Recommendations on The Future of Residential Care for Older People in Scotland

Part 2: Home and Environment

Personalised care requires a setting and physical environment that itself supports individual preference. This will involve the idea of 'Place Making' - residential facilities should not be developed in isolation from the communities they serve. It also requires thought to be given to the workforce that underpins the delivery of care and support arrangements.

Place Making

Place Making is about creating a range of high quality, aesthetically pleasing, shared-living care and accommodation options for older people that offer the maximum opportunity for personalised support and community involvement.

The Scottish Government and COSLA's vision is to support older people to remain in their own homes or other homely settings. We need to take steps now to develop a range of 'other homely settings' that will meet the needs and aspirations of a larger population of older people for the next 20 years. At the same time, there is a need to promote supported shared-living as a positive choice and not simply a second best necessity.

Forward planning will be essential. There is a lengthy lead-in time for designing and delivering new builds, not least due to the investment required in those new buildings and adaptations required to existing sites. We also have to then live with the buildings we commission for a realistic period of time, meaning it is important to get it right in the first place. In order to assess current capacity and plan future provision we need to be clear about what we want accommodation-based options to deliver, and the range of needs they have to meet. This is in addition to meeting basic quality and registration requirements. In order to future-proof buildings, we need to anticipate now the likely future demands on provision. For example, all care facilities ought to be dementia-friendly, and there is good evidence of what this needs to look like.⁷ Similarly, if we want future provision to put more emphasis on personal space, then we need to look now at how that can be achieved, and what the impact is likely to be on capacity and cost.

Scotland's older population is as diverse as its younger population, and so the planning of care provision has to reflect cultural, racial, and lifestyle diversity. Older people are not a homogeneous group. Individuals and groups may therefore want different things and have different priorities. Place-making has to be part of our wider commitment to personalisation and the move away from a one-size-fits-all approach.

Future care provision should be planned, located and designed to maximise community and family involvement, and service integration. This may include the potential for co-production and co-location. Just as with schools and other community facilities, care settings should be an active part of communities, and be seen as community assets, rather than as institutions for the elderly. One way to create greater community ownership would be to establish community engagement arrangements for care homes, similar to those employed by some schools. This would allow greater community involvement in the day-to-day activities and management of the facility - and it would connect the care home to wider community initiatives. It would also encourage greater participation in volunteering in care homes.

Care Homes and Housing with Care should be seen as part of a continuum of provision for older people and be subject to the same planning processes. To make this a reality, we need to create a more integrated planning framework that encompasses the range of care and accommodation and applies a consistent set of principles to new development.

As part of this work, there is a need to determine the extent to which the current range of provision meets the capacity and fitness for purpose requirements, and the extent to which the existing place-making footprint is adaptable to meet future need. We should ask some key challenging questions in respect of existing provision:

• How much of it is what is wanted or needed going forward?
• How much accommodation will need replacing in the foreseeable future?
• What is the gap between what we have at present and our place making vision for the future?
• What do we need to do to bridge that gap, through adapting what we have or through new development?
• How much commissioning and investment will it take?

To answer these key questions there needs to be an accommodation audit of existing provision. In keeping with Strategic Joint commissioning this is correctly the responsibility of Local Partnerships to carry out, in order that it reflects local needs and priorities. However, given the scale of the challenge in relation to care for older people, there also needs to be a degree of national support.

Residential care facilities are not evenly distributed across Scotland at present. There are areas of under-provision, as well as areas with excess capacity, and although this partly reflects an urban / rural split, that is not always the case. For example, much of the development of care home provision in Glasgow has been in the east of the city where land and build costs have been lower.

Much existing provision has been developed on the basis of a one-size fits all approach. The design of future premises may need to reflect more clearly the range of needs and care pathways. Smaller units within core and cluster arrangements may provide a way of balancing the provision of targeted accommodation with shared services and some economy of scale.

In short, the long-term planning of the physical estate, to ensure that it responds to future needs and connects with our communities, is a matter of primary importance.

Workforce

The communities that offer the context for place-making will be the same communities which provide the workforce. The anticipated changes in Scotland's demographics, and the increase in the number of people with complex conditions, will of course have implications for the care sector's workforce in terms of the skills, values and behaviours required to undertake the role and for employers and commissioning authorities in terms of funding. The ability of the sector to meet an increased and broad range of needs will only be as good as our ability to equip it with the necessary skills and attract the right people into care as a desirable vocation.

The current care workforce is ageing, with the average age in the sector currently 46 years - a key consideration when we consider the physical demands of caring as a career. In addition, there is a significant gender imbalance, with 85% of the care home workforce being female. There needs to be consideration of how to support an ageing workforce to ensure we maximise their knowledge, experience and caring values while accommodating and adapting to a potentially reduced physical capacity.

Part of this will involve investing in skills and training. In addition to possessing the core qualifications to practice, currently defined through workforce development bodies like the SSSC and NES, there are a wide range of training and development requirements needed in the sector. Depending on the role, this may include skills and knowledge relating to administration of medications, falls prevention, nutrition, anticipatory care planning, first aid, tissue viability, rehabilitation, moving & handling, and health & safety. It is important that core training provision on these elements is maintained. We also need to future-proof skills against the demands of a changing profile of need, particularly in respect of increasing frailties and long term conditions; dementia care; intermediate care skills and techniques, including promoting self-management; the use of technology; palliative and end of life care; and skill mix and staffing numbers across the totality of the care home workforce. Effective training is at the heart of quality care.

Increasingly, there will be a need to provide and secure highly specialist care and support for those with the most complex needs and behaviours, for example we know that there is a growing population of people with dementia. It is important that good links are established across community care and all health services (primary, community and acute settings, including mental health) to maximise the available support and expertise to care home residents and to the people who care for them in the home. While we do not advocate older people's entire health and care needs being met within the care home setting or by care staff, we recommend that the Joint Strategic Plans that will be developed under integrated working and the Public Bodies Bill are used as a vehicle for partnerships to specify how the full spectrum of primary, community, acute and social care provision will be configured in order to support older people including those who are resident in care homes, to remain cared for in a homely setting for as long as possible. In order to support the sustainability of appropriate skills in the care home sector it is important that a number of factors are addressed:

• It is critical that Nurses, GPs, Social Workers and Allied Health Professionals (AHPs) in training can experience high quality learning placements in the care home sector - both in order to promote some AHPs and others choosing to work in the sector in the future and to ensure those health professionals who go on to work in the NHS have an awareness and appreciation of the needs of colleagues working in the residential care sector. This would also ready the wider workforce for the potential use of care homes as step-up/step-down and rehabilitation facilities.
• It is important that good links are established across community care and all health services (primary, community and acute settings, including mental health) to maximise the available support and expertise to care home residents and to the people who care for them in the home. Where not already established, the Joint Strategic Commissioning Plan is a potential vehicle to ensure that the planning of these services spans independent and third sector care homes, adding real value to the services that they already provide and maximising the impact of the whole system's resources.

All of this is affected by perhaps the greatest single challenge for the delivery of a high-performing workforce into the future: terms and conditions. Care remains a low wage economy. There is no parity for the independent and third sectors in terms of pay or other terms and conditions with NHS or local authority equivalent jobs. Career progression in the sector remains challenging, making entry into the workforce a potentially unattractive career prospect. This also impacts on staff support and morale, as supervision of staff (if available), is often reported as being used as a management and performance tool rather than as a personal and professional development tool. All of this compounds the challenges we face in securing a sustainable and skilled workforce in this sector in coming years. New means of rewarding provision and the workforce need to be explored to address this, notwithstanding the current financial pressures. Levelling up the terms and conditions in the care sector to the Living Wage should be our goal. This would impact positively on workforce outcomes and outcomes for people that live in care homes. It would be expected that care home contractual processes would be the vehicle for setting out the consequential quality improvements from any funding increase. However challenging it is in the context of public sector finance in Scotland, the issue of salaries, terms and conditions of employment and parity across the whole social services workforce, needs to be part of the much wider debate on how we care for and support older citizens.

It is also the case that due to the increasing complexity of need and frailty seen in older people in care home settings that we need to consider older people's care itself as a specialism with an appropriately trained and supported workforce to meet the multiple complexities of this population. The essence of good care is not a focus only on 'task' but on 'being with' residents, focussing on personal outcomes, relationships and being person-centred. Kindness, compassion and whole person care need to be at the heart of care provision into the future.