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

A strategic examination of the purpose and desired structure of residential care services fit for the aspirations and needs of future generation.


Residential Care in Scotland

Since the development of the National Care Home Contract in 2006, we have witnessed standardised contracts and more transparent and consistent approaches to funding care. This has largely overcome the variation and complexity in the contractual relationship between the individual, the provider and the local authority, of which the Office of Fair Trading was particularly critical prior to the establishment of the National Care Home Contract. We have therefore made considerable progress on the procurement of care in care homes over the last decade. We can also be generally satisfied that work undertaken since 2006 has improved outcomes for individual services users. The introduction of national care standards and a strong and effective regulatory regime, along with a payment for quality agenda that has been devised to reward the best performing care homes, has delivered a general improvement in the overall quality of care provided.

However, the current mix of services within the care home market is not producing optimum outcomes, when viewed from a whole system and care user's perspective. There has been limited innovation in the Care Home market in terms of new models of care - for example, in the use of care homes as a means of providing intermediate care (to avoid hospital admission or facilitate discharge). Generic care provision has been variable, with growing numbers of providers operating at higher levels of quality but with a significant minority continuing to provide care at undesirable quality levels. There has been some shift towards personalised arrangements - we have considerably reduced shared bedrooms for example - but a wholesale shift to put the service user in control has not happened. What is more, residents continue to feel that there is a lack of clarity about funding - and that sometimes the funding system is unfair. There have also been isolated instances of instability and poor performance, which have contributed to calls for increased levels of scrutiny within the sector.

Equally, it has not been possible for commissioners at a local level to fully shape market behaviour, with the speculative development of residential facilities in some areas unbalancing supply and demand relationships; and, by contrast, supply issues in rural areas or where local property markets have inhibited investment in care facilities. Providers, for their part, argue that in the absence of clear commissioning strategies at local and national levels, they have had to speculate about future need and commissioning requirements.

Current Landscape

Demographic projections of recent years have presented a picture of a growing older population. According to the latest figures from the National Records of Scotland, the number of people aged 75+ is projected to increase from 0.42 million in 2012 to 0.53 million in 2022. It is then projected to continue rising, reaching 0.78 million by 2037 - an increase of 86% over a 25 year period.1 While analysis and debate is on-going in terms of the impact of population change on levels of demand, the over-arching message is clear: we will need new patterns of provision if we are to respond to the changing profile of need. More of the same will be simply unaffordable.

The most recently available Scottish care home census tells us that there are 916 care homes for older people in Scotland providing 38,465 places to 33,636 residents.2 Of those residents, at the time of the census, 32,555 (97%) were in long stay arrangements.2 We also know that care home residents' average age and complexity of need are increasing.

There are 115,410 people employed as carers in care homes across Scotland. All support workers in care homes will be compulsorily registered with the SSSC by 30th September 2015. Other professional groups are already compulsorily registered.

The quality of provision, in the main, continues to be at a good or high standard. The Care Inspectorate reports in its 2012-13 annual report that almost 75% of care homes received a grade of 4 or 5 out of 6 in the Quality of Care and Support. At the same time, there is a consistent proportion of providers - around 5% of the market - operating at grades 1 or 2, which is higher than for other service areas, as evidenced by the following table:3

1 2 3 4 5 6
Adoption 0.0% 0.0% 5.1% 38.5% 53.8% 2.6%
Adult Placement 0.0% 0.0% 5.6% 30.6% 58.3% 5.6%
Care Home 0.8% 4.4% 14.7% 34.9% 40.0% 5.2%
Childcare Agency 0.0% 0.0% 10.0% 33.3% 40.0% 16.7%
Childminding 0.1% 0.6% 4.3% 24.8% 59.4% 11.0%
Daycare of Children 0.2% 1.2% 5.4% 27.2% 57.6% 8.5%
Fostering 0.0% 1.7% 1.7% 35.0% 58.3% 3.3%
Housing Support 0.2% 1.8% 5.2% 31.3% 52.3% 9.2%
Nurse Agency 2.9% 2.9% 5.7% 28.6% 54.3% 5.7%
Offender Accommodation 0.0% 0.0% 0.0% 22.2% 66.7% 11.1%
School Care Accommodation 0.0% 3.1% 3.1% 33.8% 41.5% 18.5%
Secure Accommodation 0.0% 0.0% 0.0% 40.0% 40.0% 20.0%
Support 0.2% 2.0% 5.2% 31.7% 50.9% 10.1%
Grand total 0.2% 1.4% 5.9% 27.9% 55.1% 9.4%

One of the indicators of success in the future reform of the care home sector will be the extent to which we are able to eliminate poorer quality care.

Remit of the Task Force

Within the context of emerging legislation to integrate health and social care services, it is recognised that there is an opportunity for change in respect of the evolution of the residential care sector. As such, the Task Force on Residential Care for Older People, was commissioned by Scottish Ministers and COSLA's political leadership to set out a range of ideas and recommendations to underpin the delivery of high-quality, sustainable and personalised care and support in residential settings over the next twenty years.

The Task Force's primary objective is to examine at a strategic level the key purpose and desired structure of residential care services fit for the aspirations and needs of future generations.

The remit of the Task Force was to:

  • Outline strategic outcomes and priorities for adult residential care for the next 20 years;
  • Scope out capacity planning processes and the interface with other services within the context of integration, joint commissioning strategies and diversification of the sector;
  • Review the fee structure of care home placements, and provide options for a new fee structure and alternative methods for procurement;
  • Audit the commissioning levers available to local Health and Social Care Partnerships and make recommendations about how these can be strengthened to ensure that the sector responds to the needs of the local population;
  • Agree a compulsory risk register, to provide an early warning system for care providers experiencing challenges to the continuity of care - and an associated ladder of intervention for public authorities to co-produce solutions for exit or redesign of struggling services;
  • Review of the basic structure of residency, exploring parallels with the housing sector and the introduction of a rights-based frameworks for residents, and whether it is desirable to separate-out daily living costs such as rent, food and utilities from the cost of care, allowing a move to tenancy arrangements; and
  • Nurturing a caring workforce which is passionate about delivering high quality person-centred services, and developing caring as a career of choice;
  • Assess whether the various operational models of care home businesses bring different levels of risk (particularly around the split between property owner and care provider), and if appropriate make recommendations about how these might be overcome.


Early in its deliberations, the Task Force agreed a 'Vision' which captures the kind of care services we would like to see created as a result of our work.

To support older people in Scotland, now and in the future, to live in homes where they feel safe and respected as members of their communities. We will do this by:

  • Adapting person-centred and personalised care and support solutions to people's changing needs;
  • Developing accommodation and care options that are flexible, built around people's needs and also part of a wider community;
  • Ensuring all human rights are protected and in particular the rights to privacy and dignity are respected at all times
  • Nurturing a caring workforce which is passionate about delivering high quality person-centred services, and developing caring as a career of choice;
  • Planning services responsibly to develop sustainable communities;
  • Making funding and charges simple and transparent; and
  • Assuring quality and safety.

The Task Force met four times between July and December. Its work was mostly undertaken through six sub-groups, which focused respectively on personalisation, place-making, workforce, commissioning, regulation and funding. Membership of the Task Force is detailed at Annex A. A more extensive Task Force report, which contains the detailed deliberations of the six sub-groups, will also be published.


Email: George Whitton

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