Care homes as a model for housing with care and support

What is a care home?

A care home is a communal setting where nursing, and or personal care, and accommodation are provided together. The accommodation is purpose built and residents have their own bedroom, usually with an en-suite bathroom. All meals and refreshments are provided, as are housekeeping services such as laundry and cleaning.

Care homes include communal areas such as lounges and dining rooms and often have a garden or other outdoor space. Some offer hair salons and cafes or a bar. Family and friends are welcome to visit (although restrictions were put in place during the COVID-19 pandemic) and residents can expect to have regular social activities organised for them. These homes provide 24-hour care and visits from GPs, dentists, physiotherapists and other providers can be arranged.

There are two main categories of care homes for older adults: care homes that provide nursing care in-house are generally known as nursing homes and those that provide personal care, but not nursing care are generally known as residential care homes.

For many people a care home is their sole place of residence and although they do not legally own or rent their accommodation, it becomes their home. The size of care homes can vary considerably. The average number of beds is 29.5 per care home but the range is from a single bed to 215 beds.

Care homes actually offer accommodation rather than ‘housing’ because it is neither self-contained nor offers security of tenure through tenancy or ownership rights. Care home residents are licensees and are only entitled to minimal notice to leave. They pay an inclusive charge for accommodation, care, food and other services.

Residential care homes

Residential care homes may also be known as care homes without nursing, rest homes or convalescent homes. These homes offer personal care. Personal care involves physical assistance, or prompting with supervision, given to a person in connection with:

  • eating or drinking
  • using the toilet
  • washing or bathing
  • dressing
  • oral care
  • the care of skin, hair and nails (with the exception of nail care provided by a chiropodist or podiatrist).

Nursing homes

Nursing homes may also be known as residential nursing homes, care homes with nursing care or convalescent care with nursing. Nursing homes that offer specialist dementia care have also been known as elderly mentally infirm (EMI) nursing homes. These homes offer personal care with the addition of 24-hour support and care by registered nursing staff, providing medical support that is not routinely available in a residential setting. Nursing care includes any services provided by a nurse and involving:

  • the provision of care; or
  • the planning, supervision or delegation of the provision of care, which needs to be provided by a nurse.

Care homes can also be dual registered which means that they offer both personal and nursing care.

Number of care homes and care home beds

In 2018 there were approximately 11,100 care homes for older people and those living with dementia. Of these, 42% were registered nursing homes and 58% as residential homes. These homes have the capacity to support 416,000 older people.

There has been a decline in the number of beds per 100 people aged 75+. Care homes (including residential and nursing) have seen a decline from 11.3 down to 9.6 per 100 between 2012 and 2020 (Nuffield Trust, 2021).

Who do care homes for older adults support?

Care homes provide accommodation and care for people who need substantial help and support with their personal care. Trained staff care for residents 24 hours a day. People usually move into a care home when it is no longer feasible for them to live more independently, even with care provided at home.

Residential homes support people who do not need 24-hour nursing care but are unable to care for their own daily needs and so cannot live independently. They can also offer emergency, respite, short-term, long-term and palliative (end-of-life) care to older people.

Nursing homes are particularly suited to people who are less mobile, very frail or have a medical condition or multiple conditions that require regular attention from a nurse. Individuals who need two people to help them transfer, e.g. from bed to chair, or from a chair to the toilet may also need a nursing home because of the higher staffing levels.

Most people living in care homes have multiple health care needs and this may include sight or hearing loss, ‘frailty’ and limited mobility. Age UK report that 70% of people in care homes have dementia or severe memory problems and 60% have a mental health problem. Older people living in a care home are likely to have a high level of dependency and require support with activities of daily living.

Funding

Residents in care homes do not own or rent their room, rather fees are paid to cover costs. These fees can be paid via three key funding sources:

Self-funding

The 2021 savings and assets threshold in England is £23,250. If a person has savings and assets above this they will need to pay for their own care home costs and are known as self-funders.

Local authority funding

People with capital below the savings and asset threshold can get financial support from their local authority, which will pay some or all of their care home costs. This support is means tested. In England, nearly half (46%) of care home residents are part or fully funded by their local authority. This proportion varies by region. When fees paid by a local authority do not cover the fees for that home and a person or their family pay for the rest of the fees, this is known as a ‘top-up fee’.

NHS funding

If a resident’s needs are primarily health based, the NHS may arrange and pay for care home costs under NHS continuing healthcare (NHS CHC). If they do not meet the criteria for NHS CHC, but require nursing care, the NHS pays a contribution towards the cost of the nursing care directly to the nursing home. This is called NHS-funded nursing care (NHS FNC).

In 2021 the average weekly cost of residential care is £704 and for a nursing home is £888. Fees for care homes in England vary and have been found to be highest in the South East.

Currently, the care homes sector is heavily dependent on self-funders and typically, a self-funder will pay more than a local authority for the same care home.

Regulation

Each of the four countries in the UK has its own regulatory body. In England, the Care Quality Commission is the independent regulator of health and social care and inspects and rates residential care homes and nursing homes. 

Commissioning

Local authorities: The Care Act 2014 places duties on local authorities who are responsible for commissioning care places for those in their communities who are eligible for public funding support. They also provide advice on available places both for those going into local authority-funded places, and for those who are self-funding.

Clinical commissioning groups (CCG): The CCG’s role is to commission NHS Continuing Health Care (CHC) from nursing homes.

Ownership

Care homes can be run by the private sector, local authority, the NHS or voluntary sector (not for profit). Figures for UK are shown in the table below. Over 80% of all care homes beds are in the private, for-profit sector.

Care home beds by sector

Source: Care homes market study (appendices), GOV.UK, 2018

Sector

All care homes

Residential homes

Nursing homes

Private sector

82.6%

73.5%

90.2%

Local authority

3.9%

7.9%

0.6%

NHS

0.3%

0.6%

0.1%

Voluntary (not for profit)

13.1%

17.9%

9.1%

Case study

Promising practice examples

  • Nightingale House Open

    Model of housing or service: care home

    Principles of excellence: person centred and outcome focused; community connectedness; adopting innovation

    Nightingale House, located in South West London, is a faith-based, residential care home. It is run by the Jewish charity Nightingale Hammerson, which has been working with the Jewish community for over 180 years. The home houses on average 185 older Jewish people across six self-contained units, each with separate adapted facilities. Three units specialise in providing nursing care for people with high dependency needs, including dementia, palliative and end-of-life care. The remaining three units are residential, catering for more independent residents, and provide personal care.

    The home focuses on offering holistic, relationship-centred care. It has a café garden, library, concert hall, activity hub, namaste and sensory rooms, hairdressing salon and a shop on site. It also has a synagogue where people can visit whenever they like and where many Jewish festivals are celebrated and regular Shabbat services are held.

    In September 2017, Nightingale House opened ‘Apples and Honey’ nursery. An intergenerational programme is delivered daily between the nursery children and care home residents. Results of a 2019 evaluation, found that the intergenerational sessions alleviate symptoms of loneliness and depression, stimulates the brain in different ways and lifts the spirits of all involved.

    We were very touched and amazed by the interaction of both the children and the residents – our friend is unable to make any form of contact with us but she put out her arms for a little girl to sit on her lap and the little girl was happy to do so – very touching for us especially as our friend kept eye contact with the little girl – something she is unable to do with us.

    Friend of resident with dementia

    Nightingale House is at the centre of The Network of Care Home Researchers (NoCHR) which was founded to support research in care homes. The home aims to use research to improve quality assurance and standards for its residents and staff.

    In 2018 Nightingale House was named Care Home of the Year by the National Gold Standards Framework Centre for End-of-Life care and was awarded ‘Outstanding’ by the Care Quality Commission (CQC)

  • Sanctuary Care Open

    Model of housing or service: care home

    Principles of excellence: adopting innovation; person centred and outcome focused

    Sanctuary Care, part of Sanctuary Group, an exempt charity, runs 100 care homes in England, Scotland and Wales with up to 4,400 residents. The homes offer a variety of care including, residential, nursing, dementia, palliative and respite care.

    Sanctuary Care was awarded a technology accolade at the Care Home Awards in 2020 for its bespoke, in-house electronic planning app called ‘kradle’. The app means that staff do not need to spend time filling out paperwork but instead can immediately update their residents’ care plans electronically at the point of care using dedicated iPhones. The app was created in partnership with Sanctuary Group’s IT team, many of whom have worked in the care homes. The team used their expert knowledge to ensure that kradle has been designed to meet the needs of staff and help them to provide the best care for residents. The app can also be updated and improved following feedback from staff.

    Sanctuary Care Programme Manager Jemma Robinson said: ‘kradle is also great for recording those personal details that make us able to deliver truly person-centred care. An example is if someone loves a particular meal because it reminds them of their mother’s cooking, or if they always like a drink on their bedside before they go to sleep’.

    Sanctuary Care also seeks to develop person-centred care by learning more about each resident and aiming to provide individualised activities. Examples include: a resident hosting fortnightly baking or fitness sessions for fellow residents; a care assistant coming in on her day off every two weeks to take a resident who loves swimming to the pool and attending to cultural food preferences.

  • The Close Care Home Open

    Model of housing or service: care home

    Principles of excellence: person centred and outcome focused; strong leadership, culture and workforce; co-production and shared decision making

    The Close Care Home is a private sector care home based in Oxford. It provides high-dependency nursing care, bariatric care, ABI (acquired brain injury) care as well as general nursing, dementia, residential and respite care for up to 90 people. Care is offered across four distinct suites, each of which cater for particular needs.

    The Close prides itself on being a ‘resident lead care home’. Residents are treated individually and care is tailored to meet specific needs with cultural diversity being embraced and enhanced. Staff engage in life story work with each resident, learning about their interests, routines and hobbies and every resident receives an individual care plan which is designed to build upon their strengths and to improve quality of life.

    ‘Butterfly time’ has been introduced. This involves the provider, leadership team and staff spending time with people to ensure a consistent focus is maintained on people being treated and valued as individuals. In 2020, CQC found this approach to be exceptional at helping people to express their views so that staff and managers at all levels understood their experiences, preferences, wishes and choices.

    Residents are involved in staff recruitment whereever possible. This includes supporting staff with the interview process.

    The leadership team has introduced innovative ways to manage risk and enable people to live with as few restrictions as possible and people are empowered to take maximum control of their lives. One example of this is a resident who expressed a need to be involved in the domestic jobs of the home being given a uniform and being able to assist staff following risk assessments. The leadership team has also gone to great lengths to ensure that people who required pureed food still experienced the same standards and experience as everyone else, employing a specific chef whose job it was to puree and remould food to its original state.

    In 2020 the Close Care Home was rated Outstanding by CQC. The Close is the largest home ever to receive the rating across all five domains. Between 2017 and 2020, the home won a number of Care Home Awards, including: ‘Best Individual Care Home Provider’, ‘Management Team of the Year’, ‘Activities Team of the Year’, ‘Best Outdoor Environment’ and ‘Best for Food, Nutrition and Dining Experience’.

  • Parklands Care Homes Open

    Model of housing or service: care home

    Principles of excellence: strong leadership, culture and workforce; community connectedness

    Parklands Care Homes is a private sector, residential care provider. It operates eight care homes in Moray and the Highlands providing care for almost 300 older people in small, rural communities and is one of the largest independent care providers in the north of Scotland.

    All of Parklands staff are recruited from the communities in which it operates. Training is delivered in-house through the company's innovative Parklands Academy which allows it to devise training and development plans tailored to the needs of individual staff. A career development programme ensures that employees can progress through the business, working in a variety of frontline and managerial roles. Many of Parklands' senior staff joined in more junior roles and have progressed through the organisation. The majority of Parklands' staff have been with the organisation for 10 years or more.

    Parklands’ care homes work to connect people and their communities. A programme of activities is provided for residents including the use of a mini bus for days out to the cinema, nearby visitor attractions, local ceilidhs or for lunch or shopping. Local musicians, artists, dancers, school children and therapy pets regularly visit the homes to entertain and support residents. Throughout 2019, social events were held to promote awareness about dementia, provide support for those living with the condition, as well as those who care for them, and bridge the generational gap. In addition, Parklands launched a multimedia campaign to capture the oral testimony of older people and celebrate the places that mattered most to them. Residents were also invited to share their life tips with the younger generation.

    In the 2020 Care Home Awards, Parklands Care Homes were awarded ‘Best Smaller Care Home Group’ and ‘Best for Communication’.

  • Cornerstone Health Care Open

    Model of housing or service: care home

    Principles of excellence: strong leadership, culture and workforce; person centred and outcome focused

    Cornerstone Health Care is a private sector nursing care home provider which operates three ‘lodges’ in England supporting up to 209 residents. It provides specialist care for people who present with ‘behaviours that challenge’ associated with complex neurodegenerative conditions such as dementia, and underlying mental health needs. The lodges offer flexibility of living through mixed and gender-specific units, while tailored care models enable support to be offered to those with long-term, progressive and degenerative conditions. The specialist care offered allows the homes to consider and often admit individuals who have been rejected by other services or who have previously experienced placement breakdown.

    Cornerstone offer a service unavailable elsewhere in Hampshire to meet the needs of older people with challenging behaviours as a result of mental health issues. I hold Cornerstone care to be of a higher quality than other Tier 4 homes in the area.’ Healthcare Professional

    Cornerstone Health Care’s approach and attitude towards specialist care, which has received industry recognition, focuses on four core areas: clinical, staff, tools and outcomes. The leadership and culture encourage staff to see beyond the diagnosis to the individual needs of each person with an emphasis on presentation over diagnosis. Staff include a mix of general and mental health nurses with high staffing ratios. In-house specialist training is provided to ensure consistency across the service. Staff are encouraged to focus on de-escalation and distraction.

    While support is offered from a clinical and holistic perspective, residents also play a role in their treatment programmes and the multidisciplinary team (MDT) aims to maximise their abilities. Measuring outcomes is a crucial part of planning and includes an initial 28-day assessment, monthly care reviews and surveys and feedback from residents, families and professionals.

  • St George’s Park Open

    Model of housing or service: care home

    Principles of excellence: strong leadership, culture and workforce; person centred and outcome focused

    St George’s Park is a private sector residential, nursing, palliative and specialist care home which offers accommodation for up to 71 residents including those living with Alzheimer’s and other dementia-related illnesses. The two individual units within the home are split across two specialised floors. St George’s often works with older adults who have had failed placements in other care settings, taking some of the people who have been most challenging to find a home for in the county. The staff do not medicate to resolve issues around behaviour, instead they aim to investigate, take a step back and try different approaches, all while talking with the local authority and families.

    St. George’s Park has a person-centred approach and family and friends are encouraged to visit and join in with activities. This invitation extends to mealtimes when residents are encouraged to eat how, where, when and with whom they like. If residents choose to sit alone, join friends and family or even eat while walking around, then this will be catered for. The home is very proud to have been shortlisted as a finalist in the 2020 Care Home Awards category of ‘Best for Nutrition, Food and the Dining Experience’.

    My mum has been a resident at St George’s Park nursing home since January 2018. During this time, she has been cared for with the utmost respect and dignity by all of the management and staff. At the time of the COVID pandemic restrictions, every effort was made for me to maintain contact with my mum, and when this was not possible due to Government restrictions, I had every faith that she was still being cared for with the same care and attention. I am very pleased with the care offered to my mum at St George’s Park.

    Linda

    More reviews

  • Millers Grange Open

    Model of housing or service: care home

    Principles of excellence: adopting innovation

    Millers Grange is a private sector residential and nursing care home based in Whitney, Oxfordshire which offers care for up to 52 older people. The home also provides short-term respite and dementia care.

    The home was awarded ‘Best for Architecture, Interior Design or Communal Spaces’ at the 2020 Care Home Awards. The building’s appearance is designed to represent a group of smaller domestic scale dwellings. Each of the two floors at Millers Grange is divided into two suites, each has its own bistro-style dining room and lounge and a cluster of en-suite bedrooms. This design helps to create an intimate atmosphere that is particularly calming for people living with dementia. Some of the ground floor rooms have their own patio doors, which open onto secure, landscaped gardens. The home has been built to a design in keeping with local, vernacular architecture, using local Cotswold stone. The contemporary interior meets latest dementia-friendly design standards, both in terms of lighting, signage and wall/floor coverings, and also in providing areas for meaningful occupation and social activities. Outside, raised flowerbeds, a bar area, a circular pathway, and a range of seating areas provide opportunities for fresh air and relaxation.

  • Avery Healthcare Group Open

    Model of housing or service: Care home provider

    Principles of excellence: community connectedness; person centred and outcome focused; strong leadership, culture and workforce;.

    The Avery Healthcare Group is a private sector care provider and operates 56 residential, dementia and nursing care homes throughout the UK, with a focus on the highest possible standards of living for residents and peace of mind for family and friends alike. The Group has a well-defined values framework which underpins everything it does. The leadership and management believe that this starts with investing in staff and they therefore spent two years designing an Apprenticeship and Training Scheme to create teams that embody the Avery ethos. Staff also receive the best possible ongoing coaching and development. This investment in staff creates a motivated culture that delivers a positive way of life for those living in in the homes.

    Wellbeing is another priority, and Avery Healthcare has a comprehensive programme that covers the physical, psychological, social, and nutritional needs of the residents. All homes have a busy schedule of recreational and leisure activities, both indoor and outdoor, as well as regular outings to local garden centres, pubs, and educational trips. Links with local schools, colleges and social groups are also established at each location, all of which builds a sense of community connectedness. The Group is also committed to life stories and reminiscence, which are an important part of daily activities at all care homes and explore in detail the lives and memories of all residents, and which thereby capture colourful resident stories.

    Avery Healthcare Group was nominated as a finalist in the Care Home Awards 2021. In 2020, it won the ‘Residential care provider of the year’ award at the Health Investors Award where one of the judges commented that:

    Avery firmly positions itself as a high-end residential care provider, and 2019 saw the introduction of further innovative approaches heavily focused on enhancing the experiences not only of residents but also its staff, thereby cementing its enviable position as one of the pre-eminent UK care home operators.

  • Strong Life Care Open

    Model of housing or service: care home

    Principles of excellence: co-production and shared decision making; strong leadership, culture and workforce

    Strong Life Care, a private sector company, offer residential, nursing, dementia and day care for up to 199 people across four facilities in England.

    Strong Life Care has implemented an initiative called ‘Recruit with the Resident’, allowing residents to be involved in the interview process for new staff candidates. Management recognise that ultimately, it’s the resident’s home and it is the residents that potential candidates will be supporting. Residents can ask the candidate questions about their past experience, why they want to work in care and their reasons for wanting a role in a particular home. The candidates are also afforded the opportunity to ask residents questions about their experience at the care home and what changes or improvements they would like to see from new staff.

    In 2020 Strong Care Life was awarded ‘Best for Training, Recruitment & Retention’ and ‘Care Home Employer Award’.

  • Croft Communities Open

    Model of housing or service: supported living, care home

    Principles of excellence: person centred and outcome focused

    Croft Communities, a registered charity based in Newtownabbey, Northern Ireland offers residential, supported housing, respite and day-care options for adults of all ages with learning difficulties.

    Croft Communities seeks to provide housing, care and support using a holistic approach to meet the physical, emotional and spiritual needs of those that avail of their services. It currently offers nine residential places providing care in the communal Mayne House, 34 tenants in supported living accommodation, enabling a more independent lifestyle, and seven respite places in the recently opened Croft Lodge, which serves around 100 families. It also has a day care service offering meaningful activities for 27 people from Croft and the wider community.

    The key focus at Croft, with the help of all its partners, is to empower adults with learning disabilities to live fulfilling lives within their local community. Croft also seeks to come alongside the families of those who use its services to see how best it can support them in meeting the overall needs of their loved one. Croft focuses on a ‘can do’ attitude which encourages staff and residents to go beyond what they imaged could be done.

    ‘Our daughter moved into the Croft Community nine months ago. With the companionship and care she receives she has never been happier. On regular home visits we notice that her domestic skills have improved considerably, and she is a very willing helper with daily kitchen and household chores. We are delighted with her increased independence, and the fact that she has a positive future in the Croft Community.’