Response by the Registered Nursing Home Association
to the Consultation document on the
Proposed Amended Environmental Standards for
Care Homes for Older People and Younger Adults

1.	Introduction

As a national association representing the interests of more than a quarter of all nursing home owners in the United Kingdom for more than thirty years, the Registered Nursing Home Association holds the unique position of having gathered more knowledge and acquired more wisdom on those matters which are specifically pertinent to the provision of nursing home care than any other organisation in the field.  We are, therefore, pleased, and very well placed, to respond to the consultation document on Care Homes for Older People and Younger Adults. National Minimum Standards for Care Homes for Older People.  National Minimum Standards for Care Homes for Younger Adults. Proposed Amended Environmental Standards

The commitment of the Registered Nursing Home Association, and that of our members, is, as always, to high standards of nursing home care.  We continue to promote the view that the care of older people should be driven by outcomes, rather than inputs, and we maintain the view that a proper balance between outcomes / inputs has not been achieved in the National Minium Standards for Older People.  

2.	Background

Derek Whittaker, the former Chairman and now Vice President of the Registered Nursing Home Association, was a member of the Steering Group set up by the Centre for Policy on Ageing to advise the Department of Health on creating a set of minimum standards for care in residential and nursing homes.

Derek Whittaker and Sheila Scott, Chief Executive of the National Care Homes Association, were a minority voice on this Steering Group in trying to bring some reality to an agenda which was more aspirational than pragmatical.  Of particular concern to home owners at that time, and now, was whether or not is was possible to make the physical changes to buildings which were being demanded.

Surveys amongst nursing home owners were undertaken and produced as evidence to the Steering Group that a large number of buildings currently in use as residential homes or nursing homes would be incapable of being altered to meet the proposed changes in environmental standards.  The result of the survey made it clear at that time that this could only lead to closure of many homes.

Whilst that evidence was dismissed at the time by the Centre for Policy on Ageing, Ministers within the Department of Health did recognise the difficulty which the representative bodies such as the Registered Nursing Home Association were highlighting and introduced a transitional period for the introduction of a number of the physical environment standards.

The reality which we tried to bring to the Steering Group has manifested itself over the past eighteen months by home owners across the whole of England deciding to determine their own destiny by closing homes which either would not meet the new standards, or where the cost of meeting those standards would not be economical.

There appears to be an unhelpful opinion amongst Government advisors that home closures are simply due to home owners taking advantage of a healthy residential property market.  This is not the case, a successful nursing home should have a greater value as a business than it does as a building site.  Unfortunately, the deliberate holding down of fees by local authorities has reduced the value of the business to less than its value as a building site.  It is only after the decision to close a home has been taken that the question of disposal is addressed.

There are a number of basic business and viability issues which lead to the decision to close a home. These include observations from lending sources where, for example, bed numbers will be reduced, that they are not / may not be prepared to lend an increased amount of money against a reduced asset.  This is compounded by an apparent lack of understanding amongst department advisors that day to day costs are unlikely to reduce in a consistent ratio with the reduction in bed numbers.  

In simple terms, if compliance with the published environmental standards resulted in a 30 bedded home being reduced to 26 beds, the costs of running the home would not reduce by any significant amount.  This would mean that if the income from 26 beds was not increased to that which was achieved from 30 beds, then the home would have no alternative but to close, with a loss of 30 beds from the overall capacity for that area.  This scenario has become commonplace throughout the country over the past eighteen months. It could have been avoided by recognising that representatives of the providers were raising genuine, indisputable concerns. 

Recognition by the Government that it is necessary to take urgent steps to rectify the situation by the proposed changes to the National Minimum Standards is welcome.   It is hoped that the observations which we, and other providers, will now raise in relation to this current consultation will be seen in this light of informed knowledge, and that the rate of home closures will be stemmed.

3.	Our Observations

3.1	Those Changes which are welcome

We welcome the specific wording changes to each of the National Minimum Standards and they have the acceptance of our members.

The general thrust of the proposed changes is very welcome in the stabilisation it might bring to the current loss of confidence being experienced in the independent long term care sector.  We are particularly pleased to see the introduction of the term ‘pre-existing’ and the obvious benefit in clarifying potential areas of misunderstanding between regulator and provider.

The proposals recognise the status quo and do not seek to introduce a step change, now or at any predetermined date in the future.  It has always been our contention that market forces will continue to ensure that the provision of all forms of care will evolve, especially residential home care and nursing home care.  

However, it is a sad reflection that the introduction of the National Minimum Standards has had such an affect on the long term care sector, especially nursing homes, that the loss of capacity has no doubt put a temporary hold on the evolutionary power of market forces to improve standards.

3.2	Concerns over Report Writing

We recognise the need for a balance between homes which fully comply with the new standards and those which are allowed a relaxation against certain environment standards.  Our concern is to be found in the terminology which may be used to differentiate between those providers who meet the higher spatial standards and those who do not. This is a very sensitive area and failure to achieve a proper balance may  result in simply a temporary reduction in home closures which will then accelerate when  inspection reports begin to take affect.

It is doubly sensitive in that homes which do meet the higher spatial standards will, naturally, have concerns over homes which do not.  Fee levels being generally as low as they are necessitates consistently high occupancy levels to remain viable, the sector is, therefore, very competitive.

On behalf of those providers who do not meet the higher spatial requirements we would want to register a concern over the way in which the National Care Standards Commission might interpret the introductory paragraphs of the consultation document  in the way they report their findings on inspection.  

In particular we have concern over the statements in paragraph 2 which appear to conflict.  “certain environmental standards will no longer apply” is not compatible with “the National Care Standards Commission will note in its inspection reports , which are available to residents and the general public, the extent to which care homes comply with these and other national standards”.  Surely, if standards “do not apply” they cannot be commented upon ?

We would like to emphasise that if inspection reports score these environment standards as not being met then those homes concerned will, once again, begin the decision making process as to whether they should continue, or close.  We will return to the capacity difficulties which appear to have led to the publication of this consultation document.

3.3	Multi Occupied Rooms

Another issue which is more pertinent to the nursing home sector than the residential home sector is the question of multi occupied rooms.  There are a number of pre-existing homes who were making use of multi occupied rooms on 31st March 2002.  Standard 23.7 limits the number of people sharing a room to no more than two.  
Those homes which make use of multi occupied rooms are usually using them for specific healthcare reasons, e.g. palliative care, which remains an acceptable route in a healthcare model.  The limitation of National Minimum Standard for Older People No. 23.7 is as likely as any of the other proposed changes to cause homes to have to undertake a viability exercise as to their future.  Some recognition that, in certain circumstances, multi occupied rooms can be used would recognise this important aspect within the healthcare model.

3.4	Funding Levels

It was always the argument of the Centre for Policy on Ageing that the setting of standards should be separate from, and not be compromised by, the availability of funding.  Altruistically, this view is no doubt correct.  Pragmatically, funding levels have a very real consequence on whether or not standards can be achieved.

The proposed changes in the consultation document may not have been necessary had there been sufficient funding of long term care for those who are placed by local authorities.  It is significant to note  that even with the higher fees which local authorities pay themselves when purchasing their own care, many local authority homes fail the spatial standards.

The Government must recognise that the introduction of regulations alone will not improve standards of the provision of care.  Better quality requires better funding.  A mechanism should be sought whereby those who achieve the National Minimum Standards are adequately rewarded for doing so.  To fail to do so will discourage investment in new capacity.

3.5	Providers who have already reacted

There are a large number of providers who have already responded to the new National Minimum Standards by further investment or, in some cases, by selling the nursing home.  Many of these people are disappointed that the new relaxations have come too late to benefit them.  

It is important that Government are aware of the two, particular, consequences of this; firstly that a precedence has been set and that providers will not be so keen to react as quickly in the future.  This is especially worrying in that there are other standards to be introduced over a period of time which some providers believe are unlikely to be met, for example, training requirements.

Secondly, that it is important that all of the consequences of the changes are thought through to their natural conclusion so that there will not be any further changes necessary.

4.	Conclusion

There are a number of, at times, conflicting conclusions which emerge from the consultation document.  Many home owners have already responded to the published National Minimum Standards and are now concerned over the proposed relaxation which might have made their work unnecessary.  At the same time, it is abundantly clear that many of the physical standards are not possible within the fabric of many buildings, which would only result in lower bed numbers.  The proposed changes may, therefore, be seen as a welcome compromise.

The way in which the National Care Standards Commission undertake their role in reporting their findings following inspection will be crucial to the success or otherwise of the proposed changes.

William Laing in his recent work for the Rowntree Foundation, recommended higher fees for local authority funded patients linked to incentives to compliance with the new standards.  Such a route has the double advantage of rewarding those who meet the higher standards and, at the same time, encouraging those who do not endeavour to do so.

It is likely that there will be many responses from people who do not have direct knowledge of the provision of residential or nursing home care but who will insist that the National Minimum Standards should not be amended.  The Government are urged to heed the message which many previous home owners have given in selling their homes.

Throughout the consultation process which lead to the creation of the National Minimum Standards we sought to establish that quality of care should be outcome driven and not input based.  We re-state our philosophy concerning standards,  the purpose of which  should be to measure that which is important, rather than  to make important that which can be measured,

Frank Ursell
Chief Executive Officer