Long Term Nursing Care

Current gaps in nursing care are the most pressing issue for commissioners in Manchester presently. Qualitative issues remain in pockets, however, we have worked incredibly hard to secure improvement, which can be demonstrated through significant upward trajectory in CQC ratings as one major proxy measure.

The two pressure points are overall market capacity (volume and locality distribution) and the ability to secure increasingly complex packages.

Part of the market capacity challenge relates to workforce, with beds being unavailable due to providers struggles to recruit, retain and develop an appropriate number of both care and nursing staff, in addition to the need to attract additional nursing provision to the City. A number of closure over the last 18-24 months have reduced available nursing beds, particularly in the south of the City. Further, another 68 bedded dual registered is at high risk of closure due to issues relating to its parent company.

The fair cost of care exercise has emboldened providers in terms of their fee rate expectations, with the number of beds secured on local authority frameworks dramatically reduced. The obvious constraints in capacity have further compounded this issue with reduced supply and more complex care leading to very high increases in admission rates for most nursing homes, which are far outstripping the inflationary increases and ‘move toward’ fair cost of care efforts.

Long Term Residential Care

Some of the challenges relating to long term nursing care apply to residential care also. Workforce issues play a part in regard to pockets of undersupply across the City, however, the issue is not as acute as it is with nursing care, with supply more readily available.

Suitability of estate is another factor which constrains supply in the City, with very few purpose built residential homes. This is particularly prevalent in North Manchester, with many residential homes being converted houses with no room for expansion.

Additionally, residential providers report that increasingly complex care is becoming problematic, particularly in relation to staffing ratios and the ability to manage the complexity when it causes a detriment to other residents.

Community Care – Homecare

Homecare challenges in Manchester affecting capacity are primarily workforce related, with some smaller challenges sometimes leading to sporadic issues with availability.

Similarly with both residential and nursing care, recruitment and retention are incredibly difficult. All homecare providers are currently contracted to pay Foundation Living Wage, which has aided providers ability to recruit in some areas, other areas remain challenging. For example, Wythenshawe has always been a difficult area to recruit within as has most of more affluent parts of South Manchester more generally. Whilst Manchester is supporting a move toward it’s fair cost of care rate, local service and manufacturing industries pay rates are accelerating far beyond those of care providers. An example of this being Manchester Airport, recently announcing a 17% pay rise for staff working in security, operations, firefighting, traffic and car parking and will also receive a lump sum worth up to 9.6% plus enhanced pension benefits.

Community Care – Extra Care

Our extra care model in Manchester has been incredibly successful, with 13 schemes offering over 760 units across the City. Vacancy rates are generally low, due to the success of the overall planning, strategy and approach There is also a strong pipeline of schemes to be completed over the next 4 years with close links to social work ensuring that they are built in the right neighbourhood to meet local demand and to ensure that the schemes are promoted to people who may otherwise go into residential care.

Community Care – Supported Living

An excellent core of supported living providers operate in Manchester caring for some of the most vulnerable people in the City. Our biggest market capacity challenges in this area are related significantly increasing costs due to the level of commissioning with this small core group. A more diverse market and range of providers is required to help drive up outcomes for individuals as well as create a more competitive commercial environment, which will drive efficiency in our existing provider base.

Some gaps exist at the very complex end of the market, with a desire to reduce the number of people placed out of area, as well as offering the opportunity to those previously placed out of area to return to Manchester if they wish.

Workforce

We are currently working with providers across all types of care to better support recruitment and retention across the city. Initially, this has focused on facilitation and funding a number of recruitment events on a citywide and individual locality basis. Initial feedback from the first two events has been extremely positive.

Further work with providers over the coming months will identify other opportunities to develop a more sustainable and vibrant workforce.

Long Term Nursing Care

The two main sustainability issues for nursing care are current constrained capacity in general, plus the ability to deliver an increasing number of highly complex packages of care.

For winter 23/24, we have a range of plans to ensure sufficient capacity is available, despite concerns that occupancy levels are higher than ever, due to closures of homes over the past 18-24 months.

Firstly, we are seeking to support a 68 bedded dual registered care home to remain open following the parent company being placed in administration due to issues with the company structure and an FCA investigation into their ownership. Retaining this provision will not only safeguard the future for existing residents, but will provide the opportunity of creating up to 24 additional vacancies that are not currently admittable.

Secondly, we will continue to work within our Discharge to Assess models, as in 22/23, to ensure a level of flexibility within our existing provision is available to support hospital discharge, thus minimising the effect on the wider care home market of increased activity over the winter period. We may also use any winter funding available to block book small cohorts of beds to ensure they are available to move citizens out of D2A services into long term care.

Thirdly, we are exploring with a small number of providers who are currently dual registered as to whether the conversion of existing unoccupied residential beds could be redesignated as nursing and to support homes with any necessary recruitment to additional nursing roles.

Further, we are seeking to understand why any homes that are under-occupied remain so, given the current availability challenges and will be working with those homes specifically to identify which beds that are not currently admittable could be returned to service for winter 23/24.

Finally, in the longer term we have committed to our care home market to work with them over the next 12 months to produce a 10-year care home strategy which will focus on workforce, improving the overall estate, attracting new provision to the City, improving end of life care and supporting the increased demand for complex care.

Long Term Residential Care

The main sustainability issues for residential care are an ageing estate and the movement towards more complex care within a residential setting. We believe the cause of this to be related to improving peoples independence and helping them to live at home for longer, meaning traditional residential care has reduced in desirability for the citizen and the advancement of degenerative conditions, such as dementia mean that people enter residential homes with a greater level of co-morbidities.

For winter 23/24, it is unlikely that major change can be affected with regard to the estate currently available to us. Residential care homes in Manchester are generally at the lower end of bed numbers, with many being between 20 – 40 beds with a number of those being converted houses rather than being purpose built for care. With these types of services, land availability for expansion is limited and owners are generally smaller businesses who do not necessarily have the access to financing to enable extension, remodelling or the acquisition of new sites. However, we are supporting the continuation of one home, which was due to close and which is now going through a sale process. Retaining this provision, will again protect the future for residents within the home, but also mean that an additional 20+ vacancies are not taken up through the rehousing of people should the home close.

Our 10-year care home strategy will seek to address the estate issues we are currently experiencing and will also work with our care homes to support them with dealing with increasing complexity, which is likely to attract higher fees than traditional residential care, thus improving market sustainability.

Finally, the direction of travel for residential commissioning is a reducing one and we do not believe that we will experience any significant under-supply problems as long as we don’t see significant market failure at scale in this area.

Community Care – Homecare

The re-procurement of all homecare services will work to reduce some of the current market issues we have in addition to the support to providers in relation to workforce recruitment and retention.

For winter 23/24 our aim is to again work with an expanded rapid discharge block to provide advance notice to neighbourhood providers of the incoming workload and therefore allow for a greater level of planned hours and improved management of their recruitment pipelines.

We are also currently engaged in two homecare pilots aimed at improving management of low-level health tasks and retaining provision for a fixed period of hospitalisation to ensure citizens care packages are retained in weekly rotas.

Community Care – Extra Care

Our growth plans for extra care housing continues, with a current housing needs analysis setting out a need for a further 904 units over the next 15 years and a continued shift of 20% less residential care needs

Our newbuild extra care programme is likely to include ‘nursing wings’ as bolt-on provision to ensure there is a pathway within the community for more complex needs as a person-centred, holistic approach

Community Care – Supported Living

The re-procurement of all Supported Housing arrangements for both Mental Health and Learning Disability aims to provide a more robust commissioning approach both for commissioners and providers, offering more transparent arrangements, through a new dynamic purchasing scheme (DPS).

Additionally our strategy for Supported Living (all cohort) is being invigorated through a new Enabling Independence Accommodation Strategy to better align commissioners to land and development opportunities with housing providers.