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Unequal access to care homes across Wales 

A study examining how the location of residential and nursing care homes in Wales compares with where older people live, showing clear regional differences in access to care.

Key messages 

  • care home provision in Wales included 25,607 residential and nursing beds across 1,069 sites in March 2020 
  • the average care home had around 24 places, although many homes were small and over a quarter had six or fewer places 
  • only around 9% of care home places were provided by local authorities, with most delivered by independent providers 
  • there were on average 53.3 care home places for every 1,000 people aged 70 or over, but this varied widely between areas 
  • cities and densely populated areas had more care homes, but they also had higher demand for places 
  • where people live strongly affects access to care homes, with some communities having far fewer nearby options 
  • simple measures of care home supply can hide local inequalities, especially in rural areas 

Policy implications 

  • use detailed mapping of care homes and population need to identify areas with limited access to residential care 
  • improve coordination between neighbouring local authorities when planning care home provision 
  • target investment in areas where demand for care is increasing but local provision is limited 
  • include population ageing, deprivation and health needs in long-term care planning 
  • monitor how financial pressures and changes following COVID-19 affect the stability of care home services 

Gaps 

  • demand was estimated using the number of people aged 70 or over, which does not fully reflect health needs or disability 
  • the study did not include data on how many beds were already occupied, meaning real availability may differ from total capacity 
  • financial barriers to accessing care homes were not included in the analysis 
  • the study did not consider differences in care home quality, fees or specialist services such as dementia care 
  • travel assumptions were based on driving distances and may not reflect access for people without a car 

Commentary 
This study looks at how access to care homes varies across Wales depending on where people live. The researchers mapped the location of care homes and compared this with the distribution of older people who may need residential care. This helps show whether some areas have better access to care home places than others. 

The results show that care homes are not evenly distributed. More homes tend to be located in urban areas and the post-industrial valleys of south-east Wales. However, these areas also have larger older populations, which means demand for care home places is higher. As a result, the actual availability of places may not be as high as the number of homes suggests. 

Some rural areas appear to have a better balance between the number of places and the number of older residents. However, people in these areas may still face challenges because care homes are further apart and travel distances can be longer. This can make it harder for families to visit relatives and for people to remain close to their communities when they move into residential care. 

The study also highlights how the organisation of the care sector affects access. In Wales, most care homes are run by independent providers rather than local authorities. This means the location of homes is partly shaped by market conditions and business decisions, not just local need. Areas that are less profitable or harder to operate in may therefore have fewer services. 

These patterns matter for care equity. If some communities have fewer nearby care homes, people living there may have fewer choices or may need to move further away from their families and support networks. This can affect wellbeing and continuity of care. 

Overall, the study shows that looking at where services are located, and where people live, can help policymakers understand where gaps in care provision exist. This kind of analysis can support better planning of care home services and help ensure that access to residential care is more evenly distributed across regions.

Structure and sustainability of the social care provider market in England

A report examining the structure of the adult social care provider market in England, highlighting fragmentation, funding pressures and regional variation in service provision.

Key statistics 

  • adult social care in England is delivered by more than 14,000 provider organisations, creating a large and highly fragmented market 
  • around 840,000 people receive long-term social care support, many of whom rely on services delivered by independent sector providers 
  • approximately 84% of adult social care services are provided by the independent sector, including private and voluntary organisations 
  • local authorities purchase a large proportion of care services but do not directly control the structure of the provider market, which has developed through private and voluntary sector provision 
  • the Covid-19 pandemic placed significant financial and operational pressure on providers, highlighting existing vulnerabilities in the market 

Key messages 

  • the adult social care provider market in England is highly fragmented, with thousands of organisations delivering services 
  • long-term structural pressures, including funding constraints and workforce shortages, affect provider sustainability 
  • the Covid-19 pandemic exposed existing weaknesses in the social care market 
  • local authorities play a key role in commissioning services but have limited influence over market structure 
  • reform efforts must address wider structural issues rather than focusing solely on funding increases 

Policy implications 

  • strengthen oversight and support for the sustainability of social care providers 
  • review commissioning and contracting practices to promote stable service provision 
  • improve long-term funding arrangements for adult social care 
  • support local authorities in market shaping and service planning 
  • develop national strategies that consider the structure and resilience of the provider market 

Gaps 

  • the report focuses on market structure rather than detailed analysis of service quality or care outcomes 
  • limited analysis is presented on how market fragmentation affects different regions or local populations 
  • further research is needed on the relationship between funding levels, provider sustainability and care quality 
  • additional evidence is required on how policy reforms may reshape the social care provider market over time 

Commentary 

This report examines how adult social care services are organised and delivered in England. Unlike the NHS, which is largely publicly funded and structured through national systems, adult social care is delivered through a complex market made up of thousands of independent organisations. 

More than 14,000 providers deliver social care services across England. These organisations range from small local charities and family-run care homes to large national care companies. This diversity creates a highly fragmented system, where services vary widely in size, resources and organisational structure. 

Local authorities play an important role in commissioning care services for people who are eligible for publicly funded support. However, most care is delivered by independent sector providers rather than directly by councils. This means that local authorities influence the market through commissioning and contracts but do not directly control how the market develops. 

The report highlights long-standing financial pressures within the sector. Many providers operate on narrow financial margins, particularly when providing services funded by local authorities. These pressures can affect provider stability and the ability of organisations to invest in workforce development or service improvements. 

The Covid-19 pandemic placed additional strain on providers. Increased costs, staff shortages and infection control requirements exposed existing weaknesses in the system and raised concerns about the resilience of the care provider market. 

From a health and social care equity perspective, the structure of the provider market can influence access to services. Differences in local provider availability, financial stability and commissioning arrangements may affect the availability of care across regions. Some areas may have a wider range of providers and services, while others may face shortages or limited choice. 

Overall, the report argues that reform of the adult social care system must address the underlying structure of the provider market. Sustainable funding, stronger market oversight and clearer national strategy may be needed to ensure stable and equitable access to social care services across England.

The costs of care in residential homes for older people

A study examining care work in residential homes for older people, focusing on working conditions, care routines and the relationship between workforce culture and quality of care.

Key messages 

  • quality of care in residential homes is closely linked to available resources 
  • workforce culture shapes daily routines and philosophies of care 
  • care workers play a central role in translating organisational priorities into practice 
  • time pressures influence how care is delivered to residents 
  • divisions of responsibility within care homes affect staff experience and care outcomes. 

Policy implications 

  • resourcing levels directly affect the capacity to deliver high-quality care 
  • workforce culture should be considered alongside staffing numbers 
  • clearer allocation of responsibilities may support safer and more consistent care 
  • time allocation per resident is a critical factor in care quality. 

Gaps 

  • limited exploration of how responsibilities are divided across staff roles 
  • need for further research on time pressures and their impact on care delivery 
  • findings are based on residential care settings only 
  • wider system-level influences on care home resourcing are not examined. 

Commentary 
This study provides a detailed account of how care work is organised and experienced within residential homes for older people. By focusing on everyday routines and interactions, it shows how care quality emerges from the interaction between resources, organisational culture and staff practice. 

The findings emphasise that good care is not solely a function of individual commitment. Workforce culture and material conditions shape what care workers are able to do, how time is prioritised and how responsibilities are distributed across teams. 

From a care equity perspective, the study highlights how under-resourcing and time constraints can create uneven care experiences for residents. When staff are required to ration time or negotiate unclear responsibilities, some residents may receive more attentive care than others. These dynamics reflect broader inequities in how care is funded and organised, rather than individual failings of workers. 

Overall, the paper stresses the importance of viewing workforce conditions as central to equitable care. Ensuring fair allocation of time, clarity of roles and adequate resources is essential if residential care homes are to provide consistent and dignified care for all residents.