and prevents people requiring higher levels of care and support.
Within current provision, there are limitations and challenges that need to be addressed to meet the future expectations of the aging population including:
- Limited availability of flats available to the self funder market (those able to fund their own accommodation and care and support needs)
- Limited availability of two bedroomed flats
- Not all provision is wheelchair accessible
Currently the need for a placement within Extra Care Housing in Sutton forms part of a housing need pathway rather than primarily a care and support pathway. The Council is seeking a determination for each of the 3 Extra Care Housing schemes as ‘specified exempt accommodation’. On approval, our Extra Care Housing schemes will be defined as accommodation which provides care, support or supervision. Extra Care Housing will then form part of a care and support pathway, which should lead to a reduction in inappropriate placements.
In the meantime, there is a need to ensure the appropriateness of placements into Extra Care Housing.
Need and Demand
Sutton, like many other places, has an increasing older population.
To understand the housing and accommodation needs of an aging population including the requirement for different types of accommodation (including supported schemes such as Extra Care Housing), Sutton has commissioned a new Strategic Housing Market and Local Housing Needs Assessment which will provide updated projections of population and housing needs for Sutton.
Diagram 20 : Percentage Breakdown of over 65s in Sutton in receipt of support from Adult Social Care
Data Source: Adult Social Care Sutton
Diagram 21 : Percentage Breakdown of over 65s in Sutton
Data Source: Adult Social Care Sutton
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 22 : 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 23 : Dementia Prevalence Projections in Sutton and Neighbouring London Boroughs
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.
With the increase of the prevalence of dementia it is anticipated that there will be a further need for specific capacity within the Extra Care Housing provision within Sutton. Dementia specialist units currently make up 19.4% of the currently available provision.
How we need the market to develop for the future
Over a number of years we have identified options for service redesign or improvement that will assist us to meet need and support people to live as independently as possible within Sutton including:
- Partnerships involving people with lived experience contribute to the development of new innovative, integrated service models within Sutton
- Service innovation and development is influenced by national and international models of excellence
- Extra Care Housing is included in the development of whole system care pathways which provide appropriate alternatives to residential care
- Care provision within Extra Care Housing is personalised, with a focus on choice and control, person-centred outcomes and positive risk taking
- Better use of digital and care technology, research and development within Extra Care Housing such as electronic care planning, Telehealth, sensors and monitoring devices to help keep tenant’s safe.